Better Learning Through Chemistry
Every morning Cathy McCormick awakens her 8-year old daughter Sandra with a soothing body massage, lingering to provide gentle pressure on the knees, ankles, and elbows. For breakfast--and every other meal during the day--McCormick makes sure Sandra adheres to a diet loaded with vitamins and low on dairy products and unnecessary sugars. In the materials that Sandra takes to school, her mother has made bookmarks with drawings of a child sitting quietly at a desk, and other picture-reminders about still hands, closed mouths, and open ears. Some of the other children at school have asked if Cathy can make bookmarks for them too, but these are meant to be special to Sandra. You see, Cathy McCormick is doing everything she can to keep her daughter off drugs.
Sandra churns through her days and nights like a locomotive with a jammed throttle. Glib and precocious, she chats up strangers with the earnest affability of a conventioneer. Sleeping straight through the night is a rarity for her. Her mother says that, until recently, when she would help Sandra slow down enough to get dressed in the morning, her daughter would occasionally "go ballistic," yanking off her socks and shirt.
It was not surprising, then, that when the McCormicks attended an October parent-teacher conference in the Twin Cities suburb where they live, Sandra's second-grade teacher suggested that she might suffer from Attention Deficit Hyperactivity Disorder, or ADHD. But Cathy was taken aback by how readily drugs were invoked as a potential remedy. "Ritalin was mentioned three times in my first meeting with school officials," she says. "And each time I said I am not in support of drug use until after we try other methods."
McCormick is no stranger to the world of kids and schools and behavior problems. She's a special-education teacher at the other elementary school in town, working in a classroom with eight children diagnosed with learning difficulties that are more severe than her daughter's hyperactivity. Assisted by eight teacher's aides, only two of McCormick's students are on medication.
After the conference at school, McCormick fashioned an intensive program to combat Sandra's hyperactivity without using drugs. In addition to the massages and diet, she had Sandra focus on changing certain troublesome behaviors through a pattern of reminders and rewards. "It has really taken the edge off," she says. "If she only gets up from the table once during supper, or sleeps through the night, she gets a sticker. When a row is full of stickers, she gets to do something she wants, like stay up later one night or say what we all eat for dinner. For school, we focus on her not losing her pencils and on keeping her desk area neat. She has really taken to it; she loves getting those stickers. It's working out really well," McCormick says, then adds wryly, "Of course, the people at her school don't think so. There hasn't been a lot of support for what we are trying to do."
When she laid out her plan in a late November meeting with the school psychologist, he argued that the dietary restrictions would make Sandra different than the other kids and hurt her socialization. On Ritalin, apparently, she would fit right in with the rest of her class.
"Some children need medications; I understand that," McCormick says. "If I saw that my daughter was failing at school or that her self-esteem was falling apart, then I'd look at it more seriously. But on her last three math tests she hasn't scored any lower than a 93, and while she is struggling with her reading and writing, she is not failing. She'll come home and tell me in detail what happened that day, including what the teacher was wearing, so it's hard to think she's missing something. She just learns better when she is moving and that's a hard learning style for her teacher to deal with. But that's not a reason to give her drugs."
Or, as Sandra's father, Dave McCormick, says, "Sometimes I wonder how any of our business leaders made it through school. Look at the employment ads; what kind of people are they looking for? 'High energy, highly creative, self-motivated' people. But how do you stay that way if the attitude of the school is to keep everybody moving down the middle of the road, without going too far one way or the other? What the schools want is for kids to act in ways that are convenient. And if they don't, well, they can always drug them."
It is ironic that as intensive anti-drug propaganda campaigns such as the DARE program continue to be widely implemented in the schools--on the grounds that the best time to educate children to the dangers of drugs is when they are young and impressionable--the medicating of our nation's youth has suddenly become a booming business. According to the National Institute of Mental Health (NIMH), there are now twice as many children taking Ritalin, a potentially habit-forming stimulant treated as a controlled substance by the Drug Enforcement Agency, than there were just five years ago. Approximately 90 percent of the 1.5 to 2.5 million children diagnosed with Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder are given medication--primarily Ritalin--for their condition.
The medicating of children with antidepressants is also on the rise, attributable in part to the discovery of a new class of drugs that includes Prozac and Zoloft, which are considered to have fewer side effects. One national study found that doctors prescribed, recommended, or administered antidepressants to children (birth to age 18) 4.6 million times in 1992. According to USA Weekend, Prozac is being tested to treat premenstrual syndrome in teenagers. Peter Brown, a child psychologist at the Washburn Child Guidance Center in Minneapolis, says it is not uncommon for children aged 7-11 to be prescribed Prozac for anxiety or depression. He estimates that "a third to a half" of the children who come into Washburn are put on medications (including Ritalin), adding that "this is a pretty conservative area for prescribing medication compared to other cities I've been in."
After some heated scientific debate on the subject, it is now generally conceded that ADHD is a biochemical condition. "But what that means is that it affects 3 to 5 percent of the population in China and New Zealand as well as in America," says Dr. Barry Garfinkel, a child psychiatrist at the University of Minnesota. "Yet more than 80 percent of the world's Ritalin supply is used in this country." Of course the United States consumes the lion's share of many medical drugs and procedures. But what seems to be happening is that as the use of psychotropic medications by adults soars, the taboo against giving them to children is diminishing. An October 1994 study published in the Journal of the American Medical Association found that more than half of all mothers of 3-year-olds had given their children some type of over-the-counter medicine within the previous month. Meanwhile, Jensen says that medical researchers "are very concerned" that antibiotics are being overprescribed, especially to children, leading to new forms of bacteria that are resistant to the drugs.
There's no question that Ritalin and Prozac have helped a lot of kids. But as the number of children being prescribed such drugs continues to skyrocket, the chances for misdiagnosis and overtreatment become more acute. Even staunch advocates of drug therapy for children acknowledge that an array of medical, social, political, and economic factors have created significant flaws in the way these medications are administered.
Begin with the fact that the overwhelming majority of drugs given to children have not been adequately tested for use on them. (Ritalin is an exception.) "By and large, prescribing physicians have almost no reliable data to guide them on these meds," says Dr. Peter Jensen, who heads the children's disorders research branch of the NIMH. "Oftentimes we have research data on adults and we can do longitudinal studies for safety and efficacy [with experimental drugs] on animals that would obviously be unethical to do with children." As experience with common aspirin has demonstrated, what is safe and effective for adults or animals may not be safe and effective for children. According to Jensen, the crucial complicating factor in prescribing drugs to kids is that "they are developing organisms, with neurotransmitters in dramatic change. Do we run the risk of altering biological set-points or thresholds in the midst of their development? We don't know the answer to that."
One of the reasons for the sharp rise in ADHD diagnoses may be that in some children those neurological set-points are not clicking along fast enough to adjust to changes in modern society. "A hundred years ago," notes Jensen, "an ADHD child could be reasonably well managed in a one-room schoolhouse as the student who stoked the fire and chopped the wood. It was easier for him to become a hunter instead of a lawyer."
Gerald August sees children literally becoming victims of circumstance in this way all the time. August, an associate professor of psychiatry at the University of Minnesota, directs a clinic that tests children thought to have learning and developmental disorders. "What might be behaviorally disruptive in one setting may not be in another setting," he says. "A child growing up on a farm in western Minnesota is not as likely to be identified [as having ADHD] as a child in suburban Burnsville, where things are more regimented. I used to go play in the fields after school. Today, everybody piles into a station wagon to go to soccer or hockey practice, where they all wait in line to play and are told to work together as a team. That's intolerable to some kids at a certain time in their development.
"The world has changed," August says. "We used to have more two-parent families where one parent stayed home and took care of the child. Now there is more divorce and dual-income families, where the child gets dropped off at daycare, where again, things are more regimented than they would be if he were home. Years ago, the imposition of outside control was not put on children so early and they were able to utilize internal self-regulation skills. Now, you go to daycare with a lot of other children and it is 'time for a nap' and 'time to be quiet.' Some children simply haven't evolved in the pace of their neurological development to deal with that kind of structure yet."
Instead, the systems designed to implement the structure--education, health care, and criminal justice--have done the evolving. "Until the late '70s, adolescents could be deemed 'incorrigible' and jailed for things that would not have been crimes if they were adults, such as running away, drinking, and truancy," says Hans Skott-Myhre, clinical director of The Bridge, a short-term shelter for runaways between ages 10 and 17. "That began to change in the late '70s when the federal government began to tie funding to a reduction in the jailing of people for these 'status offenses.' In its place we got residential treatment centers and redefined them as sick; they were no longer incorrigible, they were psychiatrically disabled. But residential treatment centers became cost-prohibitive during the late '80s and early '90s. So the nation is swinging back to some incarceration. But also to the use of these new types of medications that allow them to essentially be furloughed in the schools through drugs."
Meanwhile, in 1991, the secretary of education under President Bush ruled that students diagnosed with ADD or ADHD were able to qualify for special education services and resources, overturning exclusionary policies that were in force in 48 of the 50 states. "In 1990, you probably had many children not getting help [for ADHD]," says Jensen. "But since the federal ruling, the schools have been put on notice and there is potential for overidentification. It is certainly possible that ADHD has become the diagnosis of the day in the schools."
"The whole structure of the schools is on a medical model--the need for a diagnosis in order to get services," says Roberta Opheim, ombudsman for Mental Health and Mental Retardation, an independent state agency here in Minnesota. "Rather than saying a kid needs a little more love or attention, the teacher says, see the school psychologist or a physician and get a diagnosis. Because with a diagnosis, the student will receive services and the school will get more money. It is very box-oriented, and if you don't fit in a particular box, or if your condition is somehow between boxes, you very well might not get help."
The rise in medications for children is also a function of the changing health care industry. One of the fundamental ways that HMOs and managed-care plans save money over traditional fee-for-service medicine is by compelling family doctors and internists to treat a higher percentage of patients and give fewer referrals to specialists. And a month's worth of Ritalin costs less than a single visit to a child psychiatrist. (Some health insurance plans simply don't cover treatment for ADD or ADHD, which is a different problem altogether.) Health professionals throughout the system cite such shortcuts as a primary cause of misdiagnosis and overmedication of children.
"First of all, medication isn't an automatic first option. Before I would recommend a drug trial for a child, I have to feel I know this kid and that I know his environment," says Brown, the psychologist from Washburn Child Guidance Center. "By the environment, I mean what kind of home life does he or she have? If the child has come to see me on the recommendation of a teacher, is it really related to the child, or because the teacher is overwhelmed or has an attitude? All of this is very work-intensive and time-consuming, but it really pays off in getting the proper diagnosis.
"Now, under some medical insurance plans, there is tremendous pressure on the front-line physicians to be competent in many areas. The physician may see the child for 25 or 30 minutes and that kind of screening may be OK when all the symptoms line up. But when they don't line up and there is this pressure to treat patients rapidly, that's when the clinicians may not do the kind of follow-up I'm talking about."
"The problem is that you've got people making judgments and writing prescriptions in areas of medicine where they are not competent," says a Minnesota child psychiatrist who prefers to remain anonymous. "There are only 70 board-certified child psychiatrists in this state, and only 50 are actually practicing. We know that about 18 percent of kids have some psychological problems; about 5 percent have severe emotional disturbances. Yet most are not getting the kind of comprehensive assessment and care that they need.
"To treat a child for depression or ADHD with medication but not some kind of therapy is totally inappropriate. The norm is for a family doc to prescribe psychotropic drugs like Ritalin with maybe one or two follow-up visits per year. We've got almost 2 million kids on Ritalin in this country and most have had no comprehensive assessment of their condition and few things tried in conjunction with their medication: Primary physicians simply treat ADHD with Ritalin. That's what they do. As the saying goes, when all you've got is a hammer, everything looks like a nail."
According to Garfinkle, a recent study bears this out. Given one child's hypothetical case study and asked to recommend treatment, only half the child psychiatrists surveyed would have prescribed Ritalin; when family practitioners reviewed the same file, 90 percent said they would prescribe the drug.
This over-reliance on medication isn't restricted to a single type of drug or prescription. "There are a number of clinicians in town we know of who, when a certain drug trial is not going well, will add a different drug. And if that doesn't go well, they add another one," says Brown. "We've had kids come in here all screwed up on three or four different medications. Their parents are angry, and I have to tell them that we are taking their child off all medication for at least a couple of weeks--and believe me, that isn't easy on some of these families--and then starting over with a combination of therapy and medication."
At the Hennepin County Home School in Minnetonka, a school for teenagers who get in trouble with the law, Ritalin is rarely used. Instead, the Home School's staff psychiatrist, Dr. Larry Dailey, has tended to prescribe lithium, a mood stabilizer most often associated with the treatment of bipolar disorders, for students who, in his opinion, need medication. Speaking off the record, no fewer than three child psychiatrists were harshly critical of this form of treatment. (Dailey himself declined to be interviewed for this story.)
"The use of lithium on children is a big controversy nationally," says Jensen. "We have data about the effect of it on adults, and some data about lithium with children who are severely unmanageable and have to be restrained or hospitalized. The controversy is over what is causing impulsivity in children: Some see it as severe ADHD, where others might see the same thing and call it mania, [brought on by] a bipolar disorder. The research shows that these children will respond to Ritalin but some will also respond to lithium. Ritalin has fewer side effects and is more robust."
According to Home School officials, as of mid-November, the majority of the residents taking psychotropic medications were on lithium. Furthermore, the number of residents at the school on medications jumped from 7 percent in 1986 to 14 percent in 1990 to 24 percent in 1994. Recently, there has also been a surge in the number of residents already on drugs when admitted to the school. "Even a year or two ago, we'd have three or four students coming in who had prescriptions for medications; now it is 13 or 14," says nursing supervisor Kay Kelly. Have all these pills done any good? "Certainly I've seen kids who have been bouncing off walls and assaulting staff who have benefitted," Kelly says, but adds, "We have tried three times to quantify the impact and we just can't separate it out from the recreational therapy and horse program and all our other programs. I've read things where some people [in the field] like what we are doing and some don't but nobody really knows because there is no right way that it can be measured."
As for tracking residents once they leave the Home School, superintendent Terry Wise says, "Aftercare is a weakness. We have attempted to get money for follow-up and supervision of our youth, but it doesn't make it past our own bureau in the budget process. The money isn't there."
Some version of the same story is told in practically every institution that deals with children: a sharp rise in the level of medication without a corresponding increase in the awareness of its drawbacks and benefits. It's an exasperating situation for parents as well as their children. One longtime health care worker, who has a son diagnosed with ADD, says that "the system is crazy, absolutely nuts. I find it to be intimidating and unfriendly, and very difficult to understand. And I have a college degree and 20 years of experience in the field. I can't imagine what it is like for someone coming in fresh. One of my friends also had a child diagnosed ADD and she wound up seeing over a dozen different doctors; then they overdosed her child on medication. It has been more than a year and I still don't know if the dosage is right. That family has been traumatized by the system."
Who are the kids most likely to be caught up in this process? Nobody really knows. In recent years, an occasional news story has pointed to the apparent overmedication of children in juvenile correctional facilities in California and New Jersey and among schoolchildren in the Baltimore area. But two years ago, when the cost of health reform was being debated in Washington, federal officials had precious little data about children with behavioral, mental, or emotional problems. Jensen and the NIMH have just initiated a comprehensive nationwide survey to establish a credible perspective.
Given the past evidence of cultural bias in the school system and other societal institutions, one might assume that minority youth, particularly African American males, would be overidentified for attention deficits and hyperactivity. Keyah Davis, a registered nurse who also works as a health program officer for the Urban Coalition, says, "I run into African American families almost every day that have a child on medication. Most of the time, it seems as if the parent is listening to an authority figure at school and they are stressing medication instead of behavior modification."
But, adds Jensen, "What little evidence we do have indicates that children of color are less likely to get treatment of any sort." On the basis of people who come to see her at the ombudsman's office, Opheim agrees: "I will guarantee you that some kids are getting medicated who shouldn't be. But I also guarantee that there are many kids who should be getting services who aren't. I suspect that includes many African Americans." Aviva Inberg, a licensed social worker at Minneapolis North High School, where the student body is 80 percent nonwhite, says there is a great need to deal with temporary depression brought about by isolated incidents of trauma at home or in the neighborhood.
"I've referred students for medication," she says, "and they are very hesitant about taking them. When I ask if they want to see a psychiatrist, they immediately tell me, 'I'm not crazy.' So there is a stigma attached. I have an ongoing caseload of 75 to 100 kids and right now only one is on Ritalin; a while back I also had one on Prozac. But that's it."
Gerald August recently completed a project instructing 22 suburban schools how to teach more self-regulatory behavior to students diagnosed with ADHD as a means of treatment. "The problem is that we are becoming an uneven society," he says. "Sports and athletic programs at the lower skill levels are being taken away from many poorer schools because of budget pressure." As an example of a positive activity, he cites karate classes, which teach self-control as a means to deal with confrontation; are competitive without requiring kids to fit into team roles and team goals; build self-esteem; and are considered cool by the students. Obviously, August says, kids in the suburbs are more likely to have the access and resources to participate in karate. On the other hand, he notes that the privilege and wealth of the suburban lifestyle may create unrealistic expectations and demands on children. "Should students be given medications to pass a college exam, or score an extra goal in a big game? You might laugh, but we face those kinds of questions; we call it 'playing the ADHD card.' It becomes a way for parents to rationalize underachievement."
Over at The Bridge, the runaway children that Skott-Myhre encounters comprise a wide variety of racial and economic backgrounds. "We see poor and homeless kids who are being needlessly medicated, but we see kids from wealthy families too. We had a young woman who I judged to be from a middle-class family who is a survivor of sexual trauma and assault. Her parents were working very hard for her to take an anti-depressant which was prescribed by her physician, but she adamantly refused, and said, 'it is not appropriate for me to be happy right now and it is not right to take this pill and just be happy.' One of the great travesties this culture pushes on people is the notion that if you are not 'happy' and 'functional' there is something wrong with you.
"More than the race or economic status of a family, I think the real issue with kids and meds is respecting kids for who they are and allowing them to act their age," Skott-Myhre says. "I'm not opposed to youths taking meds. But I am totally opposed to bullying them into it. And there is no question that many kids are bullied. In this culture, if your developmental pattern doesn't fit in to the norms experienced by the most productive part of adulthood, which is roughly ages 35 to 55, then your views are essentially disqualified as 'not real.' So you have elderly people and young people with different states of awareness and mood swings, with imaginary playmates and high energy levels that are not 'productive' energy; we tend to medicate those two groups of people because we are not sure they know what reality is. Adults bully by saying to kids, 'we know what normal people do, which is how you should be behaving, and if you don't we will impose it on you, we will chemically discipline you, so that you don't interfere with our productivity. That's the way our culture works.
"I know families working two or three jobs to make ends meet. And when they hear the school complaining about their kid--because with most of the kids I see, it is the schools complaining, not the parents or the youth--the parents feel compelled to respond. And the easiest option is medication. Rather than getting the schools to work effectively with different learning styles, it is cheaper to medicate people. And rather than provide families with adequate time to raise their children, it is a hell of a lot cheaper to medicate them."
Three weeks ago, Cathy McCormick took her daughter Sandra to a group in Wisconsin known as Allergy Associates for testing. They have determined that she is allergic to sugar, milk, and wheat. At first, Sandra completed her tasks very well, as befits an 8-year-old with a 116 IQ. "Then they gave her some sugar and she rolled up in a ball and said she wanted to go to sleep. When they gave her dye [as a placebo], she did fine again. Then they gave her milk and she flew off the chair and fell on the floor. It was very clear that sugar depresses her and tires her out and dairy products make her hyper. And when we started on the diet, in the month between her evaluations at school, from October to November, she stayed on task far more often."
Still, McCormick admits that her resolve to stay away from Ritalin is weakening. "I've had a couple of parents I really trust say it has helped them. The diet will take months before we see the full effect and it will have to be constant to really work. The Ritalin is instant. So yeah, the pressure is there; I have another consultation with the physician at the end of this week that I'm really dreading. Maybe he will say we're OK the way we're going, but maybe he won't. If not, my husband and I have talked about trying her on Ritalin for two weeks without telling the school and seeing if they notice a difference. My first instinct is still no drugs. Maybe we'll try them and they won't work; that happens with some kids. That would be the best thing that could happen." CP
News intern Mary Ellen Egan contributed research to this article.
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