    [House Hearing, 108 Congress]
    [From the U.S. Government Publishing Office]

                               PROTECTING CHILDREN:
                      THE USE OF MEDICATION IN OUR NATION'S
                     SCHOOLS AND H.R. 1170, CHILD MEDICATION
                                SAFETY ACT OF 2003

                                      HEARING

                                     BEFORE THE

                         SUBCOMMITTEE ON EDUCATION REFORM

                                       OF THE

                            COMMITTEE ON EDUCATION AND
                                   THE WORKFORCE

                             HOUSE OF REPRESENTATIVES

                           ONE HUNDRED EIGHTH CONGRESS

                                  FIRST SESSION
                                   ____________

                  HEARING HELD IN WASHINGTON, DC, MAY 6, 2003

                                 Serial No. 108-14

               Printed for the use of the Committee on Education
                                 and the Workforce

     87-723 pdf
       __________________________________________________________________________
       For sale by the Superintendent of Documents, U.S. Government Printing Office
       Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; DC area (202) 512-1800
           FAX: (202) 512-2250  Mail: Stop SSOP, Washington, DC 20402-0001

                         COMMITTEE ON EDUCATION AND THE WORKFORCE
                            JOHN A. BOEHNER, Ohio, Chairman

    THOMAS E. PETRI, Wisconsin					GEORGE MILLER, California
    CASS BALLENGER, North Carolina				DALE E. KILDEE, Michigan
    PETER HOEKSTRA, Michigan					MAJOR R. OWENS, New York
    HOWARD P. "BUCK" McKEON, California			DONALD M. PAYNE, New Jersey
    MICHAEL N. CASTLE, Delaware				ROBERT E. ANDREWS, New Jersey
    SAM JOHNSON, Texas					LYNN C. WOOLSEY, California
    JAMES C. GREENWOOD, Pennsylvania				RUBE?N HINOJOSA, Texas
    CHARLIE NORWOOD, Georgia				CAROLYN McCARTHY, New York
    FRED UPTON, Michigan					JOHN F. TIERNEY, Massachusetts
    VERNON J. EHLERS, Michigan					RON KIND, Wisconsin
    JIM DeMINT, South Carolina					DENNIS J. KUCINICH, Ohio
    JOHNNY ISAKSON, Georgia					DAVID WU, Oregon
    JUDY BIGGERT, Illinois					RUSH D. HOLT, New Jersey
    TODD RUSSELL PLATTS, Pennsylvania				SUSAN A. DAVIS, California
    PATRICK J. TIBERI, Ohio					BETTY McCOLLUM, Minnesota
    RIC KELLER, Florida					DANNY K. DAVIS, Illinois
    TOM OSBORNE, Nebraska					ED CASE, Hawaii
    JOE WILSON, South Carolina					RAU?L M. GRIJALVA, Arizona
    TOM COLE, Oklahoma					DENISE L. MAJETTE, Georgia
    JON C. PORTER, Nevada					CHRIS VAN HOLLEN, Maryland
    JOHN KLINE, Minnesota					TIMOTHY J. RYAN, Ohio
    JOHN R. CARTER, Texas					TIMOTHY H. BISHOP, New York
    	MARILYN N. MUSGRAVE, Colorado
    	MARSHA BLACKBURN, Tennessee
    	PHIL GINGREY, Georgia
    	MAX BURNS, Georgia

               Paula Nowakowski, Chief of Staff
         John Lawrence, Minority Staff Director

                            SUBCOMMITTEE ON EDUCATION REFORM
                         MICHAEL N. CASTLE, Delaware, Chairman

    TOM OSBORNE, Nebraska, Vice Chairman				LYNN C. WOOLSEY, California
    JAMES C. GREENWOOD, Pennsylvania				SUSAN A. DAVIS, California
    FRED UPTON, Michigan					DANNY K. DAVIS, Illinois
    VERNON J. EHLERS, Michigan					ED CASE, Hawaii
    JIM DeMINT, South Carolina					RAU?L GRIJALVA, Arizona
    JUDY BIGGERT, Illinois					RON KIND, Wisconsin
    TODD RUSSELL PLATTS, Pennsylvania				DENNIS J. KUCINICH, Ohio
    RIC KELLER, Florida					CHRIS VAN HOLLEN, Maryland
    JOE WILSON, South Carolina					DENISE L. MAJETTE, Georgia
    MARILYN N. MUSGRAVE, Colorado

                              TABLE OF CONTENTS

    OPENING STATEMENT OF CHAIRMAN MICHAEL N. CASTLE, SUBCOMMITTEE ON
    EDUCATION REFORM, COMMITTEE ON EDUCATION AND THE WORKFORCE, U.S.
    HOUSE OF REPRESENATIVES, WASHINGTON, D.C.	1

    OPENING STATEMENT OF RANKING MEMBER LYNN C. WOOLSEY,
    SUBCOMMITTEE ON EDUCATION REFORM, COMMITTEE ON EDUCATION AND THE
    WORKFORCE, U.S. HOUSE OF REPRESENATIVES, WASHINGTON, D.C.	3

    STATEMENT OF HON. KATHERINE BRYSON, STATE REPRESENTATIVE, UTAH
    HOUSE OF REPRESENTATIVES, OREM, UTAH.	5

    STATEMENT OF WILLIAM CAREY, M.D., DIRECTOR OF BEHAVIORAL PEDIATRICS,
    CHILDREN'S HOSPITAL OF PHILADELPHIA, PHILADELPHIA, PENNSYLVANIA	6

    STATEMENT OF LANCE CLAWSON, PRIVATE PSYCHIATRIST, CABIN JOHN,
    MARYLAND.	8

    STATEMENT OF REPRESENATIVE MAX BURNS, COMMITTEE ON EDUCATION AND
    THE WORKFORCE, U.S. HOUSE OF REPRESENATIVES, WASHINGTON, D.C.	15

    APPENDIX A - WRITTEN OPENING STATEMENT OF CHAIRMAN MICHAEL N.
    CASTLE, SUBCOMMITTEE ON EDUCATION REFORM, COMMITTEE ON EDUCATION
    AND THE WORKFORCE, U.S. HOUSE OF REPRESENATIVES, WASHINGTON, D.C.	33

    APPENDIX B - WRITTEN OPENING STATEMENT OF RANKING MEMBER LYNN C.
    WOOLSEY, SUBCOMMITTEE ON EDUCATION REFORM, COMMITTEE ON
    EDUCATION AND THE WORKFORCE, U.S. HOUSE OF REPRESENATIVES,
    WASHINGTON, D.C.	37

    APPENDIX C - WRITTEN STATEMENT OF HON. KATHERINE BRYSON, STATE
    REPRESENTATIVE, UTAH HOUSE OF REPRESENTATIVES, OREM, UTAH.	41

    APPENDIX D - WRITTEN STATEMENT OF DR. WILLIAM CAREY, M.D., DIRECTOR
    OF BEHAVIORAL PEDIATRICS, CHILDREN'S HOSPITAL OF PHILADELPHIA,
    PHILADELPHIA, PENNSYLVANIA.	53

    APPENDIX E - WRITTEN STATEMENT OF DR.  LANCE CLAWSON, PRIVATE
    PSYCHIATRIST, CABIN JOHN, MARYLAND.	59

    APPENDIX F  - WRITTEN STATEMENT OF REPRESENTATIVE MAX BURNS,
    COMMITTEE ON EDUCATION AND THE WORKFORCE, U.S. HOUSE OF
    REPRESENATIVES, WASHINGTON, D.C.	79

    APPENDIX G - WRITTEN STATEMENT FROM AUDREY SPOLARICH, CHAIR,
    COALITION FOR CHILDREN'S HEALTH SUBMITTED FOR THE RECORD BY
    REPRESENTATIVE CHIS VANHOLLEN, SUBCOMMITTEE ON EDUCATION REFORM,
    COMMITTEE ON EDUCATION AND THE WORKFORCE, U.S. HOUSE OF
    REPRESENATIVES, WASHINGTON, D.C.	83

    APPENDIX H - WRITTEN STATEMENT BY DR. KAREN EFFREM SUBMITTED FOR
    THE RECORD BY REPRESENTATIVE MARILYN MUSGRAVE, SUBCOMMITTEE ON
    EDUCATION REFORM, COMMITTEE ON EDUCATION AND THE WORKFORCE, U.S.
    HOUSE OF REPRESENATIVES, WASHINGTON, D.C.	115

    APPENDIX I  - WRITTEN STATEMENTS FROM THE NATIONAL MENTAL HEALTH
    ASSOCIATION SUBMITTED FOR THE RECORD BY RANKING MEMBER LYNN C.
    WOOLSEY, SUBCOMMITTEE ON EDUCATION REFORM, COMMITTEE ON
    EDUCATION AND THE WORKFORCE, U.S. HOUSE OF REPRESENATIVES,
    WASHINGTON, D.C.	129

    APPENDIX J  - WRITTEN CORRESPONDENCE FROM UTAH CONSTITUENTS
    SUBMITTED FOR THE RECORD BY HON. KATHERINE BRYSON, STATE
    REPRESENTATIVE, UTAH HOUSE OF REPRESENTATIVES, OREM, UTAH.	137

    Table of Indexes	144

              PROTECTING CHILDREN: THE USE OF MEDICATION IN OUR NATION'S

               SCHOOLS AND H.R. 170, CHILD MEDICATION SAFETY ACT OF 2003
            ______________________________________________________________

                                 TUESDAY, MAY 6, 2003

                              HOUSE OF REPRESENTATIVES,

                           SUBCOMMITTEE ON EDUCATION REFORM,

                       COMMITTEE ON EDUCATION AND THE WORKFORCE

                                   WASHINGTON, D.C.

    	The subcommittee met, pursuant to call, at 2:07 p.m., in Room 2175, Rayburn House Office
    Building, Hon. Mike Castle [chairman of the subcommittee] presiding.

    	Present:  Representatives Castle, Wilson, Musgrave, Woolsey, Mrs. Davis of California,
    Case, Kucinich, Van Hollen, and Majette.

    	Also Present: Representative Burns.

    	Staff Present:  David Cleary, Professional Staff Member; Kevin Frank, Professional Staff
    Member; Melanie Looney, Professional Staff Member; Krisann Pearce, Deputy Director of
    Education and Human Resources Policy; Liz Wheel, Legislative Assistant; Deborah Samantar,
    Committee Clerk/Intern Coordinator; Joe Novotny, Minority Staff Assistant/Education; Lynda
    Theil, Minority Legislative Associate/Education; and Ann Owens, Minority Clerk

    OPENING STATEMENT OF CHAIRMAN MICHAEL N. CASTLE,
    SUBCOMMITTEE ON EDUCATION REFORM, COMMITTEE ON
    EDUCATION AND THE WORKFORCE, U.S. HOUSE OF
    REPRESENATIVES, WASHINGTON, D.C.

    Chairman Castle  XE "Chairman Castle"  .  A quorum being present, the Subcommittee on
    Education Reform and the Workforce will come to order.

    	We are meeting today to hear testimony on "Protecting Children, the Use of Medication in
    Our Nation's Schools, and H.R. 1170, Child Medication Safety Act of 2003."

    	Under committee rule 12(b), opening statements are limited to the chairman and the ranking
    minority member of the subcommittee.  Therefore, if other members have statements, they may be
    included in the hearing record.

    	With that, I ask unanimous consent for the hearing record to remain open 14 days to allow
    members' statements and other extraneous material referenced during the hearing to be submitted in
    the official hearing record.  Without objection, so ordered.

    	Let me say good afternoon to the witnesses, and let me begin by welcoming our guests,
    witnesses, and members of the committee.  Thank you all for being here today.  I appreciate the
    opportunity to discuss the Child Medication Safety Act and look forward to your comments and
    recommendations.

    On September 29, 2000, the Committee on Education and the Workforce held a hearing
    entitled "Behavioral Drugs in Schools: Questions and Concerns."  Witnesses testified about the use
    of psychotropic drugs by youth.  In September of 2002, the House Committee on Government
    Reform held a hearing to explore the use of psychotropic drugs in our Nation's schools.  They
    found that in many cases, parents are being required by school officials to place their child on a
    psychotropic medication such as Ritalin or Adderall to allow them to remain in the classroom.
    Psychotropic drugs, when prescribed and monitored by a licensed medical practitioner, can be
    helpful for individuals properly diagnosed with attention deficit disorder (ADD) or attention
    deficit-hyperactivity disorder (ADHD).

    	These medications can help to control the symptoms of their disease so that these
    individuals can function.  However, these drugs have the potential for serious harm and abuse.
    They are listed on schedule 2 of the Controlled Substances Act.  Drugs are placed on schedule 2
    when the drug has a high potential for abuse or may lead to severe psychological or physical
    dependence.

    	School is an important source of information for families, and we encourage an open line of
    communication between schools and families.  Parents, however, should never be forced to decide
    between getting their child into a school and keeping their child off of potentially harmful drugs.
    School personnel should never presume to know the medication needs of a child.  Only medical
    doctors have the ability to determine if a prescription for a psychotropic drug is physically
    appropriate for a child.

    	To address the significant problem, my colleague on this committee, who will be here with
    us shortly, Representative Max Burns of Georgia introduced H.R. 1170, the Child Medication
    Safety Act of 2003.  The goal of this Act is straightforward.  It would require states to establish
    policies and procedures prohibiting school personnel from requiring a child to take medication in
    order to attend school.  This would prevent parents from being forced into making decisions about
    their child's health under duress from school officials.

    	We look forward today to hearing from our witnesses about the benefits and dangers of
    psychotropic drugs and about the efforts by parents and state legislators to address the coercion
    issue.

    WRITTEN OPENING STATEMENT OF CHAIRMAN MICHAEL N. CASTLE,
    SUBCOMMITTEE ON EDUCATION REFORM, COMMITTEE ON EDUCATION AND THE
    WORKFORCE, U.S. HOUSE OF REPRESENATIVES, WASHINGTON, D.C. - APPENDIX A

    Chairman Castle  XE "Chairman Castle"  .  With that, I yield to my colleague from
    California, Ms. Woolsey, for any, whatever opening statement she wishes to make.

    OPENING STATEMENT OF RANKING MEMBER LYNN C. WOOLSEY,
    SUBCOMMITTEE ON EDUCATION REFORM, COMMITTEE ON
    EDUCATION AND THE WORKFORCE, U.S. HOUSE OF
    REPRESENATIVES, WASHINGTON, D.C.

    Ms. Woolsey  XE "Ms. Woolsey"  .  Thank you, Mr. Chairman.  I said before when the subject
    of psychotropic drugs, particularly the subject of Ritalin, has come up before this committee, that I
    raised four children, and I am absolutely sure that their schools would have suggested Ritalin for
    them if they were in school today, and I am as just as certain that I would not have taken the bait,
    because I knew the difference then and I know the difference now, and this is what I think we need
    to be talking about today, is the difference between boys behaving badly versus a serious problem,
    versus behavior modification.  And that is what I hope we are going to be talking about.

    	I have concerns, because I think that we are blurring the line between the behavior of an
    active high-spirited child and child with a disability, and this is not to suggest that attention deficit
    hyperactivity disorder, ADHD, is not a very real disability for many children.  ADHD robs so
    many children of their parents and their parents of the pleasures of child and the pleasures of
    family, and children are labeled as bad for actions they can't control.  The parents find themselves
    frustrated and often angry, and that is not a way to feel about your kids as you are raising them.

    	Properly prescribed and coupled with other therapies, Ritalin and other psychotropic - it has
    enabled thousands of children with ADHD to achieve at school, to bond with their family and to
    feel better at home.  The success of Ritalin has been well documented, and it is an important
    resource that medical professions should be able to consider when planning treatment for a child
    with ADHD.

    	However, the growing increase in the manufacture and prescription of these drugs is a cause
    for concern, as far as I am concerned.

    	The decision to treat a child with any drug, but certainly a stimulant like Ritalin, must be
    made very carefully and only after comprehensive evaluations and diagnosis.  It is crucial that
    parents be well informed about the drug, both its possible successes and its possible side effects.  If
    it is being considered for their child.  And it goes without saying that parents should have the final
    word in deciding whether or not their child takes a drug like Ritalin.

    	I look forward to your discussion and hearing from you, because you are a panel of experts,
    and we want to hear what you have to say about this.  Thank you very much.

    WRITTEN OPENING STATEMENT OF RANKING MEMBER LYNN C. WOOLSEY,
    SUBCOMMITTEE ON EDUCATION REFORM, COMMITTEE ON EDUCATION AND THE
    WORKFORCE, U.S. HOUSE OF REPRESENATIVES, WASHINGTON, D.C. - APPENDIX B

    Chairman Castle  XE "Chairman Castle"  .  Thank you, Ms. Woolsey.

    	We have a very distinguished panel of witnesses before us, and I thank them for coming
    today.

    	The first witness is the Honorable Katherine Bryson.  Ms. Bryson currently serves as the
    state representative for the 60th district of the Utah House of Representatives.  I come from
    Delaware, so we do not have 60 of anything in Delaware.  That number impresses me.  She is the
    chairwoman of the Business and Labor Committee and a member of both the Judiciary Committee
    and the Higher Education Appropriations Subcommittee.  Additionally, Ms. Bryson is the sponsor
    of H.B. 123, a bill to prohibit school personnel from making certain medical recommendations for
    a child, including the use of psychotropic drugs.  She is also the state vice chair for the American
    Legislative Exchange Counsel and a member of the National Federation of Women Legislators.

    	The second witness will be Dr. William B. Carey.  Dr. Carey is the director of behavioral
    pediatrics at the Children's Hospital of Philadelphia.  Prior to his current position, he served as a
    clinical professor of pediatrics at the University of Pennsylvania School of Medicine.  Dr. Carey is
    also the author of several books, including Developmental Behavioral Pediatrics, Understanding
    Your Child's Temperament, and Coping With Children's Temperament, a Guide for Professionals.

    	Our final witness today will be Dr. Lance D. Clawson.  Dr. Clawson is currently a private
    psychiatrist in Cabin John, Maryland.  Additionally, he serves on the D.C. Commission on Mental
    Health in Washington, D.C.  Prior to his current position, Dr. Clawson worked as a staff
    psychiatrist at the Walter Reed Army Medical Center in Washington, D.C.  He is the recipient of
    several awards, including the American Academy of Child and Adolescent Psychiatry Presidential
    Scholar Award, and the Washington Psychiatric Society Award For Outstanding Services.

    	Before the witnesses begin their testimony, I would like to remind our members who are
    here today that we will be asking questions after the entire panel has testified.  In addition,
    committee rule 2 imposes a 5-minute limit on all questions.

    	Before we begin with Ms. Bryson, the light system you have in front of you will show
    green for 4 minutes, yellow for 1 minute, and red at the 5-minute mark.  I think you can probably
    figure out what all that means, without further explanation.  But essentially when you see the red, if
    you could finish winding up, that would be wonderful.

    	And then when the witnesses, or all 3 of you are through testifying, we will go to the
    various members up here, and the exchange is also measured by 5 minutes, including questions and
    answers, just so you understand basically what the rules are.

    	With that, we will start with Ms. Bryson.  Thank you for being here.

    STATEMENT OF HON. KATHERINE BRYSON, STATE
    REPRESENTATIVE, UTAH HOUSE OF REPRESENTATIVES, OREM,
    UTAH.

    Ms. Bryson  XE "Ms. Bryson"  .  Thank you.  Thank you so much for the opportunity to come
    before you this afternoon, and thank you for the opportunity to speak about this grave national
    issue.  Let me start by commending the committee for recognizing that the coercive use of
    psychotropic drugs on children is not a few isolated incidents, but is actually impacting hundreds, if
    not thousands, of families across America.

    	While Utah was once the Ritalin capital of America, this schedule 2 drug seems to have
    dropped to a national average level now in our state.  However, in the wake of raised public
    awareness about the risks of Ritalin, other stimulants like Adderall and the amphetamine Dexedrine
    are deluging the child psychiatric market in its place.  In fact, Adderall now comprises 32 percent
    of the national stimulant market, with 6.1 million prescriptions in the year 2000, and 248 million in
    sales.  Yet this drug has already been cited in a North Dakota criminal judgment in 1999, where a
    young father was not held criminally responsible for the murder of his 5-week-old daughter,
    because he was in a psychotic state caused by Adderall.  Psychiatrists testified that the drug
    induced the psychotic state causing delusions.

    	There are other drugs not covered by schedule 2 of the Controlled Substances Act that are
    also forced onto children, including Cylert, a schedule 4 drug, and antidepressants that are not
    scheduled at all.

    	Zoloft and Paxil are among the group of new antidepressants that, in 1999, were prescribed
    to 1.7 million children.  In fact, between 1995 and 1999, there was a 19-fold increase in 2-year-olds
    to 19-year-olds prescribed these drugs.  A Fox National News series last November found that a
    person taking Paxil is 8 times more likely to attempt and commit suicide than if taking a placebo.

    	More than half of the last 12 school shootings have been committed by teenagers who were
    taking psychotropic drugs.

    	Meanwhile, school personnel faced with children who often have not been properly taught
    to read, who may be coming to school on a breakfast of sugar or no breakfast at all, who could be
    affected by lead, mercury or other toxic substances, or a plethora of explainable reasons, are
    assessing them in the classroom as having a learning disorder or attention deficit hyperactivity
    disorder.

    	From here, parents are being coerced into drugging their children with threats of the child's
    expulsion or charges of medical neglect by child protective services against the parents who refuse
    to give or take their child off a psychotropic drug.  Parents are losing their right to choose.  They
    are being told that ADHD is a neurobiological disorder, when even the Surgeon General's 1999
    report on mental health cannot confirm this.

    	They are being denied access to tutors or additional education services for the sake of a
    quick-fix drug like Ritalin that some studies say is more potent than cocaine.

    	Often once the child is medicated, the various side effects associated with the drug and
    which I have found were too often not disclosed to the parents when they were first given the
    prescription, become apparent.  The child could have difficulty sleeping or eating.  They may have
    stomach problems and may become irritable.  Worse yet, when withdrawing from the drug, he or
    she may become so emotionally disturbed as to feel suicidal.

    	While the parents may want to take the child off the drug at this point, they are too afraid of
    the implied consequences and feel powerless.

    	While we spend over $50 billion on the war on drugs, we are allowing our teachers to be
    used as mental health clinicians, diagnosing learning problems as disorders and diseases and
    forcing this belief on parents.  I realize the gravity of the situation dealing with Ritalin after being
    contacted by many parents in Utah and hearing what I can only describe as horror stories, some of
    which I have attached to my written testimony.  I ran a bill in 2002 to prohibit school personnel
    from pressuring parents into drugging their children.  That bill actually passed by an overwhelming
    majority of 89, but tragically the governor of our state failed to listen to the needs of our families
    and vetoed the bill.  Thus, condoning the coercive drugging of Utah's future generation.

    	Unless we as legislators do something about this, we become accomplices.  I support H.R.
    1170, but I have to say that I believe the committee would be remiss if they did not broaden it to
    include all prescribed psychotropic substances.  Again, thank you for allowing me to come
    forward.

    Chairman Castle  XE "Chairman Castle"  .  Thank you, Ms. Bryson.  We appreciate your
    testimony.

    WRITTEN STATEMENT OF HON. KATHERINE BRYSON, STATE REPRESENTATIVE,
    UTAH HOUSE OF REPRESENTATIVES, OREM, UTAH - APPENDIX C

    Chairman Castle  XE "Chairman Castle"  .  And we will now turn to Dr. Carey.
    STATEMENT OF WILLIAM CAREY, M.D., DIRECTOR OF BEHAVIORAL
    PEDIATRICS, CHILDREN'S HOSPITAL OF PHILADELPHIA,
    PHILADELPHIA, PENNSYLVANIA

    Dr. Carey  XE "Dr. Carey"  .  Mr. Chairman, ladies and gentlemen, in the last two decades, the
    United states has experienced a great increase in the diagnosis of attention deficit hyperactivity
    disorder, or ADHD, and its treatment with stimulants.

    	Not only child health professionals, but now also a wide variety of unqualified persons such
    as preschool teachers and acquaintances are freely offering the diagnosis and confidently urging
    parents to accept their judgment to obtain drug treatment such as methylphenidate or Ritalin for the
    child.  If the physician formally applies a label, educational and governmental authorities
    sometimes attempt to coerce parents into accepting the verdict and giving the medication or face
    the possibility of exclusion of the child from the school or being judged unfit parents.

    	This chaotic situation urgently requires intervention at several levels, including the Federal
    Government.

    	One should acknowledge at the outset that virtually all well-informed observers agree that
    about 1 to 2 percent of the child population are so perversely overactive or inattentive that they are
    very difficult for anyone to manage.  And although the cause of their problems is often not clear,
    they are likely to perform better with medication as a part of their management.  However, why are
    up to 17 percent or more children being given this label, and why is 80 percent of the world's
    methylphenidate being fed to American children?

    	Several reasons.  In the first place, the diagnosis of ADHD is very impressionistic and
    highly subjective, making it easy to include a broad variety of children.

    	For example, the component symptoms such as often talks excessively are not clearly
    different from normal.  There is no confirmatory laboratory tests, nor proof that the behaviors are in
    fact due to brain malfunction.  The diagnosis is usually made at the practical level by vaguely
    worded brief questionnaires.

    	Secondly, even if one accepts the current definition, there is abundant evidence that it is not
    being applied rigorously at the practical level.  Two large surveys of medical practice in the leading
    psychiatric and pediatric journals have established that about 60 percent of the time medical
    practitioners are not using the established criteria.

    	Thirdly, contrary to the popular notion, the stimulants being prescribed today are not
    specific for ADHD.  Improved behavior when taking them is not proof of the diagnosis.  Ritalin
    would make any of us function better, you and me.

    	I am one of a group of pediatric moderates who say that both the radical critics who speak
    of conspiracies and fraud and the American Psychiatric Association's diagnostic system are wrong.
    We believe that these children do have real problems, but that the diagnosis and management is not
    so simple as it is presently being proposed by the association's official manual and management
    guidelines.

    	There is no easy answer to this chaotic situation.  The main elements of a solution would
    be, one, a better diagnostic system; two, better research; three, better education of professionals and
    the public, and as to the range of normal behavior; four, better individualized evaluations of
    children; five, better treatment with greater reliance on psychosocial and educational interventions;
    six, better monitoring of aggressive advertising by the drug companies; and number seven, better
    reimbursement schemes so that physicians can be allowed to take the time necessary to do adequate
    evaluations.

    	The appropriate professional groups must solve the first five of these steps, but the last two,
    drug companies and medical insurance, are within the proper range of the federal government.

    	To these measures, I add the need for national legislation to prevent educational and
    governmental officials at any level from requiring parents to accept the diagnosis and use drug
    treatment for fear of legal actions of exclusions from school or child protective agency
    interventions for your special consideration today.  My reasons are simple.  The definition of
    ADHD is extremely vague.  The application of it in medical practice today is inadequately
    disciplined.  And the current treatment is nonspecific and noncurative.

    	For parents to be penalized in any way for skepticism and noncompliance would be
    medically unsound and ethically unsupportable.  Thank you.

    Chairman Castle  XE "Chairman Castle"  .  Thank you, Dr. Carey.

    WRITTEN STATEMENT OF WILLIAM CAREY, M.D., DIRECTOR OF BEHAVIORAL
    PEDIATRICS, CHILDREN'S HOSPITAL OF PHILADELPHIA, PHILADELPHIA,
    PENNSYLVANIA - APPENDIX D

    Chairman Castle  XE "Chairman Castle"  .  Dr. Clawson.
    STATEMENT OF LANCE CLAWSON, PRIVATE PSYCHIATRIST, CABIN
    JOHN, MARYLAND.

    Dr. Clawson  XE "Dr. Clawson"  .  First of all, let me thank Chairman Castle for the
    opportunity to appear before the subcommittee.  My testimony today is on behalf of the American
    Academy of Child and Adolescent Psychiatry, or AACAP for short.  I ask that my written remarks
    be entered into the record.

    	The American Academy of Child and Adolescent Psychiatry is a national professional
    association representing 6,700 child and adolescent psychiatrists who are physicians with at least 5
    years of specialized training after medical school, emphasizing the diagnosis and treatment of
    mental illness in children and adolescents.  The AACAP is concerned about the effect of H.R.
    1170, legislation that was attached as an amendment to H.R. 1350, the Individuals With Disabilities
    Education Act.

    	This amendment requires schools to develop policies and procedures prohibiting school
    personnel from requiring that a child be placed on psychotropic medications as a condition of
    attending school.  Although there have been highly publicized and isolated events that cause us all
    concern, there is no reliable evidence that such practices regularly occur or that this is a pervasive
    problem.  Medication assessment and prescription is the exclusive role of a qualified medical
    professional, not school personnel.  The decision to include medication as part of the treatment plan
    for a child or adolescent with a mental illness should be a decision agreed to by parents and
    caregivers in close consultation with a qualified and trusted medical professional.

    	Schools are critically important, as they are a source of information for families about the
    children and their children's emotional and mental well being.  The importance of open
    communication between school professionals and families about the health and well being of
    students, and where indicated, the freedom to recommend a comprehensive medical evaluation
    cannot be overstated.

    	The AACAP is concerned about legislation that would restrict school professionals from
    communicating with families about legitimate mental health-related concerns.  While H.R. 1170
    does not explicitly prohibit communication between school personnel and families about mental
    health concerns, its stern enforcement provisions could cause school personnel to be fearful about
    communicating with families regarding a student's emotional or behavioral difficulties.

    	The more pressing issue as reported by the Surgeon General in 1999 is the unacceptably
    high number of children with mental illnesses that are not being diagnosed or treated.  The AACAP
    is concerned that H.R. 1350 may create a barrier for children and adolescents to treatment, and
    many of these children are identified in school settings.

    	As noted in the opening remarks, we are here today to talk about the identification,
    diagnosis, and treatment of childhood mental illnesses such as attention deficit hyperactivity
    disorder, or ADHD for short.

    	As a child and adolescent psychiatrist, when I think of ADHD, I think first to the faces of
    children and families that I have seen.  For instance, I think of an 8-year-old boy who is about to be
    left back in 2nd grade due to his disruptive behavior.  He has poor peer relationships, his
    schoolwork is very inconsistent, the teachers have labeled him difficult to control.  He has one
    other friend in school, and he is teased mercilessly by his peers.  He breaks down at home saying
    that he is stupid and no one likes him.  He is already convinced that he is bad and different, and
    with appropriate evaluation and treatment, this young man made a tremendous turnaround.

    	I am as reminded of a 15-year-old girl.  She is in 9th grade.  She has a measured IQ of 140.
    She is well liked.  She has never really had had to put out much effort in school, but here she is in
    9th grade.  She is starting to fail classes, overwhelmed trying to keep up, cannot take notes, and
    cannot keep her mind focused.  She is often getting her homework done and then forgetting to hand
    it in.  She is having trouble being organized.  She is anxious and depressed about her performance.
    Her parents are overwhelmed, and once again this individual with appropriate diagnosis an
    appropriate treatment intervention had a tremendous turnaround.

    	And finally, I think of a 42-year-old insurance broker who has been treated for depression
    and anxiety for years.  He was relieved and appreciative when he received an accurate diagnosis,
    but felt he had wasted 20 years of his life with these feelings of being ineffective.

    	So let me be very clear.  ADHD is not an easy diagnosis to make, and you cannot do it in 5,
    10, 15, or even 30 minutes, and it should not be taken lightly.  There is good research to show that
    this diagnosis occurs in approximately 5 percent of the child and adolescent population.
    Approximately 50 percent of these individuals maintain their symptoms into adulthood, and we
    have made a number of recommendations that are listed at the end of my testimony, and which you
    can refer questions to me later.

    	But I just want to underline that the research really demonstrates that it is really a minority
    of children that are being identified and being treated for this condition.  It varies between
    localities, but in general, there is an under diagnosis in treatment.

    	So in summary, let me emphasize that child psychiatric disorders including ADHD are very
    real and diagnosable illnesses that affect a lot of kids.  The good news is that they are treatable.  We
    cannot cure all the kids we see, but comprehensive individualized intervention can significantly
    reduce the extent to which their conditions interfere with their lives.  So we must free teachers and
    parents to collaborate freely in order for the early identification and appropriate evaluation and
    intervention with these children.  Thank you.

    WRITTEN STATEMENT OF LANCE CLAWSON, PRIVATE PSYCHIATRIST, CABIN JOHN,
    MARYLAND. - APPENDIX E

    Chairman Castle  XE "Chairman Castle"  .  Well, let me thank all of the witnesses.  You
    raised many strong questions that we need to address or are being addressed, perhaps by legislation
    that is being introduced in states and before us here.  But obviously we understand all this is
    problematical, too.  So perhaps we can shed some light on it with a few questions here.

    	Let me start the questions.  I will yield myself 5 minutes, and I will start with Ms. Bryson.
    Do you think that your own activities have made a difference in terms of what is happening in Utah
    with respect to the schools being a little more reluctant to make it a condition that students must
    have psychotropic-type drugs in order to come back to school?  Do you find from your study of this
    and you have studied it more extensively than I have, that there are pockets where there is a
    problem that is abused much more than it is in other areas, such as certain school districts or
    administrators?  What can you tell me about those subjects?

    Ms. Bryson  XE "Ms. Bryson"  .  Thank you for the opportunity to address your questions.
    First of all, maybe I will start with your latter question having to do with pockets.  I believe that
    there are some within our state.  I know it was brought to my attention that one school in particular
    had a high number of students who were all on Ritalin.  There were classrooms where apparently
    there was some agreement that 80 percent of the kids in the class in a fourth grade class needed to
    all be on Ritalin or a psychotropic drug.  That is very frightening.

    	I come from a state where a quarter of our population is children.  There have absolutely
    been situations within the state of Utah.  The legislation that I was involved with in the year 2002
    brought the issue to the forefront, and I know that our school and our board of education, has taken
    a few very minimal steps with regard to this.

    	I will say that while I was working on the legislation, I did hear from several school districts
    that were looking at this and of course had some concerns, and we discussed this back and forth.  I
    think that one in particular probably led the charge, but we will be meeting with some of our
    administrative Rules Committees in the next few months trying to look at what has been introduced
    by the school administration.

    Chairman Castle  XE "Chairman Castle"  .  Thank you.  I could go further with all that, but I
    want to ask the others a question.  I was going to ask you separate questions, but I am going to try
    and combine this perhaps into one.  I am a little concerned about what role the teachers and the
    schools play in this.  Our concern with legislation obviously is that it is a feeling that the schools
    are sort of dictating the need to get medical help.  I assume in each instance that is happening.
    They go to a doctor and get the prescription, that is the way it actually works.  And I agree with
    what you said, Dr. Carey, that we do need to train our teachers more thoroughly, especially to make
    sure they are not inappropriately identifying children who have disabilities.

    	But I am concerned about that.  We have enough trouble training our teachers to teach
    math, English or whatever the subject matter may be.  There is a lot of discussion about that.  They
    have to deal with children with a variety of disabilities, some of which are not the disabilities that
    we are talking about here.  They have just the normal social problems to deal with as well.  And I
    am not sure exactly what responsibility we should be giving to these teachers.  Dr. Clawson, is it a
    teacher's responsibility to or is it the responsibility of the parents or perhaps everyone together?

    	But I do not want to shift too much of the burden to the schools, and I am not sure that
    professionally they are capable of that.  What additional training would they need in order to do
    this?  I am not sure how much more professional training teachers can stand out there.  So that is a
    series of questions inherent in my sort of statement if you could take a stab at it, both of you,
    please.

    Dr. Carey  XE "Dr. Carey"  .  I find that teachers, in spite of all their training, know very little
    about the normal range of behavior.  I think that this charge could be levied against some of my
    fellow medical practitioners as well.  I spent 35 years studying normal term remit differences, and I
    know that everybody has them, that some of them are hard to get along with, and that only rarely
    do they indicate that there is something wrong with the brain.

    	Most kids who are active are just active and there is nothing wrong with them.  Most kids
    who are inattentive are just less attentive than average.  That does not mean that you have a
    pathological difference just because you are a little bit off of the mean.  And teachers need to
    appreciate that just because a kid is annoying doesn't mean that you have to ship them off to a
    physician with a request for medication.  I am covering an awful lot of material in just a few words,
    but to sum it up, I would say one thing that needs to happen in teacher education is that they need
    to have a greater appreciation of normal variation of kids' behavior and to know that there are some
    normal behavioral traits of stubbornness, shyness, loudness and so on which are annoying, but
    which are not abnormal and do not deserve to be treated with medication.

    Chairman Castle  XE "Chairman Castle"  .  Dr. Clawson, the same question to you, maybe
    with some emphasis on just what responsibility teachers and administrators should have in this
    circumstance too.

    Dr. Clawson  XE "Dr. Clawson"  .  Well, my sense is that it is not the purview of educators to
    recommend medication.  They know that.  That is actually the job of a licensed and trained
    physician with at least a reasonable amount of mental health expertise.  Teachers are generally
    good at recognizing when they are having difficulty with a child.  If that is the case, then the typical
    process is that they may discuss it with their principal, the school counselor, and the child's parents
    to come to some kind of collaborative conclusion that perhaps the problems are severe enough or
    the usual methods that they have attempted to rectify the problem if they have not been effective,
    so they would refer for a medical evaluation and a mental health evaluation.

    	That is very appropriate.  What happens from that point on has nothing to do with the
    school.  The reality is it is the physician's job in collaboration with the patient and the patient's
    parents with information provided by the school as well as multiple other sources, including
    thorough medical evaluation, laboratories, studies, et cetera, to determine whether medication
    might be helpful.

    	There are cases that come to me, which I do not prescribe medication.  I may suggest
    further classroom interventions, even though I am an individual that does prescribe medication.  It
    is not up to the school to decide that, and it is also up to the physician if the school is insisting on
    medication.  It is up to the physician to advocate for the patient to do what is appropriate, and
    therefore my sense also is that many times there is an over reliance on medication when there is an
    undersupply of mental health professionals, and we have a terrible undersupply of qualified mental
    health professionals in this country to assess children.  So many pediatricians or family
    practitioners that do not have a significant mental health background are being sent; saying this
    child is out of control, do something.

    Chairman Castle  XE "Chairman Castle"  .  My time is up, but I do want to ask you a question
    to understand where you are coming from vis-�-vis what we do, which is creating laws here.  Mr.
    Burns has joined us.   What is your position on this legislation, which is before us?  It basically
    says that school personnel at some level cannot absolutely rule that the kid cannot attend the school
    unless the child is receiving medical treatment.  Do you support, oppose, or remain neutral with
    respect to this?

    Dr. Clawson  XE "Dr. Clawson"  .  Conceptually it is an interesting idea, because what we have
    been talking about, at least the other witnesses have testified to abuses.   However, I am talking
    about the general need to enhance collaboration between families and schools which is shown to -

    Chairman Castle  XE "Chairman Castle"  .  I do not have a problem with that.  I -

    Dr. Clawson  XE "Dr. Clawson"  .  Once we start sanctioning schools for bringing up their
    concerns, we could be creating further barriers.  That is -

    Chairman Castle  XE "Chairman Castle"  .  But they are not bringing up their concerns.  They
    are making an absolute barrier to the child attending the school, and that is the question.  I have the
    same question.

    Dr. Clawson  XE "Dr. Clawson"  .  I have seen no evidence to show that this is pervasive.  I do
    not doubt that there are situations where this has happened, but that is a miscarriage of the
    educational system.  I myself have been involved in cases where the school wants the child on
    medication.  The recommendation is the child should be on medication after a thorough evaluation
    and the parents continue to refuse, and so that is dealt with in an open forum in terms of how to
    provide the child services, even though they are not on medication.  And they are potentially not
    learning or even posing a danger.

    Chairman Castle  XE "Chairman Castle"  .  Maybe I should drop out of this and let you and
    Ms. Bryson debate each other about how pervasive it really is.

    Dr. Clawson  XE "Dr. Clawson"  .  I could not say that, but I have seen nothing in the
    literature.

    Chairman Castle  XE "Chairman Castle"  .  I believe I am going to - oh, I am sorry.  Dr.
    Carey, did you want to comment on that?

    Dr. Carey  XE "Dr. Carey"  .  Perhaps we can say that the school has the prerogative to exclude
    a child if he or she is so disruptive that it is destroying the classroom proceedings, but they do not
    have the right to indicate what should be done about it.  That is fairly clear.

    Chairman Castle  XE "Chairman Castle"  .  That is helpful.

    	Let me, at this time; yield 5 minutes to Mr. Case.

    Mr. Case  XE "Mr. Case"  .  Thank you, Chair.  I would like to stay with the same train of
    thought, because I do have some of the same concerns.  I preface my remarks by saying that I
    cosponsored this legislation with my colleague, Mr. Burns, because I share his belief that perhaps
    there are situations out there that represent abuse.

    	Dr. Clawson, you are probably as good a person to ask as any.  We have an obligation
    under IDEA to provide a free and appropriate education.  That has been interpreted rightly to
    require that children with special needs be accommodated in the regular classroom, not shunted to
    the side.

    	How frequent is it that a child with special needs who is diagnosed with a condition that
    Ritalin could address satisfactorily, no question about it, does not take that drug, could not be
    reasonably accommodated in the regular classroom?  That is the question I have.  I guess the
    question that I am really putting to you, or thinking out loud about and inviting any of your
    comment about, is: is an absolute prohibition really the right place for us to go?  Are there
    situations where we do want to say that we cannot accommodate, "we" being the school, in
    conjunction with the medical providers and under the diagnosis of the medical provider, what we
    do not believe that the child can be accommodated in the regular classroom without some
    medication?  That is the question, I think.

    Dr. Clawson  XE "Dr. Clawson"  .  In my experience, that is a frequent occurrence.  Many
    times medication allows the child to be in what IDEA would refer to as the least restrictive
    environment.  And the aim would be the regular classroom.

    	I do not know if you have been in many elementary school classrooms recently, but they
    tend to be very large, and the teachers really have a difficult time managing them.  To put children
    that are very disruptive in a regular classroom tends to disrupt the educational process for all the
    children.

    	So I would say there are probably many cases that I run into on a weekly basis where the
    judicious application of psychotropic medication after a thorough medical and psychiatric
    evaluation does help the child function within the regular education setting, or within the least
    restrictive environment.

    Mr. Case  XE "Mr. Case"  .  How do we accommodate that basic thought - which I think makes
    a lot of common sense, with the concern that, in essence, we are overmedicating in order to really
    cop out, if I can put it that way, of the need to accommodate a child with special needs in a way
    that takes care of his or her rights under federal law?  What the bill says as introduced at least, and
    we can obviously change it, is "any school personnel".  I suppose that means any medical doctor on
    staff rather than teachers, but is that the place to do that.  I assume you have worked with special
    needs children.

    	Is the place to do that in the formulation of the IEP, that we could say in the context of that
    IEP that if there is that situation where a child can really only reasonably be accommodated in a
    classroom with some use of drugs refuses that medication with his or her parents' input, that that
    could be a condition of not being accommodated in the regular classroom and really retreated
    outside the classroom?

    Dr. Clawson  XE "Dr. Clawson"  .  Yeah.  I think that is -

    Mr. Case  XE "Mr. Case"  .  And be subject to the full range of the ability of the parents to sue
    and have a due process hearing, if that is what it took - .

    Dr. Clawson  XE "Dr. Clawson"  .  Those rights are in place now and that is a process I have
    been involved in before in terms of children requiring more restrictive environments because the
    family is not in support of medication.

    Mr. Case  XE "Mr. Case"  .  Is that process working?

    Dr. Clawson  XE "Dr. Clawson"  .  In my experience it is.  It can be fairly contentious, and the
    parents have to be fairly motivated or tough to resist the school saying, they would like to have
    your child in the regular class or this type of class, but we really cannot manage them.

    Mr. Case  XE "Mr. Case"  .  So perhaps what we are really getting at in the context of this
    legislation is a situation where the parents might not be quite as involved in the IEP where the
    schools possibly are overmedicating or are too quick to medicate, if I can put it that way.

    Dr. Clawson  XE "Dr. Clawson"  .  Well, the schools are not the ones medicating.

    Mr. Case  XE "Mr. Case"  .  I understand that, but you have got the bill saying "school
    personnel".

    Dr. Clawson  XE "Dr. Clawson"  .  Schools do not medicate.  They can mention medication,
    but the most a school can legally or realistically do is encourage the family to take the child to a
    physician for an evaluation.  We hope at that point that the physician engages in a comprehensive
    medical psychiatric assessment to determine the need for psychotropic medication.

    	My concern is with this amendment.   Even though it might sanction those individuals who
    are abusing it, this legislation could throw a pall over the entire educational system.  Teachers feel
    tremendous pressure to try and accommodate children in the regular classroom.  They feel pressure
    to do that and yet they are many times overwhelmed and are already worried enough about being
    sued.

    	When you go in these IEP meetings, the schools are constantly on the defensive.  We throw
    in more laws, and they are only going to be more concerned.  So basically, the schools will cease to
    be helpful, because they cannot say anything.  They have to remain extremely legalistic.  It is sad to
    see, because you lose that collaborative process between parent and school.  And all the research
    shows that when you have a good family school collaboration, you have a better school.  Okay?

    	So the more the school is fearful of engaging the parents and expressing themselves freely,
    the more we are going to inhibit this collaboration, which is so necessary.

    	If we are taking this one-size-fits-all amendment and just tell everyone that they cannot say
    anything, then I think we are really kind of throwing the baby out with the bathwater on some level.

    Mr. Case  XE "Mr. Case"  .  Thank you very much.

    Chairman Castle  XE "Chairman Castle"  .  Thank you, Mr. Case.

    	We will now turn to Mr. Burns, who is the sponsor of the legislation.  I believe he has a
    statement, and we will yield to him for that and his questions.

    STATEMENT OF REPRESENATIVE MAX BURNS, COMMITTEE ON
    EDUCATION AND THE WORKFORCE, U.S. HOUSE OF
    REPRESENATIVES, WASHINGTON, D.C.

    Mr. Burns  XE "Mr. Burns"  .  Thank you, Mr. Chairman.  I appreciate the committee holding
    these hearings today.  I apologize for stepping in late, but I want to start with a statement and then
    have an opportunity to pose a few questions to the panel.

    	The Child Medication Safety Act of 2003, H.R. 1170, addresses a significant problem
    facing children and their parents throughout the nation.  Some schools unfortunately are requiring
    parents to place their child on drugs in order to attend school, and I think this is wrong.  No parent
    should ever be coerced by a teacher, principal, or other school official to place their child on a
    psychotropic drug.  No child should ever face the denial of educational services only because they
    are not taking a psychotropic drug.

    	Psychotropic drugs such as Ritalin, Adderall, or other drugs when carefully prescribed by a
    licensed medical practitioner and carefully monitored in the administration, can certainly help an
    individual with attention deficit disorder or attention deficit hyperactivity disorder, controlling
    symptoms of their disease so that they can function effectively.

    	These can be miracle drugs for many people, and when properly diagnosed and properly
    administered, many people benefit greatly from their use.  But for those who do not need these
    drugs, they can be harmful.  In several sad instances, children that have been placed on these drugs
    have died from complications arising from psychotropic drug use.  H.R. 1170 is not antischool.  It
    is not antiteacher.  It is not antimedication.  This bill is designed to be pro-children and pro-parents.

    	The legislation simply protects our children from unnecessary medication, and it provides
    the parents with the decision-making power that they should have for their children already.

    	I offered a modification of this bill as an amendment during the markup of H.R. 1350, the
    IDEA reauthorization.  This amendment was broadly supported in a bipartisan manner.  Because
    the amendment only applies to schools receiving special education funds, I am hopeful that this
    legislation will move as a stand-alone measure as well so that parents with children in all of our
    schools receiving federal funds can have the freedom to choose when their child should be
    medicated.

    	I thank my cosponsors for their support.  I urge the members of the committee to support
    this legislation as it works through, and I would like to again thank the chairman for holding the
    hearing today and thank the panel for their input.

    	I would like to ask Dr. Bryson to perhaps refresh my memory on the challenges in Utah.  Is
    this a pervasive problem?  Do you see this as pervasive?

    WRITTEN STATEMENT OF REPRESENATIVE MAX BURNS, COMMITTEE ON
    EDUCATION AND THE WORKFORCE, U.S. HOUSE OF REPRESENATIVES,
    WASHINGTON, D.C. - APPENDIX F

    Ms. Bryson  XE "Ms. Bryson"  .  Thank you.  And I wish it was, Doctor, but it isn't.  I do serve
    in the Legislature, but thank you.

    Mr. Burns  XE "Mr. Burns"  .  You sit with other doctors.  I thought perhaps.  I misspoke.

    Ms. Bryson  XE "Ms. Bryson"  .  Thank you.  I will tell you that running this legislation in the
    year 2002 was a real eye-opener, because I discovered that Utah was not alone.  There were a
    number of states, particularly in the eastern part of the United States, and neighboring states around
    me, including Colorado, Nevada, Arizona, and California, were all dealing with similar problems,
    where there was coercion felt by parents, that if they did not give these drugs to their children, their
    children would not be allowed in the classroom.

    	In our state we have what is called DCFS, the Division of Child and Family Services, and it
    was a condition of neglect if you did not give your child medication.

    	Now, in my state as well, I mentioned earlier that a fourth of our population are kids.  I am
    a mother of 6 children.  You label my oldest child Lisa with ADHD, and I cause a ruckus in my
    school.  Most likely, my other 5 children are going to suffer in school, and that is what is really sad
    in the state of Utah.  Once the child is labeled, then what is the recourse for the parent?  I mean,
    this is supposed to be parental rights, and what we were trying to do with some legislation was to
    ensure that the parents had the information.  By the way, they are the taxpayers.  They are the ones
    that support us in government in these offices, and we need to be aware that they have rights.
    These are their children.  And I believe that what we were trying to do was to ensure that they did.

    	Unfortunately, I mentioned earlier that our governor did not support that legislation,
    although it was unanimous in our House and our Senate.  But it is pervasive.  I believe that there
    are problems.  I believe that particularly young boys are being labeled, especially those that are
    rambunctious and anxious.  They do fidget in the classroom.  I have often suggested that those
    members of the Legislature in my state have every single one of these remarkable, what I would
    call qualities that may label them as ADHD.  I have often thought, yes, and you have to be
    aggressive to become a legislator.  So maybe that as well.

    	But in looking at all of this, it is a sad situation when we have to drug kids to teach them.  I
    taught school myself in California back in the mid 1970s.  I had kids who were in my little 5th
    grade class who were going out and being medicated at noon and coming back in the classroom,
    and they were literally what I would term zombies for the rest of the afternoon.  Now, that was not
    a situation where I could help meet their education needs.  They were in a position where they were
    not receptive.  They could not be receptive, and it was a wonderful classroom.  They were now
    compliant.  Yes, they were compliant, but were they teachable and were they learning anything?  I
    do not believe so.

    I believe it was a total disservice to them, and unfortunately, I have to say in defense of
    teachers, I think that this is a responsibility we should not be placing on them.  They are there to be
    teaching.  That is not what they went to school to learn.  I think all of us that were teaching school
    believed that we were coming there to give help to see young people succeed.  I do not believe that
    the intent was ever to have us start diagnosing.  My heart actually goes out to teachers that have
    been expected today do this.  I think it is a real misplacement of responsibility.

    Mr. Burns  XE "Mr. Burns"  .  I think as our educational system recognizes that their role is
    one of a participant, as perhaps Dr. Clawson pointed out.  I certainly support strong parental
    involvement throughout the educational process, and to ensure that each child achieves their
    highest maximum potential.

    	Perhaps there is disagreement on the panel about the pervasiveness.  Dr. Carey.

    Dr. Carey  XE "Dr. Carey"  .  Pervasive?

    Mr. Burns  XE "Mr. Burns"  .  Pervasiveness.

    Dr. Carey  XE "Dr. Carey"  .  Of what?

    Mr. Burns  XE "Mr. Burns"  .  As far as the excessive use of medication in our schools today.

    Dr. Carey  XE "Dr. Carey"  .  Are you talking about pervasiveness of symptoms or of the use
    of the medication?

    Mr. Burns  XE "Mr. Burns"  .  The use of the medication.

    Dr. Carey  XE "Dr. Carey"  .  Well -

    Mr. Burns  XE "Mr. Burns"  .  Is it a pervasive problem?  Do you see it as a pervasive
    problem?

    Dr. Carey  XE "Dr. Carey"  .  Yes, it is.  It really is.  I guess you did not hear my statement.

    Mr. Burns  XE "Mr. Burns"  .  I did not.  That is why I have to ask you.  I would like to see if
    there is consensus.  Dr. Clawson, do you see it as a pervasive problem?

    Dr. Clawson  XE "Dr. Clawson"  .  Basically, there is recent research that was published in
    September 2002 where an old research mentor of mine from Columbia, Dr. Peter Jensen, in 4 cities
    across the U.S. - in Atlanta, New Haven, Westchester and San Juan, Puerto Rico - went into the
    records and evaluated 1,285 children in depth using stringent criteria, and what they found was 5.1
    percent of the children between the ages of 9 and 17 qualified for a diagnosis of ADHD.

    	Interestingly, only 12.1 percent of these children were being medicated.  Okay?  Out of the
    approximately 1,300.

    	Out of the 1,300, there were 8 children that were being medicated for ADHD that probably
    did not meet full criteria for ADHD.

    Mr. Burns  XE "Mr. Burns"  .  That was a study of a thousand in 4 locations?

    Dr. Clawson  XE "Dr. Clawson"  .  No.  Four locations, a study of nearly 1,300 children.  And
    so all I can say is the recent research shows at least in these large metropolitan areas, we are not
    necessarily over diagnosing or overmedicating.

    	If you will look at Rochester, Minnesota, the Mayo Clinic did a very detailed study and
    followed kids for 6 years that had tremendous access to medical care.  Out of all the children that
    were diagnosed with ADHD, approximately two-thirds or three quarters were being medicated that
    had formal diagnoses.  So it is hard for me to say prevalence other than what I know is out there in
    the research.

    Mr. Burns  XE "Mr. Burns"  .  I will wrap up.  Do you see this legislation as doing harm?  Do
    you see any down side?  You know, the objective here is to protect children.

    Dr. Clawson  XE "Dr. Clawson"  .  I think this legislation is kind of the after effect of having
    severe mental health shortages for children and adolescents in this country, and we are trying to
    legislate telling teachers, not to say there is a problem or mention medication.  My sense is, if we
    take this blanket approach to where children are being under diagnosed and under medicated, we
    will put a further pall or further barrier to potential access, although I am not - .

    Mr. Burns  XE "Mr. Burns"  .  Is your perception that we are under diagnosing and under
    medicating?

    Dr. Clawson  XE "Dr. Clawson"  .  All the research that I have seen actually says that we are
    under diagnosing.  I cannot say under medicating.  There are certainly circumstances where it
    appears that -

    Mr. Burns  XE "Mr. Burns"  .  How does that break out by ethnicity?

    Dr. Clawson  XE "Dr. Clawson"  .  I do not have those figures right now in front of me.  There
    have been studies that have revealed that children of minority backgrounds are more frequently
    medicated.

    Mr. Burns  XE "Mr. Burns"  .  Three times, I believe, more -

    Dr. Clawson  XE "Dr. Clawson"  .  And I will also point out that there is also indication that the
    less mental health resources you have available, often the higher the use of psychotropic
    medication.

    Chairman Castle  XE "Chairman Castle"  .  Thank you, Mr. Burns.

    Mrs. Davis  XE "Mrs. Davis"  .

    Mrs. Davis  XE "Mrs. Davis"  .  Thank you, Mr. Chairman, and I am glad that that issue came
    up, because I guess that would be a concern.  I know that several years ago in San Diego when we
    began assessing children's medical care and the largest majority of children came to school for their
    health care, essentially they saw the nurse as their primary care provider, and in those situations
    then, kids are less likely to get the kind of help and support that they need.

    	I wondered, Representative Bryson, if in the Utah area, you had an opportunity to - if there
    had been any scientific data collected to indicate prevalence.  I know that anecdotally we are all
    concerned about that, and I can appreciate that, especially when you have groups or classrooms in
    one particular school or several schools cluster that seem to indicate very high levels of children
    that perhaps are under medication.  Were there any scientific studies that indicate what those
    numbers actually reveal?

    Ms. Bryson  XE "Ms. Bryson"  .  Thank you.  Not to my knowledge.  The only thing that we
    were trying to find out was how many prescriptions had been written and what amounts of these
    types of drugs were being prescribed.  So there was not any scientific evidence.  I know that just
    recently, although I was trying to get my hands on it before coming here, the Department of Health
    in Utah apparently conducted some kind of study and determined that we were at or below the
    national average on prescriptions of Ritalin.  However, there are other drugs that are now being
    used as well.  Were there any studies on the number of uninsured children?  I am wondering if it is
    more or less with what the country would be.  Were there larger numbers of uninsured?  I guess the
    other question would be the perception of mental health and whether or not people believed that it
    was okay to seek a mental health professional, whether that was -

    Ms. Bryson  XE "Ms. Bryson"  .  I cannot tell you that there was a study conducted, but I do not
    believe the perception was always appropriate to seek advice from a medical physician, a
    psychiatrist, or someone in the medical field.  I do not think that there was any problem with that,
    but it came back to information and having information about the side effects of these drugs.  It is a
    complex issue when you are a parent and it is being suggested by school personnel that you need to
    take your child here or there rather than these are the symptoms or this is what have seen in the
    behavior of your child.  You know, being specific is always appreciated by parents.

    Mrs. Davis  XE "Mrs. Davis"  .  Right.  No, I understand that, and I think the bottom line - I
    suspect that all the witnesses would agree that information to parents is the most important thing
    we can provide, and in a nonbiased fashion.  And it surprises me having had experience with
    school districts that in fact the stories that you are sharing are representative of school policy, that it
    is actually written that a school board voted, is that correct, to do this?

    Ms. Bryson  XE "Ms. Bryson"  .  Excuse me.  I am sorry.  What was mentioned earlier was
    something about encouraging.  What I was trying to say is there is nothing that is written that will
    indicate that they have ever made a medical diagnosis.  School personnel will not admit that they
    have ever said, you need to take your child to a psychiatrist or your child needs to be on Ritalin, but
    we know that has occurred, and often.

    Mrs. Davis  XE "Mrs. Davis"  .  I guess what I am searching for as a former school board
    member is that there is a stated policy to suggest that, and if there is no stated policy, then I would
    think there would be some intervention on behalf of local officials that would basically say to
    school personnel that it is not appropriate and that there are resources available to help them, to
    support them, resources available to parents to do that.

    	And I think that is where we need to be sure and encourage, and perhaps the federal role is a
    little different in that, but I think - I was concerned because I wasn't hearing that there was anything
    specific that was in school policy.

    Ms. Bryson  XE "Ms. Bryson"  .  There has not been in school policy, and one of the reasons
    that legislation is being offered in so many states by legislators like myself is because there have
    been so many problems.  I mean, where things are being suggested to parents.  Maybe it has just
    gotten out of hand.  I believe that if you are dealing with this issue now, it is because it has gotten
    totally out of hand, in that school personnel, the expectations are that have been involved.  And it
    literally is diagnosing.  When you have a little 6-year-old - there are drugs that are not
    recommended for kids 6 years and under.  You mentioned something about some other statistics.  I
    was trying to derive statistics in my state on those who are on Medicaid, and I looked at numbers
    where children 0 to 3 were on drugs and questioning why and how and what in the world would
    ever cause someone to put a child - a baby, a baby literally, a toddler, on drugs.  It is very
    frightening.

    Mrs. Davis  XE "Mrs. Davis"  .  Mr. Chairman, I know that my time is up.  I would just - I
    think in some ways it is a jurisdictional issue.  I think that if, in fact, we have school districts that
    are "recommending," then it seems to me that there is a jurisdictional issue here whether or not
    school boards determine that, in fact, that is not appropriate district policy, and there are certainly
    guidelines that should be adhered to.  And we need to be certain that at least they are doing that,
    because I think that is a first step, no matter where you go, and the extent to which we need to
    legislate here is really a different matter, but I would certainly hope that local school boards are
    providing the direction and the support so that people know where the resources are, that they are
    out there.  People can make a judgment about that as parents, and I believe totally that parents
    should have that decision, and, you know, honestly sometimes - there is more sophistication than
    others in this area, but that is not to say that parents shouldn't have this information, and there are
    lots of ways to provide that.  And all children should have the ability to have their parents at least
    have good information.

    Chairman Castle  XE "Chairman Castle"  .  Thank you, Mrs. Davis.

    Ms. Woolsey  XE "Ms. Woolsey"  .

    Ms. Woolsey  XE "Ms. Woolsey"  .  When I was a little kid, my grandfather used to sit me down
    in a chair, and he would pay me a nickel for every minute that I did not move, and I never earned
    one nickel.  I was in my 60s before I learned how not to move.

    	So I am truly, truly worried about people who are going to be just fine, little kids, and
    putting a label on them and giving them drugs.  But I am also concerned that we are talking black
    and white.  There is no gray in what we are talking about today.  And, I mean, if a student entered
    the classroom with a broken arm and the parents absolutely refused to help this little kid who was
    in great pain, what would we do then?  And I see a kid that is in - with ADHD being in great pain.
    But that is the real ADHD; I mean, not something because we have got boys that speak out in big
    classrooms that disrupt the classroom.

    	So I just - how are we going to get to understanding that kids have to be individuals without
    coercing their parents to put them on drugs?  That is my fear.  And I want to stop that now.  I mean,
    I would go too far one way in order to stop that, I am so very, very concerned about it, but I know
    there is real need also.

    	So in talking to me about this, starting with you, Dr. Carey, would you also tell me why -
    and if you think I am wrong - that there are more kids really with ADHD than there were when I
    was a kid, when you were a kid, when you were a kid.  Is it real?  I mean, is it because their parents
    didn't take care of themselves physically or what?

    Dr. Carey  XE "Dr. Carey"  .  One cannot answer that question with complete certainty, but I
    suspect the human race has not changed very much since our childhood.  I think kids used to
    squirm, and they just squirmed.  I share your concern, and you are not going too far in saying that a
    great deal of normal behavior has been pathologized by people who do not know the full range of
    normal behavior.  As I mentioned, I have been studying this for 35 years, and I see a great deal of
    over diagnosis of normal behavior as being such things as ADHD.

    	My chums in psychiatry say they are concerned about both over- and under diagnosis, but
    they really are concerned more about the under diagnosis.  I, as a pediatrician, am more concerned
    about the over diagnosis, because I see a lot of kids who are depressed, who have come from
    abusive homes, who come to school hungry, sleepy, and the real problem is something other than
    the putative brain defect which underlies ADHD.  So keep up your struggle.  You are not going too
    far.

    Ms. Woolsey  XE "Ms. Woolsey"  .  Dr. Clawson, do you want to respond to that?

    Dr. Clawson  XE "Dr. Clawson"  .  Could you reframe your question briefly?

    Ms. Woolsey  XE "Ms. Woolsey"  .  Well, just mainly are there more children with ADHD than
    in the past?  I mean, truly - .

    Dr. Clawson  XE "Dr. Clawson"  .  Once again, that is very difficult.  I think that the field has
    advanced, and so our diagnostic specificity has improved over the years, and there is greater
    publicity and greater public education about ADHD as a diagnosis.  I do not feel that at its core
    there are more people with ADHD than there were.  I think there is perhaps an increased
    identification, as well as perhaps shifts in culture.  I might hypothesize in terms of what we are
    expecting of kids, and whether there is a tolerance for squirminess or not.

    	I do feel that there are cases of over diagnosis, but I would say the research, including the
    Surgeon General's report, shows that there is massive under diagnosis.  Only 1 in 5 kids with a
    mental illness is being treated, and these other factors that are brought up about abuse, poverty,
    those are very real issues, and those do not say that a diagnosis of ADHD exists or does not exist,
    but those are very important issues that have to be addressed as well.  Unfortunately an amendment
    like this does not really address.

    Ms. Woolsey  XE "Ms. Woolsey"  .  Well, what would this amendment do if a parent had
    insisted that the child be on drugs and the school new absolutely for sure that that kid didn't need to
    be on drugs?  What happens with this amendment?  It sounds to me like the teachers don't have a
    voice in that.  Has anybody looked at it from that regard?  Have you, Katherine?

    Ms. Bryson  XE "Ms. Bryson"  .  I have not, but you know the bottom line is the parent's right,
    and in fact, it is very unique.  I have never been in a situation where someone has come forward.

    Ms. Woolsey  XE "Ms. Woolsey"  .  Dr. Carey, do you have - .

    Dr. Carey  XE "Dr. Carey"  .  That is an unusual situation, I would submit, and it is the parent's
    decision, and it is the school's responsibility to do something only if the use of drugs is impairing
    the kid's school function.

    Ms. Woolsey  XE "Ms. Woolsey"  .  Okay.  Well, Dr. Clawson.

    Dr. Clawson  XE "Dr. Clawson"  .  I would agree that if the child is being impaired somehow,
    it is a decision that is made collaboratively with the parents and the physician, and we cannot let
    the physicians abdicate their responsibility by throwing the burden on the schools.

    Ms. Woolsey  XE "Ms. Woolsey"  .  We may do another round.  Right?

    Chairman Castle  XE "Chairman Castle"  .  Well, we may, may not.  We will have a
    discussion about that.

    	Thank you, Ms. Woolsey.

    Mr. Wilson  XE "Mr. Wilson"  .

    Mr. Wilson  XE "Mr. Wilson"  .  Thank you, Mr. Chairman.  I would like to thank all three of
    you for being here today, and I also want to congratulate the freshman Congressman from Georgia,
    Mr. Burns, for proposing this, and he has just been so proactive here in Congress.  We are really
    proud of his service.

    	This is an issue that is important to me.  I have had two sons in resource classes.  This has
    been a big week, and one of them will be sworn in to the Bar Association.  I know that the
    Congressman thinks we need more Congressmen.  And then the other will take concluding
    exams on Friday.  I am confident he will continue his dean's list position in college as a senior.  So
    it is amazing what can be done, and our family is very appreciative.  But I am concerned about this
    issue.  For all three of you, I would like to know what your thoughts are on expanding the scope of
    H.R. 1170, to include other drugs under the Controlled Substances Act, beginning with
    Representative Bryson.

    Ms. Bryson  XE "Ms. Bryson"  .  I would love to see that occur.  I think that is applaudable.  I
    think that it needs to happen, and I appreciate such consideration.  I probably could go on, but I
    think those who have much more knowledge in the medical arena could speak to this as well.

    Dr. Carey  XE "Dr. Carey"  .  Well, I guess Dr. Clawson should be the one with the answer
    here, but I would say that there are other drugs being given now.  The second most common
    diagnosis now seems to be bipolar disorder, which seems to be getting hooked onto a great variety
    of kids, and they are getting various medications for that.  Pretty soon teachers will be starting to
    tell parents that their kids have bipolar disorder and they could be getting medicated.

    	So by extension, it seems to me that, yes, it should be extended to other drugs as well.

    Dr. Clawson  XE "Dr. Clawson"  .  When you mentioned controlled substances, that is a fairly
    formal category of drugs that are felt to have physiologic, addictive, and abuse potential.  So I am a
    little confused by your question in terms of drugs being controlled.  This goes to the same issue.
    Only one fifth of children in the country are being treated for mental illnesses.  There are a lot of
    untreated mental illnesses.  Psychotropic medications are used in certain mental illnesses or at
    certain levels of severity.

    	My argument would be similar.  I do not think teachers really have the training or the
    authority to determine whether students need this drug or that drug.  Once again, we are trying to
    limit the collaborative process that goes on where teachers are providing information to parents
    who then decide on their own whether to seek medical consultation, and then collaborate with and
    decide in conjunction with their physician whether to try psychotropic medication.

    	So I would not support that for the same reasons that I cited earlier.

    Mr. Wilson  XE "Mr. Wilson"  .  Thank you very much, and, again, Representative Bryson, we
    really appreciate you being so active in this and coming all the way to Washington to educate us.

    	Do you have any ideas on how to work with teachers, doctors, and parents, to reduce the
    emphasis of medication as the first answer and instead look to other ways to work with the child to
    address the issue?

    Ms. Bryson  XE "Ms. Bryson"  .  Thank you.  I mention that I myself had taught school some
    years ago, and I kept thinking there was never any mention of medication.  There was never
    anything.  It was always classroom intervention.  I mean, there were methods to deal with
    behavioral situations.  In fact, sitting here, I thought about what we would do if there were not any
    types of medication out there, which we seem to use so freely.  Who would have thought 30 years
    ago that we would hear the term Ritalin and that 6 to 8 million kids would be on this particular drug
    or drugs like it?  But are there other issues here?  I think we need to look more carefully at when
    we do any kind of diagnosis of kids.  When we are looking at their problems as far as reading or
    math or the areas that are of real concern.

    	I am not a physician, but I know from my experience as a teacher, there were things that I
    felt could be implemented in the classroom, and I am sure that with some consideration, that this
    again - I mean, there are interventions you look at when you have behavioral problems in a
    classroom, and communication with a parent such as writing letters.  In our state trying to just
    suggest that communication done through letters was not amenable to our school boards.  It was
    almost like if you make a commitment to acknowledge that there might be a problem, that that was
    unacceptable.  It was a very strange situation and very uncomfortable for me.

    	But coming back, I think that there have to be other interventions, and maybe even the
    mental health community can look at this.  But I do not believe that in all these cases that we just
    put these kids on drugs.

    Mr. Wilson  XE "Mr. Wilson"  .  Thank you, and I know that my wife who is a schoolteacher
    would agree with you.  Thank you very much.  I now yield the balance of my time.

    Chairman Castle  XE "Chairman Castle"  .  Thank you, Mr. Wilson.

    Mr. Van Hollen  XE "Mr. Van Hollen"   is next.

    Mr. Van Hollen  XE "Mr. Van Hollen"  .  Thank you, Mr. Chairman, and I want to thank
    Congressman Burns for the hearing as well, and Mr. Chairman as well for the opportunity.

    	I just want to make sure I understand the - we have got the legislation, but then there seems
    to be a broader debate beyond the legislation as to the prevalence of ADHD and the use of Ritalin,
    because the legislation I think from the testimony on all sides, it is clear that no one thinks that
    teachers should be prescribing Ritalin or saying that we should require kids as a condition to going
    to school to take Ritalin.  I think the general consensus I hear all of you say is this is something that
    belongs in the medical practice and should be diagnosed by a physician.

    	But I would ask you, Representative, what your sense is with respect to whether or not there
    is a legitimate diagnosis for ADHD and whether you believe that it is appropriate in certain cases to
    prescribe Ritalin for that.

    Dr. Carey  XE "Dr. Carey"  .  Perhaps you missed what I said earlier.  I said that there are a
    small percentage of children who undeniably are so overactive or inattentive, that they are hard for
    anybody to manage.  But I would put that about 1 or 2 percent.  The official psychiatric view is 3 to
    5 percent, kids who really have a problem, where it is the inattentiveness or the activity that are the
    problem.

    	Now, this has become a convenient wastebasket into which all other problematic kids can
    be thrown.  The kids who are having trouble learning, who are difficult to get along with, who are
    hungry, who are sleepy and so on.  It certainly should not go any higher than 5 percent, and yet it
    does go quite a bit higher than that.  As I mentioned, 17 percent in a study in Norfolk, Virginia, and
    I heard anecdotally recently that in a certain elite private school in New York City, it is 40 percent.

    Mr. Van Hollen  XE "Mr. Van Hollen"  .  And Representative Bryson, do you have an opinion
    on this issue?

    Ms. Bryson  XE "Ms. Bryson"  .  I would agree.  I would have to agree wholeheartedly with Dr.
    Carey.

    Mr. Van Hollen  XE "Mr. Van Hollen"  .  Well, one of the issues here - we are trying to get to
    the relationship between a schoolteacher who has children in the classroom for a good part of the
    day obviously and the parents and what that appropriate relationship is.

    	If you are a parent and you seek out the advice of a teacher, you say, how is my child doing
    in your classroom, do you believe it is inappropriate for the teacher to offer an opinion on that if
    part of that opinion is, you know, he is acting like other kids who have this ADHD.

    Ms. Bryson  XE "Ms. Bryson"  .  As I mentioned, I taught some years ago.  I always felt that it
    was my responsibility to convey to the parent what was happening, at least quarterly, if not more
    often by meeting with parents and talking with them.  But I think it is important is to convey
    exactly what you are observing, rather than that this child over here takes Ritalin, and, you know,
    your son looks just like him.  Well, maybe Johnny over here should not have even been on Ritalin,
    and so that is a false assumption.

    	I believe that we need to be very puristic about this, and if we see a child and, yes, he may
    have problems in reading or, yes, he may be out on the playground and at times he seems a little bit
    aggressive.  However, I think those are things that we convey and communicate to the parents and
    let the parents who deal with that child a lot more than we do - I mean, than teacher does, makes
    those decisions, but at least present the information.

    	I think parents, ultimately, love that child.  No matter what anyone says, I believe they do
    love their children, and they want to see their child succeed.  As a mother of 6, I like information so
    that my child can strive and do their best.

    Mr. Van Hollen  XE "Mr. Van Hollen"  .  I understand.  I guess I am trying to get at the
    relationship between the parent, who I agree loves the child who actually seeks out information
    from a teacher, and whether or not what kind of limitations we may be putting on teachers that we
    may think are actually appropriate opinions.  I would be interested, Dr. Clawson - you actually deal
    with this issue on a regular basis.  What do you think the impact of something like this could have
    on that relationship?

    Dr. Clawson  XE "Dr. Clawson"  .  Well, I think as I testified to earlier, I think once again we
    are putting further restrictions on teachers.  Teachers have a number of demands and restrictions for
    documentation, what they can and cannot say.  And once again, we are telling them you can make a
    conclusion.  I have had many teachers make similar conclusions but couch it and say, listen, I have
    had other kids respond to this.  I do not know, but my opinion is you should have this investigated
    further by a medical professional.

    	It is not necessarily wrong.  Every time a teacher voices an opinion, I would not say that
    that is coercion.  That is expressing an opinion which parents can then take and investigate and
    make a decision, you know, as parents of this child.

    Mr. Van Hollen  XE "Mr. Van Hollen"  .  Right.  Ultimately, any prescription has to be made
    and diagnosed by a medical - .

    Dr. Clawson  XE "Dr. Clawson"  .  Right.  Teachers recommend vision screenings.  They
    recommend hearing screenings if they have concern regarding a child's general health in the
    classroom.  We want them to be able to do that, and in the same way, I think we would want to be
    able to allow them to feel free to make recommendations or suggestions regarding issues around a
    child's emotional and mental well-being.

    Mr. Van Hollen  XE "Mr. Van Hollen"  .  Right.  I think everyone would agree we don't want
    teachers coercing the parent, but on the other hand it seems to me the parent, as Representative
    Bryson, you said, I mean, they should have all the information.  And they can choose to disregard
    the teacher's opinion, but I guess my question is why would we want to - obviously we don't want a
    teacher saying you have to put your kid on Ritalin and making the diagnosis in order to come to
    school, but if the parent were to seek out the opinion of a teacher with the obvious understanding
    the teacher can't make the prescription, it is going to be a doctor, why would we prohibit a teacher
    from offering an opinion in response to a question from parent?  Representative - I was asking
    Representative Bryson.

    Ms. Bryson  XE "Ms. Bryson"  .  I was listening to you.  I was just thinking of what you really
    want as parent is to know what is happening to your child, but in some cases you do not want to
    discourage a teacher from communicating with you, but you also do not want them to act as the
    physician.

    Mr. Van Hollen  XE "Mr. Van Hollen"  .  I think we are in agreement on the fact that we don't
    want the teacher to act as a physician.  My concern is that we somehow prohibit a teacher from
    responding - providing their opinion in response to a request from a parent.  I mean, I may have my
    child at home and I have been observing the child, and I may have some concerns and I want to
    know what is going on in the classroom, and I want to ask the teacher about that and ask that
    teacher's opinion with respect to it.

    	I can disregard that opinion.  I mean, I guess why are we afraid of the - I understand why
    we are we would be concerned about any teacher requiring a parent to put a kid on Ritalin, but why
    are we afraid of just having the opinion of a teacher reach the parent with respect to this?

    Ms. Bryson  XE "Ms. Bryson"  .  It has been my experience that what you are suggesting is
    probably not what is occurring as frequently and what is happening is just the opposite, is where
    the teacher is approaching the parent and suggesting that there are some problems.  From there
    sometimes it goes as far as even suggesting that Johnny in the classroom is on Ritalin, and maybe
    that will help your son.  And that is the direction I guess that when I have been approached as a
    legislator, that is what I have heard.

    Mr. Van Hollen  XE "Mr. Van Hollen"  .  Thank you, Mr. Chairman.  If I could just - if I could
    have something submitted for the record.  It is a statement by Audrey Spolarich, who is the Chair
    of the Coalition of Children's Health which outlines a number of opinions on this whole issue and
    some concerns.

    Chairman Castle  XE "Chairman Castle"  .  Without objection, the document is submitted for
    the record as accepted [SEE APPENDIX G].

    Chairman Castle  XE "Chairman Castle"  .  We are going to go to Mrs. Musgrave at this
    point.

    Dr. Carey  XE "Dr. Carey"  , did you have something you wanted to say on that before we went
    to the next questioner?  Your light was on is the reason I ask that.

    Dr. Carey  XE "Dr. Carey"  .  Well, hopefully parents will understand that teachers are not
    diagnosticians and they should not be asking them in the first place, and teachers should have the
    sense not to give diagnosis when they are asked.  But we cannot stop that from happening, can we?
    Or can we?

    Mr. Van Hollen  XE "Mr. Van Hollen"  .  I guess the issue is - and just getting back to the
    distinction between something I think everyone should agree on, which is that teachers shouldn't be
    saying-playing the role of doctors and saying, you know, your kid can't come to school if they are
    not on Ritalin.  I am sure there is a big debate to the extent that is happening.  Some people say it is
    happening a lot, some people say it is not.  But between that issue and a parent who is genuinely
    concerned and is seeking information possibly from a teacher in a classroom who is observing their
    child day in and day out and wanting to get the opinion of the teacher and whether this would have
    any impact on the ability of the teacher to express his or her opinion.

    	The words of it don't require it, but-because it says they can't require them.  The bill is
    narrow in that sense.  It says, you know, prohibiting school personnel from requiring a child to
    obtain a prescription.  My question is, is part of your - is it your opinion, though, that it is - I am
    trying to get to the broader issue here.  Is it your opinion that it would be inappropriate for the
    teacher to offer an opinion in response to a question from the parent, whatever that opinion is, and
    understanding the parent can reject it?

    Chairman Castle  XE "Chairman Castle"  .  Can you respond briefly, Dr. Carey?  We need to
    go -

    Dr. Carey  XE "Dr. Carey"  .  I would rather the teacher not respond, but I do not know how I
    am going to stop it.

    Chairman Castle  XE "Chairman Castle"  .  Mrs. Musgrave.

    Mrs. Musgrave  XE "Mrs. Musgrave"  .  Before I speak, Mr. Chairman, I would like to yield a
    minute to Mr. Burns.

    Mr. Burns  XE "Mr. Burns"  .  I thank the lady from Colorado.  Just a point of clarification, and
    I appreciate my friend and colleague Mr. Van Hollen.  This is a very simple bill.  It is very specific.
    It does not in any way prohibit input or discussion or dialogue between teachers, parents, and
    physicians.  It does attempt to put the decision-making process in the hands of the trained medical
    professional and the parent, and I think that is very important.  I yield back the balance.  Thank
    you.

    Mrs. Musgrave  XE "Mrs. Musgrave"  .  Thank you.  Coming from Colorado, you are aware of
    Columbine, the stain that will forever be on our state.  The school shooters were on Luvox and
    Prozac.  And as I understand this, they would not be prohibited from school coercion under this
    particular bill.  But as we consider those kinds of drugs and the behavior of those students, it is
    alarming to me, to say the least.  And what I am wondering about today, I would like to particularly
    address the doctors here, what do we know about the long-term effects of drugs like Ritalin or
    Adderall?

    Dr. Clawson  XE "Dr. Clawson"  .  Essentially stimulants, amphetamines have been used
    longer than almost any other drug available that has been used since 1937.  Over the last 30 years,
    stimulants, particularly methylphenidate and dextroamphetamine are some of the best studied drugs
    of any drug available to humans.  They have been found to be generally safe and well tolerated.
    Like any medication, including over-the-counter medications, they can have adverse consequences,
    and that is why they require a prescription and medical management and supervision.  But -

    Mrs. Musgrave  XE "Mrs. Musgrave"  .  If I may ask, how about experience or evidence in
    regard to use with young children?

    Dr. Clawson  XE "Dr. Clawson"  .  To my knowledge, there have not been exhaustive
    longitudinal studies where, for instance, a young child would be placed on a stimulant then
    followed for 20 or 30 years, although there is data amassing to show that there are not long-term
    adverse effects.  I do not think that that is an absolute.  Any drug you give a child can have a long-
    term adverse consequence, because we do not know all of the potentials, but the fact that we have
    been researching particularly stimulants for the last 30 years gives us a tremendous amount of
    medical research data to support that dramatic adverse consequences have not been reported or
    found with these medications, other than well-described specific cases where there are adverse
    events, just like any other medication.  You can get this with Benadryl, aspirin, or many of these
    things.  Any medication can have an adverse outcome.

    Mrs. Musgrave  XE "Mrs. Musgrave"  .  Yes.

    Dr. Carey  XE "Dr. Carey"  .  There are some side effects from Ritalin and such drugs, but as
    Dr. Clawson says, they are fortunately relatively minor in the studies that have been done so far.

    	What I find most disturbing is the fact that these drugs are now being used in preschool
    children, and as somebody said, even as young as infants.

    Dr. Carey  XE "Dr. Carey"  .  At a time when the brain is still completing itself, laying down
    myelin and developing further, we have no idea what that is going to do to the development of the
    brain.

    	And there is a study going on now, but I am very apprehensive about that, and I hope that it
    will not get to be a common process.  It is very hard to know in little kids what is abnormal
    behavior and what is just a feisty kid.

    	So I have to say that we do not really know very much about little children.

    Mrs. Musgrave  XE "Mrs. Musgrave"  .  Well, I have been concerned with the way, many
    times, that we think that all children should behave in the same way.

    	I appreciate your remarks.  When you have 27 little people in a room and you think that
    they should all be compliant and acting in a certain way, I think we are making a big mistake.

    	Representative Bryson, did you find out any evidence, when you were working on your
    legislation, in regard to documenting how students performed, for instance after they have been put
    on Ritalin or a similar drug, in elementary school?  Does anyone know what their academic
    performance is in 2 years, 4 years, or 6 years?  Do we know if there is still a problem for the
    teacher in the classroom?  Have we followed these students enough to see what their behavior is 2,
    4, or 6 years down the road?

    Ms. Bryson  XE "Ms. Bryson"  .  I think we would all be curious to see that.  To my knowledge,
    there has not been any long-term study on this.  I would like to have seen it.  The only thing I had a
    chance to hear was actually from students.  As I was working on this legislation, they looked at
    quite a few substitutes, and there were a number of people, college students, who came forward and
    spoke with me and testified.  But there were personal situations where they said they were placed
    on Ritalin, but their reading skills did not improve or the skills in other areas did not improve.

    	Yes, they were compliant, but as far as any studies of anything that was documented, I have
    not seen anything.

    Mrs. Musgrave  XE "Mrs. Musgrave"  .  Well, I just wanted to end up talking about how
    vulnerable a mother feels, particularly when you have your first child in school.  You have your
    heart vested in this student, your first-born, when you go in to consult with the teacher.

    	I could put myself in that place very easily because the older of our two sons, the eldest of
    our four children, was not learning to read in first grade; and he was not hyperactive, but he was
    having problems.  I still remember what I felt like when I went before that teacher.  I had a college
    education; I probably had a little more self-confidence than some, but I went in there wanting to
    find a solution for Chad's reading problem.  And I talked to that teacher.  I can now put myself in
    the place of mothers and fathers that go in when their child is not succeeding and realize how
    impressionable they are to the comment that a teacher would make.

    	I have been a teacher.  I know the big responsibility that teachers have.

    	And I would just like to commend Mr. Burns, because I think you have crafted a bill here
    that walks the fine line.  Yes, we want to be respectful of our educators.  We want them to be able
    to communicate with parents.  But we do not want them going over the line where they would push
    a parent into doing something that they thought was best for their child, whereas this teacher really
    does not have the capacity to be giving this kind of information.

    	And so I want to stand up for those moms and dads that want the best for their children and
    are seeking advice from the teacher.  And I want that teacher who is very qualified in that
    educational arena to give educational advice, and I do not want drugs to be our first solution to very
    complex problems.

    	And I do not want all of our kids to have to be the same because they are unique and
    precious individuals, and we need to look at them as individuals.

    Chairman Castle  XE "Chairman Castle"  .  Well, thank you, Mrs. Musgrave, I would like to
    thank the witnesses for being here today.  I would like to thank all the members who participated.
    We tried to be generous of the time in this round of questions so that everybody could get their
    questions in.

    	I was talking with Ms. Woolsey, and we both sort of admitted that this is a hearing that
    probably raises as many questions as it answers.  That is not bad.  That shows something about
    insight, about all of you.  I happen to be supportive of the legislation at hand, but obviously we do
    need to be careful when we legislate in these areas; and I think we have helped to shed some light
    on that.  We appreciate very much all of you being here.

    	Let me turn to Ms. Woolsey and see if she has any closing comments.

    Ms. Woolsey  XE "Ms. Woolsey"  .  I do.  Thank you.

    	I think we all have to look at the legislation to make sure there is some gray in it, that it is
    not black and white, because every person and all of these little kids are, to some degree, between
    one side or the other on this, unless they are severely ill.  So I want to look at it from that regard.

    	And I want to protect children from being drugged because they are being children.  And I
    will say that over and over.

    	Thank you.

    Chairman Castle  XE "Chairman Castle"  .  Mr. Burns, as the sponsor did you wish to make a
    brief closing comment?

    Mr. Burns  XE "Mr. Burns"  .  I would like to thank the panel for your input, and I thank the
    committee for holding the hearing.  I think we are on the right track.  I believe we are making
    progress.  Our primary goals are the same on both sides of the aisle; and our goal and our objective
    is to protect the children of America and make sure they receive a quality education without the use
    of drugs, if at all possible.  And I support that.

    	Thank you, Mr. Chairman.

    Chairman Castle  XE "Chairman Castle"  .  Thanks again, everybody.  And with that, we
    stand adjourned.

    	[Whereupon, at 3:45 p.m., the subcommittee was adjourned.]

    APPENDIX A - WRITTEN OPENING STATEMENT OF CHAIRMAN
    MICHAEL N. CASTLE, SUBCOMMITTEE ON EDUCATION REFORM,
    COMMITTEE ON EDUCATION AND THE WORKFORCE, U.S. HOUSE OF
    REPRESENATIVES, WASHINGTON, D.C.

    APPENDIX B - WRITTEN OPENING STATEMENT OF RANKING
    MEMBER LYNN C. WOOLSEY, SUBCOMMITTEE ON EDUCATION
    REFORM, COMMITTEE ON EDUCATION AND THE WORKFORCE, U.S.
    HOUSE OF REPRESENATIVES, WASHINGTON, D.C.

    APPENDIX C - WRITTEN STATEMENT OF HON. KATHERINE BRYSON,
    STATE REPRESENTATIVE, UTAH HOUSE OF REPRESENTATIVES,
    OREM, UTAH.

    APPENDIX D - WRITTEN STATEMENT OF DR. WILLIAM CAREY, M.D.,
    DIRECTOR OF BEHAVIORAL PEDIATRICS, CHILDREN'S HOSPITAL OF
    PHILADELPHIA, PHILADELPHIA, PENNSYLVANIA.

    APPENDIX E - WRITTEN STATEMENT OF DR.  LANCE CLAWSON,
    PRIVATE PSYCHIATRIST, CABIN JOHN, MARYLAND.

    APPENDIX F  - WRITTEN STATEMENT OF REPRESENTATIVE MAX
    BURNS, COMMITTEE ON EDUCATION AND THE WORKFORCE, U.S.
    HOUSE OF REPRESENATIVES, WASHINGTON, D.C.

    APPENDIX G - WRITTEN STATEMENT FROM AUDREY SPOLARICH,
    CHAIR, COALITION FOR CHILDREN'S HEALTH SUBMITTED FOR THE
    RECORD BY REPRESENTATIVE CHIS VANHOLLEN, SUBCOMMITTEE
    ON EDUCATION REFORM, COMMITTEE ON EDUCATION AND THE
    WORKFORCE, U.S. HOUSE OF REPRESENATIVES, WASHINGTON, D.C.

    APPENDIX H - WRITTEN STATEMENT BY DR. KAREN EFFREM
    SUBMITTED FOR THE RECORD BY REPRESENTATIVE MARILYN
    MUSGRAVE, SUBCOMMITTEE ON EDUCATION REFORM, COMMITTEE
    ON EDUCATION AND THE WORKFORCE, U.S. HOUSE OF
    REPRESENATIVES, WASHINGTON, D.C.

    APPENDIX I  - WRITTEN STATEMENTS FROM THE NATIONAL MENTAL
    HEALTH ASSOCIATION SUBMITTED FOR THE RECORD BY RANKING
    MEMBER LYNN C. WOOLSEY, SUBCOMMITTEE ON EDUCATION
    REFORM, COMMITTEE ON EDUCATION AND THE WORKFORCE, U.S.
    HOUSE OF REPRESENATIVES, WASHINGTON, D.C.

    APPENDIX J  - WRITTEN CORRESPONDENCE FROM UTAH
    CONSTITUENTS SUBMITTED FOR THE RECORD BY HON. KATHERINE
    BRYSON, STATE REPRESENTATIVE, UTAH HOUSE OF
    REPRESENTATIVES, OREM, UTAH.

    144

    Table of Indexes

    Chairman Castle, 2, 3, 4, 6, 8, 10, 11, 12, 13, 15, 19, 21, 23, 24, 27, 28, 30, 31
    Dr. Carey, 6, 11, 13, 17, 18, 21, 22, 23, 25, 27, 28, 29
    Dr. Clawson, 8, 12, 13, 14, 18, 19, 22, 23, 26, 28
    Mr. Burns, 15, 16, 17, 18, 19, 28, 30
    Mr. Case, 13, 14, 15
    Mr. Van Hollen, 24, 25, 26, 27
    Mr. Wilson, 23, 24
    Mrs. Davis, 19, 20
    Mrs. Musgrave, 28, 29
    Ms. Bryson, 5, 10, 16, 19, 20, 22, 23, 24, 25, 26, 27, 29
    Ms. Woolsey, 3, 21, 22, 30

    cxxxviii

    137