Behavioral Drugs in Schools: Questions and Concerns

U.S. House Committee on Education and the Workforce Hearing

UNITED STATES HOUSE OF REPRESENTATIVES COMMITTEE ON EDUCATION AND THE WORKFORCE HEARING ON:
“Behavioral Drugs in Schools: Questions and Concerns”

September 29, 2000

STATEMENT OF DAVID FASSLER, M.D.
Representing the AMERICAN PSYCHIATRIC ASSOCIATION
And
AMERICAN ACADEMY OF CHILDAND ADOLESCENT PSYCHIATRY

INTRODUCTION

My name is David Fassler. I’m a Board Certified Child and Adolescent Psychiatrist practicing in Burlington, Vermont and Chairperson of the American Psychiatric Association’s Committee on Children, Adolescents and Families. First of all, let me thank Representative Schaffer and Representative Roukema for the opportunity to appear before the subcommittee. My testimony today is on behalf of the American Psychiatric Association (APA) American Academy of Child and Adolescent Psychiatry (AACAP). I ask that my written remarks be entered into the record.

The APA is a medical specialty society, representing over 40,000 psychiatric physicians. AACAP is a national, professional association representing over 6,500 child and adolescent psychiatrists, who are physicians with at least five years of specialized training after medical school emphasizing the diagnosis and treatment of mental illness in children and adolescents.

EPIDEMIOLOGY OF ADHD

As a practicing child and adolescent psychiatrist, I see children and their families struggling with a range of behavioral disorders including ADHD. I know from my own experience and that of my colleagues, that with a comprehensive evaluation and diagnosis we can help these children overcome their problems and enjoy and normal active childhood. Comprehensive treatment, including the use of medicine works.

According to the National Institute of Mental Health (NIMH), Attention Deficit Hyperactivity Disorder, or ADHD, is the most commonly diagnosed psychiatric disorder of childhood. It’s estimated to affect between 3 and 5 percent of school-age children, and it occurs three times more often in boys than in girls. The Surgeon General’s recent conference cited the under-diagnosis and under-treatment of mental disorders in children, particularly in African-American and other minority populations due to lack of access to medical services.

UNDERSTANDING AND DIAGNOSING ADHD

I have with me for the Committee, The Diagnostic and Statistical Manual of Disorders IV-R which is central to understanding and diagnosing ADHD. The key features of ADHD include: inattention, hyperactivity and impulsivity. The symptoms must also be interfering with the child’s life at home, in school, at work or with their friends. The diagnostic criteria are specific and well-established within the field. They are the product of extensive and numerous research studies conducted at academic centers and clinical facilities throughout the country. (see attached AMA Council on Scientific Affairs (CSA) Report 5-A-97; AACAP Practice Parameters for the Assessment and Treatment of Children, Adolescents and Adults with Attention Deficit Hyperactivity Disorder; the National Institute of Health Consensus Statement and the 1999 Surgeon General’s Report on Mental Health.)

Let me be very clear. ADHD is not an easy diagnosis to make, and it’s not a diagnosis that can be made in a 5 or 10 minute office visit. Many other problems, including anxiety disorders, depression and learning disabilities can present with signs and symptoms which look similar to ADHD. There is also a high degree of co-morbidity, meaning that over half the kids who have ADHD also have a second significant psychiatric problem. The following criteria for assessing ADHD is from the DSM-IV:

DSM-IV-R Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

Either (1) or (2):

Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with development level:

Inattention

often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities

often has difficulty sustaining attention in tasks or play activities

often does not seem to listen when spoken to directly

often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions)

often has difficulty organizing tasks and activities

often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or home work)

often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books or tools)

is often easily distracted by extraneous stimuli

is often forgetful in daily activities

six (or more) of the following symptoms of hyperactivity impulsively have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

often fidgets with hands or feet or squirms in seat

often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)

often leaves seat in classroom or in other situations in which remaining seated is expected

often has difficulty playing or engaging in leisure activities quietly

is often ‘on the go” or often acts as if “driven by a motor”

often talks excessively

Impulsivity

often blurts out answers before questions have been completed

often has difficulty awaiting turn

often interrupts or intrudes on others (e.g., butts into conversations or games)

Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

Some impairment from the symptoms is present in two or more settings (e.g., as school [or work] and at home).

There must be clear evidence of clinically significant impairment in social, academic or occupational functioning.

The symptoms do not occur exclusively during the course of a pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Diassociative Disorder, or a Personality Disorder).

The diagnosis of ADHD requires a comprehensive assessment by a trained clinician. In addition to direct observation, the evaluation includes a review of the child’s developmental, social, academic and medical history. It should also include input from the child’s parents and teachers, and a review of the child’s records. We share the view that while schools play a critical role in identifying kids who are having problems, but schools should not make diagnoses or dictate treatment. This is the proper role for the parent working with a well trained physician.

ADHD is also a condition which should not be taken lightly. Without proper treatment, a child with ADHD may fall behind in schoolwork and have problems at home or with friends. It can also have long-term effects on a child’s self-esteem, and lead to other problems in adolescence, including an increased risk of substance abuse.

The treatment of ADHD should be comprehensive, and individualized to the needs of the child and family. Medication, including methylphenidate or Ritalin, can be extremely helpful for many children, but medication alone is rarely the appropriate treatment for complex child psychiatric disorders such as ADHD. Medication should only be used as part of a comprehensive treatment program which will usually include individual therapy, family support and counseling, and work with the schools.

In terms of methylphenidate, we have literally hundreds of studies clearly demonstrating the effectiveness of this medication on many of the target symptoms of ADHD. (see attached AMA CSA Report and NIH Consensus Statement on the Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder.) It is also generally well-tolerated by children, with minimal side effects. Nonetheless, I share the concern that some children may be placed on medication without a comprehensive evaluation, accurate and specific diagnosis or an individualized treatment plan. Let me also be very clear I am also similarly deeply concerned about the many children with ADHD and other psychiatric disorders who would benefit from treatment, including treatment with medication, who go unrecognized and undiagnosed, and who are not receiving the help that they need.

RECOMMENDATIONS

The American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry and would like to offer the following specific recommendations for the subcommittee’s consideration:

First, we fully support the importance of accurate diagnosis and treatment. This requires access to clinicians with appropriate training and expertise, and sufficient time to permit a comprehensive assessment.

Next, we fully support the increased emphasis of the FDA and the NIMH on research on the appropriate use of medication in the psychiatric treatment of children and adolescents, and we welcome the commitment to expanded clinical trials and longitudinal studies for all medications prescribed for children.

We also fully support the passage of comprehensive parity legislation at both the state and federal level so there are fewer barriers to keep kids from getting the kind of comprehensive evaluations and individualized treatment they need.

And we fully support and welcome all efforts to sustain and expand training programs for all child mental health professionals, including programs for child and adolescent psychiatrists.

And finally, we fully support and appreciate the efforts of Surgeon General David Satcher to focus increased attention on the diagnosis and treatment of all psychiatric conditions, including those which affect children and adolescents.

In summary, let me emphasize that child psychiatric disorders, including ADHD, are diagnosable and real illnesses, and they affect lots of kids. The good news is that they are also highly treatable. We can’t cure all the kids we see, but with comprehensive, individualized intervention, we can significantly reduce the extent to which their problems interfere with their lives. The key for parents and teachers is to identify kids with problems as early as possible, and make sure they get the help that they need.

Thank you for the opportunity to appear before the subcommittee. I’d be happy to answer any questions.