The Last Normal Child

Little Helpers in 2024

Lawrence Diller, M.D. — Mon, 21 Sep 2009 01:36:01 +0000

This past December the prestigious British journal, Nature, published a commentary entitled "Cognitive Enhancers," in which the authors proposed reevaluating the ethics of using drugs that ostensibly improve the brain's performance. Their position likened taking a drug such as Adderall - an amphetamine, legally prescribed primarily to treat attention deficit disorder (ADD), but now increasingly used by college students as a study and exam taking aid - as not too different from the wearing of glasses, prepping for the SAT with a private tutor or simply taking vitamins.

Then in April of this year, the New Yorker Magazine published a lengthy rather sympathetic essay on the use of stimulants like Adderall at prestigious American colleges. While the tone mildly questioned the values espoused in the pursuit of goals aided by the elective (and illegal) use of Adderall, the author flatly stated that "cognitive enhancers cannot be banned."

Up until recently, amphetamine abuse and addiction have been a relative risk in the unsupervised use of this drug. But Shire, the drug company that markets Adderall (the drug most frequently abused - crushing and snorting it like cocaine to study or get high) has recently promoted a new product, a pro-drug, called Vyvanse. Vyvanse is amphetamine linked chemically to a safe amino acid, lysine - which when they are bound together makes the amphetamine pharmacologically inactive. Only when Vyvanse is swallowed does the amphetamine cleave from the lysine via digestive enzymes and the amphetamine part of the pill becomes active.

Shire clearly hopes to position its product as safer than any other kind of stimulant (Ritalin, Concerta, etc.) by making crushing, snorting or even intravenous injections useless for abuse. Technology appears to be continuing to improve the safety and perhaps, even the effectiveness of amphetamine like drugs such as Vyvanse or Concerta (the first twelve hour stimulant). No surprise really, as the demand for these product enhancers seems unending and forever growing.

Drugs like Ritalin and Adderall are now routinely prescribed to children who only in the broadest sense have trouble with attention and focus. For example, children with learning problems who only have concentration problems in school (and sometimes only for a particular subject) regularly get medication from most doctors. Similarly, academically unmotivated younger adolescents "meet" ADD criteria and receive medication without much controversy these days.

Increasingly older high school and college students and parents of younger children are asking pediatricians and psychiatrists for medication just for specific times of the week or just for studying and exam taking. The medical use of Adderall for these limited purposes are more questionable both clinically and ethically. However, some doctors are complying with these requests.

Meanwhile, there is much illegal diversion of Adderall for studying or getting high on college campuses. Some surveys report up to 35% of college students at particular campuses have admitted using Adderall or its equivalent legally (with a prescription) or illegally. With these trends in mind and with respected scientists seeking to justify the ethical use of cognitive enhancers, I imagine the following scenario for a child I'll call Winston. Winston (named after the protagonist from an infamous future dystopia) is a nine year old boy living in Esalen, a now thriving exburb of Palo Alto, California in the year 2024.

Winston's parents have been asked to attend a meeting at his school with his teacher, Mrs. O'Brien (also intentionally named for another "teacher"), the school psychologist/developmentalist and principal. Mrs. O'Brien opens the meeting, "It would appear that Winston has been mightily struggling at school and also trying to keep up with the homework we give him in the ‘enhanced' class setting. We're not sure if he should continue in the class unless somehow he can take one of the ‘little helpers' successfully."
Winston's parents knew exactly to what Mrs. O'Connor was referring. Just earlier in the morning Winston's mother had once again begged his father to reconsider yet another drug for Winston. "You know everyone in his class takes a ‘little helper.' He just doesn't have a chance to make it unless he gets the same fair assistance that all the other children are receiving," she told her husband.

"But you know Winston's situation, honey," the father replied resignedly, "we've tried any number of helpers to assist Winston and either they haven't worked or he can't tolerate them. It's truly unfortunate." Indeed, Winston had experienced multiple performance enhancers but he seemed to be the unlucky one in ten kids who physically or emotionally did poorly on products like Focusyn (where he developed nasty headaches), Execution (a rise in his blood pressure) or Simulex (the worst, when he peed blood).

Winston could overhear his parents' conversation and felt miserable. He knew he was disappointing them and his teacher. Without the pills that all his friends and classmates took, he just couldn't keep up with his peers in subjects like advanced algebra and Bernakian economics which were typical for a fourth grade enhanced class. He cried as he murmured to his parents, "I'm just a failure."

But that was earlier in the morning. Now Winston was invited to join the meeting with his parents and the school officials. Mrs. O'Brien spoke kindly to the family, "In light of your efforts to try to help Winston compete, we are entirely sympathetic, but we just don't believe it is good for you, Winston, to continue in the enhanced class. We strongly recommend to the three of you to consider having Winston join the ‘normal achievement' fourth grade class at the school. You will certainly continue to learn, Winston, albeit at a natural pace. And you never know, you could easily catch up at some point in the future."

"The normal class!" thought Winston. The normal class had only twenty students, not the forty-five Winston was used to. Winston's parents knew there was much more time for "soft" subjects like art and music in the normal class. There was even a period of time, twice daily, called recess where children were not engaged educationally and played outside.

After the meeting, Winston's parents noticed his looking quite glum. They tried to cheer him up. "Come on now, Winston," his father said, "most of the children who attend the normal class aren't bad. They're a lot like you. Most of them also just can't handle those pills that make you work harder, concentrate longer and more efficient with your time. Without those medicines, most kids, not just you, simply can't handle the enhanced class."

His mother tried to be helpful, "Winston, I do believe there are even some children in the class whose parents simply didn't want to give their kids helpers. I admit some of their values are bit old fashioned but there's something to be said about doing things naturally."
His father added, "You know, Winston, the state of California, doesn't force parents to give their kids helpers. It's up to us to decide. That's why they do still have these normal classes to accommodate a range of choices for families. Just because most kids take helpers, that doesn't mean everyone could or should. I actually think this new class is going to work much better for you and us."

Winston was barely relieved. Secretly, he hoped that the Company would come up with yet a new product for him to try so he could stay with the kids he knew and do the best he could in the enhanced class. He could see his parents were hopeful which cheered him a bit. But he remained very worried -- especially about this subject he knew hardly anything about - recess.

A version of this essay first appeared in the September 2009 issue of Communique, the national newspaper for the National Association of School Psychologists.

Public Funding of Private Schools for the Learning Disabled -- The Snake Eats Its Tail

Lawrence Diller, M.D. — Sun, 31 May 2009 18:16:45 +0000

The U.S. Supreme Court this past April revisited the highly contentious issue of public funding of private school placements for learning disabled children. Two years ago the Court attempted to address this long standing issue (I've been aware of these tensions for two decades) but deadlocked 4-4 with Justice Arthur Kennedy mysteriously (never explained) recusing himself from the decision.

Public school officials (reading Superintendents and Directors of Special Services) have been desperate for a clarification on the limits of the Individuals with Disabilities Education Act (IDEA) for years. This federal law mandates an individualized optimal education for all, but the federal government has never been close to providing full funding for all the mandated services. The financial burden has fallen heavily on individual school districts leading to the dynamic that pits the rights of the individual versus the rights of the community.

You see this tension played out regularly within the context of developing the Individualized Educational Plan (or IEP) for the child who is struggling learning wise or behaviorally (they are commonly joined together in, what we, in the industry, call "co-morbidity", especially learning problems and ADHD/ADD). At meetings with school personnel to assess for and develop the IEP, parents feel the potential adversarial qualities associated with a legal process instead of a more communal effort to help the child.

This is because the school districts are regularly advised by their legal counsels to help avoid making mistakes that might incur a costly suit to the school district. My sense is that school personnel genuinely want to help students be successful and assist the teachers on the front-lines who must instruct and manage potentially difficult to teach children (learning wise or behaviorally). However, the school district, without adequate funding from the federal government, also must attempt to conserve money that has been previously designated or reserved for the non-disabled majority of children in their general classrooms.

I recognized this tension 20 years ago and in my book, Running on Ritalin, that describes the cultural milieu of ADHD, I subtitled the chapter on learning disabilities and ADHD -- The Snake Eats Its Tail. The average learning disabled child placed into a small enrollment special day class costs the district about four times the education of the non-disabled child. If a child is placed in a private school setting, costs to the district can range from $20,000 to over six figures a year for residential "schools."

It is this last category -- placement in residential school for "learning" problems that is generating the most heat and controversy. In the case two years ago before the Supreme Court a very wealthy family sued the school district to pay for private school placement for their child who had never attended public school. In the current case before the court, a single mom with much less means is attempting to get funds for her son from the school to pay for residential placement for problems that appear primarily behavioral in nature (drug use, running away, oppositional behavior). Unlike the first child, this boy did attend a public high school but never tried a specialized public setting.

IDEA does not cover emotional problems per se. However, in a controversial administrative decision eighteen years ago, the Department of Human Services, under heavy lobbying pressure from drug company funded self-help groups like CHADD, added ADHD/ADD to the list of covered diagnoses of IDEA under the "otherwise health-impaired" (OHI) category. School psychologists predicted at the time that the vague definitions of ADHD, particularly in the borderline case, or its common association with learning problems and oppositional defiant disorder, would lead a rapid increase in the diagnosis. Indeed, the explosive twenty fold rise in the use of drugs like Ritalin and Adderall over the past two decades began in 1991, the same year ADHD was added to the IDEA covered diagnosis.

No matter -- I've been evaluating and treating children for ADHD for over thirty years and I can tell you that it's virtually impossible to distinguish the behavior symptoms of an under motivated adolescent with mild learning problems from that of a newly diagnosed teen ADD (I make the exception of a child that has struggled with impulsive behavior and hyperactivity since the toddler years -- even if he/she only comes to the doctor's attention as a teen for the first time). So the diagnosis become legal cover to allow for services and in its extreme, allows for a kind of extortion from institutions with deep pockets -- in this case the school districts.

There are many difficult to educate children who just won't make it in the regular classroom despite noble and vigorous efforts at inclusion. A very small minority of those children will not be able to live at home either (primarily for safety reasons -- threats of suicide, aggression towards others, running away). Very few families can afford residential placement (running about $40,000 to $60,000 annually). Diagnoses are stretched and contorted to justify or force school district participation in coming up with funding that is often negotiated between the family, their medical insurance company and the schools. School districts threatened with suits often just settle because it is cheaper -- but many have been hoping for more restrictive guidelines emanating from a Supreme Court decision if not by Congress.

For you see for every child funded by public education in a private residential setting you lose about one teacher's salary for the regular classroom. This places inevitable pressure with static or decreased funding to increase classroom size. As classroom size increases and the teacher can provide less individual attention and feedback, the borderline coping learning/behaviorally disabled child becomes more symptomatic and crosses the threshold into qualifying for services, leading to more funds designated for special ed away from the classroom and on it goes. The snake eats its tail.

I'm not certain what the solution is. The basic causes for this conundrum of care are deeply societal and I try at least to delineate them in my book, The Last Normal Child. I fear many will read this blog as anti-child and anti-special education. If so, the same criticism could be leveled at the thousands of special ed teachers and administrators who have devoted their careers (at a personal financial cost) to helping children with special needs. I believe some better balance on the public school funding issue for private placement must be reached. If not some, five to ten years from now there will be an even greater backlash by the general community over the needs of those who are labeled as different.

The Supreme Court Judgment Against Wyeth Is HUGE!

Lawrence Diller, M.D. — Thu, 05 Mar 2009 16:36:05 +0000

The Supreme Court yesterday gave one to the people at the expense of corporate power. In a 6-3 decision, the Court upheld a Vermont Supreme Court verdict awarding a large judgment to a woman who lost an arm against the Wyeth pharmaceutical company. Wyeth had appealed the decision on the basis that once the Food and Drug Administration approved a drug, a company was shielded from individual suits. For those who are concerned about corporate power and health care (I for one feel that for profit drugs companies are single biggest influence in the way our society -- read doctors, parents, teacher and even kids -- thinks about normal and abnormal behavior in children and how to treat them -- read drugs) the possibility, that the right to sue a drug company over an FDA approved medication be eliminated, was frightening.

And there were reasons to be frightened. Earlier in this term the Court had ruled against a plaintiff who sued over a medical device saying that the right to sue was explicitly denied in the law governing the approval of medical devices. It was over this "technicality" that the justices decided in favor of the plaintiff in this drug case. In this current case there is no explicit waiver of the right to sue in the approval of a drug by the FDA and the justices felt to expand this prohibition abrogated too many rights of the patient. Even Clarence Thomas who rarely votes against his "twin," Antonin Scalia, decided to side with the majority making the decision much more impressive at 6-3 instead of 5-4.

As an M.D. I was never a big fan of trial lawyers but in my dealings with the drug industry over the last two decades I've seen the extent of their power in my field of behavioral-developmental pediatrics in an unchecked, pro-business, post Reagan/Bushes environment. There's lots of reasons why a brain based view of behavior has gained ascendancy in the American consciousness, but from the sponsoring of medical research and medical education, to direct to consumer advertising and to free samples of drugs, the drug companies in my mind have been the single bigger factor promoting biological psychiatry. Drugs do work (at least short term) and can be a very useful intervention. I prescribe medication every day, but I remain opposed on both medical and ethical grounds to a medication first or medication very quickly approach to children's emotional, behavioral and performance problems. I feel like I've been working on an increasingly steep Sisyphisian slope for the last fifteen years.

So in America where the only way anything happens is if someone can make some money, the trial lawyers have been, in my opinion, the only check against increasing corporate power in our society. Supervising government agencies have been castrated during Republican administrations. Most politicians have huge contributions coming from industry lobbyists (Charles Grassley, the senator from Iowa stirring up "s" for academic researchers taking money from drug companies is a startling exception).

Using suits as a check against corporations is not a particularly efficient method (the lawyers take typical from thirty to fifty per cent of settlements) but taking on a Fortune 500 company with all its resources is a very daunting proposition. Many of the lawyers who have taken on the drug companies have had to borrow and scrape. I know one guy in the SSRI and pediatric depression suits who was about to be thrown out of his home because he had second mortgaged it to keep a suit going. I remember when the FDA added the black box warning to the SSRI label, he and his staff danced on the tables of a restaurant, feeling elated and saved.

So here I am a doc who's come to defend trial lawyers and the right to sue. I know they can also sue me for malpractice and have no doubt added to the cost of practicing defensive medicine. But doctors also have a great deal of power in the society and without the check of suit, their fraternity often bands together to protect one of their own. Anyway, the Supreme Court's decision yesterday protected a very important right for the American people in keeping a balance between the profits of industry and the ethical health of our country.

FALLING FROM MT. OLYMPUS FOLLOW UP

Lawrence Diller, M.D. — Mon, 19 Jan 2009 00:48:38 +0000

Joseph Biederman, America's foremost child psychiatrist, and in the midst of a serious conflict of interest scandal, has agreed to temporary limitations in his role as director of Harvard's Massachusetts General Pediatric Psychopharmacology Clinic. Dr. Biederman, pending the outcome of an ongoing inquiry has "agreed to stop participating in several industry-funded trials" and "agreed not to participate in any outside activities that are paid for or sponsored by industry, such as consulting activities or speaking engagements," according to a statement released by the hospital.

Biederman has strongly pushed a biologic pro-psychiatric drug position on children' mental illness. Information garnered by Senator Charles Grassley's investigations and statements by Biederman uncovered in court related actions has revealed both undeclared drug company financial support to Biederman and commitments on his part to further the commercial interests of the drug giant, Johnson and Johnson. These reports threaten to topple Biederman, arguably psychiatry's most powerful voice on children, from his heretofore, untouchable Olympian heights. Meanwhile, Biederman, not surprisingly, has cried foul.

He says the drug company dollars (declared and undeclared) have not influenced him or his research. He claims his science and publications are "pure", supported by a peer review system that is supposed to verify accuracy and authenticity. Finally, he challenges as "office gossip" reports of his legendary anger and intolerance of those who disagree or don't support his proposals.

Ultimately, Biederman's self-defense betrays the same rigid ideology and personal patterns that have led to his current troubles. His situation, however, is emblematic of most of a very compromised medical research and academic community that has become dependent on industry money for its very existence.

It is true that the Biederman team has published thousands of psychiatric papers in peer reviewed medical journals. However, the most fundamental assumptions of any scientific model are often the most challengeable. All of his research exists on the shaky foundation guiding modern American psychiatry first described by the edition of Diagnostic and Statistical Manual of Psychiatric published in 1980 (DSM-III). With minimal research the DSM declared that "disorders" were categorical (either you "got it" or you don't) , specific and non-context based (only symptoms were important). While not stated, it was strongly implied that disorders were biological and genetic in nature.

Any front-line practitioner can tell you children's behavioral symptoms vary across a spectrum, rarely fit neatly into one diagnosis and are highly dependent on family, school and neighborhood environments. Yet the "science" of DSM, promoted by the Biederman team, has been a prime cause of the epidemic of ADHD, depression and now bipolar disorder identified in American children. With the diagnoses have come the widespread use of psychiatric drugs which lead to the next problem with Dr. Biederman's defense.

He says the drug companies didn't influence his research. Rather they came to him because of his research conclusions and prominent academic status. The latter is likely the case but Biederman's self-belief that he hasn't been influenced is highly suspect. Virtually all researchers say they are not influenced by drug company money. The influence may be subtle. Doctors rarely out and out lie about their research, but "spin" influences how a study is set up, its statistical analysis and interpretation. Research on drug studies repeatedly shows that drug trial results are tilted towards a positive description of the drug's effects when the research is funded by a drug company rather than the government or an independent agency.

Big Pharma money is most powerful when promoting Biederman's research and point of view over any competing models. Drug companies copy and mail his important papers on psychiatric drugs to every American physician working with children. A member of the Biederman team is at every important meeting on children's psychiatric issues and medical education. Their presence and often the conference, itself, are supported by drug industry dollars.

Questioning or contrary views, in comparison, get scant attention. Only when children die or side effects are severe -- as in the FDA hearings on children and antidepressants in 2004 and the recent publicity over obesity and diabetes caused by the bipolar drugs -- do opposing viewpoints get the country's eyes and ears. Biederman's conflict of interest problems have coincidentally exposed his strong pro-drug views to the public for scrutiny.

Finally, Dr. Biederman's personality and style are not irrelevant to America's children. There seems a ready supply of hubris and arrogance for those who have made it to the top of science's academic pyramids. Fear and intimidation of the Biederman team operate quietly on the small club of child psychiatric researchers. Only when two year olds started taking three psychiatric drugs simultaneously under a Biederman protocol for bipolar disorder did the emperor's clothes become so invisible as to begin the naming of names.

Business ethics, whose main concerns are profit and operating legally, collide with medical ethics which are directed to the patient's benefit, when academic research is dependent on industry money. A new set of rules have to be formulated and enforced to restore doctors' credibility. Long term, a surcharge or tax on trade medications could contribute to a general pool of research dollars but not designated for a particular industry sponsored drug. In the meantime, elements of Greek tragedy inform us to the broader problems highlighted by Dr. Biederman's travails.

Fallen Heroes of Children's Mental Health

Lawrence Diller, M.D. — Sat, 13 Dec 2008 20:43:18 +0000

About two weeks ago, new developments were reported nationally on separate ongoing scandals involving two of America’s top experts in children’s mental health -- making their situations appear worse. The impact is sure to cause untold damage to parents’ belief in these doctors and the causes they espoused.

I’m referring first, to the growing conflict of interest problems of Joseph Biederman, head of Harvard’s Pediatric Psychopharmacology Clinic. More evidence has emerged detailing his relationship between his purported research and psychiatric drug promotion with money coming from pharmaceutical companies. The second story is less prominent, but no less upsetting to both doctors and families with children. Melvin Levine, America’s preeminent child developmentalist, resigned from the organization he founded, All Minds at a Time, while under a cloud of suspicion for child sexual abuse.

These two individuals have been so important in their respective fields that it’s hard to imagine an area of children’s mental health and development that won’t be affected by the loss of credibility engendered by these doctors’ current travails. Without a judgment of innocence or guilt, the mere facts, already reported, potentially diminish the long-term contributions both men have made in their fields.

Biederman’s work is the more controversial of the two. Some say Dr. Biederman, from his position at Harvard and supported by the drug industry, has been the most powerful child psychiatrist in the world over the last two decades. Depending on one’s point of view his work is either revolutionary and pioneering or dangerous and unethical. Biederman has vigorously promoted the aggressive use of psychiatric drugs in children. He is arguably the person most responsible for the pediatric bipolar epidemic sweeping the U.S. and the concomitant use of anti-psychotic drugs (like Risperdal and Zyprexa) in children.

Biederman’s growing conflict of interest problems highlight a systemic issue for American medical research and teaching. Thirty years ago the federal government essentially handed over to business the financing and support of medical school research and their faculties. Three decades later convincing evidence of drug and prosthesis manufacturers’ influence on research threatens the very credibility and professionalism of doctors.

Biederman’s star began to fall this past June when he became the first of a series of physicians “outed” by Senator Charles Grassley’s physician-conflict of interest campaign for having accepted $1.6 million of unreported income from drugs companies. Biederman’s defense at the time was that his interests were “solely in the advancement of medical treatment through rigorous and objective study.”

New court related emails reveal his efforts to obtain funds from the drug giant, Johnson and Johnson, to develop a pediatric drug research center at the Massachusetts General Hospital that included the goal “to move forward the commercial goals of J&J.” The overt contradictions and blatant hypocrisy seem certain on the short term to further erode Biederman’s credibility as an unbiased researcher. Longer-term consequences may result in disciplinary actions from Harvard University and legal problems over income and taxes with the Federal government.

Levine’s influence has been pivotal in international views on children’s learning problems. Previously children were viewed as slow, lazy or both. Levine’s ideas were seminal in the development of tailoring teaching to different learning styles. He’s been the guru to special education teachers and pediatric developmentalists, not to mention, the parents of affected children.

His problems, first revealed last April, involve allegations of child sexual abuse two or three decades old. Unlike the Biederman case, there are no smoking guns yet. Five adults are suing him in civil court. Their lawyer says fifty more adults-abused-as-children or their parents are ready to come forward. But it’s already a tragedy. If it’s true, doctors like me in the field will feel betrayed. It’s the professional equivalent to the shock and despair that Catholic parishioners must feel in learning of the multiple cases of abuse by priests revealed over the past decade.

The challenge for physicians and parents alike will be to appropriately “not throw out the baby with all the bath water.” The medical profession is belatedly beginning a process of reform. There are new rules for submitting articles to professional journals. Senator Grassley has proposed a Physicians Sunshine Act that will require doctors to report payments of more than $500 from drug companies. However, much more regulation is necessary if corporate money continues to be the main source of medical research funding.

Both Biederman and Levine have made valuable contributions to the field of pediatric mental health and development. But our trust in these two physicians has been broken. That is the saddest part, but also a continuing lesson. Never fully trust the biggest supermen in any scientific field. At some point they may be revealed to have some very human frailties and problems.

Palin Promises a Chicken in Every Pot -- The Slow Cooked Death of American Schools

Lawrence Diller, M.D. — Sat, 25 Oct 2008 22:02:41 +0000

Let me start by offending somebody right away when I say I'm a liberal from the Bill Clinton school of pragmatism -- like when Clinton decided to take on long overdue welfare reform. Some may argue otherwise, but there were definite perverse incentives meant to help people, but fostered generational dependency. Of course there are/were criticisms of the Clinton reforms but Clinton and company operated from the heart as well as the bottom line in making the changes.

So why I am sounding so defensive? Because I'm going to share my reaction to Sarah Palin's first (and probably only) policy statement which happens to be on special education which given her Down's Syndrome baby, earns her special and personal interest. I should state my biological pedigree and progeny here. Both my sons are in college and neither had major learning problems. But I've been evaluating and treating learning disabled children for thirty years and Palin's chicken in every pot political promise has me worried.

Palin wants to guarantee to every qualified family of a special-needs child the option to attend a private school at the school district's expense. She intends to do this by getting the federal government to fully fund its obligation to special education which in the twenty plus years of IDEA (Individuals with Disabilities Educational Act) the government has never done. Currently the federal government is contributing forty percent of its share of the funding for special education nationally.

The federal government mandates that every child should receive the optimal individualized educational plan to meet his/her needs. However, since the government has never fully funded these mandates, an adversarial relationship has developed between parents who want these services paid for (sometimes at private settings) and school districts who are left responsible, but have to draw from the general classroom funds to pay for the special services.

Fifteen years ago, I subtitled a chapter of my book, Running on Ritalin, that dealt with special education, "The Snake Eats Its Tail." I already envisioned a conundrum that in order to fund increasing numbers of ADHD diagnosed children, money meant for the general classroom would shrink. Inevitably classroom size would grow and those children on the borderline of ADHD or other learning problems would be pushed to flagrant symptomatology because of the relatively decreased attention from the teacher attending to the needs of the larger classroom. As more and more children met diagnostic and special services criteria, classroom size would continue to grow, making more children diagnostic, and so on.

As it turns out, special-needs kids and the demands on school services have grown for this and a variety of other reasons. As Kate Zernicke in the New York Times' article on Palin's promise, mentions in some districts the funds for special-needs children (usually about 15% of the school population) exceeds 50% of the budget. Every special education director and school superintendent, I know, while sincerely caring about special-needs kids' needs and services, forcefully lament that tug on the general education classroom.

Public schooling was the prize given to the middle and lower classes by the American people a bit over a hundred years ago. The idea was that educated children make better citizens and workers. Most would agree that until recently it worked. Now there are so many factors eating away at public education. At the top, the cream of students is often skimmed off to top private schools while at the other end, children with special needs command a growing part of the public budget. Again if these trends continue (and school vouchers are in this mix) the snake will eat its tail, until nothing will attract anyone to attend the general classroom in public school (except its location and cost).

I acknowledge my complete political incorrectness when I add the other phenomenon that galls and will destroy the general ed classroom -- that increasing tendency for families of means to blackmail the "deep pockets" of school districts into paying for residential care for their emotionally disturbed children. Many school districts cave and pay for at least part of the residential care even though the problems are emotional/psychiatric and not primarily educational (which are the ones mandated by IDEA). It is cheaper to settle than to fight a fair-hearing settlement in open court.

So now I've probably offended everyone. Palin's promise is just that. It'll never happen on the short term because there are too many other interests competing for their fair share of the federal dollars (especially with our current fiscal crises) - even if it's legally owed them. I think it's good that Palin has brought up the feds' persistent penury and weaseing on special education funding. However, lawyers are the ones currently making the most money suing and defending schools.

I'm not sure what the answer should be. Some kids need supported small group instruction. Some of it can happen within a smaller general education classroom environment. I'm far less convinced that primarily psychiatrically disturbed kids should be getting the bulk of their services paid for by school districts - yet I know that money must come from somewhere in the society besides just from the family.

Still more and more kids from the middle and upper middle classes have "disorders" these days - not because of "better diagnosis" - or not only because more premies are living longer, as Kate Zernicke suggests. In The Last Normal Child I posit that our WORRY about our children's feelings has ironically led to a growing intolerance of minor differences in children's behavior and school performance. This profound and pervasive cultural phenomenon will not be addressed by teachers, doctors or legislatures. American business and the Supreme Court will ultimately set limits on how much and who will pay for America's different kids.

Closing Arguments

Lawrence Diller, M.D. — Wed, 22 Oct 2008 22:09:43 +0000

Nassir Ghaemi and I have gone three rounds on "The Truth." I
appreciate his concerns about the dangers of relativism though, I
remained worried about "the truth" when employed by fanatics. In my
own practice of behavioral/developmental pediatrics, parents who come
in with "the truth" about their child's behavior problem often invoke
a reductionistic purely biological explanation and are expecting
medication to treat their kid. I'm ready to invoke a biological
component to the problem behavior. Even environmental influences of
parenting and school are ultimately expressed biologically through
brain chemistry. But just offering medication when there are
potentially effective non-drug interventions is morally dubious.

I instinctively feel that Nassir supports what I'm saying and that
his "pluralism" model (which I think someday I will need a personal
explanation to fully understand) includes this point of view. In the
meantime, let me end by saying drug companies themselves and in
concert working with physicians are not bad. This industry and its
relationship with physicians, though, are in desperate need of a new
set of rules and regulations -- not unlike our current banking and
finance system -- if doctors' credibility and professionalism are to
survive.

The Swimming Cure for ADHD?

Lawrence Diller, M.D. — Mon, 18 Aug 2008 04:12:28 +0000

The Swimming Cure for ADHD?

Michael Phelps’ amazing Olympic triumph belies the notion of a chronic disorder

In the next view days you are certain to read more about Michael Phelp’s childhood including his being diagnosed with ADHD and treated with medication at age nine for two years. A front page New York Times piece on Michael today suggested the diagnosis when his third grade teacher, Mrs. Kines, was quoted in a recent letter to his mother, Debbie, as recalling Michael having “immense difficulties concentrating and sitting still” leading Mrs. Kines to wonder “if he would ever be able to focus on anything.”
A quick Google search revealed a July 22nd local Baltimore TV news piece interviewing Debbie about Michael’s ADHD and a FaceBook essay by Debbie about the same subject. Apparently Michael was a very good athlete, talented in a number of sports growing up (no surprise – most athletic superstars have similar multi-sport histories, e.g. Roger Federer and soccer). But he was also quite hyper and not a particularly good student. So, at age nine he was taken to his doctor, given an ADHD diagnosis and started on medication which Debbie only gave him on school days because his weekends and vacations were filled with sports in which he excelled.
By age eleven he had committed himself only to swimming, which Debbie believes was particularly helpful because it was especially structured and highly regimented given his increasingly intense training. Swimming even for a team is also relatively individualistic. From my years of experience treating children with ADHD, I know that they do better with individual oriented sports like swimming or track (even tennis) compared to team sports like baseball (that’s death for an ADHD with all the waiting around in the outfield) or even soccer. At that point he no longer needed medication for school. My guess is that he had matured significantly or was so excelling at sports so as to feel more comfortable even at school. Debbie feels that Michael as an adult still has some aspects of ADHD. She feels his thoughts at times may still jump around some—apparently though not enough for a national media catering to America’s sound byte short attention span to notice.
Still Michael’s story and success are revealing about the ADHD diagnosis and prognosis in children’s mental disorders these days. I’ve said many times, it doesn’t take much in terms of under performance or misbehavior these days for worried and loving middle/upper middle class parents to take their children to a doctor to at least rule out ADHD. Besides giving parents’ an illusion of security in a name, the diagnosis opens the door for school accommodations and services. Stimulant treatment (Ritalin, Adderall, Concerta, etc.) improves everyone’s performance in boring and repetitive tasks so improvement on medication doesn’t necessarily confirm a diagnosis of ADHD but will definitely increase focus and grades on the short term – especially if there are minor learning difficulties (I strongly suspect Michael’s strengths weren’t in academics in his early years).

Michael’s success cannot be fully explained by his athletic prowess alone. His drive must also be incredible and those qualities of personality – persistence and intensity – can be highly problematic in the childhood years when a child’s interests and strengths are not academic. Things change dramatically once a child finds his/her niche which often doesn’t occur until late high school or beyond.
Michael was lucky in that he was so talented physically that he was already on the path to success at age eleven (which is when he no longer needed the drugs). It is just as well since stimulants are banned on the international competitive level in all sports. Not so surprisingly in America where ADHD is more openly accepted, the NCAA and major league baseball will allow an amphetamine positive athlete to compete if he has a doctor’s note confirming ADHD.
The Phelp’s ADHD story is otherwise important for two reasons. First it calls into question whether we should really be labeling a child with Michael with a mental disorder. One could hardly call him impaired at this time of his life. Yet academics regularly pronounce that ADHD is a life-long disorder. Indeed, perhaps the outcome for the well screened highly impaired university selected children with ADHD is more guarded. But for the garden variety, front-line Tom Sawyers, Pippi Longstockings and now Michael Phelps that make up my and most doctors’ practices, the future is much brighter (once they find their niche).
And that’s leads to the second point – that children with strong persistence and drive who are not academically oriented – who hyperfocus on things they like – but not necessarily what their parents and teachers want – have the potential to do great things. Mrs. Kines in her letter to Michael’s mother continued, on how proud she was of Michael and “it had never been focus he lacked, but, rather a goal worthy of his focus.” So if a diagnosis and medication got Michael and other children like him through a tough time (when their personality and talent peg has to fit into particularly rigid hole, e.g. school) then so be it. But one thing I know for sure -- for the immediate future swimming will be the “treatment of choice” for that hard to fit, slightly hyper, poorly focused kind of kid.

There Are No Heroes

Lawrence Diller, M.D. — Sun, 10 Aug 2008 18:01:00 +0000

Are there no heroes? Can you count on anyone these days without the distinct possibility that they will let you down in the future? The twin revelations this past week of John Edwards' acknoweldgement of his affair and the frontpage New York times story on child sexual abuse charges against America's Preemminent pediatrician, Melvin Levine, devastated me.

First, let's do Edwards. John Edwards along with Elliott Spitzer (what is it with these anti-corporate watchdogs?) were my two heroes when it came to policing the totalitarian power (as in Huxley's Brave New World) of the corporations. In my thirty years of practice as a behavioral pediatrician deciding who gets Ritalin -- for about a dozen years I've come to believe that Fortune 500 drug companies are the single biggest influence in our culture with regards to which child is or isn't mentally ill. The whole field of mental health/illness and treatment gets so tilted when corporate profits are so initimately involved in the process.

Therefore, I was so disappointed that registered Democrats did not more fully respond to Edward's campaign messages which in my mind were the clearest articulations of another way of thinking about America's business "not as usual." I had no problem voting for an ex-trial lawyer as a doctor (remember doctors are supposed to hate trial lawyers because of malpractice suits). I believe, in a society where money speaks the loudest and everybody must make a buck somehow, trial lawyers are the single group able to make money by policing corporations. It's a lousy system because victims must turn over up to half of their compensation to trial lawyers. But on the other hand the cost of doing battle with corporations is enormous because since the late 1880's they have been treated with the same rights as an individual, but one who can live forever and has potentially unlimited resources. I have grown to respect the trial lawyers who mortgaged their own homes to continue a fight against the manufacturers of SSRIs which ultimately led the warranted FDA "black box" warning.

So anyway, I cast an absentee ballot for Edwards in the California primary only to have a worthless vote when he pulled out three weeks before election day. I was bitter. Now I'm relieved and bitter in another way over another guy (this seems very much to be a guy thing, even with women in increasing power) getting narcissistic and hurbristic (his own words) and not being able to keep his penis in his pants. I'm relieved because he is not the Democratic candidate but bitter that another anti-corporate hero of mine has bitten the dust.

Then there is Mel Levine. I know Mel personally (not well) for almost thirty years. There were not many mentors in my field of behavioral-developmental pediatrics when I did my fellowship (there were only three fellowships then, now there are over fifty) in the mid-1970s. I really liked Mel's stuff. He was sensible. His notions that children learned differently and were not necessarily retarded if they couldn't read, seems mainstream now but in the early 1970s it wasn't. He wasn't as family systems oriented as my group at UCSF was, but again there weren't many confreres at the time and compared to the psychoanalysts still dominating my arena Mel was sensible (that word again).

Mel went on to co-edit the definitive textbook of behavioral-developmental pediatrics. He established his own fiefdom at University of North Carolina School of Medicine. He wrote a series of popular books, including the best-selling One Mind at a Time, that became the basis of a popular PBS documentary. He's always been sympathetic to my concerns about over diagnosis and the over and misuse of psychiatric drugs in children but was never willing to publicly support me in print. At times I was disappointed with him, especially over the bipolar issue in children -- not coming more publicly forward about his feelings -- because Mel was so powerful within the field of pediatrics and with the media and public in general. But I still respected him and hoped that he might change his mind in the future.

In the public realm of child sexual abuse claims unfortunately, it's the one arena where you're "guilty, until proven innocent." I don't know what to make of the charges of such a respected individual. I tend not to believe any of it but I am bothered by the one report (if confirmed) that he did physical examinations of prepubescent children without the presence of a parent or another professional. That strikes me as strange and I asked another colleague of mine if my memory was correct that when I was in the fellowship, we used to do physical exams, even on the kids with just major behavioral problems, just for the sense of true completeness (When I began my private practice in 1980 I decided not to do physicals and let the primary care doctor be responsible for that aspect). But even in the 1970s, whether in behavioral or general pediatrics, kids under 13 generally had a parent in the room. My memory is that for boys older than 13, when it came time to examining the genitalia (as part of any general physical exam), the mom (usually the parent present) was briefly sent out of the room (I mean for 30 seconds to a minute). I rarely did full gynecological exams on teenage girls, in which case a female nurse would always be present. So I don't get this private physical examination routine but I still know how troubled children and families can misinterpret even the most benign actions (remember McMaster!).

Since I'm naming names, another doctor, facing trial for child sexual abuse charges in January 2009, is William Ayres, the noted child psychiatrist, ex-president of the American Academy of Childand Adolescent Psychiatry. I do not know Dr. Ayres, personally (his practice was in the Bay Area like mine) but he too is charged with sexual abuse during physical examinations. He settled with one family out of court but then other families came forward (many had exceeded the statute of limitations). The local district attorney feels there is enough evidence to proceed with a trial.

So on it goes. I am not prepared to cast stones because you never know when something horrible like this could happen to you (either as victim or professional). My nineteen year old son says "But what about Barack?" Maybe because he is African-American and Hillary is a woman, the two of them have had to transcend an even higher degree of vetting and purity (Hillary had to deal with the consequences of another philandering powerful man). But I'm too broken by these recent series of allegations and revelations to really trust that this won't happen to anyone I care about in public life.

Say It Ain't So Joe

Lawrence Diller, M.D. — Sat, 14 Jun 2008 19:24:00 +0000

Most parents have never heard of him but Joseph Biederman, head of Harvards Massachusetts General Child Psychopharmacology Clinic, may be the most influential doctor when it comes to determining whether or not children are normal or mentally ill in America. That’s why the New York Times report last Sunday on Senator Charles Grassley’s revelation that Biederman did not declare over $1.5 million in drug company consulting fees is so important, scary and tragic. If true, this scandal is yet one more stake in the heart of American academic medicine’s credibility with front-line doctors like myself and more importantly with the parents of the patients I deal with everyday.

The state of the science of children’s psychiatric medications is so primitive and Dr. Biederman’s influence so great that he may merely mention the name of a drug in passing during a presentation and within a year or two, tens of thousands of children will be taking that drug or combination of drugs – based upon word of mouth between the seven thousand child psychiatrists in America – and even in the absence of a drug trial of any kind.

In 1996 Biederman suggested that drugs like Ritalin might serve ten per cent of American kids for ADHD. By 2004, one in nine eleven year old boys was taking the drug. Also in 1996 Biederman “shocked” the established child psychiatric community by announcing pediatric bipolar disorder criteria that were so broad as to include nearly one quarter of all his ADHD clinic patients. Indeed, by 2008 Biederman and his team at Harvard are more responsible than anyone else for the child bipolar epidemic sweeping America (and no other country) that has two year olds on three or four psychiatric drugs and now, one famous (or infamous) ten year old Newsweek cover boy named Max, who has taken 38 different psychiatric medications in his short unhappy life.

I remember about six years ago my dismay when on the same day I read in the main professional journal of child psychiatry a major article by the Biederman team on the advantages of a non-Ritalin drug pathway for ADHD, I also heard him giving a speech for a Wall Street audience in New York promoting a new drug by Eli Lilly called Strattera. Strattera turned out to be rather a bust both clinically and commercially for ADHD but still I was shaken that so prominent a researcher could be so brazen with his potential conflict of interest appearance.

So what does it mean that Biederman didn’t declare the money? The $1.5 million is only a small fraction of the full amount of research funding Biederman’s clinic receives from at least a half-dozen companies that pay for both the cost of running studies but also the salaries of the doctors involved. Virtually every doctor who receives drug company money says they are not influenced, but nearly every independent study examining the effects of such money says they are. At least Biederman can claim no one company has his ear solely.

The leadership of Harvard’s psychiatry department is strangely silent or even defends Dr. Biederman. These are good men with solid reputations both in drug and non-drug aspects of treatment. Yet they know that their psychiatry department would not exist were it not for drug company money -- what with the withdrawal of federal research dollars over the past twenty five years and the meager reimbursements psychiatrists receive for their services from insurance companies and Medical.
American medicine, with psychiatry the most culpable, has fallen back to a time more than a hundred years ago when doctor credibility was tantamount to the promotion of patent medicine. The Welch and Flexner reforms completely severed ties between medical school doctors and the drug industry – and for decades subsequently there existed a much more ethical balance between the industry and physicians.

This time, I thought reform would only come from outside the medicine – from trial lawyers, government and ultimately big business whose health insurance costs must pay for all of those very expensive me-too trade drugs. However, some small signs within the profession encourage me -- like the growth in the interest for the Carlat Psychiatry Report published by a courageous independent front-line psychiatrist who scrupulously examines paid psychiatric research and refuses all advertisements for his newsletter. More recently, I’m proud of the American Medical Students Association which has put pressure on medical faculty by publicly grading from A to F medical schools throughout the country for their conflict of interest policies.

Now I wait for Dr. Biederman’s explanation and the usual suspects rushing to his defense. But ninety years ago painful news about another “Joe” (Joe Jackson of the 1919 Chicago Black Sox) had the country wishing “Say it ain’t so.” It is with great sadness, I wonder, whether it is not now Dr. Biederman’s turn.