The debate over Vermont's K-12 drug habit
Five-year-old Cyrus Tompkins couldn't look happier than when he's slam-dunking a basketball into a kid-sized hoop.
For a while, the boy plays with his 3-year-old brother, Kyler, who is dipping plastic dinosaurs into finger paint and dancing them across a ping-pong table. Then, at the urging of his psychologist, David Egner, Cyrus wails on a punching bag for several minutes. Invariably, the boy gravitates back to his favorite toy in the therapy room, the basketball hoop.
Hearing the child's rambunctious hoots and giggles, it's hard to believe that, less than 12 months ago, he was suffering from a bout of depression. Last year, his parents, Amanda and Matt L'Esperance of Proctor, brought Cyrus to Dr. Egner after a family trauma left the boy sullen and withdrawn. Somebody had suggested he might need medication, but his mother wouldn't hear of it.
"I don't want drugs and I don't want somebody labeling him with a behavioral problem," says Amanda L'Esperance. "He was just really sad and upset and didn't know how to voice it. It's still rocky, but for the most part he's back to normal."
The L'Esperances' choice -- to medicate or not to medicate their child -- is one that thousands of parents face each day, especially as a growing number of children are diagnosed with Attention Deficit/Hyperactivity Disorder. ADHD, which is actually a class of behaviors marked by inattention, hyperactivity and impulsiveness, affects an estimated 3 to 10 percent of children. Treatment frequently involves prescribing psychiatric drugs like Ritalin -- sometimes to children as young as 3. And that's fueled a debate over the drugs' risks and benefits. The issue has captured the interest of some local mental health professionals, Egner in particular, who points out that Vermont has one the nation's highest rates of Ritalin use.
A quick Internet search turns up a plethora of websites that either tout the miraculous "cures" of ADHD drugs or condemn the meds as a chemical "quick fix." Drug supporters -- many of them parents of children with ADHD -- credit the treatment with improving reading comprehension, boosting academic performance and reducing behavioral problems.
But opponents point out the many unknowns about these drugs' physical and psychological effects on children. Just last week, the manufacturers of the ADHD medication Cylert, which has been on the market for 30 years, announced it's discontinuing the drug after a citizens' group petitioned the U.S. Food and Drug Administration to ban it due to reported cases of liver damage among users.
L'Esperance has been opposed to meds since she was a teen and her sister was diagnosed with an attention disorder. A doctor put the girl on Ritalin, which caused a near-fatal reaction. The girl began seeing Dr. Egner. A staunch opponent of Ritalin and other "education drugs," as he calls them, he switched her to an herbal remedy and helped her learn to focus with play therapy.
Egner's office, above a candy store in downtown Rutland, looks like a cross between an artist's studio and kindergarten classroom. Visitors are greeted at the door by "Caleb," a mopey-eyed Basset hound, and mellow classical music. African masks and oil landscapes decorate the waiting room. Tables and shelves are cluttered with paperbacks, gurgling fish tanks, carved wooden animals and other doodads.
At 71, Egner is bushy-haired, mustachioed and hard-of-hearing -- like an eccentric but lovable grandfather in a Disney cartoon. Dressed in a torn flannel shirt, baggy pants and sneakers, he chases the boys playfully around the therapy room, encouraging them to dig in a mound of "sculpting dirt" or paint on the walls, which are covered with images painted by previous patients.
Each picture tells a story. One mural, the work of a troubled 10-year-old, shows the Titanic hitting an iceberg. Another is a skillfully drawn skull engulfed in flames. "That kid had a monkey on his back something fierce," Egner recalls. And across the room, scrawled in bold, ominous strokes, are the letters "KIL."
But the walls of Egner's office tell another story, too -- that of an iconoclastic doctor and his decades-long crusade against the growing use of psychiatric drugs among children. Newspaper clippings posted throughout the office, some many years old, reveal an almost religious zeal to end what Egner calls "the brave new world" created by Ritalin.
"The pressure put on parents to get their kids on these drugs most people wouldn't believe," Egner says. "The education people deny the hell out of it, but it's there."
Egner has written several articles and editorials on what he asserts is the "missing link" between Vermont's high rate of Ritalin consumption and the state's prevalent use of heroin and cocaine, especially among prison inmates.
In the last few years, Egner, a former special-education instructor and corrections psychologist, has been a vocal proponent of a bill in the legislature that would prohibit public schools from requiring a child to take psychotropic drugs as a condition for attending school. Sponsored by Rep. George Schiavone (R-Shelburne), H.74 is currently in the House Education Committee and shows little sign of moving this year.
But Egner isn't giving up. He points to recent numbers from the U.S. Drug Enforcement Administration (DEA) which show that Vermont's use of methylphenidate, the active ingredient in Ritalin, Methylin, Concerta and several other drugs used to treat ADHD, is among the nation's highest. In 2004, Vermont ranked fifth in the nation in methylphenidate use, down slightly from a year before, when it came in second only to New Hampshire.
What's behind Vermont's high Ritalin use? Agent Tony Pettigrew, with the DEA's New England Division in Boston, says only that the DEA considers methylphenidate "a highly prescribed drug" in Vermont, though not highly abused like other prescription drugs such as Oxycontin, Hydrocodone, Vicodin and Valium. In fact, Lt. Glenn Hall, commander of the Vermont Drug Task Force, confirms that Ritalin "is definitely not on our radar screen" as a major problem on the streets.
Doug Dows, director of the Safe and Healthy Schools program in the Vermont Department of Education, believes the state's Ritalin rap is overblown. For one, he says, there's a popular misconception that Ritalin is only prescribed to children and young adults. "That's just not the case," Dows says. "It's changing every day because children who were put on Ritalin sometimes remain on Ritalin well into their adult years."
More importantly, Dows believes the answer may lie in how the DEA collects its data. He explains that the DEA compiles its statistics from pharmacies and distribution warehouses, which sometimes ship their medications to out-of-state stores. "So if the Burlington Drug Company ships to a pharmacy across the lake in New York State . . . the DEA is supposed to subtract that number" from Vermont's total, he says. Dows doesn't believe that's being done. He points out that five of the top 10 states in per-capita methylphenidate use have small populations, like Vermont.
But the DEA refutes the suggestion that there's anything wrong with its data-collection methods. If Vermont's high methyl-phenidate use is just a statistical anomaly, as Dows asserts, presumably other prescription meds would also appear in disproportionately higher numbers. That's not the case, according to DEA figures. On nearly all other prescription meds, Vermont falls somewhere near the middle or bottom of the pack.
Dows dismisses the idea that there's some "conspiracy" to medicate Vermont children with ADHD drugs. "I think there's a legitimate concern about medicating kids. I'm a reluctant prescription-drug user and I think everyone should be," he says. "But I disagree when people are using a legitimate concern for political purposes. That concerns me."
There aren't many drugs more politicized than Ritalin. As one Vermont school administrator puts it, if a teacher, guidance counselor or administrator merely mentions the word "Ritalin" to parents, the conversation can quickly become polarized. Some parents automatically assume that the school is pressuring them to medicate their kids as a quick fix for a behavioral problem.
The Vermont Department of Education doesn't track how many students take ADHD medications. Usually, the only way a school knows if a student is on those meds is if he or she needs to take them during school hours -- or gets in trouble for selling or misusing them. But in recent years, pharmaceutical companies have developed pills that are more difficult to abuse. And new, longer-lasting, time-released pills only need to be taken once or twice a day, eliminating the need for kids to line up in the nurse's office for their meds.
Whether or not Vermonters are being prescribed methylphenidate more often than others, it's clear that use of all ADHD drugs, including Ritalin, is on the rise nationwide -- and the vast majority of consumers are kids. Medco Health Solutions, an independent subsidiary of Merck and Co., is the nation's largest pharmacy benefits manager, providing prescription drugs to about 64 million people, or about one in four Americans. A Medco study released last year found that between 2000 and 2003, the overall consumption of ADHD drugs among children increased by 23 percent. But the most startling rise was in the use of those drugs among children under the age of 5. Medco reported that spending on ADHD-treatment drugs for that age group had jumped by 369 percent.
Several studies on the use of stimulants such as methylphenidate to treat ADHD indicate that they're most prevalent in predominantly white and affluent communities. That's not surprising, since families with more money, formal education and insurance coverage are more likely to seek out professional help for all sorts of problems, not just ADHD.
But that trend wouldn't necessarily explain Vermont's high methylphenidate numbers, either. Although Vermont may be one of the whitest states in the Union, it's not among the most affluent. Several mental-health professionals suggest another possible explanation: Vermont has smaller schools where attention disorders, behavioral problems and learning disabilities are more likely to get noticed and treated.
Daniel Silverman is a school psychologist in Hinesburg who works as an independent practitioner for several different school districts. Silverman doesn't believe Ritalin is being over-prescribed here. In fact, he says, he sees fewer prescriptions written these days for Ritalin than for other ADHD drugs such as Concerta, the amphetamine-based Adderall and Strattera, a non-stimulant drug.
Silverman, who's been working with kids and adolescents since 1990, performs about 150 to 200 evaluations on children each year. About half, he estimates, are to determine whether the child has ADHD. Silverman says he's seen different techniques used over the years to diagnose ADHD, some that are good and comprehensive, others abbreviated and shoddy. Occasionally, he'll see a child who was misdiagnosed with ADHD while other possible causes have not been considered, such as a hidden medical condition, a below-average reading level, an anxiety disorder, depression or an abusive household. But that occurs less frequently than it used to, he says, especially as diagnostic tools have become more sophisticated.
"I think Vermont is one of the better states [at evaluating children]," Silverman says. "I see a lot of kids who come from out of state who have had much fewer options to be assessed than kids in Vermont."
Silverman has heard of teachers urging parents to medicate their kids, but says he tries to discourage the practice. "Parents typically recoil at the idea of someone saying, 'Put your kid on medicine,' without them really understanding why they would do that," he says. "It's kind of a slam on the parents."
John Stempek, assistant superintendent of the Rutland School District, has heard similar complaints. Several years ago, the Rutland schools had a problem with Ritalin, including some students and parents who abused it; there were even a few school break-ins to steal pills. But Stempek says the district quickly got those problems under control. Today, he says, other ADHD drugs like Concerta and Strattera are more common and create fewer problems.
In all, about 4 percent of Rutland's students are on ADHD drugs, Stempek reports. He believes those medications have helped many kids improve their grades and reduce behavioral problems. "They used to tap a pencil," Stempek says. "Now the Ritalin taps the pencil for them."
Stempek emphasizes that the district has a very clear policy about what they tell parents. "The school's position is that we don't refer any kids for any kinds of medications," he says. "We recommend that if parents notice physical or behavioral difficulties with their students, that they take them to a doctor. We are not physicians. We are not diagnosticians. That's not our job."
Scott Lang, principal of Bellows Free Academy-Fairfax, has also heard parents' concerns about the pressure to medicate. But he says his school's policy is to bring parents to the table and offer them a variety of options. "Medication isn't the solution," Lang suggests. "It's just a tool for the solution, and that's the way we always have to put it out there."
Lang knows how those parents feel. When his daughter was 7, she was diagnosed with an attention disorder and put on medication. "It's tough when you're talking about a 7-year-old needing to take two pills a day. It doesn't feel very good," he says. "It's like, 'What's wrong with me as a parent?'"
Lang believes the medication served his daughter well. She's now 23, successful and due to graduate from college soon. He says his daughter had an interesting way of describing the ADHD drug's affect on her. "She said, 'You know, dad, it's like you're driving in a car and going down a hill and you've got no brakes. Everything's coming at you and you have no control,'" Lang recalls. "'And then I take my medication and slow it down; I have some control and it's not all happening to me at once.'"
The issue of medicating children hasn't been ignored in Montpelier. In the winter of 2002, Ray McNulty, who was then Vermont's Commissioner of Education, appointed a task force of medical, mental-health and education professionals to look into ADHD drugs in the schools. In a March 2003 memo to superintendents, principals and special-education administrators, McNulty wrote, "While research has been done which demonstrates the effectiveness of the use of drugs to treat ADD/ADHD, there remains significant concern surrounding what many consider to be the over-medication of Vermont's children."
McNulty's seven-page memo outlined various legal and medical concerns surrounding the use of ADHD drugs and current research on their risks and benefits, as well as legislation adopted in other states. The memo also included guidelines for teachers, administrators and other school personnel. In no uncertain terms, McNulty advised that the decision about whether to medicate students must belong entirely to parents or guardians, in consultation with their physicians. "It is the view of the Vermont Department of Education," he wrote, "that schools may not condition a student's attendance on the taking of medication for ADD/ADHD."
But some parents say that legislation is still necessary, if only to stimulate public debate on the pervasive use of these drugs. Bruce Lonergan of Bennington has a 15-year-old son, Devon, who was on Ritalin and other medications from the age of 11 to treat ADHD and behavioral problems. "I can't even remember all the drugs he was on. But in terms of diagnoses, he had 'em all," Lonergan recalls. "And each diagnosis brought its own companion medication."
Lonergan recalls that Devon began experiencing problems with his meds, including clumsiness and lack of coordination. "Things would fall right out of his hands, which really frustrated him," Lonergan says. Devon's behavioral difficulties became so acute that he was put into a residential placement facility.
Lonergan eventually brought his son to Egner, who suggested changing the boy's diet and increasing his exercise. Egner also weaned Devon off the drugs. His other doctors weren't pleased. "We got flack for it," Lonergan recalls. "It was their position that we were doing a disservice to our son and putting him at risk by not medicating him. That didn't wash with me."
It took more than a year, but Devon is off all his meds, and is now a sophomore attending a public high school. He's doing much better, though his father admits that his grades aren't as good as he'd like. Still, Lonergan feels like his son is moving in the right direction.
The widespread use of ADHD drugs like Ritalin, in Vermont and nationally, presupposes that ADHD is a disorder, which some experts question. Thom Hartmann of Montpelier is perhaps best known as the talk radio host of the nationally syndicated "Thom Hartmann Show." But he's also a former psychotherapist and founder of the Hunter School, a residential and day school for children with ADHD, and the author of numerous books on ADHD, including The Edison Gene: ADHD and the Gift of the Hunter Child.
In The Edison Gene, Hart-mann contends that many of the symptoms of ADHD, such as impulsiveness, creativity and distractability, aren't signs of a disorder at all, but instead reflect skills that were well-adapted for prehistoric hunting-and-gathering societies. Hartmann, who admits he has ADHD himself, believes that about half the children diagnosed with attention disorders have learning challenges that resulted from external forces such as poor nutrition, environmental toxins and severe stress.
He theorizes that ADHD has become a "wastebasket diagnosis" that encompasses a variety of behaviors, many of which aren't really disorders at all but "variations on the human condition."
"We have a school system that is being pushed to teach in one particular way and to the tune of standardized testing and required periods of rote memorization, and we have millions of children whose brains are wired to learn in a different way," Hartmann writes. "As a society and culture, we have faced two possible responses to this: change the schools or change the children."
Hartmann suggests in his book that the pervasive use of ADHD drugs like Ritalin reveals that society has chosen the latter. And he believes the reduced amount of exercise and playtime children get, as well as their excessive television viewing and video game playing, are all contributing factors. He says that simply increasing a child's physical exertion will increase oxygen flow to the brain, boost endorphin and dopamine levels, and generally improve a child's focus and sense of well-being.
It's an approach Egner has taken for years. As he watches the L'Esperances' son slam-dunk another basketball, he comments that the boy has been focused on the game for almost an hour. "Working with kids this way is a blast," he says. "Some doctors make it so complicated. It really isn't."