Copyright 2000 Federal News Service, Inc.
Federal News Service
September 29, 2000, Friday
SECTION: PREPARED TESTIMONY
LENGTH: 1707 words
HEADLINE:
PREPARED STATEMENT OF DAVID FASSLER, M.D.
BEFORE THE
HOUSE EDUCATION AND THE WORKFORCE COMMITTEE SUBCOMMITTEE ON
OVERSIGHT AND INVESTIGATIONS
SUBJECT - BEHAVIORAL DRUGS IN
SCHOOLS: QUESTIONS AND CONCERNS
BODY:
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
underdiagnosis 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
A. Either (1) or (2): (1) 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
(a) often fails to give close attention to
details or makes careless mistakes in schoolwork, work or other activities
(b) often has difficulty sustaining attention in tasks or play
activities
(c) often does not seem to listen when spoken to directly
(d) 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)
(e) often has difficulty
organizing tasks and activities
(f) often avoids, dislikes or is
reluctant to engage in tasks that require sustained mental
effort (such as schoolwork or home work)
(g) often loses things
necessary for tasks or activities (e.g., toys, school assignments, pencils,
books or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
(2) 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
(a) often fidgets with hands or feet or squirms in
seat
(b) 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)
(c) often leaves seat in classroom or in other
situations in which remaining seated is expected (d) often has difficulty
playing or engaging in leisure activities quietly (e) is often 'on the go" or
often acts as if "driven by a motor" (f) often talks excessively Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or
intrudes on others (e.g., butts into conversations or games) B. Some
hyperactive-impulsive or inattentive symptoms that caused impairment were
present before age 7 years.
C. Some impairment from the symptoms is
present in two or more settings (e.g., as school (or work) and at home).
D. There must be clear evidence of clinically significant impairment in
social, academic or occupational functioning.
E. 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.
END
LOAD-DATE: September 30, 2000
