Protecting children: the use of medication in our nation’s schools and h.r. 1170, child medication safety act of 2003

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Protecting children: the use of medication in our nation’s schools and h.r. 1170, child medication safety act of 2003

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

HEARING

BEFORE THE

SUBCOMMITTEE ON EDUCATION REFORM

OF THE COMMITTEE ON EDUCATION AND THE WORKFORCE

HOUSE OF REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

HEARING HELD IN WASHINGTON, DC, MAY 6, 2003

Serial No. 108-14

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

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

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COMMITTEE ON EDUCATION AND THE WORKFORCE

JOHN A. BOEHNER, Ohio, Chairman

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

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

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

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

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

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

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

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

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

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

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

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

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

Table of Indexes.......................................................................................................................... 144

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

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

TUESDAY, MAY 6, 2003

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON EDUCATION REFORM,

COMMITTEE ON EDUCATION AND THE WORKFORCE

WASHINGTON, D.C.

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

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

Also Present: Representative Burns.

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

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

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

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

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

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

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

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

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

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

To address the significant problem, my colleague on this committee, who will be here with us shortly, Representative Max Burns of Georgia introduced H.R. 1170, the Child Medication Safety Act of 2003. The goal of this Act is straightforward. It would require states to establish policies and procedures prohibiting school personnel from requiring a child to take medication in

order to attend school. This would prevent parents from being forced into making decisions about their child's health under duress from school officials.

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

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

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

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

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

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

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

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

The decision to treat a child with any drug, but certainly a stimulant like Ritalin, must be made very carefully and only after comprehensive evaluations and diagnosis. It is crucial that

parents be well informed about the drug, both its possible successes and its possible side effects. If it is being considered for their child. And it goes without saying that parents should have the final word in deciding whether or not their child takes a drug like Ritalin.

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

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

Chairman Castle. Thank you, Ms. Woolsey.

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

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

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

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

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

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

you could finish winding up, that would be wonderful.

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

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

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

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

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

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

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

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

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

disorder.

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

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

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

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

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

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

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

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

Chairman Castle. And we will now turn to Dr. Carey.

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

Dr. Carey. Mr. Chairman, ladies and gentlemen, in the last two decades, the United states has

experienced a great increase in the diagnosis of attention deficit hyperactivity disorder, or ADHD, and its treatment with stimulants.

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

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

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

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

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

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

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

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

There is no easy answer to this chaotic situation. The main elements of a solution would be, one, a better diagnostic system; two, better research; three, better education of professionals and the public, and as to the range of normal behavior; four, better individualized evaluations of

children; five, better treatment with greater reliance on psychosocial and educational interventions; six, better monitoring of aggressive advertising by the drug companies; and number seven, better reimbursement schemes so that physicians can be allowed to take the time necessary to do adequate evaluations.

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

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

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

Chairman Castle. Thank you, Dr. Carey.

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

Chairman Castle. Dr. Clawson.

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

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

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

This amendment requires schools to develop policies and procedures prohibiting school personnel from requiring that a child be placed on psychotropic medications as a condition of attending school. Although there have been highly publicized and isolated events that cause us all concern, there is no reliable evidence that such practices regularly occur or that this is a pervasive problem. Medication assessment and prescription is the exclusive role of a qualified medical

professional, not school personnel. The decision to include medication as part of the treatment plan for a child or adolescent with a mental illness should be a decision agreed to by parents and caregivers in close consultation with a qualified and trusted medical professional.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chairman Castle. That is helpful.

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

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

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

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

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

the regular classroom.

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

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

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

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

Dr. Clawson. Yeah. I think that is -

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

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

Mr. Case. Is that process working?

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

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

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

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

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

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

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

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

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

Mr. Case. Thank you very much.

Chairman Castle. Thank you, Mr. Case.

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

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

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

The Child Medication Safety Act of 2003, H.R. 1170, addresses a significant problem facing children and their parents throughout the nation. Some schools unfortunately are requiring parents to place their child on drugs in order to attend school, and I think this is wrong. No parent should ever be coerced by a teacher, principal, or other school official to place their child on a psychotropic drug. No child should ever face the denial of educational services only because they

are not taking a psychotropic drug.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Carey. Pervasive?

Mr. Burns. Pervasiveness.

Dr. Carey. Of what?

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

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

Mr. Burns. The use of the medication.

Dr. Carey. Well -

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

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

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

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

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

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

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

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

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

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

Dr. Clawson. I think this legislation is kind of the after effect of having severe mental health shortages for children and adolescents in this country, and we are trying to legislate telling

teachers, not to say there is a problem or mention medication. My sense is, if we take this blanket approach to where children are being under diagnosed and under medicated, we will put a further pall or further barrier to potential access, although I am not - .

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

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

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

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

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

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

Chairman Castle. Thank you, Mr. Burns.

Mrs. Davis.

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

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

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

seek a mental health professional, whether that was -

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

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

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

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

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

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

a baby, a baby literally, a toddler, on drugs. It is very frightening. Mrs. Davis. Mr. Chairman, I know that my time is up. I would just - I think in some ways it is a jurisdictional issue. I think that if, in fact, we have school districts that are "recommending," then it seems to me that there is a jurisdictional issue here whether or not school boards determine that, in

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

Chairman Castle. Thank you, Mrs. Davis.

Ms. Woolsey.

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

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

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

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

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

My chums in psychiatry say they are concerned about both over- and under diagnosis, but they really are concerned more about the under diagnosis. I, as a pediatrician, am more concerned about the over diagnosis, because I see a lot of kids who are depressed, who have come from

abusive homes, who come to school hungry, sleepy, and the real problem is something other than the putative brain defect which underlies ADHD. So keep up your struggle. You are not going too far.

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

Dr. Clawson. Could you reframe your question briefly?

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

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

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

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

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

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

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

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

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

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

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

Thank you, Ms. Woolsey.

Mr. Wilson.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chairman Castle. Thank you, Mr. Wilson.

Mr. Van Hollen is next.

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

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

belongs in the medical practice and should be diagnosed by a physician.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Chairman Castle. Mrs. Musgrave.

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

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

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

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

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

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

Mrs. Musgrave. Yes.

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

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

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

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

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

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

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

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

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

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

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

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

impressionable they are to the comment that a teacher would make.

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

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

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

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

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

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

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

Ms. Woolsey. I do. Thank you.

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

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

Thank you.

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

Mr. Burns. I would like to thank the panel for your input, and I thank the committee for holding the hearing. I think we are on the right track. I believe we are making progress. Our primary goals are the same on both sides of the aisle; and our goal and our objective is to protect the children of

America and make sure they receive a quality education without the use of drugs, if at all possible. And I support that.

Thank you, Mr. Chairman.

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

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

Table of Indexes

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

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Protecting children: the use of medication in our nation’s schools and h.r. 1170, child medication safety act of 2003

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

HEARING

SUBCOMMITTEE ON EDUCATION REFORM

ONE HUNDRED EIGHTH CONGRESS

Serial No. 108-14

TABLE OF CONTENTS

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

Table of Indexes