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February 3, 2001, Copyright The National Journal Inc
kids get thrown out of school for taking drugs. But Michael Mozer was thrown
out of school in Millbrook, N.Y., for not taking drugs, said his mother,
Patricia Weathers. On the advice of school officials and psychiatrists
looking for ways to calm first-grader Michael during the day, the boy began
taking Ritalin, which scientists say alters brain chemistry to boost
concentration. A cocktail of drugs deemed necessary to curb Ritalin's side
effects soon followed. By the fourth grade, Michael had become withdrawn,
periodically angry, and listless. In December 1999, his parents pulled him
off the drugs, and, Weathers said, his mood soon improved. But then, school
officials "kicked him out of school," she said. "They called Child
Protective Services on me and charged me with medical neglect (for failing)
to give him the 'necessary medical treatment.' "
response, Weathers transferred Michael to a private school where, she says,
he is doing much better. Kids "don't need drugs, they need individualized
education" and better family life, she says. "The priorities are all screwed
Weathers found some support for her beliefs in a much-publicized study
released in the February 2000 Journal of the American Medical Association.
The study showed that the use of Ritalin and comparable drugs among children
ages 2 to 14 had tripled during the 1990s. A May 1999 study by Washington
State University showed that the use of such drugs in children ages 5 to 18
tripled between 1990 and 1995. Roughly 5 million children are now using
these drugs, say critics. In Washington, the report prompted politicians as
dissimilar as then-first lady Hillary Rodham Clinton and the House Judiciary
Committee's then-Chairman Henry J. Hyde, R-Ill., to call for reviews of
Ritalin usage or curbs on Ritalin prescriptions. The fight over Ritalin is
only one aspect of a much broader political controversy being stoked by the
rapid advances in scientific knowledge about the brain. The new knowledge is
affecting debates and public policy in areas as diverse as health care,
education, crime, and sex.
crime policy, Congress last year authorized federal Mental Health Courts,
which allow some defendants charged with nonviolent federal crimes to
substitute mental health treatment for jail sentences. In health care,
advocates favoring increased mental health spending trumpeted a report
released in December 1999 by the Surgeon General's office that claimed
mental health problems pose a greater burden to society than cancer.
Throughout 2000, then-Vice President Al Gore, when seeking support on the
campaign trail for a proposed $50 billion toddler-education program, cited
studies of early-childhood brain development. In December 2000, Bill Ivey,
the chairman of the National Endowment for the Arts, claimed that brain
research shows that art is important to "childhood education ... to the work
of rescuing young people who struggle to align their behavior with the
demands of society."
Advances in neuroscience are also reshaping long-running debates over human
nature and behavior. Those on the right generally say that recent
discoveries confirm their long-standing claims about the immutability of
human nature, but they also express concern that widespread use of
brain-altering drugs could undermine traditional behavior-shaping
institutions, such as family and religion. On the left, most believe that
the discoveries about the brain should lead the government to find new ways
to help people, by means of mental health and community-building programs.
But some on the left also say they're worried that this new knowledge could
be improperly used to sort people and push them into particular social
roles, such as motherhood or manual labor, thus curbing personal autonomy.
is a new set of politics coming down the road," said Dr. Steven E. Hyman,
director of the National Institute of Mental Health in Bethesda, Md. NIMH's
annual research budget of almost $1 billion is accelerating the arrival of
the new politics. At his 1997 White House Conference on Early Childhood
Development and Learning, then-President Bill Clinton said the new
understanding of the brain will bring the nation "closer to the day when we
should be able to ensure the well-being of children in every
domain--physical, social, intellectual, and emotional."
past decade, scientists have made significant progress in recognizing and
treating severe mental health problems such as schizophrenia and severe
depression. They've also had tantalizing peeks at the neurological roots of
attributes such as intelligence and aggression. These advances were in part
fueled by federal research funds that began to flow to scientists after
President Bush and Congress declared in July 1989 that the 1990s would be
"The Decade of the Brain."
Scientists now agree that brain activity is shaped by both nature and
nurture. The "nature" component is one's genetic inheritance. Factors in the
"nurture" category include childhood nutrition and the quality of one's
family life and education, as well as maternal hormones that shape fetal
brain growth. Nature and nurture intertwine to produce a person's
intelligence, charm, memory, and countless other attributes.
scientists are only beginning to understand the brain's complex functions.
So, policy prescriptions based on today's knowledge could later go the way
of some earlier claims that were also built on preliminary science. For
example, Sigmund Freud was mistaken, say his many critics today, in his
claim that sexual trauma underlies most mental problems. Vladimir I. Lenin
prophesied in 1917 that scientific socialism and secret-police terror would
evolve a noble human, a new "Soviet Man."
And in the United States,
the U.S. Supreme Court's 1927 Buck vs. Bell decision affirmed the
then-fashionable claim of eugenics scientists that selective human breeding
would improve society. Declaring that "three generations of imbeciles are
enough," the Court permitted states to forcibly sterilize poor and mentally
deficient people, a practice that went on until the late 1970s and affected
some 100,000 people.
of Ritalin and similar drugs grew threefold during the early 1990s, partly
because it was being prescribed more often to boys diagnosed with Attention
Deficit/Hyperactivity Disorder. In children, the disorder's symptoms are
"fidgetiness or squirming in one's seat ... excessive running or climbing
... difficulty playing or engaging quietly in leisure activities ... or
talking excessively," according to the latest version of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR), which is published by
the American Psychiatric Association. (Because the manual certifies the
existence of new mental health problems, health insurance companies use it
as a guide to establishing reimbursement policy.)
addition to the studies showing a tripling of the use of Ritalin and
comparable drugs, a smaller study published in mid-1999 by pediatric
psychologist Gretchen LeFever concluded that 17 percent of white boys in two
school districts near Richmond, Va., were being prescribed such drugs--but
only 7 percent of white girls and 9 percent of African-American boys were
getting the prescriptions.
sudden rise in Ritalin prescriptions and the disparities cited in LeFever's
study have fueled criticism by experts such as Dr. Peter Breggin, who runs
the International Center for the Study of Psychiatry and Psychology in
Bethesda, Md., and Dr. Lawrence Diller, a behavioral pediatrician in Walnut
Grove, Calif. They say the drugs are promoted by school officials and
harried parents trying to pacify unruly schoolboys. "The use of drugs is
cheaper and faster" than other approaches, says
Diller, author of
Running on Ritalin. "But is it the moral equivalent of better parenting
or schools?" Breggin says, "The emphasis on 'brain disorders' in people who
are in conflict with society or their families or schools is a scam."
Ritalin's critics charge that there is no conclusive test for ADHD; and
mental health experts admit they can't yet test for the presence of ADHD as
they can for Alzheimer's, brain cancer, or stroke. "If we are being really
honest ... we are not there," said Hyman, speaking of ADHD testing. He
believes a test will be available in three to five years.
test for ADHD, the federal government, Diller and other critics argue, acted
improperly when it created an incentive for schools to have outside
psychiatrists diagnose students as afflicted with ADHD and put them on
Ritalin. The incentive was created in 1991 by Bush's Education Department,
which acted under the authority of the 1990 Individuals With Disabilities
Education Act to grant schools special-education funds for students
diagnosed with learning disabilities such as ADHD. With a $5 billion budget
for special-education programs, the department gives school districts
roughly $795 for each child diagnosed with ADHD or a related learning
disorder, such as Reading Disorder, Mathematics Disorder, and Disorder of
Written Expression, that is described in the American Psychiatric
Association's diagnostic manual.
parents have joined the backlash against Ritalin, and now reject expert
advice to use it and related drugs. The Colorado School Board and the
American Academy of Pediatrics have tried to make prescribing Ritalin more
difficult. The National Black Caucus of State Legislators in 1999 passed a
resolution that "strongly urged a national examination of the use of
psychiatric drugs and their effects on children." On Nov. 3, 2000, the Texas
state Board of Education voted 8-6 to urge education officials to seek
alternatives to Ritalin.
Ritalin's defenders, such as Hyman, say the drug helps children with mental
health problems to learn, and to become productive members of society.
Ritalin and related drugs are "the best tool we have" to deal with ADHD,
especially when they are combined with behavioral therapies, Hyman said.
Drug industry officials say Ritalin prescriptions are the result of a mental
health professional's diagnosis of a child's needs, and that
up to 10 percent of
children may have ADHD.
of the opposition to Ritalin comes from social conservatives; Democrats are
either neutral or supportive of the drug,
Breggin and Diller said. But Stephen Stryyssar, a self-described liberal and
a member of the state-appointed 30-person education advisory panel in
Colorado, is also a Ritalin opponent. "The only ones who will give me a good
hearing in the legislatures are conservative Republicans," he said. "It is
disappointing that I can't get a good hearing from people in my own party."
Treatment of mental health problems in children is getting more top-level
political support than it used to. Tipper Gore promised during the 2000
presidential campaign to provide more money to help teachers "learn how to
spot signs of mental illness in their students." At the White House
Conference on Mental Health on June 7, 1999, Hillary Rodham Clinton urged
greater focus on mental health treatments for children; she added, "part of
what we've got to do, though, is reflect (on) how we can both identify and
get help to children who need it, whether or not they want it or are willing
to accept it."
neuroscience's greatest accomplishment over the past decade has been to
steadily improve the understanding and treatment of serious mental diseases.
These include schizophrenia, bipolar disorder, severe depression, and
obsessive-compulsive disorder. For all of these diseases, researchers now
have diagnoses and treatments that have received broad acceptance. Over the
past 10 to 15 years, "the weight of this (brain-related) science has ...
shaped (public) understanding of mental illness, and that is moving policy,"
said Hyman. The public has become more willing to view mental illness as a
treatable condition, he said.
shift has prompted Congress and 32 state legislatures to shape new and
sometimes controversial policies to govern insurance coverage for mental
illnesses. Some states have mandated that insurance companies cover severe
mental and physical illnesses equally. But advocates for broad mental health
coverage have had a hard time replicating such insurance victories outside
the relatively narrow area of severe disorders.
According to a report published in December 1999 by Surgeon General David
Satcher, roughly 2.6 percent of the population suffers from "severe and
persistent" mental illnesses. But the report cited a much larger group as
well: "At least one in five people (20 percent) has a diagnosable mental
disorder during the course of a year." These milder disorders include
nonsevere depression, eating disorders, Narcissistic Personality Disorder
(marked by "a pervasive pattern of grandiosity, need for admiration, and
lack of empathy"), Social Anxiety Disorder (marked by nervousness in front
of crowds), and bereavement.
distinction between severe and mild mental illnesses frames the insurance
debate in Congress. Sen. Pete V. Domenici, R-N.M., favors parity with
physical ailments as the right standard to use in designing coverage for
severe mental disorders. His frequent ally on mental health issues, Sen.
Paul Wellstone, D-Minn., supports parity for nearly all mental health
problems that are described in the Diagnostic and Statistical Manual of
Mental Disorders. A Domenici staff member said fiscal prudence requires that
parity in mental health insurance be limited to those severe disorders that
can be diagnosed from physical neurological evidence and stand a chance of
Unsurprisingly, the health insurance industry opposes parity rules. It
argues that any expansion of coverage will drive up costs because many
mental disorders are difficult to diagnose, and many cures can't be
verified. Critics also say the DSM has expanded the definition of mental
illness, and more illnesses mean higher treatment costs. For example, under
the manual's current definitions, mental health experts say that 13.3
percent of the population suffers from a social phobia. That figure is well
above estimates of less than 3 percent in the 1980s and early 1990s,
according to a pair of articles in the February 1996 issue of the
Archives of General Psychiatry.
Social-phobia drugs such as Paxil, and comparable psychotropic drugs such as
Ritalin and Luvox, have been sharply criticized by social conservatives. The
Rev. Richard John Neuhaus, editor in chief of the magazine First Things,
says the new drug therapies for behavioral problems are based on "an
extraordinary simpleminded materialism that views people as machines. Just
turn that screw, relax that bolt, and you can get the machine to operate the
way the mechanic wants it to operate." He added, "That's very dangerous for
free will, for our understanding of good and evil, and for how a virtuous
health advocates such as Satcher reject that charge. They argue that the new
science proves that mental health disorders have physical, brain-based
causes and deeply influence a person's free will. "Free will is determined
by a lot of influences--the environment, internal chemical makeup, etc.,"
Satcher said. That means the federal government must work with families,
religious groups, and others to promote mental health, he said. "It is the
role of the government," according to Satcher, "to make sure there is a
minimum (level of) access to health (care) ... especially for the most
vulnerable amongst us."
Political factions are trying to use the new brain science to support their
agendas. Conservatives, liberals, and libertarians are all "attempting to
put the best spin on it and use it for their own advantage," said Robert H.
Blank, a professor at Brunel University in England and the author of
Brain Policy: How the New Neuroscience Will Change Our Lives and Our
Politics. Policy advocates cite brain-related research in disputes over
a vast range of topics, including sexuality, intelligence, crime, and the
legality of late-term abortions. But in all of these disputes, Hyman said,
both sides must recognize the inability of scientific truth to provide
political solutions to social problems. In some debates, discoveries in
neuroscience won't even produce a shift in the partisans' basic positions.
example, in matters of sexual orientation, advocates from both
traditional-family and gay and lesbian groups say the possible existence of
genes, proteins, or hormones that promote homosexual behavior should be
irrelevant to policy-making. Advocates for traditional-family norms, such as
Peter Labarbera, a senior analyst at the Family Research Council, say that
if scientists ever did find a brain-based cause for homosexuality, it would
not change the traditionalists' opinion that homosexuality is immoral.
Moreover, he said, even in the face of such a discovery, those affected can
still exercise their God-given free will to resist the tendency toward
homosexuality. On the other side, Wayne Besen, a spokesman for the Human
Rights Campaign, said he hopes scientists will find a biological cause for
homosexuality, but that wouldn't change society's duty to accept
homosexuals. However, both Labarbera and Besen agree that the discovery of a
brain-based cause for homosexuality would help advocates for gay and lesbian
rights make their case in political debates and civil rights lawsuits.
like nature and nurture, politics and science are intertwined. Politics
already shapes the direction of brain-related research. For example, Hyman
said, the impact of a person's homosexuality on his or her mental health "is
an area of research that has been self-censored within science for political
reasons." Despite Hyman's willingness to fund such research at NIMH,
scientists generally want to avoid the political controversy surrounding it.
Another reason scientists decline to investigate possible brain-related
causes of homosexuality, he said, is that the American Psychiatric
Association removed homosexuality from its list of mental disorders in 1973.
Thus, homosexuality "doesn't have mental illness implications. ... That's
political, and I understand it," Hyman said.
Similarly, suspicion from the left and the right has slowed research into
possible neurological causes of criminal behavior, said Adrian Raine, a
professor of clinical neuroscience at the University of Southern California.
A study Raine published in the February 2000 Archives of General
Psychiatry showed that a high percentage of criminals have roughly 10
percent fewer thinking-related neurons than noncriminals. Raine suggested
that childhood trauma could account for the disparity. He also said the
Right fears that such studies might provide biological excuses for lighter
sentences, while the Left worries that these studies might be used to
wrongfully identify potential criminals.
Right stands to gain the most from advances in brain science, Blank
predicted. Science, he said, will prove the claim that human behavior is
deeply rooted in nature, thus undermining the philosophical position
associated with the Left that human nature and the brain are plastic, and
behavior can be readily modified by government policies. But any gain by the
Right will not come without controversy, said Charles Murray, a libertarian
author at the American Enterprise Institute for Public Policy Research. His
1994 book, The Bell Curve: Intelligence and Class Structure in American
Life, ignited a firestorm by arguing that blacks' academic tests showed
them to have a lower average intelligence than whites, and pushed them
toward the bottom of society. Critics on the left and on the right argued
that Murray overstated genetic causes for the disparity.
Democratic Party might gain at the ballot box when its politicians offer new
brain-improving drugs and programs to disadvantaged voters, Blank and other
observers predicted. The Republican side shows signs of a split between the
libertarian wing, which argues that people should be free to buy and sell
behavior-improving drugs, and the social conservative wing, which wants such
drugs to remain secondary to traditional character-building institutions
such as religion and the family. But some on the right straddle the issue:
Patti Johnson served until January on the seven-member Colorado School
Board, where she argued the social conservative position that schools should
not promote Ritalin use. However, she said, people should be free to use
these drugs as they wish without interference from the government. "That's
perfectly within their rights," she said, adding that it would be better for
individuals to pull themselves up by their bootstraps than to rely on drugs.
matter what new truths emerge from neuroscience during the coming decades,
scientists won't be the ones deciding how their discoveries are translated
into policy. Pundits, lobbyists, politicians, and voters will have to absorb
each new advancement in knowledge and draw their own conclusions about its
policy implications. Given the complexity of brain science and the tendency
of both the Right and the Left to put their own spin on any discoveries the
moment they appear in scientific journals, establishing policy won't be an