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A Talk with the Producers Marcela Gaviria and Marty Smith talk about what they learned in the course ofresearching and reporting  FRONTLINE's Medicating Kids.

What got you interested in the story?

Martin Smith: It came from my own personal experience. I have two children who are in grade school, and I knew of friends of theirs who were being medicated, and I knew friends of theirs who had been diagnosed and not medicated, and then I realized how common it was. And then it hit us personally. We were told by the teachers that we should have our own children looked at. But I was just aware of it because you cannot avoid being aware of it, as a parent of a grade-school child.

I think there's a lot of gurus out there that are convincing parents that this is the most understood disorder in the history of psychiatrics, and I don't think that's quite the case. Marcela Gaviria: From my perspective, it was kind of bizarre because I actually studied psychopharmacology at the university. So I was very much, at least in my younger years, in tune with these medications, and very much a believer in them, I suppose. So I guess we were coming from very different backgrounds.

MS: Let's say I was very leery--I would say that--of the whole phenomenon, because it was so new. Just as with Cyrille DuPerret, it hit us like a cold shower.

Did either of you "switch sides" during the course of your research on how you felt about psychopharmaceutical medication for children?

MS: I think when we began the project, Marcela and I had many discussions in which she was more positive about medication and I was more dubious. And I think as we did the project, we both came to a middle ground where we realized that it applies in some cases and not in others.

MG: Yes.

MS: I think I came to the point of view that you have to take this issue case by case, and that there are cases where these drugs appear to be helping, and there are cases where this seems like clearly an over-diagnosis.

MG: Yes, definitely. You just start wondering when it's helpful and when it isn't. When you think it's going to be helpful, the kid actually might not have been helped, and vice versa. But I also was born and raised in a culture that doesn't medicate their kids, and where all of these diagnoses just don't exist. So it was an eye-opening experience to see so many kids in these classrooms that are medicated.

Were there things that surprised you in your research, that you didn't expect to find?

MG: When I used to interview all these parents, I was sort of amazed at how easily they accepted medications in their lives, for the most part. I think I must have interviewed around 50 families, and for the most part everybody was pretty gung-ho on these things, and hadn't really thought about the long-term implications too much. So that was kind of weird.

So you found there were many more families that were open to medication than were leery of it?

MG: Yes. It was hard to find, actually, Cyrille DuPerret.

MS: But it wasn't hard to find families that had initially gone down the medication route, who then had second thoughts about it. So it's not to say that everybody just goes down this road and is happy forever after. I think one of the things that surprised me is how many kids seem not to enjoy the medicine at all. ... Getting the dosage right is a very difficult thing for the psychiatrists and for the families.

What didn't they like about it? How did it make them feel?

MS: We hear different comments from different kids, of course. But jittery is one of them.

MG: And most of them will say things like, "I don't feel like myself." That's the most common comment.

MS: And the parents worry about the side effects, such as loss of sleep or reduced appetite.

Isn't it true, too, that although Ritalin in particular and all these drugs have been studied a lot, [researchers] haven't done a lot of longitudinal studies? They don't really know what the long-term effects on these kids will be?

MG: They haven't done a lot of longitudinal studies, but these drugs have been used since the 1960s. So far, you've got a lot of patients that have been on it for a long time. So I think there haven't been serious studies of that sort, but on the other hand they've been in the market for a while, and usually drugs that are dangerous get taken off the market.

MS: The one thing that I've heard said about these drugs is that they leave your system quickly. The amphetamine class (such as Dexedrine and Adderall), they go in your system and then they leave your system; whereas drugs that are in the antidepressant class, like Prozac and Zoloft, they know less about what those drugs' long-term effects will be. For one, they haven't been around that long. And two, they don't leave the system so quickly.

How did you pick Denver as a community to look at? I know that there's a lot of disparity among different communities in terms of the rate of ADHD diagnosis and stimulant prescriptions. Where's Denver on that continuum?

MG: I think that we didn't necessarily want to go to a place that had a lot of over-medication. We wanted to go to just a typical place. We were looking at some of the statistics about where the incidence of ADHD was, and it's generally in suburban white middle-class communities. So you can narrow down a certain amount of places based on that. Something very interesting was occurring in Denver, October 1999, about four months before we started research, which was the school board issue. So we felt like it was interesting politically. Something had happened there and issues were being discussed.

MS: The school board had held hearings on whether or not the schools were pressuring parents to put their kids on Ritalin, so it had become a political issue in the communities.

MG: That was the first time that it had ever happened, nationwide, where some kind of a resolution like that had been put into effect. Even if it was non-binding, it was at least getting a lot of coverage in Denver. We thought it would be interesting to see how families reacted to this very personal, intimate decision when all these headlines were saying extreme things, like "kiddie cocaine" or, vice versa, "This is the best thing that ever happened."

Was it hard to get them to open up? The stories in the film are very personal. I imagine that it was difficult for the families to talk about some of this.

MS: Marcela was responsible for approaching the families and talking them through what it would be like to participate. She spent a lot of time with them, and I think that was key. We also made the decision to work with a [digital video] camera, and put a crew into the homes of these families for many more days than we regularly would spend. Because of the lower cost of shooting with DV, we were able to spend a lot of hours and get them acclimated to being filmed.

Why do you think they agreed to do it?

MG: I was definitely looking for families that wanted to participate because they felt that their experience would help other people. Sometimes people want to participate for the wrong reasons, but I was confident that these families had been through certain things, and that they wanted to participate because of their desire to help other families understand what this is like.

MS: I think also, parents that go through this feel that there's a lot of misunderstanding, and that other parents misunderstand their decision to medicate or their decision not to medicate. This was an opportunity to go public and to show and discuss what it was that they went through. So I think that they felt that they might reach more understanding even within their own communities, as well as help families beyond their communities.

What about the controversy over definitions? I know there's a lot of debate both about the etiology of ADHD and about how you actually diagnose ADHD. Where did you end up coming down on that? Do you think it's a brain disease? And do you think it's a definable condition?

MS: That's the million dollar question!

Well, if you can't answer definitively, did your feelings shift towards one end of the spectrum or the other?

MS: I think there's a portrait of the scientist in the story. Dr. Castellanos at the National Institute of Mental Health gives the most compelling evidence that I have ever seen that there is some kind of brain difference. However, the diagnosis that is used to determine whether a child has ADHD is a subjective set of questions. There's a big difference between the kind of work he's doing in the laboratory with the MRI, and what happens when a child goes to see a psychologist. Of course, depending on [psychologists'] training and sensitivity and prejudice, the diagnosis can vary quite a bit.

MG: In general, I feel like there's been a huge tendency to simplify this as a brain disorder. I think a lot of doctors would do the community a lot of service to say, "The brain is the most complex thing that we know, and definitely something is up there. But we can't pinpoint it, and we can't pretend that we know these answers." I think there are a lot of gurus out there who are convincing parents that this is the most understood disorder in the history of psychiatrics, and I don't think that's quite the case.

What is it about the ADHD issue that makes it, of all the psychiatric diagnoses, so politicized and so polarized?

MG: It's politicized because kids are the most innocent, impressionable beings out there, and we have a hard time believing that there could be something wrong with their brains, and that they have a mental illness. On the other hand, mental illness is hard to pinpoint because they don't have a litmus test to figure out what this is, who has it and who will get it. So therefore it becomes a very difficult and subjective diagnosis.

MS: Yes. I'd add that schools also are battlegrounds, for a whole set of reasons. We have gone through a revolution in our educational institutions. We have larger classrooms. We have open classrooms, which make a child who has maybe some relative difficulty concentrating a more challenging experience. Together with a larger classroom, it's of course going to be harder for teachers to handle children that in the bell curve are outliers in terms of attention or impulsivity. So a lot of people who are told that their children are at fault, turn around and say, "No, it's the school that's at fault. They aren't teaching our children correctly."

Another reason it's highly politicized is because there's a tremendous amount of stigma when a public institution tells you that something is wrong with your child and wants to label him. And so I think that's another reason that it's not just a private family matter. It's between the family and a public institution.

Is it your sense that the rate of diagnosis has peaked? Or will it keep going up?

MS: I believe it's still going up. I think that the rate of prescribing medications to children is rising, and I think that you're seeing more and more of the antidepressants, too, and not just the stimulant class.

MG: I definitely think it's going to keep on going up. And the proof of that is how the pharmaceutical companies are practically each one developing three new products for ADHD that will be out on the market by the year 2002. So they clearly see a growing market.

What about the kids in the film? Is there an update on how they're doing?

MG: Noelle is still in the seventh grade. She got straight As last semester. She went on to the state gymnastics championship and won it. She's doing beautifully, and has switched from Ritalin to Adderall. Initially she didn't like it, but seems to be on the right dose of Adderall at the moment, and doing quite well.

Alex is still struggling in school. He was getting Cs in class, and a few Ds. The plan is to take him off the antidepressant Effexor this coming summer. He is going to be on Adderall probably throughout school, according to his psychiatrist. Actually, I think the filming did a lot for him as well. I think he's the one that blossomed with the attention, and it was a very positive experience for him.

Then there's Robin. My latest update is that he's no longer taking medication. Apparently the teachers in his new school say that he's a completely different kid than he used to be last year. Apparently he's doing really, really well without the medications, according to his mom. He's very popular and adjusting very well.

Nicolas is not taking medication. He is in kindergarten. They did switch his teachers once during this period, because he didn't adapt that well to the first one, but he's doing beautifully with the next teacher he has.

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