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Brain Politics by Neil Munro


The National Journal, February 3, 2001, Copyright The National Journal Inc.; Reprinted with permission.
Some 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 By the fourth grade, Michael had become withdrawn, periodically angry, and listless.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.' "

In 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 up."

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.

In 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.

"This 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."

In the 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.

But 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.

Ritalin Reversal

The use 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.)

In 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.

The 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.

With no 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.

Many 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.

Most 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."

Can Insurance Cope?

Perhaps 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.

That 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.

This 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 being cured.

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 society operates."

Mental 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."

Science Meets Politics

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.

For 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.

But 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.

The 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.

The 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.

No 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 easy task.

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