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interview: dr. harold koplewicz

Vice chairman of psychiatry at New York University, Koplewicz believes that ADHD is a legitimate brain disorder. He wrote It's Nobody's Fault: New Hope and Help for Difficult Children and Their Parents. He is also director of the New York Univ. Child Study Center

FRONTLINE interviewed Koplewicz on September 11, 2000.

You've been a child psychiatrist since the 1980s. Tell me how it has changed. What did you know then that is different from today?

The largest change that we've seen in the past 20 years in child psychiatry is a change in the way we think about psychiatric illness in particular. It wasn't that long ago--maybe around 40 years ago--that we blamed mothers who were very cold and who didn't pick up their children enough times for causing autism. . . . It was only 20 years ago that we started to realize that it was caused by kids who had brain damage; that kids who had autism had different brains than kids who were "normal." . . .

We used to blame moms who have children with Attention Deficit Hyperactivity Disorder for being inconsistent or for being lazy or for working or for getting divorced. . . . The change that has occurred in that antiquated way of thinking is that these are no-fault brain disorders. These are disorders that occur in the brain, that have very specific symptoms; these are kids who are harder to parent, but aren't caused by inadequate parenting. They're also not children who are just lazy and willful and that they're just causing difficulty. They really don't have an easy time paying attention. It's like telling a kid who has to wear glasses, "Squint," you know, "Just try harder. Try to see the blackboard," when there's something wrong with their eyes. . . .

What about the impact of the discovery of these medications? It definitely alters the views of psychiatry. How has it altered your practice?

. . . The good news is that the medications are remarkably safe. The reason that they're so safe is that you take them and they have a very short half-life, meaning that you metabolize them very quickly and they're out of your system in several hours. Because of that, you have to know that they only work when you take them, so that this is a treatment, not a cure. When it does work--and it works in about 80 percent of the cases--you see children who, all of a sudden, are able to use their intelligence, able to use their wit, their charm, so that they can focus on the blackboard. They can listen to the teacher. They can pick up social cues. . . .

A lot of parents have a hard time giving kids medication. How would you allay their fears and make them feel a bit more at ease?

I can understand completely why most parents wouldn't want their children taking medicine. . . . But if you have a disorder, if you have a real illness, and if the illness is Attention Deficit Hyperactivity Disorder, the only treatment that we know is effective is medication.

There are other treatments that might be helpful in addition to the medicine. But to date, the first line of attack is medication. Therefore, parents have to look at two things. They have to look at the potential side effects of giving their child the medicine, and the potential side effects of their child not taking the medicine.

The potential side effects of taking this medicine are usually very short term. They decrease your appetite and they decrease your ability to fall asleep. The good news is that frequently those two very common side effects disappear with time, and sometimes when lowering the dose, they will be able to get rid of those effects.

I can understand completely why most parents wouldn't want their children taking medicine. . . . But if you have a disorder, if you have a real illness, and if the illness is Attention Deficit Hyperactivity Disorder, the only treatment that we know is effThere are some less frequent symptoms that are very bothersome. Kids will become more zombie-like; they seem to lose their spark. They don't seem to be as fresh and as with it. In those cases . . . even though the child's able to pay attention, you've lost the essence of who that child is. The good news is that all these side effects are short term and are reversible. If you stop the medicine, the side effect goes away.

The thing is that I think most parents worry about are the myths about these medicines. They think, "If my child takes this medicine, I'm teaching my child how to take drugs." The truth is that kids who have ADHD who don't get treated are much more likely to abuse illicit drugs, bad drugs, than kids who take the medication. Because when you're taking the medication, you're less impulsive; you're more attentive; you're more on-target. And you're also learning, hopefully, from your parents and your doctor that you have a more sensitive brain, and that you should really avoid these bad drugs like marijuana and cocaine and even alcohol, because they may have a stronger reaction in you than it would in an average person.

The other piece that we have to think about for parents is that they worry about the kids' growth. Will my child not grow? Well, the evidence after many, many years of following children who took medicine and are now 25 or 30 years after being diagnosed and treated is that kids who take the medicine on a long-term basis seem to grow slower than children who don't take the medicine. But they eventually reach full growth. So it's not stunting. It's just, in many ways, slowing down the growth. . . .

If you don't give the child medicine, there's a ten times greater rate of your child dropping out of high school than the average child. When you drop out of high school, your risk for driving problems, for problems with the law, problems with getting employment--all become very, very high. One has to really question whether or not to give medicine based on those decisions and those facts, rather than just on the feeling that, "I don't want my kid taking medicine." Because no one really does want that. . . .

I suppose the fear stems from the fact that these drugs are classified as Schedule II drugs. Do you believe that these medications warrant that classification?

. . . We hear about children abusing Ritalin or selling their Ritalin, and it always baffles me, since it's a lousy drug of abuse. It doesn't make you high; it doesn't give you the euphoric feeling. Kids supposedly chop it up and snort it. I think the only thing it's going to do is make your nose bleed. It's going to make you super-focused, but it doesn't sound like a great recreational drug. So I question the necessity of keeping Ritalin on a Schedule II. . . .

Is there under-medication or over-medication of ADHD kids?

I don't know if there's under-medication or over-medication . I'm not sure if the right kids are getting medicated. That's part of the problem. To do a proper diagnosis of a child who has a psychiatric illness or a child who has ADHD really requires time. It takes time to interview the mother and father. It takes time to get a hold of a questionnaire, for observation from the teacher. It takes time to examine the child and talk to the child. And all this then requires some thinking and putting together and synthesizing this information, to decide what is the possible diagnosis, and what else could be causing these symptoms.

When kids are being diagnosed by primary care physicians on a very, very tight time schedule . . . I question whether or not the right children are always getting the medication. There are also certain populations in the United States that are very opposed to giving their children medication. Historically, the African-American population has a bias against giving psychostimulant medication to their children.

. . . There are regional differences in the United States. For some reason, we find now that the southeast part of the United States seems to have higher prescription rates of Ritalin and Ritalin-like medications versus the rest of the country. I'm not sure we know enough as to what is happening in those parts of the country, versus other geographical parts of the country, that is affecting the prescription policies and the prescription practices.

And then there's the fact that the US doles out, I think, five times more prescriptions for Ritalin than anywhere else in the world. How would you explain that?

The United States uses more Ritalin than any other country in the world. And I'm not sure if that's something to be ashamed of or something to be proud of. I'd be interested in knowing if we use more antibiotics than anyone else does, and if we use more chemotherapy than anyone else does. Do we use more asthma inhalers than anyone else? So the fact that we might be more sophisticated in identifying these children and offering these children treatment is not something that we should be ashamed of. It's something worth examining.

What are the biases in other countries? For instance, in Italy, Ritalin and Dexedrine are not permitted. So what is the effect? How do you take care of those children? There can't be a country that is free of Attention Deficit Hyperactivity Disorder. So you start looking at high school graduation rates. In the United States, nearly 70 percent of the population graduates high school. In Italy, it's 28 percent. Now, I'm not suggesting it's all Ritalin. It may be cultural biases also. But there's no doubt that, if they had the same three to five percent of their childhood population with ADHD, and . . . they have no adequate or effective treatment, then they're going to run into problems. . . .

We know, most times, that once we find an effective treatment and we let the public know there's an effective treatment, patients start to appear. You've touched on some of the reasons why there might be a rise in the amount of people being diagnosed with ADHD and the amount of prescriptions out there. What's behind this trend, this increase in people being diagnosed?

. . . The reason for increased prescriptions would most probably be that we have more kids diagnosed, and therefore more children needing treatment. We have an effective treatment. In fact, we know, most times, that once we find an effective treatment and we let the public know that there's an effective treatment, patients start to appear.

I think the best example is another disorder. Look at obsessive-compulsive disorder. When I was in residency training, they told you that people who have obsessive-compulsive disorder . . . were only one percent of the psychiatric population. This meant that, from the people who came to a clinic, one out of a hundred had OCD. Today, since we started doing some epidemiological work on this, we find that it's three out of a hundred of the general population.

What happened in 20 years? Was our water supply different? How did we all of a sudden find ourselves with lots of patients and lots of people in the population who have obsessive-compulsive disorder, when 20 years before, we didn't have it?

The big change was that we found a treatment that really worked--two major treatments. . . . Then we had a whole new generation of medicines, like Prozac and Luvox and Zoloft, and they worked. And then we had a whole group of psychologists who came up with talk therapies that were very effective in treating these disorders. So patients who thought they were going crazy and didn't want to share it with anyone because there wasn't an effective treatment, have now come out of the woodwork and say, "I have OCD and I need to be treated for it. And I'm not even embarrassed about it, because I want to get rid of it." . . .

Does ADHD happen to brighter kids? Is there any study on that?

ADHD happens to everyone. You can have Attention Deficit Hyperactivity Disorder and be dumb, and you can have ADHD and be very smart or be very average. It's clear, though, that it makes learning more difficult. . . .

Is ADHD a mental disorder?

Yes. ADHD is definitely a mental disorder. It's well defined when we say it's a "no-fault" brain disorder. . . . There is something different in the brains, whether it's the metabolism of glucose--the sugar packets that are energy in the brain . . . or whether it's a dopamine deficiency. There are several different theories. But the bottom line is that these children have an unusual brain, or a more sensitive brain, than the average child does.

Why do you call it a mental disorder? Why isn't it just a personality trait?

. . . A disorder, a mental disorder, is a group of symptoms that are not necessarily traits, because traits are not something that we can treat and make go away. They're a group of symptoms that hang together, that cluster around, and that also have a specific type of prognosis. They look a certain way when the child's a preschooler, and they look a certain way when a child is a school-age child, and a certain way when a child's an adolescent or a young adult. Those symptoms are treatable, and when they're treated, they actually disappear. And the prognosis can change dramatically. . . .

Some parents would rather not medicate their kids, even though it's an option and it helps a lot of kids out there. What would you say to parents who would rather not take that option?

. . . For a parent who says, "I don't want to give my child medicine," I would say to that parent that they have to think very carefully about what the potential side effects are of not taking that medication. Will my child be able to be maintained in a mainstream setting? Can they stay in the school? Will they be socially rejected because they're so impulsive and inattentive that they miss all the social cues? What's going to happen to my child because of these symptoms that are causing him so much distress and dysfunction, and is it worth not taking medication?

There are many school districts today that are saying that if a child has had an evaluation and a confirmation that they have ADHD, the parents have to give kids medication. Otherwise, it's neglect. I'm not a lawyer. But I have to tell you that, if that's the only effective treatment to date, you have to wonder why a parent wouldn't want their child to have the most effective treatment, if the child really has had a thorough and effective diagnosis. . . .

Can you outgrow ADHD?

You don't outgrow ADHD. All the long-term studies show that ADHD is a lifetime diagnosis. The symptoms change. Long-term studies show that kids diagnosed as ADHD had problems. They didn't do as well in high school. They didn't do as well in interpersonal relationships. They had more trouble with the law. But more important is the kids who did do well. What made them so special? In those cases, you see that most of those kids took medication longer. They had parents that were really involved in their lives with making sure that the schools were user-friendly for them . . . and encouraging them intermittently to take medicine. . . .

You chose an interesting title for your book: It's Nobody's Fault. Can you explain that a bit?

I wrote a book called It's Nobody's Fault, because after about 20 years of sitting and listening to parents tell me about their children and listening to children, I was struck by how often parents came in to see me and felt guilty or felt angry at their kids, feeling that somehow, someone was responsible and literally at fault for causing their child's difficulty. . . . The evidence is that, while having a child with psychiatric illness is more challenging and more difficult, we need someone to be responsible to do something to make it better. It really isn't anyone's fault that a child would have ADHD.

And yet critics would probably say that all of this appeals to parents because they don't want to feel guilty.

I don't think they should feel guilty. I don't think parents should feel guilty when their children have leukemia. And I don't think that parents should feel guilty when their kids have muscular dystrophy or when their kids have asthma. I think they should feel guilty if they do nothing about it. I think they should feel absolutely awful if they are not getting their children properly evaluated and properly treated.

That's not to say that having any child that's ill isn't more difficult than having a child who's healthy. Having a child with diabetes requires you to watch their diet and make sure that they take their insulin and make sure they exercise. Having a child who has Attention Deficit Hyperactivity Disorder means that they have to take their medicine; you have to be more organized; you have to be more consistent; you have to keep on top of your child; you have to have better communication with the school and with maybe accommodations that your child needs that the average parent doesn't have to do.

I'm not letting anyone off the hook about the responsibility of doing something to make things better. But I think it's unfortunate, and it's downright inaccurate to say to someone, "It's because you didn't wipe that child the right way. You didn't toilet that child the right way. You didn't suckle the child the right way. It's because you worked that this child has this psychiatric illness," when there is no evidence to support that.

But not all mental illness is biologically based.

Maybe all psychiatric illness isn't biologically based, or maybe all psychiatric illness is biologically based, and we just don't know yet. Remember, we're still in the frontier. We still don't know. We don't have a blood test. But the fact that there are genetic influences in almost all psychiatric illnesses, and the fact that psychiatric illness is responsive in many cases to biological treatments, starts to give us more and more evidence that there is a biological component to it.

Now, that doesn't mean that psychosocial interventions can't work. But they have to be very specific psychosocial interventions. For instance, if you're treating someone with depression, we know that a specific type of psychosocial intervention works. It's called cognitive behavioral therapy. We know that just being supportive to someone who's depressed doesn't work, that that is not going to make it better. The depression itself may go away by itself, but it's not the treatment that's making it better. We also know today that, with Attention Deficit Hyperactivity Disorder, psychosocial interventions haven't been proven to be effective. . . .

So there are 6,000 studies, and a hundred and some-odd double-blind control studies out there that proves that ADHD is a valid disorder. Why is there a controversy?

. . . I think that, basically, people have difficulty believing that their children can become psychiatrically ill. How could that possibly be the case? Children are supposed to be happy. Children are supposed to be able to function. Childhood is just synonymous with joy. And I think that a lot of people have trouble with the concept that someone could be so disturbed that they would need medication, and that they would need psychiatric care when they're only six years old or four years old or eight years old. . . .

A lot of people out there say that all of this is just a fraud, that you've invented this disorder, along with hundreds of other psychiatrists and along with the pharmaceutical industry, which just wants to make more money. They say that there is no litmus test diagnosing ADHD, and this is just a whole bunch of subjective symptoms. What do you say to those people?

I think that the most important part is that when you're able to systematically study what these kids look like long term, you start to recognize that without treatment, these children lose out on a normal life. They can't get the joy of getting decent grades. They can't get the joy of being picked to be on a team. They get very demoralized. They don't necessarily get depressed, but life becomes a very demoralizing place. If you're yelled at on a continual basis at your job, you'll quit. If you go to school on a regular basis and you're constantly missing out on whatever is being taught and you start to feel that you're foolish and stupid, you learn to quit. And that's maybe one of the reasons why you drop out. . . .

To suggest that this is a fraud, that somehow children are being abused by these treatments, is really an outrage, because for these kids, to not get treated is really the greatest abuse and neglect. . . .

Other people would say that the only reason you can say that is because most of the studies are financed by pharmaceutical companies, so therefore pharmaceutical companies only pay for drug studies.

That's a great question. I think that we should look very carefully at who's funding science. I think you'll find that, overwhelmingly, the studies looking at treatment have been funded by the federal government. The National Institute of Mental Health has spent millions and millions of dollars looking at treatments. . . . When you looked at the medicines--all different kinds of medicines that basically have the same mechanism of action--they did work, and they were effective. And when you looked at behavioral therapy, you found that behavioral therapy wasn't effective unless they were taking medications. The federal government doesn't have a bias. They're not looking to support one treatment versus another. . . .

But yet there are pharmaceutical companies that do lobby politicians, and are out there and are pushing certain things and trying to get more funding for certain other things. And sales reps come around doctors' offices and invite doctors on cruises.

I don't think the pharmaceutical companies are affecting what the National Institute of Health is funding. I think that the reason why that's considered the gold standard is, to get funding from the National Institute of Health, you have to have a scientific research project that is peer-reviewed. Your peers review it and decide whether or not they think it's scientifically sound to use federal funds to study it.

The other question, though, about sales reps, is worthwhile. . . . Quite clearly, if a rep comes to your office and quickly tells you about a medication that's effective and easy and safe, that may influence your prescription practice more than reading a peer-reviewed journal. . . . And I think that that's a real problem when you have doctors who don't have enough time to keep up to date.

Whether or not doctors are affected by being taken on a cruise, I don't know. I'm a great example. I'm a biological psychiatrist. I'm a pediatric psychopharmacologist. Certainly no one's offered me a cruise. No one has offered me those kinds of perks. I decide what medicine to use for each kid based on what I've read, what I've studied, and what research I've done. . . .

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