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15 February 1980
Mrs. Catherine Boykin
Dear Mrs. Boykin,
Enclosed please find a check for the balance of your fee for
Ian's six weeks at the Charles Town Montessori School. It was
with some reluctance that we found it necessary to end Ian's
experience at your school so very abruptly. Our decision to
write to you is based not so much on our concern that you under-
stand the circumstances of our particular situation as on the
concern we feel for the other children llke Ian whom you will
no doubt encounter in the future.
Mrs.. Fleck and Mrs. Johnson have, as you know. expressed the
opinion that Ian has an attentional disorder (which goes by a
variety of names; e.g.,Attentional Deficit Disorder, Minimal
Brain Dysfunction, Hyperkinetic Child Syndrome. etc.). Mrs.
Fleck urged us to consider giving lan some sort of medication
and recommended we contact a doctor who is currently treating a
child at the school with seemingly similiar behavioral characteristics.
While we did not agree with Mrs. Fleck's diagnosis or method of
treatment, we did follow her suggestion and contacted Dr. James
Ward and discussed this question with him, Dr. Ward suggested
that we pursue this with our pediatrician, Dr. Edward West, in
whom Dr.Ward has a great deal of confidence with regard to this
particular problem. While Dr. West did suggest that the great
discrepancy between Ian's mental and emotional ages could be
the basis for some behavior problems in the classroom, he could
find no evidence of any learning disorder and would never, as a
responsible physician, medicate any child for behavior modification
alone.
Because of our concern for Ian's well-being, we have visited.
over the past two years, several experts in the identification
and education of the gifted and creative. These experts have
included Dr. E. Paul Torrance, professor of education at the
University of Georgia and author of numerous books on the
highly gifted and creative, and Marie Friedel, Director of the
National Foundationn for Gifted and Creative Children In
Warwick, R.I. Both of these authoritles have rated Ian as
extremely gifted and creative and neither one suggested in any
way that he might have an attentional or learning disorder:
In fact, slnce this is a common misconception and many gifted
and creative children Are mistakenly believed to have
minimal brain dysfunctlon. part of the testing included
tuo tests designed to rule out any disorder - the Memory-
For-Designs and Simkov Perceptual. Neither test showed any
indication of any learning disorder. His behavior, however.
is consistent with the characteristics of the highly gifted
and creative as specified by the National Foundation for the
Gifted and Creative on the list enclosed wlth this letter.
Attentional Deficit Disorders are complex and involve not
only education but several specialtles and subspecialties
of medicine, one of which, clinical pharmacology (the study
of drug effects in humans) is my area of subspecialization
within internal medicine. Of great concern to us were the
very strong statements and recommendations from Mrs. Fleck,
which reflected many misconceptions about this disorder and
gross ignorance of the mechanism of action of the drugs used
to treat this problen and the hazards involved in the use of
these drugs. As I stated to Mrs. Fleck, and confirmed by
talking with Dr. Ward and reviewing the extensive llterature
on the subject, neither Dr. Ward nor any of the researchers
who have published papers on this topic believe that there is
at present any hard evidence for a biochemical cause for this
disorder. I would like to emphasize that it is not, as Mrs.
Fleck stated, an enzyme deficiency. Furthermore, the mechanisms
of action of the various drugs used to treat thig disorder are
poorly understood, partlcularly the aspects of their action
responsible for the calming effects. What is known, however,
is the range of hazards associated with use of these drugs.
The two most commonly used drugs, methylphenidate (Ritaiin)
and dextroamphetamine (Dexedrine and others) are Schedule II
controlled substances, the most rigorously regulated drugs
available in the United States. The reasons they are on this
list are the high degree of toxicity and abuse potential. It
is known that about 14% of children treated wlth these drugs
will have hallucinatlons, insomnia, severe loss of appetite or
depression. Most children will have some degree of growth
retardatlon. All children will have an increase in heart rate
and blood pressure, the long term significance of which is unclear.
And finally, whether use of these drugs in chlldren leads to
subsequent drug abuse is unknown, but of great concern to many
experts in this field. Incidentally, Ritalin is not approved
for use in chlldren under six years of age.
Included with thls lettcr are a number of articles and portions
of books we feel are the best of the ones we have reviewed.
Of particular importance is the package insert for Ritalin and
the February 1978 review from Science by Gina Earl Kolata.
Many excellent points are ralsed in this revlew: first, the
cause of this syndrome is unknown; second, that normal and hyper-
active chlldren respond slmilarly to the drugs used in treatment
(which disputes the claim of a biochemlcal disorder) And most
important, that there is no evidence that use of these drugs
improves long term learnlng or emotional adjustment. There is
of course no question but that stimulant drugs can decrease
disruptive behnvior and inprove short term performance on
standardized tests. There is also no question that these
drugs have played a role in the managemeent of this disorder.
However. Mrs. Fleck's recommendation, based upon her many
misconceptions, that one of these drugs-be used in a child
with a few of the behavior. characteristics of this disorder
and all of the characteristics of the highly gifted and Creative,
is most disturblng.
We are greatly concerned for the children for whom the
indiscriminate use of these drugs might be advocated in the
future. As we recognize your expertise in matters of Montessori
philosophy, we would urge you to recognize your need to utilize
the expertise of authorities in the fields of gifted and
creatlve chlldren, hyperkinesis and clinical pharmancology.if
you are to responsible counsel parents of children who fit into
one or more of these categories. More important than commitment
to any particular system is the optimum physical and emotional
development and growth of each child, whether or not they
can be accomplished within the confines of that system.
Respectfully,
Timothy C. Fagan M.D. |
