When Patricia Weathers's son Michael had problems in his first-grade class, a school psychologist told the New York mother he had attention deficit hyperactivity disorder, or ADHD, and needed to be medicated with stimulants. If not, he would be sent to a special education facility near his Millbrook, N.Y., school.
Confused and intimidated, Ms. Weathers says she consented to put Michael on Ritalin, a commonly used stimulant that doctors prescribe to decrease the symptoms of ADHD - restlessness, disorganization, hyperactivity.
But Michael exhibited negative effects from the drug, such as social withdrawal. Instead of spotting the side effects, Weathers says, school officials again pressured her back to the psychiatrist's office, where Michael's diagnosis was changed to social anxiety disorder and an antidepressant prescribed.
Finally, says Weathers, "I saw that the medicines were making Michael psychotic, so I stopped giving them to him." When she stopped the medicine, the school reported her to state child protective services for child abuse.
Though charges were dropped, the Weathers case has become a symbol of the simmering controversy surrounding attention deficit disorder/ADHD, treatment for it, and the subjective diagnostic tests some critics say has led to an overuse of stimulants in schools.
Though there is no official count of people claiming coercion, (Weathers says some 800 parents have logged complaints of similar coercion on her website www.ablechild.org), child abuse allegations appear to be infrequent, perhaps because states are moving to pass laws that to some degree limit what schools can say or do regarding ADHD and other behavioral disorders.
To date, according to activists who track the issue, seven states have laws prohibiting school personnel from recommending psychotropic drugs for children. Over the past few years, 46 bills in 28 states have either passed or are awaiting action.
Currently, one federal bill, the Child Safety Medication Act, prohibits schools from making medication a requirement of attendance and calls on the Government Accounting Office to track how often schools pressure parents to seek ADHD diagnoses. It passed the House in 2003 but is currently stalled in the Senate.
Yet even as courts and legislatures muddle through the question of offering protection to parents who choose not to medicate their children, controversy deepens over the use of stimulants like methylphenidate - the generic name for Ritalin - by children.
According to testimony given before Congress in 2000, ADHD diagnosis in children grew from 150,000 in 1970 to 6 million in 2000, representing 12 to 13 percent of US schoolchildren.
On the one hand, a recent National Institute of Mental Health study, published in the April edition of the journal Pediatrics, confirmed long-held assumptions that consistent use of stimulants mildly suppresses children's growth - at an average rate of about an inch over the course of two years, in addition to weight loss in some children.
At the same time, another part of the same study gave the use of medication a boost when it comes to the treatment of ADHD. The study showed that strict behavioral regimes, used without drugs, were not as successful as treatments involving stimulants. They suppressed ADHD symptoms in 34 percent of the children tracked over a two-year period, while medication worked in 56 percent of cases.
Yet if the study was reassuring to some who work with children, it was alarming to others.
"The study helps prove that the country is only hearing half the story about ADHD," says William Frankenberger, a professor at the University of Wisconsin, Eau Claire, who has been studying ADHD for almost two decades. "If these medicines suppress growth, you have to ask what else they are doing that we can't measure."
Dr. Frankenberger says pharmaceutical companies pitch ADHD medications in part as a way to help children improve academic performance. While stimulants immediately increase focus (for children with or without ADHD) and often lead to short-term betterment of classroom performance, Frankenberger says his longitudinal research suggests that ADHD medications caused no boost in academic achievement over the long run.
In addition, the length of time a student uses the medication and the type of test given can cloud test results, says Marc Atkins, director of psychology training at the University of Illinois at Chicago. Dr. Atkins, who sometimes works as a paid consultant for Alza, the maker of a popular ADHD medication, calls the NIMH study "cause for some concern" and says it should prompt the medical community to reevaluate the ease with which stimulants are prescribed.
But Atkins - who agrees that schools should not be allowed to mandate medication - takes issue with laws that prevent school healthcare professionals from offering recommendations or a diagnosis to parents.
"To cut schools off from giving parents good information is not what you want," he says.
Frankenberger says one of his research projects examined the origin of initial referrals to psychologists to explore the possible presence of ADHD in children.
"In about 80 percent of the time, we found that it came from teachers," he says.
But overreliance on teacher observations and recommendations to drive use of medication can be problematic, say some experts. It may make judgment calls all the more complicated for parents.
Teachers and school administrators interviewed for this story generally agreed that for some students diagnosed with ADHD, stimulants make a remarkable difference, calming internal storms and bringing normalcy to scattered young lives.
But several also noted worrisome trends in diagnosis, noting, for example, that teachers in crowded, cash-strapped classrooms are more likely to steer a disruptive child toward medication.
Several observed another complicating factor: white middle class or upper middle class boys form the majority of diagnosed cases while minorities - whether due to stigma or lack of access - often go untreated.