TalkBack Live

The Debate Over ADHD: Is It Over-Diagnosed?

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BOBBIE BATTISTA, HOST, TALKBACK LIVE: An estimated 3 million American children are believed to have attention deficit hyperactivity disorder, commonly treated with the drug Ritalin. ADHD is characterized by short attention span, impulsiveness and difficulty sitting still, behaviors some experts say are simply youthful rambunctiousness being suppressed with drugs.

(BEGIN VIDEO CLIP)

DR. MARY ANN BLOCK, AUTHOR, "NO MORE RITALIN": These drugs are mind-altering drugs, and in the case of Ritalin, it's a drug that's almost identical to cocaine.

(END VIDEO CLIP)

BATTISTA: Now the debate over ADHD and Ritalin is headed to the courts. Two lawsuits filed last week say the makers of Ritalin conspired with the American Psychiatric Association to encourage over- diagnosis of ADHD.

(BEGIN VIDEO CLIP)

DR. PETER JENSEN, COLUMBIA UNIVERSITY: Yes, over-treatment and over-diagnosis does happen. But the much bigger problem, to my mind, is that many children are still being missed and ignored.

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BATTISTA: Is ADHD being over-diagnosed and Ritalin over- prescribed? Or is the disorder on the rise?

Good afternoon, everyone, and welcome to TALKBACK LIVE.

Well, two new lawsuits, as we said, are re-igniting the debate over ADHD and the drug Ritalin. How you can tell the difference between a child who is merely active and one who is seriously hyperactive?

Joining us first to talk about this today is Dr. Peter Breggin, author of the book "Talking Back to Ritalin: What Doctors Are Not Telling You About Stimulants for Children." He is a consultant in a class-action suit that accuses the makers of Ritalin of conspiring with the American Psychiatric Association and others. Also joining us today is Dr. Jefferson Prinze. Dr. Prinze is a child and adolescent psychiatrist at Massachusetts General Hospital and Harvard Medical School.

Welcome to both of you.

Dr. Breggin, let me start with you, as you are consultant in this lawsuit. What exactly are you accusing the makers of Ritalin and others of doing?

DR. PETER BREGGIN, AUTHOR, "TALKING BACK TO RITALIN": Well, there are four lawsuits now, two in California and two for the United States. And what they are doing is accusing not only Novartis, the manufacturer, and the American Psychiatric Association, but also a parents group called CHAD, of conspiring in a fraudulent way to push the diagnosis of ADHD and also to push the drug Ritalin, methylphenidate, without adequately warning people about its limits and its danger.

In fact, ADHD is simply a collection of behaviors that can mean almost anything. Under hyperactivity, the No. 1 is squirming in chair. Under impulsivity, the No. 1 is interrupting the teacher when she's asking a question. And then No. 1 under inattention is not paying attention to details.

We have put together a list of behaviors which can mean anything from a child is bored in class, too far behind, too far ahead, to the teacher is boring, to the class is too large, to it's just a normal kid under ordinary circumstances. And in order to subdue children, which this drug does, we've made that a disease.

We know how the drug works. We know from animal studies, from studies of normal kids. The amphetamine-like drugs, and these are -- Ritalin is amphetamine-like. It's in schedule II of the DEA with methyl -- with methamphetamine, with cocaine, with morphine, the most dangerous schedule that the Drug Enforcement Administration has for addictiveness.

BATTISTA: OK, let me stop you right there, because we're getting way ahead of ourselves and there is much to discuss today. Before we go farther, though, let me read a statement from the American Psychiatric Association in answer to not this most recent lawsuit that's been filed, but one last May.

"Allegations that the American Psychiatric Association conspired with others to create the diagnoses of Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder as part of its diagnostic and statistical manual so that the medication could be used to treat these disorders are ludicrous and totally false. The APA will defend itself vigorously by presenting a mountain of scientific evidence to refute those meritless allegations."

I also should read a statement from Novartis Corporation. Again, they have not yet been served with the papers pertaining to these most recent lawsuits, but they say: "Any charge that Novartis somehow conspired with professional and/or patient third-party groups is absurd. Furthermore, any charge that ADHD is not a medically valid disorder is contrary to medical evidence and scientific consensus."

BREGGIN: Well, should I grab a couple of those?

BATTISTA: Well...

BREGGIN: The APA takes an enormous amount of money from pharmaceutical industry. It was actually growing -- it was going broke in the early '70s, and its board of directors consciously determined -- this is outright -- determined to take a lot more money from drug companies and to act as if suffering conflict behavior problems are medical so that the profession of psychiatry could regain its income and its status. All that's been carefully documented in a number of my books and in other sources.

As for its being a medical, a medical syndrome, there's no biological basis. There couldn't be. A child who's squirming in their chair or talking out of turn is simply doing that, and then you've got to figure out, does this child need discipline, does this child need a more interesting classroom?

And finally, Novartis at the peak was giving almost half a million dollars a year to CHAD, the parents group that then went ahead and acted like an independent parents group and actually lobbied the government to try to drop Ritalin out of Schedule II, out of the schedule with cocaine and morphine, so the doctors could even more readily give it. So we've got some real links here.

BATTISTA: Let me read a statement from CHAD that came to us this afternoon also that said: "Membership dues are CHAD's primary source of revenue. Grants from pharmaceutical companies make up only a small percentage of CHAD's funds and are earmarked for programs to benefit the ADHD community."

Let me bring Dr. Prinze...

BREGGIN: They did pull back, incidentally. After I blew the whistle that one year they got almost half a million in one year, about three years ago, after we blew the whistle on that, the drug companies, under threat from DEA, have begun to back down in their amount of money that they give.

BATTISTA: I just lost a microphone here. Let me switch with Chris. Let me bring Dr. Prinze into the conversation now.

As a practicing physician who has prescribed Ritalin yourself, how do you feel about these lawsuits?

DR. JEFFERSON PRINZE, CHILD AND ADOLESCENT PSYCHIATRIST: Well, I think these lawsuits -- I don't know the particular families or the cases that are involved with them. I think that in general the families whose children and whose parents actually suffer from this disorder experience extreme impairment. Certainly, the diagnosis can be made inappropriately, and there may be what we term false- positives, where people are inappropriately or quickly diagnosed. But the disorder has a clear biological substrate. It has a history from the early 1900s of being described in the medical literature up to the present day, and it's something that responds well to the medicine. And when the medications are used appropriately, they're very effective and safe treatments.

Many -- children need lots of things, and there are a wide range of behaviors in children, all the way from appropriate squirming and fidgeting to children who impair themselves as well as others by their behavior. And this is a neurocognitive disorder. It's a brain thing.

And to suggest that it's not just really deters people from getting treatment, and it's scary.

BATTISTA: It is very difficult, however, to diagnose, correct? I mean, there is not a diagnostic test, per se, that will definitively tell that something is ADHD?

PRINZE: Well, the way the human attentional systems are regulated in the human brain -- they're widely scattered. So first, the disorder is heterogeneous. It may look different in different people. This presents diagnostic challenges, but it does not make it terribly difficult to diagnose.

BREGGIN: I hope you're listening to the double talk here. I hope the double talk is really clear.

PRINZE: One of the...

BREGGIN: There's no biological basis.

PRINZE: The best way we have to diagnose the disorder is really from a clinical history in which multiple informants are obtained, from a child's teacher, school personnel, parents, friends. And we gather this information, and look at both the beginning and early childhood, and the persistence of the symptomology as well as the impairment over time. And what you need to do is both take and understand the symptoms and what's going on with the child at this time, and then look at how is it impairing them, and then make a decision about whether medication is or is not warranted.

BATTISTA: See, I'm not sure that that's what's going on, though, you know. I'm -- in other words, the question is who is competent to diagnose something like ADHD, because it seems like -- because we've done this show -- this topic a number of times, and we always have parents and kids in the audience who are taking Ritalin, and it is incredible to me how many times that it's teachers who start making -- and I'm not going after teachers here -- but teachers who make the initial diagnosis...

PRINZE: Right.

BATTISTA: ... then they simply go to the family practitioner and the Ritalin is distributed without any sort of...

BREGGIN: But, Bobbie, it wouldn't make any difference who makes the diagnosis. Anybody can see if a child is squirming in their chair or talking out of turn or interrupting like I just did.

BATTISTA: I have to say that's not what they described. Like I was talking to Jordan here a few moments ago about, you know, the symptoms that she had when you were diagnosed with ADD and you -- squirming wasn't it, you said your mind literally left your head, your brain walked away. What did you mean by that?

JORDAN: Yes. I meant -- when I say that it's -- I would be doing my work and the next thing you know, I would just start wandering and, I mean, it's literally like my mind just left and I couldn't do anything. It was like thinking, and then next thing you know it's like cut off -- you're just in a different world, you go into a -- have a really wild imagination, and you just go from one place to another and you just -- you can't control it.

BATTISTA: So, Dr. Breggin, if she feels like she's in, for lack of a better term, some sort of altered state like that, that doesn't feel normal to her, how do you treat that?

BREGGIN: I would love to meet this youngster, she sounds interesting and exciting. She sounds like a...

BATTISTA: Well, they're all like that.

BREGGIN: ... future novelist, a future movie writer. She sounds a lot like me, my mind goes all kinds of places. I would like to see somebody work with her on her power, not on her disability. And this obviously has nothing to do with the ADHD diagnosis anyway, this is about a great imagination that hasn't been brought yet under the discipline of adulthood. God bless you, grow and really don't let anybody tell you that you're abnormal because you've got a wild imagination.

BATTISTA: Now, Doctor...

BREGGIN: Now, it could be that this child also has had some trauma, that I don't know, that's separate from this show, but that is not about this mythical biological ADHD. If this child has seen some horror that makes her mind want to leave her body, that's a whole another issue.

BATTISTA: Dr. Prinze, the thing that concerned me was I did ask her that when she was diagnosed whether or not it involved, you know, a number of opinions and behavioral therapy, or nutrition assessment, all these sorts of things -- none of that happened.

PRINZE: Right. Well, Bobbie, it's really important to remember that diagnosis is based on behaviors and getting a clinical history, and that's the best tool we have right now. Nutritional therapies and supplements hare really not shown to be important and are not really sanctioned as part of the diagnosis, it's really based on behaviors that are persistent and begin early in childhood and cause impairment.

Now, it's interesting in the patient that you just -- the young woman you just spoke with, that often girls have a more inattentive symptoms and distractibility, et cetera, than boys who have more externalizing behaviors that may interfere with others that lead to an earlier diagnosis, so that very often girls can be overlooked. Now, people need to be qualified, and certainly teachers are not in the business of making diagnosis, that should really be within the purview of medicine, but there are multiple types of professionals who can appropriately diagnose it, child neurologist, child psychiatrist, pediatricians may be appropriate.

BREGGIN: Bobbie...

(CROSSTALK)

BATTISTA: I -- and I guess I -- you know, I have to go to break, gentlemen here. I do have to go to break, and we'll continue in just a moment. I guess the point I was making was that I'm afraid that what's going on out there is that most of those people you are talking about are not involved in the diagnostic process.

As we come back -- you talked about nutrition, Dr. Prinze, and that you don't think it has that much to do with it. We'll have a guest a little bit later on in the show who felt that was the key to her child's ADD when she refused to take Ritalin, so we'll talk to her.

We do have to go to break. When we do, please weigh in on our online viewer vote at cnn.com/talkback. Today's question: Is ADHD under diagnosed, over diagnosed, or appropriately diagnosed? We'll be back.

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BATTISTA: A couple of e-mails that came in, Leo in New York says, "Ritalin is the most effective treatment for ADHD, but I think it is over prescribed. Placing more responsibility on doctors and parents is as important as blaming pharmaceutical companies." Lynn in Washington says, "My son was diagnosed with ADHD in late 1989 and placed on Ritalin. He went from being an overly active child to a zombie. Today my child is moody and depressed. I fought every therapist about these drugs, but was always told it was the best for him. Now he doesn't know. He's asking a question."

We were just talking to the kids in the audience, and in the relatively small audience that we have today, and we have maybe 10 teenagers in the audience, over half of them have been on Ritalin. I think -- I just think that's sort of startling.

PRINZE: Right.

BATTISTA: And I don't know...

BREGGIN: Bobbie, it's a national catastrophe, you know.

BATTISTA: Well, let me ask Dr. Prinze...

PRINZE: That's not true.

BATTISTA: ... you're writing the prescriptions, why are so many children on Ritalin?

PRINZE: Well, in fact, Bobbie, the diagnosis is still under diagnosed, and we advocate that the -- more children need to be identified appropriately and with the proper assessments, and that many treatment -- children are being under treated rather than over treated. Now, that doesn't mean that it's not used -- the medicine is not used inappropriately or by people who shouldn't be using it. But there are many people who suffer greatly with this disorder. And despite what Dr. Breggin says, this is a disorder and it causes significant impairment in the lives of children. It puts them at risk for things such as mood disorders, substance abuse problems, conduct problems. And by intervening and helping them with their cognition and learning and behavior and socialization, you can actually improve their self-esteem so that you can...

BREGGIN: This -- this is nonsense.

BATTISTA: Let me go to Michelle. Let me go to Michelle in the audience.

BREGGIN: Bobbie...

BATTISTA: Michelle took Ritalin for a while. She had a similar experience to Len's child, right? You said that you had -- it was mood-altering and it was not a good experience for you.

MICHELLE: Yes. I did not enjoy taking the Ritalin. I was on it for a while. My teacher was the first one who said that I should be on it because I was on the floor a lot and I was not concentrating on my work. But then when I got on the Ritalin I had no choice but to pay attention, because I felt like I was out of it.

And as I was taking the drug, my parents finally took me off of the drug and I started doing a diet program. And that worked -- that worked much better for me, because after I got off of food coloring and BHT, I could concentrate more. I did not feel like I was on a drug. I felt like healthy inside.

And I think nutrition is a big part of what we, you know, what we need. We don't need drugs and artificial stimulants to help us concentrate. We just need...

BATTISTA: Do we need to look at the connection, Dr. Prinze? You were quick to dismiss any connection between food and diet.

PRINZE: Well, Bobbie, what I'm talking about is what's known about the scientific data and the literature. Back earlier in the '70s and the '80s, people have looked very carefully at multiple different diets, and they haven't really proved to be effective in group data.

Now, that doesn't mean that for a person such as Michelle that it didn't work. I'm thrilled that it did. And being a practical person, I'm for whatever works. So we need to look at these things. But in terms of the scientific data, clearly the stimulant medications are the most helpful. Now, nutrition composes an appropriate part of every child's development and we need to look at these...

BREGGIN: Bobbie, could I talk about the science? The doctor keeps mentioning science.

PRINZE: What?

BATTISTA: All right.

BREGGIN: What's very clear is that when you give these drugs to any creature -- child, animal -- they crush spontaneity. Play is reduced, socializing is reduced, love is reduced.

PRINZE: That is just not true.

BREGGIN: Getting together with people is reduced.

PRINZE: That's not true.

BREGGIN: What these drugs do is to flatten all spontaneous behavior, and then they enforce, as one of the youngsters said, obsessive behavior: You may not even want to, but you do what you're told. You get obsessive and narrow and focused. It's a form of brain dysfunction and it causes brain damage.

PRINZE: That is clearly not true. ADHD in some ways is a bit of a misnomer in that it's not a difficulty in paying attention all the time. It's really a difficulty in regulating one's attention, so that the -- one should be able to do what the intent is. And these medicines help improve people being able to focus on what it is they choose and need to focus on according to their own power.

I think it's just a falsehood that these are mind-controlling drugs. In fact, the -- Dr. Breggin refers to the pharmaceutical industry's support of this and that. Recently, the largest pediatric psychopharmacology study was reported on in December of '99 -- the MTA study -- really looked at a variety of different treatments, but really the space shuttle of behavioral treatments.

And in fact it was shown that the medication, which in that study they used immediate release, name-brand Ritalin, was as effective as the combination of behavioral treatments and with medication, and more effective than behavioral treatments alone.

BREGGIN: Bobbie, the study...

BATTISTA: But we don't -- one thing we don't know...

BREGGIN: Bobbie, can I answer about the study because it's a farce?

BATTISTA: Yes, quickly. Quickly, I've got to take a break.

BREGGIN: It didn't -- it wasn't double blind. When you have a study, you're supposed to do double blind where the investigators don't know who's getting what. There was no placebo control. It was just one more of these government-motivated attempts to push the drug on the country.

PRINZE: Well, I think conspiracy theories are easy to scare people...

BATTISTA: No double-blind. No placebo control.

PRINZE: There are over...

BATTISTA: Well, the main concern -- the main concern that I have and I think a lot of parents probably have is that we definitely, I think you both will agree, do not know the long-term effects of Ritalin.

BREGGIN: We know some harmful long-term effects, Bobbie. We know in animals...

BATTISTA: That there's -- as I understand it, though, there have been no real long-term cognitive studies of the effects of these drugs.

BREGGIN: No. There are no long-term because nobody wants to do them.

PRINZE: Well, Bobbie, this medicine has been around since 1955. There are millions and millions of exposures and people who have taken it for many years.

You're correct. Is there a group of people from 1955 to present that have been studied? No, that's true. However, these are exceedingly safe medicines. They are some of the oldest medicines prescribed in -- ever. And so...

BREGGIN: They're actually among the most dangerous. That's why they're in schedule II, the DEA. They cause psychosis, mania. They cause depression of growth.

PRINZE: They do -- they do...

BATTISTA: I have to take another break here at this time.

PRINZE: They do not cause depression of growth.

BATTISTA: I have to take another quick break. And Dr. Breggin, thank you very much for joining us today. Appreciate your time.

When we come back, we'll find out what happened after our next guest refused to put her son on Ritalin after he was diagnosed with ADHD. We'll be back in a moment.

(COMMERCIAL BREAK)

BATTISTA: ADHD, which is the most commonly diagnosed behavioral disorder of childhood, occurs in 3 to 5 percent of school-aged children. Boys are four times more likely to have the illness than girls.

All right. Joining us now, behavioral pediatrician and the author of "Running on Ritalin," Dr. Lawrence Diller. He is in Washington, by the way, attending the U.S. surgeon general's conference on children's mental health.

Also joining us from Miami today Diana Hunter, author of "The Ritalin-Free Child." She is the mother of two sons, one of whom who was diagnosed with ADHD. She refused to put him on Ritalin.

Diana, welcome to the show.

DIANA HUNTER, AUTHOR, "THE RITALIN-FREE CHILD": Thank you.

BATTISTA: Let me start with you first. Tell me what happened with your son.

HUNTER: At the age of five, I was told that my son was very hyperactive and inattentive of the classroom: basically, that he stood outside -- stood by the window looking outside at birds and such, and that they felt he was hyperactive. They thought that he was brain- damaged possibly, autistic and other things.

And I told them I didn't think that that was a feasible response for what I was looking at was my son. I thought he was very intelligent. So we went ahead and let them put him in a gifted program. And they told me if they didn't put him on Ritalin, they would go ahead and throw him out of the program and possibly out of school. So I allowed them to throw him out of the program and did not put him on Ritalin and started my research studies on it from there.

BATTISTA: And that led you into the area of nutrition and diet.

HUNTER: Yes, it did. I'm currently working towards a Ph.D. in nutrition.

BATTISTA: And you think that -- are you saying that you think nutrition was the cause of your child's ADHD?

HUNTER: Well, I never like to say that he had ADHD. I think that children can be hyperactive and attentive. I think kids can be kids. I think we need to look at those perspectives. A lot of different things can cause hyperactivity and inattention. I think diet does play a significant role. I think that the central nervous system needs to have correct vitamin-oriented levels in it.

And I think that we need to look at all the different perspectives before saying a child is ADHD and labeling them with a disorder.

BATTISTA: Dr. Diller, should more parents be taking the approach that Diana took -- I mean, not they should go get a Ph.D. in nutrition -- but taking more of an approach that way?

DR. LAWRENCE DILLER, BEHAVIORAL PEDIATRICIAN: You know, I think the diet issue reflects a deep mistrust of the medical system. And I think people want a natural way of operating on this problem. And so the diet approach is a very popular one. Unfortunately, when it is looked at systematically, it hasn't really panned out for most of the kids who have these kinds of problems.

BATTISTA: Do you think, though, that her approach of refusing to put her child on Ritalin, though, and look at other ways of dealing with her son's hyperactivity problems, do you think more parents should be doing that?

DILLER: Well, I can't say that based on one person's experience. But I do feel very strongly -- you know, I prescribe medication -- but I feel we are very quick very often to offer medication to children and not explore the other possibilities. So I support the woman very much so on exploring the other possibilities.

BATTISTA: Let me ask you this, can you make -- it sounds like Diana did this -- can you make hyperactivity in a child or an adult work for you? Does it always have to be an impairment?

DILLER: Well, you know, it depends on how it is defined. I mean, impulsivity can be also defined as spontaneity and being a free- thinker and being creative. However, the child does have to be able to be -- sit a couple hours a day at school. And if they don't do that, and you've explored the learning issues, and you've explored the family dynamics, and the kid is still struggling, and the school is doing the best they can, it is not unreasonable, in my opinion, at that point, to utilize medication.

Bobbie, I hope you get to the suit with me -- and also what is happening at the Surgeon General's Conference.

BATTISTA: I will. As a matter of fact, we will talk about that as soon as I take a break here. I also want to talk to a member of our audience who has a son who was put on Ritalin when he was 2 1/2. So we will talk about that.

Also, this programming note: We are awaiting comments from President Clinton on the Senate action on the China trade bill. CNN will bring that to you live as soon as it happens.

But we will be back here in just a moment.

(COMMERCIAL BREAK)

BATTISTA: Join our TALKBACK LIVE discussion. Phone us at 1-800- 310-4CNN. Fax us at 1-800-310-4FAX. Send an e-mail to TALKBACK at cnn.com. Or join our online chat by going to cnn.com/talkback and hitting the "Chat" link.

A couple of e-mails, speaking of those.

David says -- David e-mails us: "Medication lets my daughter concentrate and be a student, not an interruption to the class. She is now a straight-A student."

Richard in Texas says: "No children are being subdued, because parents are too busy to be parents. ADHD should stand for Adult Discipline in Home Deficient."

OK. Let me go to Monique quickly in the audience, because she has to leave us here shortly to catch a plane. I was intrigued, when we were talking earlier, because your son Preston was put on Ritalin when he was 2 1/2. How did that happen? I even didn't think that was legal.

MONIQUE: Well -- yeah, they -- he was the youngest the pediatrician have ever -- has ever tried putting him on Ritalin. But he was so uncontrollable. And they had done tests, even at an early age, of finding out whether he was an ADHD candidate. He did have that.

We also have -- I have two other sons. They're also -- one is ADHD, and the other one hypo, which is the other direction. And my husband is also ADHD. And so we've dealt with this. But I do -- in listening to your show today, I was thinking that. I was wondering what long-term effects the Ritalin has caused, because we eventually had to -- he was on Ritalin.

Then they advanced him to other, more serious drugs. And those drugs -- my older son and this son both ended up having tics and other problems. And so I finally -- we finally just took him off completely. And the schools and the day care didn't know how to deal with them, because they said, "Now, what are we going to do with your child when he is off this medication.?" And I said: "We're going to deal with something else. I can't have him on this anymore."

BATTISTA: Let me have let Dr. Prinze respond to that.

PRINZE: Well, Bobbie, first, that is a great story that even in younger children, sometimes the medication is indicated and can be appropriate. And the issue of tics and the like is an important one. It would be interesting to know when the tics started. And the question is -- really not resolved whether or not tics cause more -- or stimulants cause more tics.

Certainly, stimulants may exacerbate tics. But often, in patients with tics disorders, the ADHD symptomology can be some of the most impairing. There are many -- like, going back to the woman who declined to use medication -- there are many ways to try to manage these things and many causes for hyperactivity and inattention. And hyperactivity and inattention don't equal ADHD.

And ADHD doesn't necessary equal treatment Ritalin. One of the things in taking care of children -- and I salute and applaud the families of these children -- they will go to extreme measures -- often the psychopharmacologist is below the eating -- the food chain than the orthodontist. I mean, people go to extreme measures before they come to do this, because it's a very difficult decision. The medication can be a tool.

BATTISTA: Well...

(CROSSTALK) BATTISTA: ... Dr. Diller, let me tell you what I think is -- because I think that we are hearing one thing from you guys in the medical community. I am getting a completely different view of this from our audiences and our e-mails and this kind of thing. The bottom line is...

DILLER: Can we talk about this the surgeon general?

BATTISTA: Yes, because I hope this is the things that you are talking about at that conference.

DILLER: This is precisely what's going on at the surgeon's general conference on children's mental health today. I mean, this -- Ritalin and toddler's issues...

BATTISTA: Wait, I'm sorry, let me interrupt, please forgive me. We have to go to Lou for some breaking news in the news room.

(INTERRUPTED BY CNN COVERAGE OF BREAKING NEWS)

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