Children and Psychiatric Medication

Children and Psychiatric Medication

Sam Goldstein, Ph.D.
This is a SamGoldstein.com Monthly Article - March, 2005
Copyright © 2005 Dr. Sam Goldstein - All Rights Reserved

After receiving eight reports of adverse reactions ranging in severity from convulsions to minor skin rashes, Health Canada took Adderall XR, the stimulant preparation used to treat ADHD, off the market on February 9, 2005. Health Canada noted the drug has been linked to twenty sudden deaths and a dozen strokes, including some among children. In this month's article, Dr. Goldstein raises concern about an impending backlash in the use of psychiatric medications to treat children. Though this trend seems to be based on politics and personal ideology rather than science, it may result from both the failure of the mental health community to police itself, and the public's perception of an incestuous relationship between mental health professionals and the ph armaceutical industry.

Two weeks ago I was having lunch with a friend at a local diner. As we were leaving a woman approached and asked if I remembered her. I recognized her as the mother of one of my patients; however, given the number of children I see I didn't remember her name. She very graciously reminded me and then told me how well her then seven-year-old son had been doing over the past twelve months. In the previous year I had diagnosed her eight-year-old with the Combined Type of Attention Deficit Hyperactivity Disorder. His symptoms were fairly severe, and his impairment was significant. He very clearly met all five criteria required to make the diagnosis of the Combined Type of ADHD. Additionally he experienced a mild reading disability along with a moderate language impairment. Efforts at providing academic and language support were only mildly successful in part because of his hyperactive, inattentive and impulsive behavior. Following my diagnosis, his physician placed him on a trial of a stimulant medication. His parents and teachers observed a significant improvement in his behavior compared with pre-medication functioning. His mother reported that over the past year he had made more academic progress than ever before. He was doing better socially, during play sessions and in Scouting. As far she could observe, there were no adverse affects from this treatment. From her perspective, the diagnosis and subsequent treatment with a stimulant medication were, in her words, "a God send."

There is absolutely no scientific doubt that children who have been appropriately diagnosed with ADHD benefit significantly from stimulant medication in the short run. The medicine reduces symptom severity and subsequent impairment. When used appropriately, these drugs are extremely effective, and generally safe compared to many other psychiatric medications. Nonetheless, concerns about stimulant use have arisen. These include: inappropriate diagnosis leading to inappropriate treatment, failure to appreciate the multiple environmental forces that could contribute to a child's ADHD symptoms, failure to track the effectiveness of or problems related to long-term medication usage, and others. In the past we were concerned about children with ADHD failing to be referred, diagnosed and treated, yet the pendulum appears to be swinging. The number of children treated for ADHD with stimulant preparations has steadily and consistently increased. During some periods over the last twenty years the increase has progressed at a dramatic pace. Furthermore, the ph armaceutical industry now markets ADHD medications directly to the consumer. Though there are no laws preventing this, one can't help but question the risks of promoting drugs controlled by the FDA because of their potential abuse and addiction. This article is not to suggest that these medicines shouldn't be used to treat ADHD, but rather to raise questions about how they are promoted, marketed, used and monitored.

In a past article (The Marketing of ADHD) I reviewed a number of the advertising strategies the ph armaceutical industry uses to attract consumers, particularly parents, to their ADHD medications. Although these advertisements are factually accurate and pass the FDA's stringent advertising requirements, I questioned whether these ads accurately represent the short versus long term benefits of treatment with medication. Keep in mind that the dramatic increase in the use of stimulants to treat ADHD twenty years ago occurred before these preparations were aggressively advertised. Further, I have not reviewed any data that suggests a correlation between the increase in advertising dollars for preparations to treat ADHD and the use of these preparations. Though this phenomena has been hypothesized by critics, as far as I am aware, it has yet to be scientifically demonstrated. Nonetheless, there is no doubt that the ph armaceutical industry aggressively markets medications to treat ADHD. Though it may be reasonable for an auto manufacturer to set a goal of having one of their vehicles in the garage of every home, it is unreasonable for the ph armaceutical industry to set a goal for a certain psychiatric medication in every medicine cabinet in America. Even the advertising industry has taken notice of this phenomena. A current nationally aired advertisement for a well known theme park features a purported drug company executive thanking Americans for engineering so much stress into their lives. He encourages Americans to continue leading stressful lives so his company can sell its products to every single citizen. The marketing of psychiatric medications should take a different approach. These companies simply cannot expect to increase sales year after year.

I also am concerned about a shift away from appreciating the benefits these medications can provide when used appropriately. As this issue becomes increasingly political and personal, concerns of over diagnosis and subsequent over-treatment are increasing as well. I have long advocated considering the long term risks of not treating children with ADHD as potentially more adverse than the risks of medication treatment. However, as more and more children are placed on medication, the absolute number of reported side effects as well as low incidence, adverse outcomes increase. The public's focus shifts away from the needs of those with the condition to the adversities experienced by some who are treated for it. As public focus shifts to this issue, the public becomes more concerned about the adverse experiences of the few than the benefits experienced by many.

This backlash against the medication treatment of ADHD is part of a larger, impending backlash against using medication to treat children's psychiatric problems. This is also happening with antidepressants and I expect will begin to happen with all FDA approved psychiatric medicines used to treat children's psychiatric problems. Take for example Health Canada's response to Adderall. Canadian regulators have asked Shire Ph armaceuticals to withdraw its Adderall extended release preparation amid reports that fourteen children and six adults taking the medication died. None of the deaths occurred in Canada and it likely will take some time before Health Canada can review these studies and ultimately rule on Adderall's safety. Interestingly, this same information was provided to the United States Food and Drug Administration. They changed the drug's label, by suggesting the drug should not be prescribed for people with structural, cardiovascular abnormalities, but chose to not remove the drug from the marketplace. However, consumers are not so easily convinced. In the past two weeks a number of pediatricians I know have reported a flood of requests from parents of children taking Adderall to shift to other medications. It is only a matter of time before parents begin to worry that if one stimulant preparation is potentially harmful, they all may be potentially harmful.

News reports reflect the perception, or perhaps accurate data, that stimulant medications increasingly find their way into the hands of individuals for whom they are not prescribed, particularly to enhance studying. It is interesting that while some medications find their way on to college campuses as "party" drugs, the stimulants find their way on to college campuses as "study" aides. Students take them not to have a good time but rather because of their attention and effort enhancing qualities. Consider further that a number of states are reviewing proposed legislation to prohibit teachers from discussing these medications. In some ways suggesting that teachers not diagnose mental health problems but rather describe children's classroom difficulties and ask parents to seek help is good. On the other hand, limiting a teacher's ability to communicate with students and parents is not.

The backlash is broadening. In September, 2004, Texas Republican Congressman Ron Paul introduced an amendment on the floor of the U.S. House of Representatives to the pending Department of Health and Human Services Annual Appropriations Legislature. His amendment would prohibit any federal government funding of all mental health screening programs. Some argue that mental health screening programs intended to identify problems lead to un-necessary treatments, in particular the excessive and inappropriate use of psychiatric medications for children. Though the amendment was defeated 95 for and 315 against, it is significant that 94 congress persons were convinced by Representative Paul's arguments and by what they have heard and read in the media. Representative Paul subsequently introduced House Bill 5236 titled "Let Parents Raise Their Kids Act of 2004." The bill states that "because of the subjectivity of psychiatric diagnoses, it is all too easy for a psychiatrist to label a person's disagreement with a psychiatrist's political beliefs a mental disorder." This legislation would prohibit federal funding of "universal or mandatory mental health screening." Consider also that at least twenty-nine states have drafted legislation to regulate psychotropic drug use in the public schools.

In November, 2004 following the presidential elections, conservative columnist Armstrong Williams wrote, "Let's hope the Whitehouse can focus on the issue of the over-medication of young people with psychotropic drugs." He then went on to question whether certain patterns of behavior in children represent disease, disorder or normal variation of childhood. What is lost in this view, however, is the issue of impairment. If a child experiences impairment, our goal should not be to pathologize, moralize or demonize him or her, but to identify the impairments and related factors and do something to help. A diagnostic process and validated diagnostic protocols are essential to this process. The anti-psychiatry campaign that has represented the selective interests of certain groups over the past twenty years has found new allies and fuel in some cases because of the erroneous interpretation of scientific facts. However, in other cases they recognize inconsistently applied standards, and the business-like approach to mental health. The ph-armaceutical industry must realize that unlike other businesses which try to increase the number of consumers, market share and total sales per year, convincing every man, woman and child in America to take a psychiatric drug is not a legitimate goal.

Perhaps the campaign against mental health services is based on deliberate distortions of facts and takes advantage of well publicized situations of abuse by some companies, government officials and treatment providers. This campaign which at times focuses on ADHD, appears to be about promoting certain right-wing agendas rather than mental health. Nonetheless, I believe it is an ineffective strategy for mainstream psychiatry, medicine and the related mental health fields to pretend that all that is wrong with the system is these individuals and their agenda. By far the majority of children in America with mental health problems are never diagnosed by professionals. Children with mental health problems experience impairment not in genes and biology but in the environments in which they are being raised and educated. This argument is not to criticize parents and educators nor deny the role of genetics in mental illness. It is simply to suggest that we must find a way to avoid having mental health become just another industry. We must find a way to spend equal dollars on researching all promising treatments, not just those of interest to profit driven corporations. I am concerned that if as a professional field we don't take the initiative to find a better path to educate the public and utilize effective mental health treatments, others will do it for us at the expense of America's children.