Medicating Our Kids: The Agony of Making a Decision
In his June 6 Director’s Blog, Thomas Insel, head of the NIMH, reports that:
- According to a CDC study cited at a recent Carter Center symposium, 10,000 toddlers may be receiving psychostimulant medication, such as Ritalin.
- According to the National Center for Health Statistics, 7.5 percent of US children ages 6-17 took meds for “emotional or behavioral difficulties in 2011-2012.
- The CDC reports a five-fold increase of kids on psychostimulants from 1988-2010. Also, some 1.3 percent of kids are on antidepressants.
- According to a study of the National Ambulatory Medical Care Society, antipsychotic prescriptions for children increased six-fold over the same period.
Chances are, your reaction is along these lines: Drugging our kids, psychiatry gone wild, bad parenting, bad schooling, big Pharma marketing machine.
Indeed, says Dr Insel, that’s pretty much the way the media reported events. It’s a compelling narrative, he says, except that the facts don’t fit: For one, families have limited access to psychiatrists. Most families resist medication. Toddlers are receiving meds years before the schools get involved. And drug companies have reduced their marketing in the US.
Also, our perspective may be a bit warped. Says Insel:
Surely, if we discovered more children were being treated for diabetes or immune problems, we wouldn’t blame the providers or the parents. We’d be asking what drives the increase in incidence. And, there actually are large increases in the incidence of Type I diabetes and food allergies.
A lot of what drives our skepticism, according to Dr Insel, is the absence of biomarkers for psychiatric diagnoses. We have no equivalent of a lab test equivalent to, say, one for glucose tolerance. And, of course, without biomarkers there is risk of over-diagnosis or the wrong diagnosis.
Nevertheless, the real problem may be undertreatment of kids, not overtreatment. According to Dr Insel, citing a number of sources, only 14 percent of kids with a current mental disorder report using psychiatric meds. These are kids, he says, with functional impairment, suicidality, and associated behavioral and developmental difficulties.
According to Dr Insel:
If it is your child suffering acutely from anxiety, autism, anorexia, or depression, the problem is certainly not over-treatment. The CDC report showed that parents of more than one-half of those children who used a prescribed medication for emotional or behavioral difficulties had reported that this medication helped the child "a lot.”
So - what to make of this ...
In my experience reporting on mental illness in kids over the years, media attention and public debate appears to rotate between depression, bipolar, and ADHD, typically with the storyline that we are overmedicating our kids.
The last several years has been the season of ADHD, and a lot of it is driven by educational reformers who claim that ADHD either does not exist or that we wouldn’t have it if our classrooms didn’t tend to imitate prisons. Thus, according to educationalist Ken Robinson in a 2013 TED Talk:
I'm not saying there's no such thing [as ADHD]. I just don't believe it's an epidemic like this. If you sit kids down, hour after hour, doing low-grade clerical work, don't be surprised if they start to fidget, you know? Children are not, for the most part, suffering from a psychological condition. They're suffering from childhood.
Lest we be forced into choosing sides, let’s see if we can harmonize Drs Insel and Robinson. This requires a bit of background:
Several decades ago, as we learned more about the workings of the brain, psychiatry moved out of the era of Freud and into biological psychiatry. The catch was that in its enthusiasm for investigating cells and molecules, the field - initially, at least - largely ignored the causes and effects of environment.
This led to the type of simplistic treatment regimes we still see today, namely: If an illness is biological in origin, the right pill directed at the right biological target will make the symptoms disappear. Ergo, a serotonin pill for a perceived serotonin problem.
Unfortunately, anti-stigma campaigns by well-meaning advocacy groups continue to feed into this oversimplistic notion.
As it turned out, biological psychiatry, sometime in the late 1990s-early 2000s, widened its perspective and developed a new paradigm of mental illness. This came in the wake of a series of breakthrough brain and gene and population studies showing the complex interaction between biology and environment.
A lot of this research came from the NIMH under Dr Insel’s leadership. One study - cited many times on this blog - showed that people with a certain gene variation exposed to stressful conditions displayed a marked tendency toward depression.
So, the thinking goes - maybe we can address the depression, not just with a pill, but by changing the person’s environment to a less stressful one. This is the equivalent of eradicating mosquito populations to control malaria.
Looking at it this way, Dr Robinson’s argument is sound. Our schools, in essence, are to ADHD (and perhaps early-onset bipolar) what an asbestos mine is to pulmonary disease. Perhaps this effect also spills over into the pre-school population.
The solution is obvious: Introduce enlightened curricula, reintroduce recess and physical activity and the arts, and watch ADHD and other conditions go way down.
The catch is we are dealing with a school system that “is,” rather than how it “ought” to be. Few parents have the option of pulling their kids from school.
So here you are, a concerned parent, with your kid growing up in an increasingly winner-take-all society. Your previous rationalizations about your little one’s behavior and performance no longer hold up. You know he’s bright and talented and sociable, but he’s falling way behind and not fitting in.
His future is on the line, right here, right now. It’s time to make a decision. An extremely agonizing one. You tell me ...