Current Issues Articles


CHILDREN’S PROBLEMS IN SOCIETY

DO NOT BEGIN IN CHILDREN’S BRAINS

Ellen Isaacs, MD

There is, in America, an epidemic of children being diagnosed with mental illness. The Surgeon General?s Report of 1999 states that “Approximately one in five children has a DSM-IV disorder (mental health problem) during the course of a year”.1 The most common diagnosis is Attention Deficit Hyperactivity Disorder(ADHD), but Oppositional Defiant Disorder(ODD), conduct disorder(CD), anxiety, bipolar disorder, and depression are also diagnosed frequently, and often several ‘co-morbid’ diagnoses are made at the same time.2 Moreover, all these ‘illnesses’ are said to be due to disorders within the child’s brain, rather than to environmental stresses or the normal vagaries of childhood. We will see how this trend reflects the current bias in psychiatry towards bio-determinism, which in turn reflects the state of the world in which we live.

The prevailing model within the psychiatric profession today is that mental illness is predominantly biological in origin. “Brain chemistry is believed to be not only the cause of mental disorders, but also the explanation of the normal variations in personality and behavior.” 3 This view applies not only to severe psychoses such as schizophrenia, but to maladaptive behavior or swings in mood, which used to be viewed as responses to the stresses and losses of life or neurotic at worst.

This biological model developed in large part because of the discovery of drugs in the last 50 years which could improve psychotic symptoms, mood and behavior. Most of these beneficial effects were discovered serendipitously, but the drugs were later found to affect neurotransmitters such as serotonin or dopamine. Thus it was theorized that abnormalities in these substances were the cause of mental illness, although very little is actually known about the pathways between neurochemistry and behavior. There is no doubt that emotions, ideas and actions are all reflected in the brain, but how these pathways work, what is cause or what is effect, what is inborn and what is environmental remain largely unknown. However, by assuming that neurochemistry explains so many psychological problems, psychiatrists can treat nearly all patients with medications without dealing with their life circumstances.4 This is not only a huge boon to the drug industry, but removes any pressure to investigate how our society may be making so many people unhappy or nonfunctional.

Another significant movement within psychiatry is the expansion of the list of problems which are characterized as illnesses.5 All kinds of personality traits, such as shyness, separation anxiety, distractibility, or hyperactivity have come to be seen as diseases or symptoms of disease. If one looks at the diagnostic criteria for ADHD (Table1)6, they are characteristics that may be exhibited by almost any child in trying circumstances or may simply represent a part of the spectrum of childish behaviors. In fact, what is labeled as disease may be said, in many cases, to represent a mismatch between the child and the expectations that are placed on him or her. We require our children to attend schools with ever larger classes, fewer and more inexperienced teachers, with less time for play and the arts, to master skills at an ever earlier age, and to be subject to constant testing and rigid curricula. It is not surprising that ever more children find it hard to conform to the expectations of the schools. More and more children are also dealing with the stresses of poverty and broken homes. Even well to do children are under increasing pressure to pass tests, get into college, and compete in a shrinking job market.7 But instead of questioning the wisdom of our social and educational choices, we blame the difficulty of children in living up to our expectations on them, by labeling more and more of them as ill.

The diagnosis of ADHD has increased dramatically in the last 30 years, from an estimated 150,000 in 19708 to 5-10% of American children today.9,10 Over 85% of Ritalin in the world is manufactured and prescribed in the United States, causing the United Nations to caution against this excess.11(Figures 1&2) There is also a major variation between areas of the country in the frequency of its use. In some areas of eastern Virginia, over 1/3 of boys in fifth grade are diagnosed with ADHD.12 In other states, such as Hawaii, almost no one is on Ritalin. As publicity about the over or under-diagnosis of the condition has influenced public opinion, the rates of Ritalin prescriptions in a single place have changed dramatically in a short period of time. For example, there was a 2.5 fold increase in Maryland from 1990-5, a similar decrease in Wisconsin, and there is up to a 10 fold variation in prescription rates in counties within the same state.13,14 If ADHD were truly a disease with a medically necessary treatment like insulin, this could never occur.

Ritalin, the main drug prescribed for ADHD, is a stimulant similar to amphetamines and cocaine. It was first approved for use in hyperactive children by the Drug Enforcement Agency (DEA) in 1961, and in 1970 it was made a Schedule II drug because of its potential for psychic addiction.15 Although it is commonly thought that Ritalin has a paradoxically calming effect in children, this is not the case. It enables anyone who takes it to improve performance on various tasks, especially those requiring attention to detail and repetition, like many school exercises. There is no evidence that Ritalin, or similar drugs like Concerta, improves complex skills like reading or social behavior16 or overall long term outcome for users, in terms of graduation rates, school suspensions or legal encounters.17 The drug has few dangerous side effects in many who take it, but it often causes trouble sleeping or loss of appetite. In rare cases, it can lead to severe tics or cardiovascular problems. Most worrisome is that Ritalin has become a common drug of abuse, with 16% of college age students selling their Ritalin for a concentrated high and an increasing number of overdose hospitalizations and deaths.18

The age at which children are being medicated has also continued to decrease. Recently, a survey of toddlers in both a Medicaid and an HMO documented that 1.5% of them are on psychiatric medications,19 and many of these are on multiple medications. Other studies of drug prescriptions in this age group have shown that the use of drugs and drug combinations is totally haphazard, and that many of these children are not receiving close follow up either medically or psychologically.20,21 Not only are psychiatric drugs not approved for this age group, but this is the time of life when neuroreceptors in the brain are developing the most rapidly, and there us an unknown potential for long term toxicity of drugs targeting neuroreceptors.22 The response of the psychiatric community and regulatory agencies to this expose, however, was not to ban the use of drugs in such young children but to study them further. The problem is that we do not have the tools to assess long term effects of stimulants, nor the inclination to delve into the causes of children’s difficulties or alter the environments in which they live.

In the case of Ritalin, the National Institutes of Mental Health(NIMH) is now sponsoring a study of its use in 3-5 year olds at seven medical centers. 23 The study assumes that one can draw a line between normal and abnormal behavior at this age. One way children’s response to Ritalin is assessed by observing their performance at various nursery school tasks, like building with blocks, for which Ritalin would improve the ability of any child. By definition, only children whose parents would be willing to place their child on medication are enrolled, but those same parents will be part of assessment of success. Thus there is no doubt that this study will be said to prove the safety and usefulness of Ritalin. However, the short 36 month term of the study will not address the possible long-term toxicity of the drug in such young children, nor are parents made aware of this potential danger. It is not unexpected that the researchers at New York State Psychiatric Institute/Columbia Presbyterian Department of Child Psychiatry, who proposed this study to NIMH, are largely supported by the drug companies who manufacture Ritalin and its congeners.24

The spectrum of children diagnosed and treated with Ritalin over the years has also changed. Several decades ago, white middle class youngsters were the main consumers, perhaps reflecting the pressure on such children to do well academically and the faith of their parents in medical science. The use of the drugs was always voluntary and was often sought by parents. However, there is now marked narrowing of the gap in Ritalin usage between poor and middle class children and between whites and blacks .The ratio of stimulant use between white and African-American children fell from 2.9 in 1987 to 1.4 in 1996.25 Moreover, when ADHD is diagnosed and drugs prescribed for poor and minority children, the process is much more likely to be coercive. Often the diagnosis is suggested by a teacher who is having trouble dealing with a child in class either behaviorally or academically. The schools may then suggest that the parent see a doctor to prescribe medicine for ADHD, and the parent is then likely referred to a medical center like Columbia or a pediatrician who is biased in favor of medications and performs only a cursory evaluation of the child. If parents object to medication, they may be forced to remove the child from school or be threatened with being reported to child welfare agencies for ‘medical neglect’. When a recent series of articles on such cases was published in the New York Post, over a hundred local parents called to describe such abuses.26 In response to similar cases, several states, including Colorado, Texas, and Rhode Island, have passed laws forbidding schools from making medical diagnoses or requiring medication for children in order to attend school.

It is important to say that psychiatric medications, including Ritalin, are not always against the interest of the child. Some children have extreme behavioral or emotional problems that require intensive investigation and treatment, and medication may be a part of an overall treatment plan. What is alarming, however, is that huge and escalating numbers of children are being labeled as ill and medicated. Many of these children may have no problem at all -- they are simply active or dreamy in situations where adults want them to sit still and pay attention. Other children may have more significant problems, but their problems may reflect stresses within the family, ineffective schooling, learning disorders, medical conditions, poor diet or sleep patterns, or a myriad of other possibilities. It is a time consuming and difficult process to assess a child and his or her environment and develop a plan to improve the situation. Many schools and families do not have the resources to do this, and so they resort to a quick fix with drugs. Unfortunately, many educators and medical professionals are promoting this approach.

We cannot, however, attribute the steep rise in the diagnosis and medication of children to just a fad or a wobble in the nature-nurture debate, for more profound forces are at work. One factor is the power of the pharmaceutical industry. Psychiatric medicines like Prozac have become some of the biggest selling drugs on the market and accounted for $8 billion in profits in the US in 1998.27 Ritalin alone showed a 5 fold increase in profits from 1990-1996.28 Certainly the drug companies are eager to sell to the largest untapped market for their mind altering drugs -- children. But they could not do this if the society was not already primed to accept a biodeterministic view of life. This outlook says that a person’s social position and success are largely predetermined by his genetic makeup, and it has been used to explain social inequality for hundreds of years. Under slavery, blacks were said to be inferior to whites and attempted escape was said to result from a disease called drapetomania. The eugenics movement of the early 20th century was born in America and purported to prove the inferiority of various minority groups. Eugenics laws were enforced to limit immigration and even to force sterilization. The Nazis imported eugenic ‘science’ from the US to justify the slaughters of Jews, Slavs, the mentally retarded, the physically handicapped and others. The perpetrators of the Tuskegee experiments declared the physical difference of African Americans to explain how they contracted syphilis and why it was all right not to treat them.

Biodeterminism has always flourished when societies exhibit both great inequality and are at risk of upheaval. It is an outlook which explains inequity and blames the most oppressed and weakest members of society for their own disadvantages. It takes the onus off society to change since it declares that it is the inborn endowment of each individual that determines his or her condition. In the present day United States, we are living in an era of great and increasing inequality between the rich and the poor--poverty is increasing for the first time in 12 years and unemployment has not been so high since the last recession. Moreover, the aftermath of 9/11 and the impending war in Iraq have allowed the government to impose fearsome new limits on civil liberties. From arrests based on racial profiling to secret trials to encouragement of spying on one?s neighbors, a climate of intimidation and jingoism is growing and bears a startling resemblance to regimes called fascist in the past.

To make this new order acceptable to people, the state relies on fear and ideology, which includes patriotism, racism and biodeterminism. That is, we are urged to believe in our fundamental difference from those of other nationalities or backgrounds, who are branded as ?evil?, and to accept the stratification in our own society as based on natural assortment by ability and temperament. The growing percentage of Americans who believe themselves to be mentally ill, many of whom are on an array of psychiatric drugs, have not only bought into the idea that they are damaged goods but have been rendered unable to struggle to change their situation or conditions in society. Imagine the harm that is done to children, who from an early age are labeled ‘ill’ and who will suffer as yet unknown physical and psychic harm from decades on mind-altering drugs. This is truly medical fascism, carried out in the name of biomedical progress.

Several groups around the country are fighting this trend to over-drug our children. One such effort is by The Coalition Against the Violence Initiative in New York City, a group of parents, community activists, and health workers affiliated with The Riverside Church. We have had informational forums, leafletted schools and PTAs, spoken on radio, held demonstrations and published literature for teachers and parents. If you would like to know more about us or find about a group in your area, call 212 330-8677 or write to CAVI , c/o Social Justice Ministries of The Riverside Church, 490 Riverside Dr., New York, NY 10027.

Contact Dr. Isaacs at eisaacs@pol.net

REFERENCES

1. Mental Health: A Report of the Surgeon General, Chapter 3:Chilren

and Mental Health, 1999

2. Guevara J, Lozano P, Wickizer T, Mell L, Gephart H, Psychotropic

Medication Use in a Population of Children with Attention-Deficit/Hyperactivity

Disorder.Pediatrics. 2002;109:733-9

3. Valenstein E, Blaming the Brain. The Free Press, New York, 1998, p. 1

4. Rethinking Ritalin, The Congressional Quarterly Researcher. 1999;9:905-28

5. Ralph D, Work and Madness, The Rise of Community Psychiatry. Black Rose Books, Montreal, Canada, 1983, p. 12

6. American Academy of Pediatrics Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention Deficit/Hyperactivity Disorder. Pediatrics. 2000;105:1158-70

7. Diller L, Running on Ritalin. Bantam Books, New York. 1998. p.61-3

8. Ibid., p.22

9. Attention Deficit Hyperactivity Disorder, National Institute of Mental Health, US

Government Printing Office, Washington, DC, 1996

10. Biederman J, Are Stimulants Overprescribed for Children With

Behavorial Problems? Pediatric News, August, 1996

11. Woodworth T, Deputy Director Office of Diversion Control, Drug Enforcement Administration, Statement Before Congress, May 16, 2000

12. Griffith D, ADHD Alert Spurs Reform in Virginia, The Sacramento Bee, June 23, 2002

13. Olfson M, Marcus S, Weissman M, Jensen P, National Trends in the Use of Psychtropic Medications by Children, J Am Acad Child Adolescent Psychiatry. 2002;41:514-21

14. Parry, M, letter to Dr. Roger Lindeman, publisher Virginia Mason, March 31, 1998

15. Woodworth T (see 11)

16. Diller, p. 314

17. Lefever, G, presentation at National Convention of The American Public Health Association, October, 2000

18. Press Release, Drug Enforcement Administration, October 20, 1995

19. Zito J, Safer D, dosReis S, Gardner J, Boles M, Lynch F, Trends in the

Prescribing of Psychotropic Medications to Preschoolers. JAMA. 2000;283:1025-60

20. Rappley M, Eneli I, Mullan P, Alvarez F, Wang J, Luo Z, Gardiner J, Patterns of Psychotropic Use in Young Children with Attention-Deficit Hyperactivity Disorder. Dev Behav Pediatrics. 2002;23:23-30

21. Rappley M, Mullan P, Alvarez F, Eneli I, Wang J, Gardiner J, Diagnosis of Attention-Deficit Hyperactivity Disorder and Use of Psychotropic Medication in Very Young Children. Arch Ped Adolesc Med. 1999;153:1039-45

22. Leo J, American Preschoolers on Ritalin, Society, January/February 2002

23. Methylphenidate Efficacy and Safety in ADHD Preschoolers, NIMH Grat 1U01-MH-60903-01A1

24. www.nyspi.cpmc.columbia.edu/Kolb/index.html

25. Olfson M (see 13)

26. Montero D, columns in the New York Post, August 7,8,9,10,11,13,14,15, 2002

27. Valenstein E, p. 166

28. Diller L, p. 36


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© 2002 by Elaine Sutherland and Angelique Corthals. All Rights Reserved. Last Modified Tuesday, September 23, 2003