Are We Overmedicating Our Kids? A Review of "We’ve Got Issues" by Judith Warner

Judith Warner answers the controversial question of whether or not children are being overdiagnosed and overmedicated in her new book We’ve Got Issues: Children and Parents in the Age of Medication. One interesting thing about the author that motivated me to read this was that she changed her mind on this question during the course of writing the book. At first, she held the view that kids were being overmedicated by their affluent, competitive, perfectionistic parents. She changed this view 180 degrees in the course of researching the book. The book argues that mentally ill kids are in fact undertreated and undermedicated. Most parents are very reluctant to drug their children, and do so only as a last resort. Many children with mental health issues (about 70%) are not being treated, partly due to parental neglect or opposition, but mostly due to lack of quality, affordable mental health providers and resources in many communities.

Warner first tackles the question of whether or not there is in fact an epidemic of pediatric mental illness. There’s no question that in recent decades there has been a massive increase in both diagnosis and medication treatment. Since the early 1990’s, the number of children receiving diagnoses of mental health disorders has tripled. From 1991 to 2006, there was a 3,500 percent increase in autistic children participating in special-education programs. Prevalence of depressed children has increased from near zero in the early 1970’s to between 2 and 15 percent today. Before the mid-1990’s, there weren’t any children diagnosed with bipolar; today prevalence is up to one percent. Prevalence of ADHD went from 1.5 to 2 percent in the mid-1970’s to about 8 percent today.

With the increased diagnosis, comes increased medication usage. Prior to the 1990’s, kids usually weren’t prescribed antidepressants or antipsychotics. Now 1 to 2 percent of kids are prescribed antidepressants. Atypical antipsychotic drugs, which can cause serious metabolic changes and weight gain, were used by over half a million children in 2003. Ritalin and other stimulant use has skyrocketed along with the increased number of children diagnosed with ADHD.

Warner argues that much of the increase is due to changing diagnostic patterns; what she calls “increased visibility.” Many children who suffered from mental illness in the period from 1945 until 1980 were, depending on the symptoms, punished for misbehavior or conduct disorder, kicked out of school, institutionalized, or labeled as retarded. They weren’t diagnosed with psychiatric disorders because there were no effective treatments (this was a time when psychoanalytic techniques were dominant). Quoting Edward Shorter, “Physicians prefer to diagnose conditions they can treat rather than those they can’t” (p. 46).

Warner tackles the contentious issue of the fortyfold increase in juvenile bipolar disorder diagnosis between 1994 and 2003. She presents evidence skeptical that many of these children in fact have bipolar: the connection between the doctors promoting the diagnosis and the pharmaceutical industry; the fact that mood disorders occur predominantly in women, but juvenile bipolar is largely diagnosed in boys; and that the symptoms of extreme irritability that the supposedly bipolar children have is not a valid predictor of adult bipolar disorder. On the other hand, children diagnosed with bipolar disorder do have serious problems, and probably need some type of medication.

Warner also presents research that indicates that there has been in fact an increase in mental illness prevalence separate from changing diagnostic standards. For example, one study found that successive generations of Americans born after World War II seemed to have a greater incidence and earlier onset of depression. Anxiety seems to be increasing, also, as the number of teens between the ages of 14 and 16 who agreed with the statement that “Life is a strain for me much of the time” quadrupled between the early 1950’s and 1989.

The truth is that there’s no way to know if actual prevalence of pediatric mental illness has increased. According to Warner, “The research that could provide solid answers—epidemiological studies conducted in a parallel manner over time, asking the same questions, looking for the same disorders, using consistent language and definitions—for the most part doesn’t exist” (pp. 56-57).

My view is that she’s right, we can’t be sure of this. But it does seem that something in the environment is making kids more depressed, anxious, and autistic than before. Warner focuses on the post-World War II period, in which parents of young children today grew up. But what about if you go further back in history? It must be remembered that psychiatry, clinical psychology, and other mental health professions didn’t exist before 1900, nor did any mental health treatments. If there were so many mentally ill children (and adults) back then, wouldn’t someone have noticed it? There was no safety net; people had to pull their own weight or starve. If there were as many children and adults with disorders back then, and no way to treat them, wouldn’t society have come to a standstill?

Another way to look at things is the flip side of mental illness: creativity. Many mentally ill people are also creative. Many creative achievers of the past had mental illness. While there is no consistent way we’ve diagnosed mental illness over time, creative achievement is, by definition, public and visible. Michelangelo, Beethoven, Shakespeare, Einstein and others achieved things that make them household names today; there are no contemporary equivalents. As I’ve argued elsewhere, the rate of creative achievement in the arts and sciences declined precipitously in the 20th century, to near-zero today. People who would have achieved in the past are not achieving. There are many explanations for this, but one is that they are acquiring severe, debilitating mental illness that prevents them from achieving. Another explanation, that they are taking emotion and motivation-blunting drugs, is something that I’ll discuss below.

Warner next makes her central argument, bolstered by a variety of anecdotes and quotes from parents, doctors, and researchers. She argues that most parents don’t want to medicate their children, that they usually try a variety of useless alternative treatments before reluctantly agreeing to medication, and that they are usually pleased by the results. While medications don’t work miracles, and some of them produce side effects, they result in improvement. Children who were unable to cope or function in school can now function at a tolerable level. We should stop blaming parents and doctors for overmedicating children, and instead focus on the large percentage of children who, for various reasons, are denied effective treatment for their mental illness.

I found it interesting that Warner didn’t include any examples of cases in which medications did more harm than good. She didn’t include any examples of parents who were eager to use medication on their children. While she says that she couldn’t find such examples, a reviewer indicated that this is an example of her selection bias. There’s no evidence in the book that she took a random sample of medicated children and then tracked down and interviewed the parents. She’s a popular writer, not a researcher, so she can be excused for this unscientific methodology, but the reader must be wary of any generalizations that she draws.

It isn’t hard to find examples of unhappy results from pediatric use of medications. Stephany, the author of the blog Soulful Sepulcher, writes poignantly about her daughter, currently institutionalized, who is such an example. I would have preferred to seen a more balanced presentation from Warner.

Of course, the fact that some children don’t excel with medication isn’t an argument that medication is ineffective. No treatment is successful 100% of the time. All drugs have side effects, and sometimes the side effects are worse than the treatment effect. Another reviewer is critical of the scientific evidence that Warner presents in favor of medication use. Warner says that there are treatments for kids that “actually work” (p. 211), that allow children to “improve and live their lives to the fullest” (p.210). Warner is basing these Pollyannish assessments on short-term measures of success, especially in school. The reviewer is skeptical about how much we know about the long-term effects of drugs on children’s developing brains.

My view is that we can’t be sure of the long-term efficacy of drugs unless we do longitudinal studies, comparing control versus experimental (drug) groups, that extend up to about age 50. The reason for such a long time frame is that by the age of 50, we should know whether or not someone has been successful in his or her career. What if children on drugs do well in school, but not so well in their adult life? Since most of the drugs (except Ritalin) haven’t been used in children for more than 20 years, we’re being premature about declaring a success.

I’m not saying that we shouldn’t prescribe these drugs in children, although I do think that they should be a last resort, after every type of therapy has been tried. We also need to distinguish between the more serious types of disorders and less serious ones. For less serious childhood disorders, the ones in which children can function in some contexts (e.g. home) but not in school, I think we need to think about changing the school environment. The typical public school classroom is OK for an average student, but ones with special needs and/or abilities don’t thrive there. There are some special education classes, but to get a child into them a parent has to have significant time to deal with public school bureaucracies, or money to get into a private school program. Warner mentions this in her book; these services are effectively denied to the lower middle and working classes. We need to try to expand these services, and also think about coming up with less expensive alternatives that focus on vocational or artistic training.

As I mentioned earlier, psychotropic drugs are one of the causes of the lack of creative achievement in arts and sciences today. The legal, prescribed ones blunt emotions and motivation. The illegal ones can cause destructive addictions. Even if a child does better in school while taking drugs, will he contribute more to society than he would have otherwise? In another blog post, I mention that our society has a narrow (academic) definition of talent, that lacks context and empathy. Both context and empathy are necessary for good decision making, and in recent decades America’s political and economic leadership has made some poor decisions. Probably some of these deficits are due to the effects of drugs on people. These effects are hard to quantify, and won’t show up in a typical study, but they are incredibly important for society.

For the more serious types of disorders, in which the child can’t function anywhere, medications are an unfortunate necessity. Warner admits in her book, echoing many parents, that medication is not going to make these kids successful. It may make them less disabled than they would have otherwise been. The most important thing for us to do is to find out genetic and environmental causes of serious psychiatric disorders, to prevent them from happening in the future.

On the environmental side, we’ve covered just about every base imaginable, including diet, chemicals, vaccines, infections, etc. One thing we haven’t looked at is the effect of artificial magnetic fields. The reason for this is that scientists don’t think that humans have the ability to perceive magnetic fields. I present evidence in my research paper contradicting this. I found that I’m sensitive to artificial magnetic fields when sleeping, but not when I’m awake. If I’m sensitive now, as an adult, I was probably much more sensitive as a child. My hypothesis is that some children with serious psychiatric disorders are sensitive to artificial magnetic fields, especially when sleeping. My hypothesis would explain the increased prevalence in recent decades of serious pediatric psychiatric disorders. When I was growing up in the late 1960’s through mid 1980’s, the only artificial magnetic fields I had to worry about when sleeping were the innerspring mattress, steel bed frame, steel building structure, and a fan that I used in the summer to keep cool. Today, we have wireless Internet, home security, cordless phones, cell phones, baby monitors, computers, widescreen TV’s, iPods, central air, etc. Many of these devices and appliances emit strong magnetic fields, and are kept on while sleeping. It would be easy to test my hypothesis. Start turning things off, change to a non-magnetic bed, and see if the disturbed child becomes a little less disturbed. See if he can sleep better, which will make him function better the next day.

In conclusion, I found Warner’s book to be well written, with a lot of useful information for those interested in pediatric mental health. Its major flaw was a lack of balance in presenting evidence in favor of medication use in children.

A Beautiful Mind

I just finished reading A Beautiful Mind, the 1998 biography of mathematician John Nash by Sylvia Nasar. It’s an interesting account of a highly intelligent and creative man who suffered from schizophrenia. I’ll discuss information I gleaned from the book in this post. I’m assuming the biography is accurate, although I haven’t done any independent checking.

Like many people, I first heard of Nash by watching the movie starring Russell Crowe. The movie is true to the basic outline of the biography, but omits or fudges many relevant details. For example, the movie didn’t mention Nash’s travels to Europe or his divorce. From the movie, one would think that Nash’s disorder began at graduate school at Princeton, since that is when he first “sees” his imaginary roommate. This imaginary roommate isn’t mentioned in the book.

Although eccentric and strange, Nash didn’t suffer his first breakdown until age 30, which is relatively late for schizophrenia. If Nash had developed this disorder when he was 20, no one would have heard of him, and there would be no biography to read. It’s important to emphasize this point. For every famous person like Nash, there are thousands of talented people who, due to mental illness, never get a chance to exercise their talents.

What precipitated Nash’s initial breakdown? It could have been his marriage that occurred two years before, along with his wife’s pregnancy. Stress is known to precipitate psychiatric symptoms, and major life changes like getting married and having a child are significant sources of stress. It could have been a European honeymoon trip that Nash and his wife went on about 6 months prior to his breakdown. There’s no way to know for sure.

After his breakdown and initial hospitalization, Nash gave up his tenured position at MIT and headed to Europe, where he would spend the next 9 months, attempting to renounce his U.S. citizenship and become a “world citizen.” This behavior exemplifies that the severe mental illnesses are primarily disorders of instability. Who in his right mind would give up a tenured faculty position at MIT? Most normal people crave stability, and there’s nothing more stable than a tenured position. Mentally ill people crave the opposite; for them the stability of a tenured position is both frightening and undesirable. Nash’s travels are further indications of instability.

After Nash returned to the U.S., he had temporary episodes of sanity alternating with psychotic episodes. With some brief exceptions, he wasn’t able to resume his career until he had a remission in his fifties. This remission occurred after having lived a relatively quiet and stable life at Princeton for over ten years. Nash won the Nobel Prize in economics in 1994.

Nasar’s biography convinces me that schizophrenia is closer to bipolar disorder than Alzheimer’s Disease. Schizophrenia is an episodic disease, characterized by alternating sanity and insanity, of rational thought and delusions. At least in Nash’s case, it doesn’t appear to be degenerative.

There’s no evidence from the biography supporting my hypothesis that schizophrenia is connected to the Earth’s magnetic field. Before he developed schizophrenia, Nash traveled within the U.S., including working for a time at Rand in Santa Monica, California. If Nash were sensitive to the geomagnetic field, he should have developed a breakdown while living in California. The fact that his first breakdown occurred soon after a trip to Europe doesn’t imply that the different geomagnetic in Europe precipitated his schizophrenia.

Whether or not schizophrenia is connected to the geomagnetic field, there’s no question that it is a severely disabling disorder, probably the most disabling psychiatric disorder. That Nash was able to accomplish what he did despite the disorder, and the fact that he was able to achieve remission, is amazing.

Harry Magnet offering free consulting

For a limited time I'm offering free consulting. Check out the details by clicking here.