The New York Times Criticizes the Medical Model of ADHD

The New York Times, the most prestigious and influential newspaper in the United States, has run a series of articles in the past year or two critical of the over-diagnosis and over-prescription of ADHD drugs (mainly stimulants) for children and adults. The Times doesn’t question that there is a disorder known as ADHD that can be effectively treated with stimulant drugs. What the newspaper criticizes is a biological interpretation of the rapidly increasing prevalence of ADHD, the increasing use of prescription drugs to treat this disorder, the excessive drugging of poor children on state assistance (Medicaid), and the refusal among many in the medical community to look at alternative treatments such as behavior and psychosocial therapy. For those who, like myself, want to see a reduction in the use of medication for ADHD, this is encouraging. Here are some examples of relevant articles:

• Thousands of Toddlers Are Medicated for A.D.H.D., Report Finds, Raising Worries (May 16, 2014): More than 10,000 American children ages 2 or 3 are being medicated for ADHD, according to data from the CDC. Toddlers covered by Medicaid are especially vulnerable to being put on stimulant medication. Diagnosing ADHD and prescribing drugs in children so young is against established pediatric guidelines. “It’s absolutely shocking, and it shouldn’t be happening,” said Anita Zervigon-Hakes, a children’s mental health consultant.
  
   “People prescribing to 2-year-olds are just winging it,” according to Dr. Lawrence H. Diller, a behavioral pediatrician in Walnut Creek, CA. “It is outside the standard of care, and they should be subject to malpractice if something goes wrong with a kid.”
  
  The reason why pediatric guidelines don’t recommend diagnosing and treating ADHD in toddlers is that hyperactivity and impulsivity are developmentally appropriate at that age. Experts say that more time is needed to see if a disorder is truly present.
  
  The CDC data showed that about one in 225 Georgia toddlers covered by Medicaid is being prescribed drugs for ADHD. Extrapolating the Georgia data nationwide provides the 10,000 total number of toddlers being medicated for ADHD. An additional 4,000 toddlers covered by private insurance were also being prescribed stimulant drugs.
  
  Behavioral treatments, such as providing more structured environments for the children, are often ignored. “Some of these kids are having really legitimate problems,” Dr. Doris Greenberg, a behavioral pediatrician in Savannah, GA said. “But you also have overwhelmed parents who can’t cope and the doctor prescribes as a knee-jerk reaction. You have children with depression or anxiety who can present the same way, and these medications can just make those problems worse.”    


• Exercising the Mind to Treat Attention Deficits (May 12, 2014). This article talks about treating ADHD by strengthening the patient’s “cognitive control,” the ability to maintain focus on something while ignoring other impulses. A number of research studies have shown that it is possible for children and adults to improve their cognitive control via exercises in “mindfulness”. Noting a “growing disenchantment with the first-line treatment for [ADHD]: drugs,” and the fact that the beneficial effects of the stimulant drugs usually wane by the third year, or sooner, researchers have been looking for treatment alternatives to drugs. According to James M. Swanson, a University of California, Irvine psychologist, “There are no long-term, lasting benefits from taking ADHD medications. But mindfulness seems to be training the same areas of the brain that have reduced activity in ADHD. That’s why mindfulness might be so important. It seems to get at the causes.”
  
  ADHD isn’t unique to Americans, but the belief that only medication can treat it is. As an example, a study showed that the incidence of ADHD among Finnish teenagers is the same as the incidence of ADHD among American teenagers. The big difference between the two countries is that although most Finnish teenagers weren’t taking medication, most American teenagers were.
  
  Some attributes included in the concept “cognitive control” are delayed gratification, impulse management, emotional regulation, self-control, and suppression of irrelevant thoughts. Cognitive control increases between the ages of 4 and 12, then plateaus during the early teenage years. After about age 16, cognitive control increases again until people achieve adult levels.
  
  To improve cognitive control, therapists teach people to dispassionately monitor their thoughts and feelings. This is known as “mindfulness training.” If their attention has wandered, they are taught to renew their concentration. According to a recent study, adults with ADD given mindfulness training combined with cognitive therapy had improved mental performance comparable to that achieved by adults given medication.
  
  One consequence of mindfulness training is that it gives you “the ability to self-regulate your internal distractions”, according to Dr. Adam Gazzaley of the University of California, San Francisco. Gazzaley uses video games to help older adults improve their cognitive control.


• Report Says Medication Use Is Rising for Adults With Attention Disorder (March 12, 2014): An alternative title for this article that I came up with is: “Experts Fiddle While ADHD Drug Use Burns America.” The article refers to a study done by Express Scripts, the largest prescription drug manager in the U.S. The results of the study point to a disturbing and rapid increase in the number of prescriptions for ADHD, especially among young adults. The number of young American adults taking medication for ADHD nearly doubled between 2008 and 2012. In that same time period, the number of American adults of all ages taking ADHD medication rose 53%. Use of ADHD medication among American children rose 19%. In 2012, 7.8% of boys and 3.5% of girls between ages 4 and 18 were being prescribed ADHD medications. Almost 1 in 10 adolescent boys were taking ADHD medications.
  
  This explosion in ADHD drug use has occurred while experts fiddled, i.e. pretended that nothing was happening. The CDC last year did a telephone survey of 76,000 parents that reported a similar explosive increase in ADHD drug use. Experts dismissed the survey, similar to ones that were done every year since 2003, as lacking scientific rigor. The American Medical Association stated that these phone surveys “overestimated true prevalence” of ADHD diagnosis. Dr. Sanjay Gupta of CNN said that, “There’s not a lot of value in these studies.”
  
  It’s classic incompetence to dismiss reports of problems without doing anything. Couldn’t these “experts” have designed their own scientific studies to confirm or disprove the CDC data? According to Susanna Visser, the CDC’s lead epidemiologist for ADHD, the experts’ discrediting of the CDC survey data has been costly, not only in understanding the issue, but also coming up with solutions.
  
  One reason why the “experts” haven’t done anything is that many don’t think that increased drugging of adults for ADHD is a problem. According to Dr. Lenard A. Adler of NYU Langone Medical Center, “We still know that a majority of adults with ADHD are untreated.”


• A.D.H.D. Experts Re-evaluate Study’s Zeal for Drugs (December 29, 2013): A discussion of how the results of the Multimodal Treatment Study of Children With ADHD, which argued strongly for the benefits of medication over behavioral therapy, are being re-interpreted today. This expensive, independent study of about 600 children, which began 20 years ago, is widely considered the most influential study on ADHD. The authors found that medication reduced symptoms in 56% of children, while behavioral therapy only reduced symptoms in 34% of children. Combination therapy (medication + behavioral therapy) reduced symptoms in 68% of children, which the authors felt was only a small increase over medication alone (56%). The conclusion was that medication was superior to behavioral treatment by a considerable margin.
  
  This sanction of approval by a major study not funded by them gave pharma a powerful weapon to use in their marketing materials and doctor-education classes. According to Laura Batstra, a psychologist at the University of Groningen in the Netherlands, “the only thing we heard was . . . that medication is the answer.”
  
  There were problems with the study design that led to the medication-being-superior conclusion. According to researchers involved with the study, it was structured to emphasize the reduction of impulsivity and inattention symptoms, with less emphasis placed on improving children’s longer-term academic and social skills. Medication mainly addresses the former, while behavior therapy addresses the latter by creating less distracting and more organized learning environments. In other words, the study was designed to make medications look good and behavior therapy bad.
  
  An additional $10 million in government funding extended the study, and followed the children into young adulthood, making it a true longitudinal study. Results called into serious question the value of medication. I have already blogged about the follow-up results. One highlight is that more than half of the children stopped taking medication after an 8 year follow up. Another highlight is that children who were no longer taking medication at the time of the follow up were functioning as well as children who were taking medication.
  
  Many experts interpreted these findings as showing that the efficacy of medications dissipated over time. Pharma apologists argued that children did worse because they went off the medications. A balanced interpretation is that treatment type cannot predict long-term functioning, i.e. we cannot conclude that medication is superior or inferior to behavior therapy.
  
  The warped initial findings of the study are examples of psychiatry’s obsession with symptoms as opposed to overall functioning. This is the philosophy behind the DSM, the psychiatrist treatment manual. Not all experts agree with this symptom-based approach. According to Stephen Hinshaw, a psychologist at the University of California, Berkeley (and one of the study researchers), “My belief based on the science is that symptom reduction is a good thing, but adding skill-building is a better thing.”
  
  According to another co-author, Dr. Lily Hechtman (McGill University), “I hope it didn’t do irreparable damage. The people who pay the price in the end is the kids. That’s the biggest tragedy in all of this.”


• The Selling of Attention Deficit Disorder (December 14, 2013): I have already blogged about this article. It argues that pharmaceutical company marketing is a major culprit behind the explosion in ADHD diagnosis and treatment. The article also provides a detailed account of the various marketing tricks used to con doctors, parents, and patients into accepting the story that there are millions of undiagnosed children and adults with ADHD who would benefit from stimulant treatment.


• The The Not-So-Hidden Cause Behind the A.D.H.D. Epidemic (October 15, 2013): This article argues for a sociological interpretation of the rapid rise in ADHD diagnosis and treatment. ADHD reached “epidemic” status at about the same time as some important policy changes that incentivized diagnosis. In 1991, ADHD was included in the Individuals with Disabilities Education Act. For students diagnosed with ADHD, this allowed access to tutors, and more time to take standardized tests. By the late 1990’s, as public awareness of ADHD increased, its prevalence also increased. Another important policy change was the legalization of pharma marketing of controlled substances to the public that occurred in 1997. This allowed pharma to market stimulant drugs directly to consumers via print and TV ads.
  
  Stephen Hinshaw of the University of California, Berkeley found that in 2007, 15.6% of children ages 4 to 17 in North Carolina had received an ADHD diagnosis, while only 6.2% of children in California had this diagnosis. The reason for this geographical disparity is likely due to effects of state educational policies. North Carolina was the first state to adopt a program linking school financing to standardized-test performance, while California was one of the last. Hinshaw found a correlation between state’s implementation of these laws and ADHD prevalence. The No Child Left Behind Act was a federal program punishing or rewarding schools for standardized test scores, signed into law by President George W. Bush. The rates of ADHD diagnosis nationwide increased by 22% in the first four years after the act was implemented.
  
  Parents and educators obsessed with standardized tests results will look favorably on any intervention that improves a child’s ability to perform on tests, and prevents him from being a distraction to others. An ADHD diagnosis with medication treatment is such an intervention that has obvious short-term benefits (with less clear long-term benefits). This provides enormous pressure for the parent to have her inattentive / hyperactive child be diagnosed and drugged.
  
  The ADHD diagnosis explosion is part of a broader American trend of medicalization of traits the previous generations handled in different ways, according to Joel Nigg of the Oregon Health and Science University. Instead of punishing children who misbehave, we diagnose them with ADHD and drug them.


• A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise (March 31, 2013): I have already blogged about this article. 19% of American high school boys have received an ADHD diagnosis. 11% of school-age children overall have received the diagnosis. There has been a 16% increase in children between ages 4 and 17 being diagnosed with ADHD since 2007, and a 41% increase in the last decade.

Get the Kids to Bed on Time

As reported in the Wall Street Journal, a new study of sleep habits in children found that children with regular bedtimes performed better on cognitive tests than children with inconsistent bedtimes. Boys and girls with regular bedtime at age 3 performed better on cognitive tests given at age 7 than children with non-regular bedtimes. Cognitive tests included tests of reading, math, and spatial skills. The mother reported whether the child went to bed on time or not. The mother also reported the time the child went to bed on a weeknight (while school was in session). Over 11,000 children participated in the study.

The study found that children’s bedtimes became more regular as they got older. 19.5% of 3-year-old children didn't have a regular bedtime. This dropped to 9.1% of 5-year-old children, and 8.2% of 7-year-old children not having a regular bedtime. Children who were more socially disadvantaged tended to have less regular and later bedtimes. The study controlled for confounding factors that could influence test performance, including mother’s age, birth order, family income, parental education, parental employment, discipline strategies, hours spent watching TV, whether the child has a TV in the bedroom, and whether the mother drank or smoked during pregnancy.

With one exception, early or late bedtime didn't significantly affect children’s test scores, after other factors were taken into account. Late bedtime at age 7 reduced girls’ reading scores. The paper didn't present results on the association between test scores and specific early or late bedtime ranges at ages 3 or 5.

After controlling for the various factors affecting cognitive test performance, not having a regular bedtime at age 7 was associated with lower test scores for girls, but not for boys. For both girls and boys, non-regular bedtimes at age 3 were associated with lower test scores at age 7. The size of the association is small (the authors quantify the size of the association in the Discussion section, but as I mention in the next paragraph I question their methodology). Non-regular bedtimes at age 5 were associated with lower reading scores in girls, and math scores in boys. Girls, but not boys, who never had regular bedtimes at ages 3, 5, and 7 had significantly lower test scores at age 7. Somewhat surprisingly, boys who didn't have regular bedtimes at any 2 of the 3 ages had lower test scores, but boys who didn't have regular bedtimes at all 3 ages did not have significantly lower test scores.

It must be remembered that this is only one study, and replication is required before scientific acceptance of the link between stable bedtime and cognitive test scores. The study used the mother’s self report about whether her child went to bed at a regular time. This is both prone to recall errors, and also is inherently subjective. What exactly is a “regular time”? One mother may say that a regular time is +/- 15 minutes from a target bedtime. Another mother may say that a regular time is +/- 30 minutes from a target bedtime. I had problems with the table presentation of the results. Regression beta coefficients were presented along with confidence intervals, but statistically significant results were presented along with nonsignificant results, and there were no indicators separating significant from nonsignificant. There was no overall R^2 reported. I also had issues with the statistical inferences. A regression beta value for a binary variable like non-regular bedtime can’t be translated into the usual interpretation of beta: 1 SD of change in independent variable corresponds to (beta) SD change in dependent variable, but that’s apparently what the authors did. (How did the reviewers and editors miss this?) In the Discussion section of the paper, the authors report on the size of the associations in terms of standard deviations of test scores. I’m assuming that they are using the beta scores to determine this (the numbers they quote match the beta scores). If they are, then the association sizes in terms of standard deviations of test scores that the authors report in the Discussion Section are incorrect.

Assuming the link between stable early childhood bedtimes and cognitive test scores holds, it’s interesting to relate this to my hypothesis about ideal bedtime that I report in my human magnetoreception research paper. I've found that I have an ideal bedtime that varies according to where I am located, and whether or not daylight saving time is in effect. In the summer in Salt Lake City, UT, my ideal bedtime is about 11:35 p.m. I feel best both when my bedtime is stable, and when it is close to ideal. I’m assuming that sometime in my childhood my ideal bedtime was “set”. I grew up in Northern New Jersey. My ideal bedtime there is about 10:35 p.m. when daylight saving time is in effect. Did I consistently go to bed around 10:35 p.m. when I was a young child?

Another important thing to consider is the effect of daylight saving time. I have found that there is a 2 hour ideal bedtime difference when the time changes. (The explanation for this is rather complicated and I won’t go into this here). Ideal bedtime in Northern New Jersey is 8:35 p.m. during standard time, and 10:35 p.m. during daylight saving time. Perhaps I went to bed around 8:30 p.m. as a young child (more realistic than 10:30 p.m.). This 2 hour difference affects the meaning of “stable bedtime”. A child who goes to bed at 10 p.m. in the summer and 8 p.m. in the winter has a stable bedtime with reference to the natural environment. A child who goes to bed at 8 p.m. year round has an unstable bedtime—he goes to bed 2 hours earlier with reference to the natural environment when daylight saving time goes into effect. Studies such as this one don’t take this daylight saving time factor into account.

It’s possible that stable early childhood bedtimes can affect future mental health, as it can affect IQ. Perhaps unstable early childhood bedtimes can lead to sleep or mood disorders later in life. What about unstable early childhood environments (e.g. frequently moving)? What about the magnetic characteristics of the child’s bedroom (e.g. compass orientation of bed, and artificial magnetic fields in the sleeping environment)? These are the kinds of questions that researchers should be asking as they explore different and previously unknown environmental effects on child development.

19% of American High School Boys Diagnosed with ADHD

A recent New York Times article reported the disturbing fact that 19% of American high school boys have received an ADHD diagnosis. 11% of school-age children overall have received the diagnosis. There has been a 16% increase in children between ages 4 and 17 being diagnosed with ADHD since 2007, and a 41% increase in the last decade. The increased diagnosis correlates with increased prescriptions to stimulant medications like Ritalin and Adderall. These medications, while offering short-term increased concentration abilities in children with true ADHD, also have risks of side-effects, including addiction, anxiety, and occasional psychosis. Evidence that stimulants improve long-term outcomes in children with ADHD is lacking.

These numbers are making some academic psychiatrists concerned. James Swanson is a professor of psychiatry at Florida International University, and one of the primary ADHD researchers in the last 20 years. According to Swanson, “There’s no way that one in five high-school boys has A.D.H.D. If we start treating children who do not have the disorder with stimulants, a certain percentage are going to have problems that are predictable — some of them are going to end up with abuse and dependence. And with all those pills around, how much of that actually goes to friends? Some studies have said it’s about 30 percent.”

Think about this—30% of stimulant medication is going to children who don’t have any disorder. They are using it to focus, to stay awake, and to improve their grades. Parents, doctors, and pharmacists are essentially giving normal children access to speed. Maybe these children will do better at school in the short term. But they are risking a life of drug abuse and dependence. Sure, grades are important, but are they really that important?

Dr. Ned Hallowell, a child psychiatrist and author of best-selling books on the disorder, is another psychiatrist who has changed his viewpoint on ADHD. For years Dr. Hallowell would reassure skeptical parents by telling them that Adderall and other stimulants were “safer than aspirin.” He now says, “I regret the analogy” and “won’t be saying that again.” Halloway still thinks that many children with ADHD continue to go unrecognized and untreated, but wants more rigorous diagnostic procedures. “I think now’s the time to call attention to the dangers that can be associated with making the diagnosis in a slipshod fashion,” he said. “That we have kids out there getting these drugs to use them as mental steroids — that’s dangerous, and I hate to think I have a hand in creating that problem.”

Regarding rigorous diagnostic procedures: proposed changes to the DSM, to be released soon in the DSM-V, allow for more adolescents and adults to qualify for the disorder. Some of the proposed changes include increasing the age of first symptoms from 7 to 12; examples, such as repeatedly losing one’s cell phone, that are applicable to teenagers; and a change in the requirement that symptoms cause “impairment” to symptoms simply “impacting” daily activities.

Pharmaceutical companies predictably use their marketing power to persuade parents and doctors to get more children an ADHD diagnosis and prescription for stimulant medication. An example of this is a pamphlet for Vyvanse from its manufacturer, Shire. In the pamphlet, a parent looks at her son and says, “I want to do all I can to help him succeed.”

The stimulant drugging of our youth is a national crisis that needs to be addressed. It is unlikely that psychiatrists and pharmaceutical companies will reform themselves without outside pressure. Left alone, the corrupt pharmaceutical-psychiatric establishment will diagnose and drug more children, as evidenced by the numbers mentioned above, and proposed changes in the DSM-V. The government needs to be involved in the solution. Some needed changes include the outlawing of off-label prescribing to children, tightening the diagnostic standards of ADHD, restricting the prescribing of stimulant medications to children, encouragement of using non-drug alternative solutions to ADHD, encouraging  research in alternative treatments for ADHD, outlawing drug company advertising to the public, outlawing drug companies’ bribes to doctors, and expelling from school any children found with stimulant medication that is not prescribed to them, or any children sharing their medication with other children. There also need to be more long-term studies done of the effects of stimulant medications on children with or without ADHD.

Are American Educators Living in a Fantasy World? A review of “Real Education” by Charles Murray

I enjoy reading books by Charles Murray. Although he identifies himself as a libertarian conservative, he’s an independent thinker. His books The Bell Curve and Human Accomplishment are examples of his unique perspective. A central point of the The Bell Curve is that intelligence, which is determined by genes and early childhood experience, is a major factor in determining who succeeds in life and who doesn’t. Since whether a man is intelligent or not is outside of his control, there’s no basis for the libertarian argument that those who are financially successful have “earned” their money. A less intelligent person can work just as hard as a more intelligent one, sometimes harder, but only make a fraction of what the smart person is making. In Human Accomplishment, which celebrates past creative achievements in the arts and sciences, Murray doesn’t find any correlation between political/economic freedom and rate of achievement. I’d expect a conservative writer to argue that living in a free and democratic society promotes achievement, but that would ignore the facts of history. Most great achievement occurred by men living in monarchies and aristocracies that had very little freedom or liberty in the modern sense.

In his latest book, Real Education: Four Simple Truths for Bringing America’s Schools Back to Reality, Murray again stakes out an independent position. While one would expect a conservative writer to extol the virtues of George W. Bush’s “No Child Left Behind” initiative, Murray is very critical of it. Murray also is realistic about the limitations of conservative initiatives such as school choice, charter schools, and tuition vouchers.

Murray’s 4 simple educational truths are:

1. Ability varies
2. Half of the children are below average
3. Too many people are going to college
4. America’s future depends on how we educate the academically gifted

I’ll discuss Murray’s arguments for each of these truths. In the case of “ability varies,” Murray focuses on academic ability, which correlates highly with intelligence. The simple truth is that “half of the children are below average” in academic ability. Research has shown that there’s a normal (“bell curve”) distribution of academic ability. It follows that half the children will be on the left side of the bell curve, i.e. below average.

Murray next argues that there’s not much that schools can do to improve performance of below-average ability children. This is much more controversial than the statement that half of the children are below average. Murray presents actual questions from standardized tests that below-average ability children have problems answering. These are pretty simple questions, and it’s surprising that so many children have difficulties with them. The fact that they can’t answer them, however, could be indicative of a problem with the schools, not their lack of intelligence.

Murray then discusses various programs designed to improve students’ test scores, including preschool programs (Abecedarian Project and Infant Health and Development Program), and elementary/secondary school programs (Title I and No Child Left Behind). His conclusion is that these programs produced little to no improvement in student achievement. His case is bolstered by the results of the Coleman Report, which studied the effects of inequality of educational opportunity on student achievement. The Coleman Report found that quality of schools explains almost nothing about differences in academic achievement. Family background is more important a determiner of student achievement than any educational measure. What about the terrible quality of many American public schools, including chaotic and sometimes violent classrooms, incompetent teachers, low standards, and dearth of teaching resources such as textbooks and computers? Murray states that these “worst of the worst” inner-city schools only affect about 2 to 3 percent of all students. Based on the failure of programs to improve test scores, the results of the Coleman Report, and the small percentage of students attending failing public schools, Murray says that “[t]o continue to assert that major improvements are possible in the academic test performance of the lower half of the distribution through reform of the public schools is more than a triumph of hope over experience. It ignores experience altogether. It is educational romanticism” (p. 62).

I have a few criticisms of Murray’s argument. The first has to do with the way the book is structured. In a chapter that focuses on below-average students, Murray makes his case that schools can’t do much to lift student achievement. Murray separately discusses gifted children in another chapter. He doesn’t have much to say, however, about average and above-average (but not gifted) children. Wouldn’t better schools help improve scores of average and above-average students? Wouldn’t these students have more potential to achieve than below-average students?

I’m also not convinced that schools can’t do better for below-average students. Murray says that failing public schools only affect 2 to 3 percent of all students. But these are the “worst of the worst”, the most extreme examples of poor schools. Is he implying that no other public schools have problems with lack of discipline, gangs, violence, incompetent teachers, and low standards? In other words, that 97% of American public schools today have absolutely no problems? I think that many schools have similar problems, but not just as extreme as the worst of the worst inner city schools. Students in these moderately bad schools can perform better if their schools had higher standards.

In a book on education, it’s surprising that Murray ignores international comparisons. I constantly read articles and charts showing how poorly American students compare to students in some other countries. Based on his argument that schools can’t do much to lift ability, it follows logically that the reason why Singaporean students perform so much better than American students is that their students are a lot smarter than ours are. This might be true, but I would have liked to see Murray discuss this in his book. Is the fact that Singaporean public schools have very high standards, excellent teachers, a demanding curriculum, and no discipline problems completely unrelated to the fact that Singaporean students score higher than American students? I find it hard to believe.

Murray’s next educational truth is that too many people are going to college. He makes some good arguments that many people, including some who have the ability to get a bachelor’s degree, would do better in some other type of post-secondary education. He uses an example of a young man deciding whether to become an electrician or white-collar manager. He’s smart enough to get his bachelor’s degree in business, but is this the right choice? He has special small-motor and spatial skills that would make him a good electrician. He’d probably be an average manager. Based on his abilities, interests, and future career opportunities (mediocre managers are much more likely to be laid off than top electricians), becoming an electrician would be a good option. In fact, skilled technicians and artisans are in high demand even in this recession, while many white collar jobs have been downsized and outsourced.

There are many students such as the one described in the above paragraph, who choose a 4-year college over other options (e.g. technical school, community college, or apprenticeship). The reason why they choose college is that their parents, teachers, and guidance counselors push them in this direction. The reason why adults push children into college is that our society has made the bachelor’s degree a requirement for professional success. Murray questions this cultural worship of the bachelor’s degree. There are some for whom college is appropriate. This includes good math and science students who major in engineering and the hard sciences. It also includes good students who want to study pre-med or pre-law. But for the vast majority of students, especially those who become liberal arts or business majors, college is not the best option. It’s not good for their personal development, as they don’t learn much self-discipline or self-restraint with their light workload or partying lifestyle. It’s not good for their professional development, as their BA degree doesn’t give them the specific skills to get good jobs after they graduate. When I graduated college over 20 years ago, I was basically a liberal arts major with no job skills. My first job out of college was a management trainee at a shoe store. I eventually got a job at a computer help desk, which gave me my start in IT, but it was at near-minimum wage. Today, it’s even tougher for liberal arts majors. The recession has hit them especially hard, leaving them with a lot of student debt and little opportunity for a good job.

Murray next discusses education of the gifted. America’s future depends on the (unelected) intellectual elite, those who have risen to the top jobs that directly impact the nation’s culture, economy, and politics, along with those who influence smaller communities. “The members of the elite are drawn overwhelmingly from the academically gifted. We had better make sure that we do the best possible job of educating them” (p. 107).

Gifted children should be allowed to advance at their own pace, not be held back by their peers. This could include skipping grades, or getting advanced material within their age-appropriate grade. I found myself unchallenged as a gifted public school student, and would have been better off being pushed to take more demanding classes.

Murray focuses on training the gifted to be good citizens. This training should continue through college. “We need to structure their education so that they have the best possible chance to become not just knowledgeable but wise” (p. 112). Murray’s wisdom training of the gifted includes improving their verbal skills, teaching them how to make sound judgments, teaching them how to think about ethical issues, and teaching them humility. I’ll discuss each of these points below:

• Verbal skills—SAT-Verbal scores never recovered from their decline in the late 1960’s and 1970’s. SAT-Math scores did recover, indicating that educational priorities led to a toughening of the math and sciences curriculum. These priorities didn’t result in improvement in humanities and social sciences education, fields that depend heavily on verbal skills. Part of this failure to teach verbal skills is a result of the progressive education movement, which emphasized creative self-expression over correct spelling and grammar. When I was in high school in the early and mid-1980’s, my school had very good math teachers, but mediocre English and social sciences teachers.
• Sound judgments—Members of the elite make decisions all the time, judgments that affect the culture and nation. The Bush administration’s decision to invade Iraq still impacts us eight years later. When music company executives decide to sign a gangster rap artist, and ignore a quality musician, they weaken our culture a notch. When the FDA approves a psychiatric drug for children that has been inadequately tested, it jeopardizes our children’s mental health and development. Some components of sound judgment are unteachable, such as intuition and common sense. A teachable component includes how to evaluate data, especially the knowledge of basic statistics. Another one is pattern recognition, including knowledge of history. Personal and vicarious experience is also important in being able to see patterns in different situations.
• Ethical issues—Schools used to teach morality and virtue. Today, there is a widespread moral vacuum at all levels of education. This moral vacuum leads to nonjudgmentalism and ethical illiteracy. While there is more tolerance today than ever before, this tolerance extends to behavior that should not be acceptable in any society, including greed, selfishness, dishonesty, irresponsibility, and intemperance. It’s the function of the intellectual elite to help promote ethical behavior by example, by policy, and by writing and speaking. The default of the elite in this area has led to anomie and anarchy. We need to teach the gifted about virtue and ethics. This can be done by using examples from the great religious traditions and secular philosophers. These traditions and philosophies are in remarkable agreement on core issues (e.g. “the golden rule”).
• Humility—The self-esteem and individual rights movements have led to a widespread decline in student humility and personal responsibility. If a student gets a bad grade, it’s not his fault, but the fault of his teacher. The teacher is violating his “right” to a good grade. Students are supposed to feel good about themselves, no matter what they do or how well they perform academically. Criticism should be avoided at all cost. Research has shown that improving self-esteem doesn’t raise grades, promote good achievement, or have any positive effect. While there’s nothing wrong with praising gifted children for their successes, there’s nothing wrong with criticizing them for their failings, either. Many parents and teachers do the former, but not the latter. To gain perspective, and acquire humility, the gifted need to be challenged enough so that they fail sometimes. A little humility goes a long way in promoting sound judgments and ethical behavior.

In conclusion, Real Education provides a different and valuable perspective on the failings in American schools. We need to be more realistic about the capabilities of below-average students, we need to offer more students an alternative to college, and we need to provide better wisdom-training of the gifted. I feel that Murray is too pessimistic about the capability of public schools to improve student academic performance, especially for average and above-average students. I recommend this book as an independent perspective on American education.

Do Psychiatric Drugs Do More Harm Than Good? A Review of “Anatomy of an Epidemic” by Robert Whitaker

The idea that people with psychiatric disorders should “take their meds”, that these meds control their symptoms, that they’d better off on than off their drugs, is a noncontroversial position today. Decades of advice from doctors, nurses, therapists, academics, and drug company spokesmen have pushed people with disorders such as schizophrenia, bipolar disorder, major depression, and anxiety to take prescribed medications. We think of someone who decides not to take medications as acting in an irrational manner. Patients who are hospitalized don’t have a choice—they must take their medications.

Is this virtually monolithic societal support of the use of psychiatric drugs a group delusion, similar to the delusions that (nonmedicated) schizophrenics experience? Robert Whitaker takes up this question in his book entitled Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.

Whitaker has two main points in the book. One, is that there has been an epidemic of mental illness in America in the recent past. There is twice the rate of disabled mentally ill in 2007 compared to 1987, and six times the rate compared to 1955. This trend is even more obvious for children, where the number of disabled mentally ill children multiplied thirty-five fold between 1987 and 2007.

Whitaker bases these claims of an epidemic on SSI (Supplementary Security Income) and SSDI (Social Security Disability Insurance) statistics. He compares these figures in 2007 and 1987 to hospitalization figures in 1955 (most disabled mentally ill in the 1950’s were cared for in state and county mental hospitals). These SSI and SSDI figures are not true prevalence figures, of course, since there are people disabled by mental illness not on these programs, and people on these programs who aren’t truly disabled. Since diagnostic criteria for mental illness has changed significantly in the past half century, it’s impossible to arrive at a true prevalence figure. But his general point of a mental illness epidemic is hard to deny, considering that America spent $25 billion in 2007 on antidepressants and antipsychotics. If there was little or no mental illness, why are doctors prescribing so many pills?

Whitaker’s second point is much more controversial. He says that this epidemic of mental illness is, in large part, caused by the very drugs that are being used to treat psychiatric disorders! Whitaker presents evidence in his book that psychiatric drugs do more harm than good when looked at from a long-term perspective. He acknowledges that these drugs make the patient better in the short term, such as the 6 week period in which clinical trials of new drugs occur. But, looked at over the period of years, not weeks, patients do better off drugs than on them.

Whitaker uses several pieces of evidence to craft his argument. One, is that the epidemic of disabling mental illness occurred during the period in which psychiatric drugs were used. During the early phase of psychiatric drugs (mid 1950’s through the mid 1980’s), antipsychotic drugs were used primarily on people with schizophrenia. Anti-anxiety and antidepressant drugs were prescribed for people with anxiety and depression. Lithium was used as a mood stabilizer for people with bipolar disorder. Most of these early drugs (with the exception of the anti-anxiety drugs) had terrible side effects, such as tardive dyskinesia for the typical antipsychotics. These side effects limited the number of people willing to take these drugs. (The anti-anxiety drugs Miltown and Valium were very popular, especially among women, but also very addictive.) Studies showed that those on the drugs, including the anti-anxiety drugs, had worse long-term outcomes than those off the drugs. These studies were never widely publicized, and doctors continued to prescribe the drugs to adults (children rarely were prescribed drugs in this period, with the exception of Ritalin for ADHD).

The second period, beginning with the FDA approval of Prozac for depression in 1987, saw the release and aggressive promotion of “second-generation” psychiatric drugs, which included SSRI antidepressants (e.g. Prozac, Zoloft, and Paxil), and atypical antipsychotics (e.g. Risperdal, Zyprexa, and Seroquel). Drug companies heavily marketed these drugs both to the public and to doctors, with the help of academic leaders in psychiatry. This period also saw a major increase in the diagnosis and drug treatment of pediatric psychiatric disorders.

The second-generation drugs had fewer and less-severe side effects than the older drugs, but weren’t any more effective than these drugs. They still had some serious side effects, however, such as increased risk of suicide for Prozac, and weight gain for Zyprexa. These adverse effects were generally swept under the rug as the pharmaceutical marketing machine (with the aid of drug-money soaked academic psychiatrists) promoted them as miracle drugs.

The release of the psychiatry reference manual DSM-III in 1980 led to a major change in diagnostic criteria, leading to more reliable diagnoses based on symptoms. The DSM-III (followed by the DSM-IV in 1994) made psychiatry appear more scientific and objective, since it dispensed with vague Freudian notions like “neurosis.” But the problem was that it wasn’t accompanied by any breakthroughs in the understanding of the biology of mental illness. The “chemical imbalance” theory, i.e. that schizophrenia was a result of too much dopamine, and depression a result of too little serotonin, was demolished by research findings. But drug companies and psychiatrists continued to tell people that this imbalance theory was true. Whitaker makes a good argument that the drugs actually cause chemical imbalances, not treat them. These iatrogenic (drug-caused) imbalances force people on the drugs to continue taking them, as they get terrible withdrawal symptoms if they try to stop. Getting children addicted to these drugs was a pharmaceutical marketing home run, as the kids would be hooked for life, a reliable long-term source of income.

It was during these last 25 years of widespread prescription of psychiatric drugs that the disability numbers soared. These drugs didn’t seem to be helping people over the long term, or else why would they be forced to go on disability? Large numbers of children started becoming disabled. According to Whitaker, the second-generation drugs had as dismal a long-term effect on patients as the first-generation drugs. The problem for society was that many times more people were taking them than took the earlier drugs. The few academic psychiatrists who questioned the efficacy of drugs were stripped of their positions and funding, and marginalized. Millions of dollars in drug money flowed to virtually all the academic leaders in psychiatry.

Whitaker weaves in anecdotes along with his research findings, enhancing the readability of his book. Some of the stories are haunting, such as the case of “Jasmine,” a girl prescribed an antidepressant for bed wetting in fifth grade. The agitation she got from this drug led psychiatrists to put her on a drug cocktail that included Zyprexa. She was hospitalized in high school, and the drug merry-go-round to which she was subjected fried her brain, leaving her perpetually psychotic and mute. Of course, Jasmine is an exception, and most children and adults on drugs have much more positive outcomes, but the reader is left to wonder, “what would have happened if she never got on drugs the first place?”

Whitaker provides examples of how drugs used to treat one condition (e.g. Ritalin for ADHD) led to some children developing manic symptoms, which led them to be diagnosed with bipolar disorder, which led them to receive drug “cocktails” including powerful and harmful antipsychotics. They end up on a long-term trajectory of serious physical and mental problems, an outcome which probably would have been much more benign if they hadn’t been prescribed any drugs in the first place.

My own experience with psychiatric drugs was generally a positive one. I didn’t start on drugs until I was 27. I had many years of dysfunctional behavior, of cognitive and emotional problems. Virtually any intellectual activity at all (e.g. reading or writing) would trigger horrible “states” that would last for days. These “states” would include severe obsessions, difficulty concentrating, emotional suppression, and tics. Although I had a job, I was working well below my ability, and had little social life. It was under these conditions that I decided to try Anafranil, a drug used to treat OCD, and it did help improve my functioning for a while. I tried combining Anafranil with many other drugs that were less helpful, although I usually never took more than two at a time. Being very sensitive to side effects, I stuck to low or moderate dosages. After ten years of Anafranil, I felt that it was no longer needed, and convinced my psychiatrist to allow me to stop taking it. I followed up with 3 years of low doses of Xanax, then got off medication completely. I’ve been basically medication-free for 3 years. I think the late onset of starting with drugs, the small number and doses of drugs, and the eventual getting off drugs made me one of the few long-term medication success stories.

Whitaker is not anti-drug, and acknowledges that “there is a place for the drugs in psychiatry’s toolbox” (p. 333). But he wants psychiatrists to “think about the medications in a scientifically honest way and to speak honestly about them to the public” (p. 333). Certainly the vast majority of drug prescriptions are unnecessary and possibly harmful. After reading this book, (although Whitaker doesn’t suggest this) I think that a strong case can be made to outlaw prescribing psychiatric drugs for children. If they cause more harm than good in the long run, then it is children who have the most to lose by taking these drugs. Exceptions can be made for children already on drugs, and for the few children who are completely out of control, and whose behavior cannot be managed by any other means. Psychiatrists would howl about any such legislation, but let them (and their drug company masters) put forward studies that show children benefit long-term from drugs. If Whitaker is right, and there are no such studies, then let’s ban the prescribing of drugs for children.

I found this book to be one of the most powerful and thought-provoking books I’ve read in years. I recommend it to anyone concerned with the mental illness epidemic that plagues our country.

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.