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.

Thoughts on the DSM-V

I’ve been reading about the debate over the upcoming DSM-V, the new version of psychiatry’s reference manual, and wanted to express my own opinions. I think that a utilitarian criterion should be used to evaluate not only the DSM, but psychiatry as a whole, including the prescribing (and overprescribing) of medications. By this I mean: does this diagnostic manual or treatment properly diagnose and treat people with psychiatric disorders? Does it falsely diagnose and improperly treat people by diagnosing them with disorders that they don’t have?

I’ll make an assertion that people with full-blown (out-of-control) schizophrenia, bipolar disorder, and OCD are better off medicated. To be medicated, they must first be diagnosed, so an instrument that aids in correct diagnosis is useful. The first two editions of the DSM came out when psychiatry was still heavily influenced by psychoanalytic theory. As a consequence, they had vague, unreliable categories (e.g. neurotic vs. psychotic), and contained spurious speculation on etiology. Since psychoanalytic treatment never helped patients with serious disorders, these early editions of the DSM were pretty much useless.

Robert Spitzer led the development effort of the major revision of the DSM, known as the DSM-III, which came out in 1980. (Interestingly, Spitzer is a critic of the upcoming DSM-V.) The DSM-III largely abandoned the psychoanalytic orientation of its predecessors. It abandoned any attempt to classify by etiology. It created the symptom-based, multiaxial categorical system which, with some changes and extensions, was incorporated into the DSM-IV in 1994. The DSM-III helped psychiatrists make more reliable and valid diagnoses than past editions. It must be remembered, however, that without any knowledge of etiology, and without any valid diagnostic tests, there would always be less reliability and validity than with physical disorders.

The symptom-based model of the DSM-III and DSM-IV sets up fairly steep criteria by which to diagnose someone. For example, click here for the DSM-IV criteria for a major depressive episode. Of course, if you go to a PCP and tell him that you’re depressed, in less than a minute he’ll write you a prescription for an antidepressant, but the DSM states what criteria this PCP should be using. It also states the criteria by which patients need to be evaluated to be diagnosed in research studies. This is important because in order for drugs to be approved, they must first go through clinical trials on patients diagnosed with the disorder that these drugs are supposed to be treating. The fact that once they’re approved, they can be prescribed off-label for other disorders is a separate issue that I won’t take up here.

Enough about the history. Let’s ask the question: with the current DSM-IV, are people who should be diagnosed and medicated actually diagnosed and medicated? I think the answer is yes. If Jim has bipolar disorder, and has some means (insurance or self-pay) to see a doctor and to purchase drugs, he’ll be diagnosed, and get the drugs he needs. It’s possible that Jim doesn’t want to see a doctor or take drugs, but that’s a separate issue. No diagnostic manual can “treat” that problem (assuming that it is a problem).

The scary thing about some of the proposed revisions to the DSM-V is that they will expand the number of diagnosable disorders. This will in turn expand the use of drugs to people who don’t need them. I don’t think that this is a good thing. There are already too many people taking drugs who don’t fit the diagnostic criteria of the disorder for which the drugs were originally approved. An example of this is the unconscionable use of drugs approved for adults in children, sometimes very young children.

What psychiatry desperately needs is a more scientific basis. It needs better diagnostic tests, and a better understanding of etiology. These will in turn lead to better treatments. In the 15 years since the DSM-IV came out, while there has been some great research going on, there hasn’t been a major breakthrough. So the DSM-V is not going to help things, and will probably hurt things. Hopefully by the time the DSM-VI is published, there will be some breakthroughs. We can only hope.

Crazy Ideas

I want to talk about crazy ideas. Most crazy ideas are not influential nor socially useful. A good example is the perpetual motion machine. No one has heard of the vast majority of crazy ideas, for good reason.

Some crazy ideas are influential, some are socially useful, and some are both. I want to talk about 2 crazy ideas that came into existence about the same time, at the beginning of the 20th century: Freud's psychoanalytic theory and Einstein's Theory of Relativity. Freud's theory was influential, but socially useless. He came up with the theory at a time when psychology was in its infancy. He could get away with creating an unverifiable and unfalsifiable theory that captivated and influenced many mental health professionals, including psychiatrists. After a century of practice, there's no evidence supporting his ideas. An enormous amount of time and money has been wasted on psychoanalytic therapy. Experimental psychology has advanced enough now that he wouldn't be able to get away with perpetuating such an unscientific theory today.

Einstein's theory was both influential and socially useful. It laid the groundwork for modern physics, which is behind much of the technological advances in the 20th century. Einstein couldn't get away with a speculative and unverifiable theory like Freud's. The reason for this is that physics had several centuries of development prior to Einstein, and was much further advanced than psychology.

My human magnetoreception hypothesis, in which I claim that my OCD and tics are connected to the Earth's magnetic field, is definitely high in craziness, probably higher than Freud's and Einstein's theories. Whether it will be influential or socially useful remains to be seen. It's not quite as crazy as the idea that my symptoms are caused by the Martians, but it's close. Since I'm writing this in 2009, and there's been over a century of research in psychology, I can't get away with what Freud did. So if no one is able to verify my theory, it won't become influential. In my paper, I list specific experiments that can be done to verify my theory. Even though my data is based on subjective experience, it is still empirical, and can be verified in a double-blind manner. Compare this to Freud's theory, which is pure speculation. Compare it to the Martian idea, which obviously cannot be verified.

The key problem with my hypothesis is that human magnetoreception isn't accepted by scientists. But we know that animal magnetoreception exists, and we know that humans are animals. So there's no reason a priori to reject human magnetoreception. I'm hoping that the necessary research will be done to verify or reject my hypothesis.