Tuesday, June 18, 2013

Drugging the kids

Dr. Pieter Cohen of the Harvard Medical School and Dr. Nicolas Rasmussen (Ph.D.) attacked the increasing use of drugs to handle problems such as ADHD in the Wall Street Journal:

Walk into any American high school and nearly one in five boys in the hallways will have a diagnosis of attention-deficit hyperactivity disorder. According to the Centers of Disease Control and Prevention, 11% of all American children ages 4 to 17—over six million—have ADHD, a 16% increase since 2007. When you consider that in Britain roughly 3% of children have been similarly diagnosed, the figure is even more startling. Now comes worse news: In the U.S., being told that you have ADHD—and thus receiving some variety of amphetamine to treat it—has become more likely.

Last month, the American Psychiatric Association released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders—the bible of mental health—and this latest version, known as DSM-5, outlines a new diagnostic paradigm for attention-deficit hyperactivity disorder. Symptoms of ADHD remain the same in the new edition: "overlooks details," "has difficulty remaining focused during lengthy reading," "often fidgets with or taps hands" and so on. The difference is that in the previous version of the manual, the first symptoms of ADHD needed to be evident by age 7 for a diagnosis to be made. In DSM-5, if the symptoms turn up anytime before age 12, the ADHD diagnosis can be made.

It's also easier to diagnose adult ADHD. Before, adults needed to exhibit six symptoms. Now, five will do. These changes will undoubtedly fuel increased prescriptions of the drugs that doctors use to treat ADHD: stimulants such as Ritalin and Adderall.

Even before DSM-5, doctors were already on track to prescribe enough stimulants this year for each American man, woman and child to receive the equivalent of 130 mg of amphetamine (about 40 five-mg pills of Adderall) and an even greater amount of the very similar drug Ritalin. In this era of excessive prescribing, we seem to have forgotten the cautionary history of amphetamines in America—a history that shows how overprescribing stimulants leads to widespread dependence and addiction.

Since their introduction by the pharmaceutical company Smith, Kline & French in 1937, amphetamines have been prescribed for maladies that had more to do with societal expectations than genuine mental illness. American soldiers received stimulants during World War II to boost morale and improve performance in combat.

Meantime, back at home, amphetamine was heralded as the first antidepressant, and shortly thereafter, as an ideal weight-loss pill. One 1955 advertisement for AmPlus amphetamine tablets assured users that they would be "beachable by summer." Decades would pass until research demonstrated the lack of long-term benefit for most cases of depression and weight loss, but the lack of proof didn't hold doctors back from liberally prescribing stimulants to millions of housewives in postwar suburbs.

By 1969, doctors were prescribing the equivalent of 120 mg of amphetamine for each American—a high-water mark of per-capita consumption we are only now about to surpass. By then, the addictive potential of prescription stimulants had attracted intense scientific and public scrutiny as evidence grew that many patients were becoming dependent on the drugs. Thirty percent of patients in one study conducted in New York state admitted to using their medications recreationally. Millions of people without prescriptions easily obtained diverted pills.

In 1968, the National Academy of Sciences organized an authoritative investigation into the stimulants' true benefits and risks. The consensus: These drugs had limited efficacy and real harms. Medical experts discouraged the use of stimulants for both depression and obesity, but the warnings had little effect on doctors' prescribing habits until the Controlled Substances Act of 1971 mandated that stimulants be placed in a tightly controlled category of medications, referred to as Schedule II.

Doctors were free to prescribe the drugs but had to report each prescription. Almost overnight, prescriptions for stimulants to treat depression and obesity plummeted: Medical use dropped 90% between 1969 and 1972.

Just when it seemed that amphetamine's days were numbered, doctors began to embrace the drug for treating Hyperkinetic Reaction of Childhood—what we now call ADHD. (It became the official name in 1987.) Concern about dependence and addiction, along with the watchful eye of the U.S. Drug Enforcement Administration, kept prescriptions for ADHD at low levels during the 1970s.

But by the 1990s, experts and advocacy groups for ADHD, some funded by pharmaceutical companies, began to argue that stimulants did not lead to addiction when treating children for the disorder, and that the stimulants actually decreased the risk of future drug abuse. Their main argument was that ADHD itself is a significant risk factor for future substance abuse, and that stimulants, by treating the underlying illness, also reduced the likelihood of future drug use. Concerned parents were told that starting their children on stimulants when young would decrease the risks of future trouble with alcohol and drugs.

The problem with this reassuring message is that it was based on flimsy evidence. Experts had relied on studies of children treated with stimulants by their personal physicians, compared with children who had ADHD but did not receive stimulants. These community studies were fraught with confounding variables and were only suggestive.

Three months ago, the only randomized trial to study future substance abuse by ADHD kids refuted the notion that stimulants, when taken in childhood, have a protective effect. Investigators found strong evidence that ADHD itself in fact predisposes children to later substance abuse—but no evidence that stimulant medication reduces this rate any better than treating ADHD with behavioral approaches. Further evidence that stimulants do not protect children from addiction was provided in a comprehensive review published last month in JAMA Psychiatry.

We still do not have a single randomized trial to help determine if starting stimulants as an adolescent or adult further increases the risk of future substance abuse, although the long and checkered history of medical stimulants would suggest it does. Certainly, the risks from recreationally using stimulants are already well-documented.

In 2010, Adderall was second only in popularity to the painkiller Vicodin as a prescription drug of abuse among high-school seniors, according to the National Institute on Drug Abuse. Adolescents often perceive prescription drugs as safer than illicit ones, but abusing prescription amphetamines can lead to seizures, psychosis and life-threatening heart disease.

Stimulants can certainly benefit some young children with truly disabling ADHD. However, history has already taught us that overprescribing stimulants to millions of Americans leads to dependence, addiction and overdose. By medicating children for wiggling in their chairs, losing their homework and shouting out answers, we are not teaching them vital coping skills to manage their behavior. Instead, we are teaching them to take a pill. One day, we'll look back and wonder: Why did we do this? Again.

Dr. Cohen is an a assistant professor of medicine at Harvard Medical School. Dr. Rasmussen is a professor of the history of science at the University of New South Wales in Sydney, Australia, and the author of "On Speed: The Many Lives of Amphetamine" (New York University, 2009).

11 comments:

Anonymous said...

My adopted son was diagnosed with ADHD when he was 6 by a doctor at UMC after a thorough test. He's now 7 and if he doesn't take his methylphenidate, he bounces off the walls and can't seem to control his behavior. We've tried alternatives - behavior specialists, going gluten free, Advocare Spark (Google Texas Tech study on Advocare Spark to treat ADHD), but nothing works well enough to control his behavior other than his methylphenidate. It's unfortunate because the medicine kills his appetite, and he's a growing boy. We tried taking him off the medicine for the summer time, but he began getting in trouble at summer camp for fighting. I truly wish there was another answer, but there's just not right now, at least for us.

Kingfish said...

They acknowledged there were legitimate cases of ADHD and proper uses of the drugs to treat them. However, I'll give you one example. Diagnosis of Autism Spectrum disorders has improved tremendously over the last 15 years. What was thought to be ADHD or ADD turned out to be an ASD but was treated with drugs.

Anonymous said...

I see some truth in overdiagnosis. When I was a kid my mother "doctor shopped" me, wanting me on ritalin because she couldnt handle being a mother.

When that didnt work, she doctor shopped herself some painkillers.

The Libertarian said...

ADHD=just being a boy

Anonymous said...

Most likely, a majority of children taking medications such as Ritalin and Adderall have had a tremendous underdosage of wood to ass, both at home and at school.

Anonymous said...

My son takes a low dosage of Focalin for ADD only on school days. It has never been a behavioral issue with him as he has always been a well behaved boy. He just can't focus for the periods of time that are required in class without this medication. It is truly helpful & I'm glad that it is available to him. It's irritating to me that so many people assume that all parents jump to medicate their children before trying every other alternative. That's simply not the case.

Anonymous said...

My oldest son was misdiagnosed around age 7 with ADHD and was put on Ritalin. It greatly stunted his growth so we finally took him to Memphis to have him re-evaluated. He was taken off Ritalin for all but school days. It didn't help much.

As he became a young teenager, his behavior deteriorated and he was evaluated again, taken off Ritalin and put on 2 other medications for depression/anxiety. He immediately gained a lot of weight and failed at school.

As he became 17/18, he became violent and near psychotic. He was re-evaluated again, and was diagnosed severely bipolar. The doctors believe the early medication due to misdiagnosis may have contributed to worsening the condition.

I have no answers. I tried many doctors, and nothing helped. My son is now totally "disabled", unable to work due to the wild mood swings. It's been a total disaster.

Anonymous said...

As a child I was ADD. I can remember trying my best to pay attention in class only to slip into daydreaming or random thoughts, then gathering myself and trying to figure what page we were on. Trying to come up with methods to help me stay focused like staring hard at the teacher, sitting on my leg, taking better notes, etc., only to discover myself yet again lost in my own thoughts. I stayed mad at myself. My grades sucked. I cheated my ass off. I was called lazy, I was told I didn't care. Fast forward...I saw it in my son when he was in the third and fourth grade, but unlike my parents who wrote it off as just not caring, I pushed the Dr to get him on Vyvanse. He is now in high school and he kicks schools ass.
It makes me very proud that I knew what 'to do' so that my son knows nothing about the shame of bad grades and labels from teachers and parents. He is an A student with big plans for the future.
If you don't have to deal with this, your lucky. Just don't judge others.

Anonymous said...

I am a nurse with over 25 years experience. In my opinion the problem lies with physicians who prescribe these medications without a complete/adequate evaluation. There are clinical guidelines from the American Academy of Family Physicians that specify what steps/testing to complete to fully evaluate for ADD/ADHD but these guidelines are frequently overlooked (read "ignored") or if family practice is not the physician's specialty they feel the guidelines do not apply and if Mama says he has it, then he needs a prescription. I know of a few physicians who simply renew a prescription for college students any time they call and request a refill with no questions asked. Very few fully evaluate the effectiveness of the drug only asking if they are doing better in school and taking the answer at face value - no specific review of grades, no information from teachers about classroom behavior, etc. I know privacy is an factor but any parent with a child needing this treatment should be willing to give permission for specific questions to be asked at intervals.
They do not seem to understand that Adderall and some of the other drugs in this category are often abused/overused/sold for profit.....

The Libertarian said...

Medical establishment/government approved checklist:

1: Evaluate "is patient male or female?"
2: If male, evaluate to what level he is not listening to authority or acting out.
3: Erase all spirit of rebellion and individuality with drugs.
4: Feminize the new, blank slate so you will have a good little obedient drone to mindlessly repeat the party line. (make sure you have his firearms removed since, ya know, hes on psych drugs..hint hint, wink, nudge)

Anonymous said...

While they are gone, we remove one chair.



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