Sleep Apnea

In ancient Greek, pneuma meant the breath of life and apnea meant the cessation of that breath. Pneuma in modern medicine is only a fragment of many words related to breathing but apnea has made the transition from the ancient lexicon unchanged.  It means no breathing. Sleep apnea is a condition in which breathing halts over and over during sleep, sometimes hundreds of times a night. The resulting disruption of sleep and respiratory physiology triggers chronic health problems like high blood pressure, cardiovascular disease and strokes. Other negative results are psychosocial and accidental, stemming from chronic daytime sleepiness. Motor vehicle accidents are but one example.

My first exposure to someone with sleep apnea was during childhood, in my grandparents’ house, where visiting grandchildren were divvied up among the adult rooms for sleeping.  My grandmother was a Camel smoker who read the New Jersey tabloids late into the night. I knew she was finally asleep when her snoring began, at first softly with a regular cadence, and then gradually increasing in volume and depth, building to a crescendo that would suddenly end…in silence. I tried holding my breath as long as she held hers, but seldom made it to the point when she would suddenly snort, inhale in a ragged fashion and then settle back into the snoring rhythm, building up to another period of no breathing. I gave up worrying about whether or not she would restart, because she always did. I wondered why my grandfather, a Lucky Strike smoker snoring away in an adjoining bedroom, breathed steadily, never stopping like she did.

The upper airway is the problem

While smoking can cause snoring, my grandmother stopped breathing intermittently because her upper airway was anatomically different from my grandfather’s and it became obstructed when the muscle relaxation caused by sleep made her throat go slack. In 1965, upper airway obstruction was finally discovered to be the cause of the marked daytime sleepiness that often affected obese people, whose airways collapsed under the excess neck fat when they lay down and fell asleep. Charles Dickens made this kind of  hypersomnolence famous in the 1800s by  his creation of the character Joe the Fat Boy in The Pickwick Papers.

Sleep research begins

The discovery of the cause of daytime sleepiness in obese people happened to coincide with the development of interest in and funding for research into sleep disorders. The first sleep lab was begun at Stanford University in 1964. Prior to that time not much was known about normal sleep, let alone disordered sleep.  By the 1970s the hundreds of awakenings interrupting the sleep of people with upper airway obstruction had been demonstrated. Sleep cycles were continuously disrupted in these patients, and sleep apnea was on its way to being tagged as a common disorder with serious consequences in terms of morbidity and mortality.

Risk factors

Who suffers from sleep apnea? According to one estimate, approximately one quarter of people between 30 and 70. Despite the increased awareness of sleep apnea in the last few decades, experts also estimate that 70-80% of people who suffer from the condition remain undiagnosed. Men are about four times more likely than women to be affected. Obesity is the largest risk factor because increasing body fat encroaches on the upper airways. Smoking irritates sensitive tissues, making them swell and further narrowing the throat. In some people, the jaw shape and position are anatomical culprits. Sleeping medicines and alcohol consumption can also alter breathing patterns in sleep and contribute to sleep apnea.

Snoring is the first symptom

Not every snorer will develop sleep apnea, but snoring is the first phase of the condition. When the snoring becomes associated with breathing cessation, problems begin.  Apnea causes an immediate fall in blood oxygen and a rise in carbon dioxide. Rising carbon dioxide triggers the respiratory drive center in the brain. The sleeper wakens in order to breathe, though he may not be aware of it.  Multiple awakenings interfere with normal cycling through progressively deeper stages of sleep back up into lighter stages of dreaming sleep, cycles that are necessary for mental and physical health.  Over time, lack of normal sleep cycles takes significant physical and mental tolls. Levels of inflammatory markers and hormones associated with stress rise; the vascular changes that lead to heart disease speed up; heart rhythms become erratic; blood pressure goes up and stroke risk rises.  Profound daytime sleepiness results in attention deficits, errors of omission, motor vehicle accidents, mood disorders and memory problems.

Other clues

Might you suffer from sleep apnea? If people complain about your snoring, if you awaken with headaches and feeling unrested, if you are lacking in energy though not ill and if you cannot stay awake once you are not physically up and about – for instance when you sit down to read or watch TV, you might want to talk to your doctor about the possibility of sleep apnea, especially if you are also overweight.

Diagnosis

The definitive diagnostic test for sleep apnea is an overnight stay in a sleep lab, where polysomnography – multiple measures of physiologic function including electroencephalography or brain wave testing are monitored while the subject is sleeping. Treatment will depend on the severity of the findings. How many awakenings occur per hour? Are there associated heart rhythm or brain wave abnormalities during the apnea?

Treatment works

In mild cases, lifestyle treatments such as weight loss, cessation of smoking, alcohol and sleeping pills, and avoidance of sleeping on the back are all that will be advised. In other cases, the addition of a mask and device that pumps continuous positive air pressure (CPAP) into the upper airway is necessary. CPAP treatment is very effective, and improvements occur rapidly. Less commonly, mouthpieces to alter jaw position, or surgery to increase airway space are advised.

I never noticed daytime sleepiness in my grandmother.  She weighed no more than 100 pounds and was an Irish whirlwind of housekeeping activity. Until she developed an autoimmune disease in her 70s, she was, to all appearances, healthy, despite the ever present cigarettes. Sleep apnea is a medical condition on a continuum, dependent not on just the upper airway obstruction component but on other aspects of the sufferer’s health. As with all physical problems, differences in disease severity reflect differences in the whole people in which the problems occur.

Floaters

Eventually, everyone sees floaters- the dark wavy lines or spots or cobwebby filaments that drift lazily through the visual field of one eye or the other. Quick eye movements up, down or sideways will clear them from your line of sight, but slowly, because floaters move through a jelly like substance in the center of the eyeball. Like the ghosts wandering around Harry Potter’s Hogwarts School, ocular floaters are most often harmless annoyances. And like so many of life’s problems, they are an accompaniment of aging, particularly in people who are nearsighted (those who require glasses to see clearly at distances).

Blame aging
Aging produces changes in collagen, the structural protein that gives form to much of the body. As a result, we develop skin wrinkles, stiff tendons, unpliable heart valves and brittle cartilage, to name just a few obvious accompaniments of living to old age. Few people know that there is collagen in the middle of the eye, which is filled with a glob of jelly-like material called the vitreous humor. Most descriptions of the vitreous humor conjure up a picture of a clear, colorless ball of Jell-O that fills the posterior chamber of the eye (the space between the lens behind the pupil and the retina lining the interior of the eyeball). The vitreous keeps the eyeball from collapsing and helps hold the retina in place.

Vitreous humor – a complex structure

But appearances are deceiving. Though the transparent, jelly-like glob is composed of 99% water, it is also a delicately complex structure in which collagen plays an important  structural role. Like skin, the vitreous ages. Along with the years come the floaters.
You are born with the vitreous humor in place. Should it be removed, by surgery or trauma, you will not grow another. This is in contrast to the aqueous humor, a clear liquid that fills the space between the cornea that protects the eye and the colored part called the iris (called the anterior chamber of the eye – see diagram). The aqueous humor is manufactured by the ciliary body, a muscular structure that gives rise to the iris. From its manufacture point just behind the iris, the fluid circulates through the pupil, fills the space behind the cornea, and exits via a channel  formed by the junction of the iris and the cornea. This evenly balanced system of fluid manufacture, circulation and exit controls the pressure within the whole eye. No such recycling system exists for the vitreous humor – as in Las Vegas, what happens in the vitreous humor stays in the vitreous humor.

eye anatomy

What happens without recycling?

The  collagen structure within the vitreous humor is an airy honey-comb of interconnected collagen fibrils – microscopic fibers cross-linked and held apart by chemical and electrostatic forces. The network is loosely attached at some points to the retina that lines the inside of the back of the eyeball. The spaces in the honeycomb contain a solution of many minerals and polysaccharide molecules (chains of sugars) dissolved in water. The collagen network is, in part, held open by the pressure of the watery solution. With age, the system has mini-collapses of collagen fibrils, resulting in some clumping of the collagen networks. Floaters are the result. Occasional macrophages (white blood cells that clean up debris) float about, but they are a lonely workforce.

When are floaters more than a nuisance?

A sudden increase in the number of floaters, accompanied by transient light flashes, is sometimes indicative of a segment of the vitreous pulling away from an attachment point on the retina. This condition is known as a posterior vitreous detachment. By itself, a posterior detachment is not a serious problem, but occasionally the point of shrinkage also pulls the retina away from the vascular layer underneath it. Now you have a retinal detachment, and your vision either develops a blind spot or the sensation of a curtain pulled over part of the visual field. Such symptoms require immediate ophthalmologic evaluation and treatment to prevent further detachment of the retina.

Treatment

There is no special treatment for floaters but at times, floaters are troublesome enough for an ophthalmologist to attempt to remove the vitreous humor entirely. The surgery is very difficult and fraught with hazards such as retinal detachment or damage resulting in partial blindness.  Called a vitrectomy, it is a procedure done more often  for other reasons such as  eye trauma. After vitrectomy, the vitreous has to be replaced to maintain the shape of the eye. Research by physicists and bioengineers on suitable replacement substances has been the biggest source of information about the physical nature of the vitreous humor and the origin of the near universal phenomenon of floaters. However, to date the replacement is still done with saline, which is then naturally replaced by the same fluid that fills the anterior chamber.

Natural history of floaters 

What happens once you begin to notice floaters? They come and they go – eventually sinking out of view. The process is very slow because there is no circulation pattern in the vitreous humor and the body has not assigned a vigorous cleanup crew to the problem. Because of this slowness, and because the vitreous passively absorbs substances from the bloodstream via the blood vessels in the retinal layer, coroners sometimes use the vitreous humor to search for toxic substances like drugs at autopsy. Chemical traces remain there after they have disappeared from other body fluids; and. the vitreous humor also retains its integrity longer than other parts of the body.

Plato’s cave

As for “seeing” floaters? You are not actually looking at the clumps of collagen. Just as in Plato’s story about people in a cave interpreting shadows created by firelight as reality, you see only the shadows of floaters cast on the retina by light coming through the pupil. For this reason, floaters are clearest when you are looking at a bright background such as snow or water. Even when you see floaters with your eyes closed, light is passing through the thin eyelid and into the pupil, the only opening in an otherwise light proof box. Who knew these little annoyances could illustrate a philosophy lesson?

 

 

The Role of Alcohol in Dementia

O God, that men should put an enemy in their mouths to steal away their brains!”

Cassio (Act II, Scene iii)    William Shakespeare

The Diagnostic and Statistical Manual of Mental Disorders, the official compendium of acceptable psychiatric diagnoses, lists a syndrome called “alcohol-induced persistent dementia.” This condition was once described as the “common end reaction of all alcoholics who do not recover from their alcoholism or do not die of some accident or intercurrent episode.”  But alcoholic dementia has never been a frequent diagnosis and alcohol is still not listed as one of the risk factors for dementia. In guidelines for reduction in harm from alcohol consumption, the governments of the US, Canada, Australia, Great Britain and the EU all acknowledge the role alcohol plays in a host of chronic health and social problems, but dementia is not mentioned. Growing epidemiological evidence suggests that this omission is an error, and even that alcohol-related dementia might be a “21st-century silent epidemic.”

Epidemiological Evidence

Some evidence comes from a 2018 British study that correlated the appearance of dementia with the alcohol habits of British civil servants over a period of 23 years. The data showed that people consuming more than 14 units of alcohol a week (the equivalent of 60gm of alcohol or about 6 drinks) had an increased risk of developing dementia.  The more they consumed, the higher the risk.  A 2018 French study concluded, from a vast analysis of hospitalizations related to alcohol disorders, that there was a distinct association of alcohol use disorders with all kinds of dementia, that alcohol was responsible for a much greater proportion of dementia than previously estimated, that alcohol should be considered as one of the main causes of dementia appearing before age 65, and that, of all the risk factors related to dementia, alcohol was the easiest one to change.

A subject that doctors and patients avoid

Abstinence, over time, improves the symptoms of alcohol related dementia. Why, then, do we not make vigorous attempts to educate patients and families in the early stages of dementia evaluations about the possibility that ceasing all alcohol intake might be beneficial, and certainly not harmful, no matter what the cause of the dementia? Doctors who evaluate patients for symptoms of dementia should question patients carefully about their current and past alcohol use patterns. Often, they do not. Patients being evaluated for dementia, and the concerned family members who bring them to the doctor, should provide honest and accurate accounts of alcohol use. Often, they do not. Alcohol use is a subject which people tiptoe around for many different reasons, but one which should be addressed openly and compassionately, with an educational goal.

The path of alcohol through the body

The first goal is understanding how alcohol affects the brain, and how age and sex influence its effects. Alcohol is absorbed into the bloodstream within five minutes of entry to the stomach. On its first pass around the body, it is metabolized by an enzyme called alcohol dehydrogenase. This enzyme declines with age and is less active in women than in men. Alcohol that is not metabolized immediately circulates in the blood and is measurable as a “blood alcohol level.”  Some of it goes to the liver where it is broken down to a substance called acetaldehyde and some is broken down to acids – all these chemicals escape in urine, as well as in your breath and through the skin (the source of the “morning after” boozy smell that lingers long after the party is over).  In the brain, the un-metabolized alcohol enters brain cell membranes and dissolves some of their fats, changing receptors that transmit information from cell to cell. As more and more alcohol is absorbed, blood alcohol levels rise and a predictable sequence of events occurs: mild euphoria, mild in-coordination, then imbalance, confusion, depressed mental activity, stupor, deep anesthesia, and, ultimately, death.

Tolerance reflects changes in brain cell membranes

Depending on tolerance, alcohol’s effects on brain function occur at varying blood alcohol concentrations, with some alcoholics able to remain awake and alert at blood alcohol levels that might kill novice drinkers. Enzymatic breakdown of alcohol occurs a little faster in people accustomed to heavy drinking, but most of their tolerance to alcohol’s effects comes from persistent changes in their brains.

Altered brain cell membranes change the personality

Brain scans of chronic alcoholics typically show atrophy – shrinkage of the brain tissue, and, at autopsy, the brain of a chronic heavy drinker may show loss of some cells and white matter. But unless there are coexisting problems like old trauma, Alzheimer’s disease or vascular damage, there is no specific pathology that identifies alcoholic dementia. In life though, the result of altering brain cell membranes chronically by dissolving parts of them in alcohol is dementia – the gradual disintegration of a personality structure with persistent impairments in attention and memory, problem solving, language use, planning abilities, visuo-spatial understanding, and in emotional control and responsiveness. Memory problems can be the most prominent feature in alcoholic dementia, and emotional instability and paranoia also occur.

Not all bad

Is all alcohol bad for the brain? Not necessarily. Both studies mentioned earlier confirm a modest increased risk of dementia in strict teetotalers, an observation made many times in the past and never well understood. Research in the last decade suggests that small amounts of alcohol enhance the function of the “glymphatic” system, a term coined to describe the way spinal fluid flows deep into the brain and clears waste from it.  Sleep and exercise also heighten this pattern of spinal fluid flow. (Exercise is known to have a protective effect on the brain, lowering dementia risk. Sleep deprivation, at its extreme, produces symptoms indistiguishable from dementia. More research into the glymphatic system may help explain these observations.)  The slightly increased risk of dementia in teetotalers is not considered a reason to begin drinking for someone who prefers to abstain.

Understanding alcoholic beverages

Knowledge and awareness are keys to moderation in alcohol consumption. The alcohol in beer and wine comes from fermentation of sugars. Alcohol in whiskey, vodka and other spirits comes from distillation and the process produces additional chemicals which are like alcohol, but more toxic.  The percentage of alcohol in beers, wines and spirits can vary widely. As a rough guide, standard drinks like a 12 oz. beer (typically 5% alcohol), a 5 oz. glass of wine (12%alcohol) and a 1.5oz. shot glass of distilled liquor (40% alcohol) contain roughly the same amount of alcohol – 12-14 gms.  Label reading is important since the percentage of alcohol can vary significantly among different beers and wines.  A 12 oz. craft beer may be the equivalent of 1.4 drinks because of a 7% alcohol content.

The risk of dementia begins to climb after about 60gm/week for men and 40gm/week for women on a regular basis – about 5-6 servings. It takes about an hour to metabolize 150 mgm of alcohol/per kilogram of body weight, which translates to about 1 oz. of 90 proof whiskey for a man of average weight. Take in more over that hour and the excess alcohol circulates in the blood and begins dissolving membranes in the brain, and mental effects appear. As alcohol is cleared from the body recovery occurs in the brain and the mental symptoms resolve. With chronic, repetitive, excessive exposure, some changes fail to reverse and dementia is the result.

If you are concerned about alcohol “stealing away your brain,” and want to rethink drinking, there is much useful information for you at the link below.

https://www.rethinkingdrinking.niaaa.nih.gov/How-much-is-too-much/Whats-the-harm/How-Can-You-Reduce-Your-Risks.aspx

The Gratitude Attitude: Five Best Days

Gratitude is an attitude that mental health professionals say promotes mental well-being. They advise practices such as noting three good things about each day and writing them down at night. Studies actually show that such habits durably improve mood. In the giving spirit of the Christmas season I would like to share with you one of our family traditions that, in retrospect, I realize promotes the gratitude attitude over the course of each year.

We began taking our boys to Colorado to learn to ski when they were very little. Economic and time constraints meant one week a year, determined by my husband’s surgical on-call schedule. That week included the turn of the year on New Year’s Eve. Children’s skiing torchlight parades, followed by dinner at a Chinese restaurant and early bedtimes gradually gave way to a movie (usually laughably bad) followed by dinner at a locals’ Italian restaurant with paper-covered tablecloths and crayons for doodling. The family expanded to include our boys’ friends – first as children and teenagers along for a vacation, then as young men who worked as ski instructors. Somewhere along the way we began the habit of discussing our five best days of the year over New Year’s Eve dinner.

The crayons and the paper table covers are very convenient – everyone begins jotting down their five best days, in order, almost as soon as the menus arrive. The entire dinner time winds up devoted to going around the table in five rounds, hearing from each person about what made each wonderful day and how they decided where to rank it in the list. The choices are life stories in snapshots, changing with growth and priorities. They are funny, poignant and surprising. We also hear from people who have been with us on past New Year’s Eves, calling, e-mailing, or texting their top five days, sometimes accompanied by pictures. They all get heard.

The reason this tradition promotes gratitude is a very practical one. If you know you are going to have to come up with your five best days of the year on New Year’s Eve you learn pretty quickly that memories are weak. You cannot cram for this test. You have to start noticing potential top five days as they happen over the course of the year. You start writing them down. Pretty soon you actually have a little journal and it contains good stuff. The good things that happen in life start to break into your awareness and compete with danger-surveillance program that runs continually in the background of your mind. All good, with none of the side effects of mood enhancing drugs (which fail in the long run anyway).

Just as a matter of historical interest, we traced this tradition back to its origins. It actually began with my husband’s surgical training at Massachusetts General Hospital. The surgical interns and residents on the general surgery service met at the end of each day and were asked to talk about the cases they helped with and to explain what they had learned. The practice helped everyone process what they had done and learn from their experiences. As a family, we were always sit-down dinner people,  with candles even when there was still a high chair at the table. Like the surgery residents, we  always talked about everyone’s day. Skiing days included lots of bests. Best fall, best jump, best run, best lift ride. The evolution to a summing up of bests at the end of a year was inevitable. What is a surprise is the way the practice has continued and spread from our families to others. Maybe you would like to give it a try.

Human Diversity: A Mind Thing

(A version of this essay was published in Minnesota Medicine in March, 2005.)

The first snowy egret I ever saw was standing in a shallow pool, a beautiful white creature with a wispy headdress floating in a gentle breeze. When he lifted off, trailing his long black legs, I was startled by a flash of bright yellow – he looked like he was wearing a child’s rubber boots, designed to hug a bird’s clawed feet. He did a loop around the pond in  flying low in a peculiar, non-aerodynamic position. His legs hung down rather than stretching out parallel to his body. He dipped closer to the water and his dangling yellow feet brushed the surface. He’s landing, I thought. But he didn’t. He repeated the maneuver four times.  He’s afraid to land, I thought. But then he touched down with hardly a splash, and dipped his beak to catch a fish, then another, and another. In a moment of bird-watching epiphany, I realized that his feet were like a fisherman’s lure. He’d rounded up his lunch. 

I looked around the pond. I’d just watched a bird with bright yellow feet use them to attract the curiosity of his prey. Across the water was a bird with a lower bill that expanded into a pouch to collect fish as he skimmed, openmouthed, over the water. Perched high above was another, just about to dine on a large fish he’d  skewered with  fearsome talons. What an impressive display of diversity!  If people were this diverse, New England fishermen would grow waterproof, blubber lined hands, typists would develop extra fingers, and mothers really would have eyes in the backs of their heads.  

But people are pretty much the same as far as their bodily equipment goes.  Five fingers on each of two hands, ten toes divided between two feet, two eyes, upright posture, and a narrow range of physical abilities, notwithstanding the spread between ordinary and Olympian. The traits we associate with human diversity are superficial – hair color and texture, skin color, facial appearance. Almond shaped or round, eyes still see. Long, elegant skeletal frames and short squat ones all support bodies against the universal force of gravity. Skin pigmentation protects the body covering from the sun, more or less depending on the power of the sun in the areas of the world where the people originated. We are much more like each other than we are different in our biology. The birds have it all over us in the diversity contest.  

After my egret experience, I packed up my binoculars, got on my bike and headed home, humbled a little by the thought that all of the talk and concern about diversity among people is overblown, maybe just another representation of man’s abiding sense of self-importance. But along the way I passed bikes and cars, houses and stores, a radio broadcast tower, and a museum.  I crossed a bridge between two islands and waved to a fisherman in his boat. And I realized that each of these man made things  I passed began as an idea, somewhere, some time, in somebody’s head. We might not differ much in anatomy and physiology, but no two of us have identical thoughts. The mind is the site of the real diversity among humans. The mind is plastic and ever developing. It records, collates, recalls, communicates, and combines unrelated information in new ways. Yellow feet catch the eye, but minds change the world.

Medicating Childhood Behavior: Caution Ahead

In Hannibal Missouri, Huckleberry Finn’s house sits next door to Mark Twain’s.  Tom Blankenship, the real boy who lived in the tiny house, was the model for the wild and fictional Huck, as Mark Twain was for the impish prankster Tom Sawyer.  In the sleepy little town set on the banks of the Mississippi River, it is easy to imagine the two real boys living the lives Twain created for his characters. And it is just as easy to imagine what would happen to two such boys in the modern world. Twain and Blankenship would be disruptive children, seeing the school psychologists and being medicated for attention deficit disorder.  Is this progress, or are too many children today labeled with psychological disorders and taking drugs to modify behavior?

Reasons for psychoactive medication use in children

The most legitimate reason for identifying and labeling children as disordered is that some psychological disorders that appear early in life express themselves more severely in adulthood than later onset versions do. Early treatment helps prevent more dysfunction later, especially in problems like autism. Other reasons may be less admirable.  Prescribing drugs to treat emotional and behavioral symptoms is easier and less time consuming than dealing with the psychological problems that lie beneath the symptoms, problems which do not reflect abnormal brains.

How did we get to medicating behavior?

Attempts to treat psychological symptoms with drugs began in earnest with the serendipitous discovery in the 1950s that certain drugs, used for treating infections and high blood pressure, appeared to elevate mood. They seemed to have a direct effect on behavior.  Pharmaceutical companies then began to develop drugs specifically targeted to brain function.  Later, scientists discovered that these drugs led to changes of levels of chemicals in the brain that transmit information between nerve cells and they developed the neurochemical theory of psychological disorders.  The drug age of treatment of anxiety, depression and psychosis took off on the assumption that the drugs treated some native chemical imbalance in the brain. Because there is no direct evidence for such imbalance, some respected psychiatrists now question the neurochemical theory. Additionally, careful review of many drug studies show their effects to be little better than placebos (sugar pills). Nevertheless, drug treatment of psychological symptoms has ballooned in all age groups, particularly in the late 1900s and early 2000s. Between 1987 and 1996 the use of psychoactive drugs in children from ages 6-17 jumped 2-3 times. By 2000, 8.8% of 6-17 year olds were taking some kind of psychoactive drug. By 2017 the number of children medicated for behavior was over 7 million.

The diagnoses that prompt drug treatment in children

The behaviors of modern children that prompt treatment are divided into diagnostic categories: attention deficit disorder (ADD or ADHD); mood, anxiety and disruptive behavioral disorders; autistic spectrum disorders and childhood schizophrenia. The latter two categories reflect distinct disorders of brain function, but the first four are defined by behaviors that are often related to age and circumstances. But even autistic spectrum disorder diagnoses capture many children with behaviors that were once considered part of the normal range of human personality and behavior – social ineptness, obsessional interests and unusual styles of learning and communicating.

Non-medical factors involved in the rise in psychoactive drug prescriptions

Non-medical factors which have added to the enthusiasm for drug treatment of behavioral symptoms have been the tremendous changes in society since World War II –in family structure and values, leisure time activities, employment patterns, the educational system and in the non-governmental institutions like churches and community groups that used to provide moral and structural support.  While schools once neglected girls’ needs, boys are now immersed in an educational system geared to girls, who are more verbally adept at younger ages than boys are.  Sitting still and learning to read is a task that boys confront several years earlier than they used to, and many lack the required maturity.  When they fail and act out, they are thought to be inattentive and impulsive, garnering them ADD evaluations and drug treatment significantly more often than girls.

Changes in the practice of medicine

Changes in the practice of medicine, with more emphasis on tests and drugs now than on time spent in direct contact with patients and families, also contribute to the ease with which drugs are used as the primary approach to all kinds of medical problems, not just psychological ones. Another problem for children is “off-label” drug use, a term applied to the perfectly legal practice of prescribing drugs for reasons other than those used in the trials that determined their safety. It is estimated that 70% of all pediatric drug use is off-label, and for most of the psychoactive drugs used in children, testing has been done only in adults. In addition, the majority of psychoactive drugs used in children are prescribed by family practice or general pediatricians, not by psychiatrists. Pediatric psychotherapists, whose help might supplant the need for drugs or improve the outcome of drug treatment, are in short supply. For children without private insurance, psychoactive drug prescription rates are higher than for the privately insured.

Long term concerns

The concerns about widespread use of psychoactive drugs in children extend beyond the many side effects such as decreased appetite, insomnia, cardiac problems, and sudden death  (stimulants used for ADD), and weight gain, sleepiness, liver problems , diabetes, and increased suicide rates (antidepressants , antipsychotics and mood stabilizers).  Some neurodevelopmental biologists think  we may be trading one set of problems for another delayed and potentially more troublesome set,  because psychoactive drugs  have long term effects on the immature brain that are not seen in the adult. The developing brain is meant to learn from experience and modify its behavior in a process we call maturation and  it is not at all clear that interfering in development with drugs that change behavior passively is superior to helping the child learn without drugs,  by improving the social environment and providing competent psychological help.  We should remember that role models for Huck and Tom grew up to be a judge and a famous writer.

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