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.

Polar Moods

Bipolar disorder, previously called manic-depressive disease, is a not a new diagnosis. But it is one being made with increasing frequency, particularly in children and young adults. In psychiatry diagnoses are legion, but they all fall into one of three categories: disorders of mood, thinking, or personality. Bipolar disorder is a problem in the sphere of mood, described in the 1880s by Emil Kraepelin, the German psychiatrist whose Compendium der Psychiatre was the world’s first systematic classification of mental disorders. At the time, psychiatrists recognized separate illnesses called mania and melancholia, but Kraepelin was the first to see that some patients cycled between these opposite poles of mood. Over time, the term cyclical insanity gave way to manic-depressive disease, and finally to bipolar disorder, type I or type II (the milder variety). Melancholia is now called unipolar depression and mania is no longer a diagnosis but rather a  behavioral symptom in all kinds of psychiatric disorders.

Normal ups and downs in mood

 

Everyone has ups and downs in mood. Mood involves both  subjective feelings and  outward behaviors. It is clear from “normal” mood  swings that both internal and external factors influence ups and downs. Many of those factors, such as sleep, stress, physical activity, diet, and abuse of alcohol, nicotine and drugs, also affect general health.

The definition of mood disorder

Normal ranges of mood vary greatly from person to person, so the psychiatric definition of “mood disorder” rests on the degree to which disrupted behavior interferes with carrying out the normal activities necessary for functioning at a given stage of life. Clearly abnormal symptoms like hallucinations, which define the thinking disorder schizophrenia, may also appear in bipolar type I. New genetic work suggests that mood and thinking disorders are not as separate as our classification systems try to make them, so it is not surprising that symptoms at times overlap.

The down side of the mood spectrum

Depression, the low side of the mood spectrum, robs a person of interest and joy in his activities. He has little energy, sleeps more than usual, or may be unable to sleep through the night, waking up anxiously at two or three AM. He may gain or lose weight. He tends to ruminate, repetitively chewing over negative thoughts. Sadness permeates his world. Of course these  same symptoms  can be completely appropriate responses to terrible life events that cause profound grief.  A depressed mood becomes abnormal when it occurs or persists unrelated to circumstances, blocks the activities necessary for normal life, and/or includes persistent thoughts of death or suicide.

The up side

At the other end of the mood spectrum, mania, the mind speeds up. Thoughts are rapid, distractibility is high, speech is pressured, and ideas become grandiose. Sleep isn’t necessary. The manic person engages in risky behaviors and feels invincible. He undertakes grand schemes, spends money with abandon, and becomes obsessed with projects or ideas. When the exuberant moods are still under some control (hypomania), they can be very productive. The afflicted individual seems lively and charismatic, the life of the party. But when mania spirals out of control it can become life threatening. As mentioned above, mania not confined to bipolar disorder. It is a symptom that can happen in mood, thinking and personality disorders.

Bipolar: more down than up

Most patients with true bipolar disorder spend far more time on its depressive side, experiencing few manic phases. In fact, it is now felt that many cases unipolar depression, with no history at all of hypomanic or manic episodes, actually represent bipolar mood disorders, making diagnosis tricky. Correct diagnosis is important. In unipolar depression, the response to conventional antidepressant therapy takes weeks, but in bipolar depression, the same drugs can tip the patient into a manic state quickly. It is possible that the reported cases of suicide shortly after antidepressants are started may be related to this phenomenon.

The danger of wrong diagnosis

In our current medical and economic climate, the threshold for using antidepressants is very low. Frequently the drugs are prescribed by non-psychiatrists, without concurrent talk or behavioral therapy, and without adequate follow-up. So it is imperative for patients who are given antidepressants to understand that a rapid response, within days to a week, and feelings of agitation or irritability might mean that the diagnosis of unipolar depression is wrong. For bipolar patients, the drug of choice is a mood stabilizer, which calms manic states and can prevent return of depression.

Stabilizing the mood

The most effective mood stabilizer is lithium. Lithium is a simple chemical element in the same family of elements as sodium, potassium, calcium and magnesium, rather than a complicated molecule like other psychoactive drugs. Its mechanism of action remains elusive, though it is thought that it makes the neurochemical transmitter norepinephrine less available and less effective in the brain. Lithium must be monitored carefully, with urine levels performed regularly. Toxic side effects include diarrhea, tremors, thirst, weight gain, drowsiness, and impairment of kidney and thyroid function.
If lithium is ineffective or poorly tolerated, drugs normally used for treatment of seizures may work as mood stabilizers. One, valproate, is particularly effective for people who also have substance abuse problems, a not uncommon occurrence. Antidepressants may also be necessary at some point, but not without concurrent use of mood stabilizers. Bipolar disorder is a lifelong problem that requires careful monitoring, variable amounts of drug therapy, and simultaneous counseling aimed at development of cognitive skills and habits that help blunt the effects of mood swings on behavior.

Are we creating more lifelong psychiatric problems with drug treatment?

Some psychiatrists feel that the widespread use of antidepressants and other mood altering drugs to treat poor behavior or reactions to life’s inevitable problems changes brains enough to change the way true psychiatric problems now evolve. These days, we have increasing numbers of bipolar diagnoses. Compared to past decades, bipolar patients now cycle more rapidly between highs and lows. While the increasing frequency of bipolar disorder diagnosis may represent increasing labeling of behavioral problems, we also must consider the disturbing possibility that temporary alteration of brain activity with drugs is leading to long term psychological and behavioral changes. Readers who are interested in more extensive discussion might want to read Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America by Robert Whitaker, Broadway; (August 2, 2011).

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