IN THIS ISSUE
The overmedication of our youth: An interview with Brent Dean Robbins, PhD
Within the past decade, the use of atypical antipsychotics with pediatric patients has doubled. This massive increase has been primarily motivated by an astronomical rise in diagnoses of pediatric bipolar disorder, which has seen a 40-fold increase in the same time period. These dangerous neuroleptics have also been used in the treatment of pervasive developmental disorder, mental retardation, attention-deficict/hyperactivity disorder (ADHD) and disruptive behavior disorder. In some cases, we have even seen these drugs used as sleep aids for children. These trends are quite alarming considering the high potential for very serious side effects with this class of drugs. What is the fastest growing market for these neuroleptic drugs? Believe it not, children between the ages of two and five. Anyone who understands the nature of these medications will immediately grasp the gravity of this situation. It’s hard to imagine why any child younger than 5 could possibly require antipsychotic treatment, yet the numbers of children medicated with these drugs has seen a very dramatic rise. What is going on? A search for the answer to that question was the primary impetus behind the publication of "Drugging Our Children: How Profiteers Are Pushing Antipsychotics on Our Youngest, and What We Can Do to Stop It," which is co-edited by Sharna Olfman and Brent Dean Robbins (2012).
Drugging Our Children scrutinizes the problem of overmedication in four ways: 1) The role of the pharmaceutical industry in creating a child market for antipsychotics; 2) the impact of antipsychotics on a child’s developing brain and body; and 3) the factors that have led the field of child psychiatry to make a devil’s bargain with the pharmaceutical industry in its relentless promotion of antipsychotic medication as a first-line treatment; and 4) the ways in which American culture undermines children’s healthy psychological development and foments the belief that the lion’s share of children’s behavior and emotional issues are biochemical processes that can be fixed with a pill. But the book does not stop at a diagnosis of the problem; it also examines potential solutions.
The ethical and legal ramifications of over-drugging children is a major focus of the book. Parents are offered advice on what they can do if they believe their children have been harmed by medication, and the risks they face if they refuse to allow their children to be medicated. Mental health practitioners, especially nonprescribing practitioners, are advised about their ethical and legal rights and responsibilities when they become aware of a child who is being wrongfully medicated and, as a result, harmed.
The most hopeful aspect of the book is the final section which addresses how families and communities have the capacity to foster and protect the healthy development of children in order to prevent and ameliorate behavioral problems. Various successful therapeutic interventions are detailed which offer effective treatments for children with behavioral problems who are currently being subjected to drugging with unnecessary and harmful neuroleptics.
Co-editor Dr. Robbins is Secretary of the Society for Humanistic Psychology and was co-chair of the annual conference in Pittsburgh this year. He is director of the psychology program and associate professor at Point Park University in Pittsburgh, Pa. We asked him the following questions about the book and the topic of over-medicating children.
Question: What got you interested in the topic of the overmedication of children?
BDR: Initially, I became interested in the side effects of neuroleptics because I witnessed a loved one who was forced to take these drugs to very bad effect. The side effects were much worse than the original symptoms they were used to treat. And, worse, the doctors seemed less than prepared to acknowledge these side effects. So, I began to do my own investigation, and as a result, I learned a great deal. In the meantime, through my colleague Sharna Olfman, especially her book on bipolar children, I became aware that there are strong social and economic forces that were leading to the increase of the use of these drugs with children. After I began to fully understand the danger of these drugs, as well as their potential benefits, I was very alarmed to learn that these drugs were being used to treat kids — sometimes children as young as 2 years old.
Question: What do you think is the cause of the dramatic rise in psychiatric drugging of children?
BDR: I do not think there is one single cause. It’s important to look at the problem from a variety of perspectives, and to understand that multiple factors likely determine this trend.
First of all, we have seen an increasing breakdown in support for caregiving of children and in the community supports for children. The last century has seen a dramatic rise in psychopathology among children as a result of the disintegration of social structures that provide for children’s basic needs.
Secondly, rather than fix the social problems causing difficulties with our children, we have a natural tendency to blame individuals. Social psychologists refer to this cognitive bias as the “fundamental attribution error.” When our families, schools and communities are failing, our children naturally present with problem behaviors. But rather than fix the broken families, schools, and communities, we blame the children and say they are the ones who are dysfunctional. That’s wrong, and it’s a kind of delusional thinking. It is a delusion that serves as a defense mechanism. It’s a defense that protects families and communities from the blow to our self-esteem that comes with the recognition that, in fact, we are failing our children in a terrible way. So, rather than face the painful truth, we blame our kids, and we look for a solution that will get us off the hook.
The pharmaceutical industry has a profit-motive to give parents and communities an easy out. And psychiatry has become increasingly identified as dispensing pharmacological treatments. So, together, pharma and psychiatry work together to enable our cultural delusion. They tell us our children are to blame for our social failures, and get us off the hook. And they give us an answer to the problem, which is a pill. Of course, the pill is not the answer, but a Pandora’s box that opens up a whole new set of problems without ever addressing the root cause of our children’s dyfuctional behavior, which is us.
Question: You say there has been a breakdown in the support of children in our society. Where do you see this breakdown occurring?
BDR: Well, for a detailed analysis of this breakdown in family and community supports for caregiving of children, you will want to read the chapter in the book by Sharna Olfman. Dr. Olfman is a licensed clinical psychologist with an expertise in child development. She’s also a social critic, who is not afraid to challenge the status quo. She points out a number of social realities that are placing increasing burdens on American families, including inadequate parental leave and nonexistent child sick leave, a minimum wage that is not a living wage, inferior schools, excessive exposure to unhealthy images in mass media, week environmental policy which exposes children to toxic substances and so on.
I would add that we are also seeing over the past century a steady disintegration of stabilizing extended family structures that previously provided supports to children. These extended families afforded more economical opportunities for child care and support because, as kin selection theory would predict, family members are more invested in the well-being of our children than are strangers who are paid to care for our kids. If you have a choice between having a grandmother as a caregiver and a daycare worker, obviously the grandmother is going to be both more affordable and more likely to be a better caregiver for your child if you need to go to work. As the old cliché goes, blood is thicker than water. Yet, in our advanced industrial society, we have a more nomadic and individualist ethos, where children travel far away from the nest. Extended family connections are maintained through telephone and social media, but the supports for caregiving are not there as much as they once were. Add to that problem the increase in divorce, and children are living fractured lives spread across multiple households, often with feuding parents, spending the majority of their time with caregivers who are not all that invested in their well-being, whether that be daycare workers or step-parents.
These conditions are going to increase the risk of problem behavior in children — and the problem is not the children. Again, the problem is the society. The problem behavior of our children, for the most part, with some exceptions, is a symptom of a disintegration of the culture.
Question: Do you think there are any circumstances in which a child might benefit from treatment by antipsychotics?
BDR: The key question is not whether a child might benefit from antipsychotics. We know for a fact that antipsychotic medications are very effective in the short term if you want to sedate someone and slow down their thinking and activity. To the extent that a trouble child may be easier to manage, antipsychotics is a mental restraint that can make a parent’s life easier, I’m sure. But at what cost? Invariable, the long-term costs of neuroleptics in children far outweighs any potential short-term benefit. In the book, this issue is examined in great depth by Robert Whitaker. When you examine the evidence, it’s plain to see the risks of antipsychotic drugs far outweigh any benefits when used for treatment of pediatric behavioral problems. The side effects are very severe in many cases: obesity, diabetes, irreversible motor disorders, etc. The subjective experience of sedation can be very unpleasant. And based on MRI studies, we know that long-term use of antipsychotics leads to dose-related loss of brain tissue independent of the severity of psychiatric symptoms. So, it’s the drugs doing the damage and not any so-called “disease.” For those who take neuroleptics, we see a foreshortened life-span of about 20 years. Is this what we want for our children? I don’t think so.
Question: If the risks of neuroleptic treatment far outweigh any benefits, why are we seeing such a fast and steady increase in prescriptions of antipsychotics to children?
BDR: I think the marketing of the drugs is the primary reason. The old antipsychotics were off patent, so they were not much of a cash cow for pharmaceutical industry. The profiteers in the drug companies decided to take those old neuroleptics and tweak them a bit chemically in order to get a new drug that has roughly the same effect as the old drugs. Only this time, they could patent the new so-called “atypical antpsychotics” as though they were a brand new drug. They’re very similar to the old neuroleptics, but they were marketed as having fewer side effects. As it turns out, they actually have all the old side effects, but in addition, some new side effects too — a tendency to cause metabolic problems like weight gain and diabetes. But we didn’t really know this when the drugs first came out, so they were marketed as safer. They weren’t safer. They were just newer and more profitable.
Once the new atypical antipsychotics hit the market, the drug industry had a narrow window of opportunity to reap the profits from this drug. They need to rake in their dough before the patent wears off, and they lose profit opportunities. So, naturally, the drug companies marketed these drugs very heavily and tried to expand the market as far as they could. In the book, Gwen Olson, who was a drug rep herself, goes into great detail about all the sales and marketing tactics drug companies use to expand the market for their drugs. It will make your hair stand on end, seriously. In any case, there were two markets that drug companies very aggressively pursued — children and the elderly. And they were very successful at doing this, despite the fact that the FDA had never approved the use of atypical antipsychotics for children and the elderly. The drug companies were subjected to billion dollar lawsuits for off-label marketing of neuroleptics, but they made many billions of profit beyond the penalties they endured. So, from a business perspective, they lost battle in court, but the won the war monetarily in the end.
Question: What are alternatives to the use of atypical antipsychotic drugs? Obviously, there are children suffering, and many believe these drugs help. If we do not use antipsychotics with these children, are there alternative treatments that are safer and just as effective?
BDR: Yes, absolutely. In the book, Tony Stanton, a psychiatrist, writes about the great success they had with a residential program that treated very troubled children without the use of neuroleptics. In another chapter, social worker George Stone discusses the great benefits of family therapy, which can benefit children without the need for antipsychotic intervention. Child therapy has been shown to be effective for many children. Effective parenting can have a huge impact on children, as can community interventions. These issues are discussed by Adena Meyers, Laura Berk and Stuart Shanker. So, there are many options for our children. Drugs, if anything, should be a last resort to help children who are suffering from dysfunctional families, communities and environments.
Question: What should mental health professionals do if and when they see children who are unnecessarily medicated on neuroleptics?
BDR: In our book, Jim Gottstein, who is an attorney, answers this question in his chapter. Gottstein makes a very compelling argument that we are ethically obligated as professionals to redress what we perceive to be a potential harm to our patients, including being prescribed unnecessary and dangerous drugs. He provides some very practical legal avenues for intervening in a way that navigates between our ethical obligation to protect children from harm while, at the same time, recognizing the limits of our professional competence. The beautiful thing is that, ethically and legally, we don’t have to just stand by and watch while we see children being placed on drugs unnecessarily. On the contrary, it’s imperative that we act within proper limits to protect that child from harm. That’s our duty. And as for the children, that’s the least we owe them.