Making Our Children Conform Using Mental Trickery

Here is an absolutely excellent article by Elizabeth Weil in the New Republic in which she analyzes the increasing use of various therapeutic techniques to get kids to conform to expected classroom behavior. It is a more subtle but insidious form of pathologizing children who are being normal children.  Much of it is predicated on the now well known delayed gratification studies of young children.  You've heard it before--the test child is told not to eat the marshmallow in order to get two marshmallows in a few minutes.

Everyone who has a child with childhood impulses is immediately struck by inner fear.  Is my child the one who can't wait?  What does this mean for her/his future career?

Now this is the basis for all kinds of behavior modification schemes used in schools.  The problems Weil outlines include that (1) we are telling our children they are mentally sick or wrong, and (2) the empirical evidence does does not support the actual interventions being used.

It is yet another case of wanting to believe this is the right way to do things because it sounds good.

Self-Regulation:  American Schools Are Failing Nonconformist Kids

Please take a look, it is worth the read.

Autism's Tipping Point

Besides being an expert at neuroscience, to the benefit of the greater good neuroskeptic also dabbles in cultural criticism of science and healthcare with an eye toward empirical observation of the ethnocultural processes of those areas.  A bit of armchair social science, but well done.

His latest piece on the phenomenal growth of autism:

Are We Headed For "Peak Autism"?

Many have observed the unnatural increase in autism over recent years.  In the midst of this apparent epidemic, news stories push "autism awareness" and "promising findings" about the cause(s) of autism.

Among practitioners, among psychiatric naysayers, among the small community of social scientists who make medicine, psychiatry and science their field of study, there has been much conjecture about the sociocultural factors behind the growth.  The usual conclusion based on observation and/or conjecture, is that the incidence of the underlying condition has probably not changed dramatically, but instead we are seeing an expanding practical definition of autism as interpreted by clinicians in the field.  You can add to this the fact of heightened awareness of the diagnosis resulting in people (clinicians, parents, teachers, etc.) seeing it where they didn't see it before (rightly or wrongly).  This, in the context of a loosely defined spectrum disorder that (like all mental health diagnoses) is determined by a check list of behavioral signs and indicators allowing for broad differences of interpretation and understanding.

Sadly the places and people with money to pay for research don't seem particularly interested in putting resources into resolving this question.

Lucky for us we have a guerrilla social science researcher in neuroskeptic who counted the number of research papers (via PubMed) on the subject of autism, relative to several other disorders.  He found that autism research has increased eight fold in 12 years, about twice the rate of ADHD (the next highest growth disorder) and maybe 4x (about) the growth of schizophrenia research.  It is hugely out of proportion to the 4% growth in science (as a whole) per year.

I might take it a step further and just state what has been clear over the last 150 years or so of psychology and psychiatry--the field, popular and professional, is driven by fads.

A Buffet of Childhood Diagnoses

I just want to promote this very good post on Neuroskeptic on the North American epidemic of diagnosing young children with the adult disorder of Bipolar and the American Psychiatric Association's attempt to fight this problem by writing yet another childhood disorder into the DSM-V.

Psychiatrists: Does Fire Put Out Fire?

What is it about North America that we want to believe all our children are mentally sick?

Is that Thorazine in the Baby's Bottle?

One of the most disturbing trends in mental health today is the increasing use of powerful antipsychotic medication to treat behavioral problems in children, even very young children. According to a 2009 report by the Food and Drug Administration, there are 500,000 children in the United States being administered regular doses of antipsychotics. Medicaid data shows public health monies spent on antipsychotic drugs for children exceeding $30 million in New Jersey and topping $90 million in Texas. It is a trend that has built relentlessly for the past ten years and continues unabated.

I find the use of these drugs on children to be appalling almost beyond words. Having worked as a mental health professional for many years, I am well acquainted with these medications. This class of drugs, sometimes referred to as neuroleptics, are major tranquilizers and are primarily used and intended for controlling hallucinations and delusions in cases of psychosis and schizophrenia. For an adult with severe schizophrenia, these medications may be a glimmer of hope, but it is always a difficult risk-benefit analysis because there are potentially severe side effects and reactions. Depending on the individual, these medications can cause tremors, involuntary spasms and movements, severe sedation, muscles of the face become rigid, and loss of pleasure sensation, just to name a few. Permanent neurological damage can occur in the form of tardive dyskenisia, and sudden death can occur from a reaction called neuroleptic malignancy syndrome. With newer forms of antipsychotics, these type of side effects are less frequent and less severe, but continue to be a risk depending on the reaction of the individual’s body. However, newer, “atypical,” antipsychotics present new dangers to the patient, metabolic changes that result in a dramatic increase in the instances and severity of diabetes and heart disease. The result is that adults on antipsychotic medications have a life span that is 20 years shorter then the average person.

We know these medications have the potential to cause permanent harm to an adult’s brain, but they are still used because it is considered by many to be worth the risks to control just some of the symptoms of debilitating disorders, and, except in the most severe cases, where a person’s legal rights have been taken away due to impairment, it is ultimately up to the patient to decide whether or not to take that risk.

What then will these medications do to a child’s developing brain? The jury is out, but it can’t be a good thing. Who makes the decision and why? Certainly not the child who will live the rest of his or her life with the consequences of that decision.

The New York Times ran a recent article on the subject, highlighting the case of one child who was started on an antipsychotic at 18 months old. This helps to highlight the human side of this tragedy:

At 18 months, Kyle Warren started taking a daily antipsychotic drug on the orders of a pediatrician trying to quell the boy’s severe temper tantrums.

Thus began a troubled toddler’s journey from one doctor to another, from one diagnosis to another, involving even more drugs. Autism, bipolar disorder, hyperactivity, insomnia, oppositional defiant disorder. The boy’s daily pill regimen multiplied: the antipsychotic Risperdal, the antidepressant Prozac, two sleeping medicines and one for attention-deficit disorder. All by the time he was 3.

He was sedated, drooling and overweight from the side effects of the antipsychotic medicine. Although his mother, Brandy Warren, had been at her “wit’s end” when she resorted to the drug treatment, she began to worry about Kyle’s altered personality. “All I had was a medicated little boy,” Ms. Warren said. “I didn’t have my son. It’s like, you’d look into his eyes and you would just see just blankness.”

Today, 6-year-old Kyle is in his fourth week of first grade, scoring high marks on his first tests. He is rambunctious and much thinner. Weaned off the drugs through a program affiliated with Tulane University that is aimed at helping low-income families whose children have mental health problems, Kyle now laughs easily and teases his family.

Ms. Warren and Kyle’s new doctors point to his remarkable progress — and a more common diagnosis for children of attention-deficit hyperactivity disorder — as proof that he should have never been prescribed such powerful drugs in the first place.

As to what’s driving this latest treatment fad?  I think there are a number of factors.  The easiest and most popular target is Big Pharma.  The pharmaceutical industry has the largest profit margin of any major industry, and do you know what their most profitable line of drugs are?  Yes, that’s right, antipsychotics.  This class of drugs brought in a staggering $14.6 billion in 2009.  Antipsychotics are marketed as heavily as any other product line, and the marketers are always looking for new markets.  Antipsychotics have been marketed for depression, for instance, and they are actively promoted to pediatricians for use on children, but, for the most part, marketing efforts keep within the limits set by the FDA and the risk-benefit decisions made industry lawyers.  The FDA approved Risperdal for use on children as young as 5, but most antipsychotics are only approved for children 10 or older.

Yet, in spite of the FDA guidelines, these drugs are being given to much younger children. Who then is to blame? The other popular targets of finger pointing are the parents (and, I would add, teachers and childcare workers). Perhaps it is helped along by marketing campaigns, but the fact is, parents are increasingly choosing to pathologize and medicate their children in lieu of other, more traditional, parenting strategies. Childcare and educational professionals add to the stampede by pressuring parents to go to the doctor when the child’s behavior puts a strain on the professional. I think we can objectively state, unequivocally, the nature of childhood needs and behaviors has not changed in recent generations, yet more and more parents go to their pediatricians insisting there is something wrong with their child and demanding some pill they can give the kid to fix the problem. Parents just want to do right by their child, I’m sure, but they fail when the don’t take the time to research what they are doing and the possible consequences.

The final responsibility, however, rests on the shoulders of the professionals who prescribe these medications. Physicians are free to prescribe off label use of drugs and are under no legal obligation to stay within FDA approved guidelines, and some physicians seem more then willing to exercise this discretion in spite of the very serious risks they are exposing the child to. Regardless of shameless marketing by drug manufacturers and the irrational pressures of frustrated parents, the physician is supposed to be the final gate keeper and is responsible to safeguarding the health and wellbeing of the young patients. Physicians who push antipsychotics on children clearly fail in their responsibilities.

The issue is further complicated by shifting diagnostic categories. Schizophrenia is a disorder of adulthood. Age of onset is typically late adolescence or early adulthood. There is no defined criteria and very little in the way of scientific data to justify giving this diagnosis to younger children, yet we are seeing it, now, younger and younger, usually tied to a prescription. Another expanding diagnosis is bipolar. This disorder is very loosely defined and as a result, unscrupulous or simply confused professionals can see it everywhere. It too used to be a disorder of adulthood but has mushroomed as a child diagnosis in the last decade. The other big diagnosis linked to antipsychotics is autism. This is a very serious and real childhood disorder and children who suffer from this take a lot of care and present a lot of challenges. However, the autism diagnosis has become hugely popular and its working definition has expanded infinitely. As in the case of Kyle Warren, just about any child can get the diagnosis at this point. It is now virtually meaningless, yet it is the justification for giving these very serious drugs to young children.

The big picture is we have an expanding culture of psychopathology in which more and more facets of human behavior are being defined as disorders and sicknesses. This extends even to the point of defining childhood tantrums as a sickness that we have to treat with a powerful drug. The pathologization of childhood started probably in the 1980’s with attention deficit disorder and this became hugely popular in the 1990’s. In the first decade of the new millennium, we saw a significant expansion of clinical depression, bipolar and even schizophrenia into younger and younger populations with related drug therapies. Additionally the autism diagnosis has been opened up into a “spectrum” disorder so now parents of children with any kind of perceived interpersonal or behavioral challenges can have an autism label slapped on ‘em at bargain basement prices.

The bottom line is that young children are being harmed by antipsychotic drug treatment and it’s no laughing matter. The trend line is very disturbing. I hope I am not one of a few lone voices in the wilderness. Is anybody listening?