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Playing With Fire –The State of Pediatric Mental Health in America

Shire Pharmaceuticals recently introduced the first selective FDA-approved alpha-2A adrenergic receptor agonist for treatment of ADHD (attention deficit hyperactivity disorder) in children. Intuniv (guanfacine) is thought to stimulate receptors in the pre-frontal cortex. Shire initially positioned the drug for children with ADHD who displayed a subset of symptoms that included “arguing with adults, deliberately annoying others, losing one’s temper, and being easily frustrated or irritable.” Shire eventually received a FDA warning letter for implying that Intuniv treated individual behaviors (which were manifested by behaviors at home like  “bedtime blowups”, “toothbrushing tantrums” and “dinnertime defiance”.  In response, Shire modified all their marketing materials for Intuniv. However, you can view screenshots from the original DTC  consumer website here, at a site that archives web content.

I happen to be the kind of person who sometimes make mountains out of molehills. A friend of mine, who also overthinks everything, jokingly refers to the two of us as ‘The Ruminators’. I don’t need a psychopharmacologist to tell me that my brain chemistry is different from some of my friends who are perpetually cool, calm and collected.

Most adults I know at times argue, blame others, throw temper tantrums and act irrationally. Fortunately, most of us learn to restrain our tongues when annoyed or irritated. Call it what you like – self control, self mastery or self modulation. Everyone at some point, from the CEO of a multimillion dollar company to the barista at Starbucks, learns it is best not to call the boss an idiot or scream at a customer.

Maturity is about learning to regulate your emotions, thoughts and social interactions. Many childhood emotional disturbances, from bipolar disorder to ADHD, involve an inability to do so. For the past 25 years, America has blamed this dysregulation on biological causes. Why do we so fervently pursue this“blame the brain” theory? One contributing factor is the tremendous profits made by drug companies in the area of pediatric mental health.

The Economics of Psychotropic Drug Use in Kids

Pathological behavior in kids has become a mega-billion dollar industry. From the astounding amounts of money spent on DTC advertising to the skyrocketing use of atypical antipsychotics in kids, the numbers are staggering. In 2011, spending on atypical antipsychotics, frequently used in children who are emotionally disturbed, was a mindboggling $18.2 billion. In 2004, three of the top five drugs prescribed for children 17 years and younger were ADHD drugs: Concerta at $.49 billion, Strattera at $.43 billion, and Adderall ranked fifth at $.41 billion.

An article published in Archives of Psychiatry reported that between 1993 and 2002, there was a 6-fold increase in pediatric office visits resulting in an antipsychotic prescription, from 201,000 in 1993 to 1.2 million in 2002. As Julie Zito had pointed out, the rate of psychotropic drug prescribing for children is much higher in the United States than other country. This is especially true for children in foster care.

ADHD medications and atypical antipsychotics are also some of the most heavily promoted, with 2007 DTC advertising expenditures for Concerta of $5.5 million (Source: Medical Advertising News, May 2008). In that same year, BMS spent $105.8 million on DTC advertising of the atypical antipsychotic Abilify (Source: Medical Advertising News, May 2008). Astonishingly, nearly 25% of children taking antipsychotic medications were under 9 years of age in a 1-year study looking at prevalence of psychiatric drug use in an outpatient prescription claims database of a large pharmaceutical benefit manager.

An article published in Archives of Psychiatry reported that between 1993 and 2002, there was a 6-fold increase in pediatric office visits resulting in an antipsychotic prescription, from 201,000 in 1993 to 1.2 million in 2002. As Julie Zito had pointed out, the rate of psychotropic drug prescribing for children is much higher in the United States than other country. This is especially true for children in foster care.

ADHD medications and atypical antipsychotics are also some of the most heavily promoted, with 2007 DTC advertising expenditures for Concerta of $5.5 million (Source: Medical Advertising News, May 2008). In that same year, BMS spent $105.8 million on DTC advertising of the atypical antipsychotic Abilify (Source: Medical Advertising News, May 2008). Astonishingly, nearly 25% of children taking antipsychotic medications were under 9 years of age in a 1-year study looking at prevalence of psychiatric drug use in an outpatient prescription claims database of a large pharmaceutical benefit manager.

The Pathologizing of Childhood Misbehavior

Fueled by an unholy alliance of the pharmaceutical industry and third-party advocacy groups like National Alliance for the Mentally Ill (NAMI), our culture has come to see emotional and behavioral problems in children as pathological processes caused by neurobiological defects.

Today, parents and physicians are sometimes treating defiance, temper tantrums and misbehavior with psychiatric medications that work in the pre-frontal cortex.

Yet, how sure are we that there are no long-term consequences of medicating children while their synaptic pathways are still developing and forming neuronal connections? Is it possible that administration of these potent medications could interfere with the normal maturing process? In fact, could our preoccupation with biologically-based behavior management lead to irreversible changes in the neurobiological processes that underlie normal development in children?

Stimulating The Pre-Frontal Cortex
Is drugging childrens’ cortical areas playing with fire?

Our pre-frontal cortex brain carries out important executive functions that we associate with maturity, like thinking through consequences and exerting control over impulses. In adults, the pre-frontal cortex inhibits aggression and modulates social judgment. Lesions of this area may result in antisocial and aggressive behavior and exaggerate responsiveness in excitatory circuits.

Children with ADHD have deficits in executive function and so find it difficult to regulate emotions and control their impulses. A functional neuroimaging study published by Crow and Blair in 2008 shows a decreased responsiveness in regions of the frontal cortex in children with mood and anxiety conditions such as bipolar disorder and PTSD.

There is no doubt that this area of the brain is influential in determining how we think, act and behave. The issue is whether children and teenagers challenges with frustration, irritability and impulsivity is a psychiatric illness or the immaturity of youth.

Children in Crisis – A Public Health Perspective

Our society chooses to see bad behavior in kids as emotional disturbances due to abnormalities in dopamine and serotonin pathways and physiologic brain functions. Even if children with bipolar disorder or ADHD display abnormal functioning of prefrontal cortical and striatal circuits, we ought not assume that ADHD is biological/genetic at its core. In fact, a large body of scientific research provides convincing evidence that familial, psychosocial and environmental factors play a significant role in pediatric disorders like ADHD. Unfortunately, such research receives short thrift in American culture where our “blame the brain” mentality has transformed our views on childhood mental health.

If the medical and consumer media disseminated more scientific research showing that nurture, not nature, contributes to psychiatric illnesses in kids, society might change its responses to the alarming rates of children with emotional disturbances and the high rate of psychotropic drug use in kids. Perhaps, we might transition from a biomedical model where we “blame the brain” to a public health perspective where we “blame ourselves.”If this occurred, we would place greater emphasis on prevention. Instead we worship at the altar of psychopharmacology, pathologizing misbehavior and drugging kids to get them to act more maturely.

While many factors contribute to the development of ADHD , several are substantiated in the medical literature.

Television Watching

Children spend an average of 3 to 4 hours per day watching TV. Several researchers, including Chrisakis, Miller & Marks and Hamer, have shown that early exposure to violent or non-violent entertainment television (more than 2.7 hours per day according to one author) leads to attentional and behavioral problems, as well as higher levels of psychological stress, in children. A study conducted by Johnson in adolescents reveals similar findings, with frequent television viewing during adolescence (more than one hour daily) associated with elevated risk for subsequent attention and learning difficulties, even after family characteristics and prior cognitive difficulties were controlled.

Also fascinating are the findings from a 2003 University of Michigan study on TV and violence. The study followed a sample of boys and girls 6 to 10 years of age growing up in the 1970s and 1980s to determine whether watching television violence as a child would be associated with later adult aggression. Follow up data revealed that childhood exposure to media violence predicts future aggressive behavior for both males and females. The relationship between exposure to violence on television and aggression was observed even when socioeconomic status, intellectual ability, and a variety of parenting factors were controlled.

These associations are concerning, especially when one considers how television has intruded into the life of children in the past sixty years. In 1946, only 0.5% of U.S. households had a television in 1946. By 1962, that number was 90%.

Tobacco Smoking

Prenatal cigarette smoke exposure (PCSE) is associated with ADHD, aggression and conduct disorders in children. In the past this association was ascribed to the effects of nicotine on the developing fetal brain. A 2008 article published in Journal of Psychiatry and Neuroscience hypothesizes that maternal cigarette smoking inhibits brain monoamine oxidase (MAO) during fetal brain development. Inhibition of MAOs is known to result in an aggressive phenotype in laboratory animals. According to Baler et al, cigarette smoke-induced inhibition of MAO in the fetal brain, may result in morphologic and functional changes that enhance the risk of irritability, poor self-control and aggression in the offspring.

Conclusion

Don’t expect to see health care policy that restricts TV watching in young children. Or laws that make it a misdemeanor to smoke while you’re pregnant. It seems that we would rather feed our children a steady diet of prescription drugs than take a hard look at how our culture and lifestyle contributes to the alarming number of children with mental health issues. While writers like Edward Shorter (A History of Psychiatry) consider the biological approach to mental illness a “smashing sucess”, future generations of children may feel otherwise. Although the biomedical paradigm of childhood mental illness is widely accepted today, someday we may consider it a failed experiment.

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