Playing With Fire –The State of Pediatric Mental Health in America
I am the kind of person who makes mountains out of molehills. A friend of mine jokingly refers to me as “The Ruminator.” I don’t need a psychiatrist to tell me that my brain chemistry is different from that of 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. At some point everyone, 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 moods, emotions, and social interactions. Many childhood emotional disturbances, from bipolar disorder to attention deficit hyperactivity disorder (ADHD), involve an inability to do so. For the past 35 years, America has blamed this dysregulation on biological causes. Why do we so fervently pursue the “blame the brain” theory? One contributing factor is the tremendous profits to be made by drug companies in the area of pediatric mental health.
The Economics Of Psychotropic Drug Use In Kids
Pathological behavior in kids is a mega-billion dollar industry.
Approximately 13% of children 8 to 15 years of age have a diagnosable mental disorder. ADHD is the most prevalent mental health disorder among children (8.6%), followed by mood disorder (3.7%), and major depression (2.7%). Promoting drugs as the primary treatment for pediatric mental health translates into big bucks.
Between 1999 and 2014, US antipsychotic prescribing for pediatric mental health increased by 50%. Some of this increase was for antipsychotic medications approved by the US Food and Drug Administration (FDA), including drugs for schizophrenia, bipolar disorder, and irritability associated with autistic disorder and Tourette syndrome. Much of the increase, however, is associated with off-label prescribing, mostly for ADHD.
Stimulants are the most commonly prescribed treatment for ADHD in youth. Global use of ADHD medications rose 3-fold from 1993 through 2003, with global spending rising 9-fold. The US share of the ADHD global market is 83.1%, with $2.4 billion USD spent in 2003. Use and spending for ADHD medications has grown in all countries, with the highest growth in the United States due to prescribing of more costly long-acting formulations.
A 2012 study of Florida Medicaid spending in children and youth with ADHD revealed a 37% increase in stimulant use from 1996 to 2005. Spending on antipsychotic medication during this period increased 6-fold. By FY 2004 and FY 2005, antipsychotic spending constituted 38% of psychotropic spending for children with ADHD.
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.
A 2015 JAMA article showed that antipsychotic prescribing to youth, almost exclusively comprising prescriptions for atypical antipsychotic medications, increased from 0.16% (1993–1998) to 1.07% (2005–2009).
In light of the excessive use of these drugs in children in foster care and those with antipsychotic treatment-emergent cardiometabolic adverse events, in recent years many states passed legislation providing for greater oversight of antipsychotic drug prescribing in children. This contributed to a reduction in the percentage of young people using antipsychotics between 2006 and 2010, although there was a rise in prescribing for adolescents and young adults during this period.
The Pathologizing Of Childhood Misbehavior
Our culture has come to see emotional and behavioral problems in children as pathological processes caused by neurobiological defects.
Today, parents and physicians sometimes treat defiance, temper tantrums, and misbehavior with psychiatric medications that work in the prefrontal cortex. But how sure are we that there are no long-term consequences to 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 maturation process? Could our preoccupation with biologically based behavior management in fact lead to irreversible changes in the neurobiological processes that underlie normal childhood development?
Stimulating The Prefrontal Cortex
Is drugging childrens’ cortical areas playing with fire? The prefrontal cortex area of the brain carries out important executive functions that we associate with maturity, like thinking through consequences and exerting control over impulses. In adults, the prefrontal cortex inhibits aggression and modulates social judgment. Lesions in this area may result in antisocial and aggressive behavior as well as exaggerated 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 post-traumatic stress disorder (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 frustration, irritability, and impulsivity are signs of a psychiatric illness or simply the natural immaturity of youth.
Children in Crisis — A Public Health Perspective
Our society chooses to see bad behavior in kids as an emotional disturbance caused by abnormalities in dopamine and serotonin pathways and physiologic brain functions. Even if children with bipolar disorder or ADHD do display abnormal functioning of the prefrontal cortical and striatal circuits, we ought not assume that ADHD is biological or genetic at its core. In fact, research provides evidence that familial, psychosocial, and environmental factors may play a role in pediatric disorders such as ADHD. Unfortunately, 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 just nature, also contributes to psychiatric illnesses in kids, society might change its response to the alarming incidence of emotional disturbance and high rate of psychotropic drug use in kids. Perhaps we might transition from a biomedical model in which we “blame the brain” to a public health perspective in which we “blame ourselves.” If this occurred, we would place greater emphasis on prevention of mental health problems in children. Instead, we worship at the altar of psychopharmacology, pathologizing misbehavior and drugging kids to get them to act more mature.
While many factors contribute to the development of ADHD, several are substantiated in the medical literature.
TELEVISION WATCHING
Several researchers, including Christakis, Miller and Marks, and Hamer have shown that early exposure to violent or nonviolent 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.
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 60 years. In 1946, only 0.5% of US households had a television. By 1962, that number was 90%. And yet little is done to mitigate the effects of television violence on youth.
Today’s children experience screen violence on multiple platforms, including computers, video games, and touch-screen devices. Scientific research suggests that virtual violence increases aggressive thoughts, feelings, and behaviors. This 2018 JAMA study found a significant association between high-frequency use of multiple forms of modern digital media (e.g., social networking, streaming movies or music, or texting) and the presence of ADHD symptoms after a 2-year follow-up.
TOBACCO SMOKING
Maternal cigarette smoking during pregnancy is associated with behavior problems in children. Children with prenatal cigarette smoke exposure are more likely to develop behavioral problems, conduct disorder, and ADHD, all of which are characterized by impulsive behavior. A 2008 article published in Journal of Psychiatry and Neuroscience hypothesized that maternal cigarette smoking inhibits brain monoamine oxidase (MAO) during fetal brain development. Inhibition of MAO is known to result in an aggressive phenotype in laboratory animals. Cigarette smoke-induced inhibition of MAO in the fetal brain may cause morphologic and functional changes that enhance risks of irritability, poor self-control, and aggression in the offspring.
Conclusion
Don’t expect to see healthcare 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 the internationally recognized historian of psychiatry Edward Shorter considers the biological approach to mental illness a “smashing success,” future generations of children may think otherwise. Although the biomedical paradigm of childhood mental illness is widely accepted today, we may someday consider it a failed experiment.
