Thursday, June 21, 2012

Youth prescribed psychotropic drugs much more often for behavior modification

Recently, in an item titled "Hypothesizing reasons for continued crime declines," Grits mentioned the theory that new and improved pharmacology is a contributing factor to reduced crime, particularly juvenile crime. So I was interested to see data describing the growth in behavior modification drugs given to youth, particularly for attention deficit disorder. According to Reuters:
From 2002 to 2010, the use of ADHD drugs grew by 46 percent -- or some 800,000 prescriptions a year. The top drug dispensed to adolescents was the stimulant methylphenidate, also known as Ritalin, with more than four million prescriptions filled in 2010.

"What the article is suggesting is that the number of children that we are treating for attention deficit disorder has gone up," said Dr. Scott Benson, a child and adolescent psychiatrist and a spokesperson for the American Psychiatric Association.

"For the most part I think the overall increase reflects a reduction in the stigma," he told Reuters Health. "It used to be, ‘You're a bad parent if you can't get your child to behave, and you're a doubly bad parent if you put them on medicine.'"

Dr. Lawrence Diller, a behavioral pediatrician who has written extensively about ADHD, was more critical of the rise in stimulant prescriptions, noting that the U.S. is far ahead of other countries in its use of the drugs.

"You have to look at how our society handles school children's problems. It's clear that we rely much, much more on a pharmacological answer than other societies do," Diller said. "The medicine is overprescribed primarily, but under-prescribed for certain inner-city groups of children."
See the abstract from the paper described. Overall, prescriptions for youth have recently declined, but mostly that's because of a reduction in antibiotics given out, a reaction to their massive over-prescription in years past. At an instinctive level, Grits is not a fan of the idea of medicating kids to instill good behavior as opposed to, say, teaching them. I understand the "stigma" attached to drugging one's kids to rein in bad behavior and part of me considers it justified (certainly IMO it should be a last resort). But Grits remains open to the notion that such medications have reduced misbehavior and even criminality among youth, though I've never seen someone try to quantify the scope of that effect. Whether that's a good or bad thing overall depends on whether the drugs also reduced creativity, stifled emotional development, whether they prevent acquisition of tools for self-control sans medication, and a host of other aspects that can't be measured by student behavior scores or crime-rate data.

I also wonder about the suggestion that psychotropic drugs are "under-prescribed for certain inner-city groups of children" (read: minority youth). Another article from the journal Pediatrics published this month declared that "Maladaptive aggression in youth is increasingly treated with psychotropic medications, particularly second-generation antipsychotic agents. Multiple treatment modalities are available, but guidance for clinicians’ assessment and treatment strategies has been inadequately developed." But if assessment and treatment strategies have been "inadequately developed," I'm unclear how they can make the normative assessment that psychotropic drugs are "under-prescribed for certain inner-city groups of children"?

According to another article from Pediatrics, "In children and adolescents the Second Generation Antipsychotics (SGAs) represent the class of psychotropic drugs whose use has grown more significantly in recent years: they are primarily used for treatment of patients with disruptive behavior disorders, mood disorders and pervasive developmental disorders or mental retardation." Notably, though, the side effects of using antipsychotics for behavior modification in non-psychotic youth are only beginning to be understood. According to this article, "In randomized studies, adverse effects were usually relatively minor, easily predictable and manageable, whereas long-term open-label studies have indicated that some adverse event, such as the metabolic effects, may be severe and potentially life threatening on the long-term."

The relation between pharmacology and crime reduction is an issue Grits would like to delve into deeper. The medical landscape has changed dramatically in the last decade regarding psychotropic drugs for youth, but the public policy implications remain poorly understood. We know the pharmaceutical companies benefit from these trends, I just hope it's also true that the kids do.


Anonymous said...

It would be more beneficial to the children I believe, to do a study on the root cause of ADHD rather than on drugs to suppress it. My guess would be the foods they eat before they go to school and then are forced to be seated indoors without benefit of fresh air (the windows do not even open in schools anymore)or movement with the exception of moving from class to class (recess is a term from "the olden days"); breathing recirculated air (I wonder how often the filters are changed in the air conditioning system). I myself would have lost my mind had I not been able to to go outside and play twice a day while in school. Loved that dodge ball, I am sure it is not allowed anymore.

Chris Halkides said...

A related question came up once before. Dr. Bernard Gesch has done studies which suggest that improving nutrition can decrease violence among young prisoners. I wonder whether starting with nutrition and only going on to drugs as needed might be a more cost-effective and better solution.

Science 25 September 2009, Vol. 325, p. 1614.

British J Psychiatry. 2002 Jul;181:22-8.
"Influence of supplementary vitamins, minerals and essential fatty acids on the antisocial behaviour of young adult prisoners. Randomised, placebo-controlled trial." Gesch CB, Hammond SM, Hampson SE, Eves A, Crowder MJ.

J Hum Nutr Diet. 2003 Jun;16(3):167-79.
Food provision and the nutritional implications of food choices made by young adult males, in a young offenders' institution.
Eves A, Gesch B.

Anonymous said...

Are these kids prescribed psychotropic medications for purely physical disorders? What these kids experience also has an effect. Imagine living in an environment where the sound of gunfire is a regular accompaniment to your life. So many of the males in these kids’ lives have hair trigger tempers and meet any challenge or disrespect with violence. All throughout their day, from morning till night, these youngsters hear “music” that either incites violence, glorifies violence, or celebrates violence. All this has to take a toll on a person’s psyche. These kids are suffering from more than purely physical disorders. The environment is neurotoxic.

Anonymous said...

Drugging behavior is a form of restraint. Behaviors are not diseases. On top of this, these are powerful, mind altering, dangerous drugs. The antipsychotics are related to neurological side effects, metabolic side effects, diabetes, etc. There is no brain test, blood test, lab test, X-ray to diagnose ADHD, the diagnosis is simply arrived at via a checklist of behaviors. ADHD drugs, however, are associated with increasing hostility, hallucinations, recreational use, and sudden cardiac death. It's ironic that drugs capable of causing poor behavior or even death would be proposed as a solution to criminality.

Anonymous said...

I have worked for a number of years with youth in alternative education campus settings. I have seen several instances where a child who has not been on medications due to parents inability to provide them 1) be prescribed meds that tremendously assist them in maintaining a acceptable level of behavior OR 2) they are at the alternative campus because they were caught with other student's medication on them. This last group I have had a large number of and they tell me they function better with the meds but they cannot obtain them legally. Self medicating helps them function but yet it is what brought them into a legal setting. I have seen very few who had adverse effects of taking prescribed meds for their behavior issues.

Anonymous said...

Call me Ariel.

I have a child with ADHD and did medicate her for the few years it was necessary. None of your reasons apply. It is a mental disorder.

I was very careful to take her to a psychologist who seldom diagnosed ADHD, known to consider it way over-diagnosed. It took him just over ten minutes and the sadness in his eyes was telling.

We watched her in the course of one year go from a child that: taught herself to add and subtract; taught herself the alphabet and was beginning to read; was sweet, pleasing, even angelic; to a child that couldn't focus, argued incessantly and irrationally, as well more. This was between the age of three to four.

It is over-diagnosed, especially with boys. However, ADHD does exist and yes behaviors are diseases, just not all behaviors.