n the winter of 2000,
the Journal of the American Medical
Association published the results
of a study indicating that 200,000 two-
to four-year-olds had been prescribed
Ritalin for an “attention disorder” from
1991 to 1995. Judging by the response,
the image of hundreds of thousands of
mothers grinding up stimulants to put
into the sippy cups of their
preschoolers was apparently not a pretty
one. Most national magazines and
newspapers covered the story; some even
expressed dismay or outrage at this
exacerbation of what already seemed like
a juggernaut of hyper-medicalizing
childhood. The public reaction, however,
was tame; the medical community, after a
moment’s pause, continued unfazed.
Today, the total toddler count is well
past one million, and influential
psychiatrists have insisted that mental
health prescriptions are appropriate for
children as young as twelve months. For
the pharmaceutical companies, this is
progress.
In 1995, 2,357,833
children were diagnosed with ADHD (Woodwell
1997)—twice the number diagnosed in
1990. By 1999, 3.4 percent of all
American children had received a
stimulant prescription for an attention
disorder. Today, that number is closer
to ten percent. Stimulants aren’t the
only drugs being given out like candy to
our children. A variety of other
psychotropics like antidepressants,
antipsychotics, and sedatives are
finding their way into babies’ medicine
cabinets in large numbers. In fact, the
worldwide market for these drugs is
growing at a rate of ten percent a year,
$20.7 billion in sales of antipsychotics
alone (for 2007, IMSHealth 2008).
While the sheer
volume of psychotropics being prescribed
for children might, in and of itself,
produce alarm, there has not been a
substantial backlash against drug use in
large part because of the widespread
perception that “medically authorized”
drugs must be safe. Yet, there is
considerable evidence that psychoactive
drugs do not take second place to other
controlled pharmaceuticals in carrying
grave and substantial risks. All classes
of psychoactive drugs are associated
with patient deaths, and each produces
serious side effects, some of which are
life-threatening.
In 2005, researchers
analyzed data from 250,000 patients in
the Netherlands and concluded that “we
can be reasonably sure that
antipsychotics are associated in
something like a threefold increase in
sudden cardiac death, and perhaps that
older antipsychotics may be worse”
(Straus et al. 2004). In 2007, the FDA
chose to beef up its black box warning
(reserved for substances that represent
the most serious danger to the public)
against antidepressants
concluding, “the trend across age groups
toward an association between
antidepressants and suicidality . . .
was convincing, particularly when
superimposed on earlier analyses of data
on adolescents from randomized,
controlled trials” (Friedman and Leon
2007). Antidepressants have been banned
for use with children in the UK since
2003. According to a confidential FDA
report, prolonged administration of
amphetamines (the standard
treatment for ADD and ADHD) “may lead to
drug dependence and must be avoided.”
They further reported that “misuse of
amphetamine may cause sudden death and
serious cardiovascular adverse events”
(Food and Drug Administration 2005). The
risk of fatal toxicity from lithium
carbonate, a not uncommon treatment for
bipolar disorder, has been well
documented since the 1950s. Incidents of
fatal seizures from sedative-hypnotics,
especially when mixed with alcohol, have
been recorded since the 1920s.
Psychotropics carry
nonfatal risks as well. Physical
dependence and severe withdrawal
symptoms are associated with virtually
all psychoactive drugs. Psychological
addiction is axiomatic. Concomitant side
effects range from unpleasant to
devastating, including: insulin
resistance, narcolepsy, tardive
dyskenisia (a movement disorder
affecting 15–20 percent of antipsychotic
patients where there are uncontrolled
facial movements and sometimes jerking
or twisting movements of other body
parts), agranulocytosis (a reduction in
white blood cells, which is life
threatening), accelerated appetite,
vomiting, allergic reactions,
uncontrolled blinking, slurred speech,
diabetes, balance irregularities,
irregular heartbeat, chest pain, sleep
disorders, fever, and severe headaches.
The attempt to control these side
effects has resulted in many children
taking as many as eight additional drugs
every day, but in many cases, this has
only compounded the problem. Each
“helper” drug produces unwanted side
effects of its own.
The child drug market
has also spawned a vigorous black market
in high schools and colleges,
particularly for stimulants. Students
have learned to fake the symptoms of ADD
in order to obtain amphetamine
prescriptions that are subsequently sold
to fellow students. Such “shopping” for
prescription drugs has even spawned a
new verb. The practice is commonly
called “pharming.” A 2005 report from
the Partnership for a Drug Free America,
based on a survey of more than 7,300
teenagers, found one in ten teenagers,
or 2.3 million young people, had tried
prescription stimulants without a
doctor’s order, and 29 percent of those
surveyed said they had close friends who
have abused prescription stimulants.
In a larger sense,
the whole undertaking has had the
disturbing effect of making drug use an
accepted part of childhood. Few cultures
anywhere on earth and anytime in the
past have been so willing to provide
stimulants and sedative-hypnotics to
their offspring, especially at such
tender ages. An entire generation of
young people has been brought up to
believe that drug-seeking behavior is
both rational and respectable and that
most psychological problems have a
pharmacological solution. With the
ubiquity of psychotropics, children now
have the means, opportunity, example,
and encouragement to develop a lifelong
habit of self-medicating.
Common population
estimates include at least eight million
children, ages two to eighteen,
receiving prescriptions for ADD, ADHD,
bipolar disorder, autism, simple
depression, schizophrenia, and the
dozens of other disorders now included
in psychiatric classification manuals.
Yet sixty years ago, it was virtually
impossible for a child to be considered
mentally ill. The first diagnostic
manual published by American
psychiatrists in 1952, DSM-I, included
among its 106 diagnoses only one for a
child: Adjustment Reaction of
Childhood/Adolescence. The other 105
diagnoses were specifically for adults.
The number of children actually
diagnosed with a mental disorder in the
early 1950s would hardly move today’s
needle. There were, at most, 7,500
children in various settings who were
believed to be mentally ill at that
time, and most of these had explicit
neurological symptoms.
Of course, if there
really are one thousand times as many
kids with authentic mental disorders now
as there were fifty years ago, then the
explosion in drug prescriptions in the
years since only indicates an
appropriate medical response to a newly
recognized pandemic, but there are other
possible explanations for this meteoric
rise. The last fifty years has seen
significant social changes, many with a
profound effect on children. Burgeoning
birth rates, the decline of the extended
family, widespread divorce, changing
sexual and social mores, households with
two working parents—it is fair to say
that the whole fabric of life took on
new dimensions in the last half century.
The legal drug culture, too, became an
omnipresent adjunct to daily existence.
Stimulants, analgesics, sedatives,
decongestants, penicillins, statins,
diuretics, antibiotics, and a host of
others soon found their way into every
bathroom cabinet, while children became
frequent visitors to the family
physician for drugs and vaccines that we
now believe are vital to our health and
happiness. There is also the looming
motive of money. The New York Times
reported in 2005 that physicians who had
received substantial payments from
pharmaceutical companies were five times
more likely to prescribe a drug regimen
to a child than those who had refused
such payments.
So other factors may
well have contributed to the upsurge in
psychiatric diagnoses over the past
fifty years. But even if the increase
reflects an authentic epidemic of mental
health problems in our children, it is
not certain that medication has ever
been the right way to handle it. The
medical “disease” model is one approach
to understanding these behaviors, but
there are others, including a hastily
discarded psychodynamic model that had a
good record of effective symptom relief.
Alternative, less invasive treatments,
too, like nutritional treatments, early
intervention, and teacher and parent
training programs were found to be at
least as effective as medication in
long-term reduction of a variety of
symptoms (of ADHD, The MTA Cooperative
Group 1999).
Nevertheless, the
medical-pharmaceutical alliance has
largely shrugged off other approaches
and scoffed at the potential for
conflicts of interest and continues to
medicate children in ever-increasing
numbers. With the proportion of
diagnosed kids growing every month, it
may be time to take another look at the
practice and soberly reflect on whether
we want to continue down this path. In
that spirit, it is not unreasonable to
ask whether this exponential expansion
in medicating children has another
explanation altogether. What if children
are the same as they always were? After
all, virtually every symptom now thought
of as diagnostic was once an aspect of
temperament or character. We may not
have liked it when a child was sluggish,
hyperactive, moody, fragile, or
pestering, but we didn’t ask his parents
to medicate him with powerful chemicals
either. What if there is no such thing
as mental illness in children (except
the small, chronic, often neurological
minority we once recognized)? What if it
is only our perception of childhood that
has changed? To answer this, we must
look at our history and at our nature.
The human inclination
to use psychoactive substances predates
civilization. Alcohol has been found in
late Stone Age jugs; beer may have been
fermented before the invention of bread.
Nicotine metabolites have been found in
ancient human remains and in pipes in
the Near East and Africa. Knowledge of
Hul Gil, the “joy plant,” was
passed from the Sumerians, in the fifth
millennium b.c.e., to the Assyrians,
then in serial order to the Babylonians,
Egyptians, Greeks, Persians, Indians,
then to the Portuguese who would
introduce it to the Chinese, who grew it
and traded it back to the Europeans.
Hul Gil was the Sumerian name for
the opium poppy. Before the Middle Ages,
economies were established around opium,
and wars were fought to protect avenues
of supply.
With the modern
science of chemistry in the nineteenth
century, new synthetic substances were
developed that shared many of the same
desirable qualities as the more
traditional sedatives and stimulants.
The first modern drugs were
barbiturates—a class of 2,500
sedative/hypnotics that were first
synthesized in 1864. Barbiturates became
very popular in the U.S. for depression
and insomnia, especially after the
temperance movement resulted in
draconian anti-drug legislation (most
notoriously Prohibition) just after
World War I. But variety was limited and
fears of death by convulsion and the
Winthrop drug-scare kept barbiturates
from more general distribution.
Stimulants, typically
caffeine and nicotine, were already
ubiquitous in the first half of the
twentieth century, but more potent
varieties would have to wait until
amphetamines came into widespread use in
the 1930s. Amphetamines were not widely
known until the 1920s and 1930s when
they were first used to treat asthma,
hay fever, and the common cold. In 1932,
the Benzedrine Inhaler was introduced to
the market and was a huge
over-the-counter success. With the
introduction of Dexedrine in the form of
small, cheap pills, amphetamines were
prescribed for depression, Parkinson’s
disease, epilepsy, motion sickness,
night-blindness, obesity, narcolepsy,
impotence, apathy, and, of course,
hyperactivity in children.
Amphetamines came
into still wider use during World War
II, when they were given out freely to
GIs for fatigue. When the GIs returned
home, they brought their appetite for
stimulants to their family physicians.
By 1962, Americans were ingesting the
equivalent of forty-three ten-milligram
doses of amphetamine per person annually
(according to FDA manufacturer surveys).
Still, in the 1950s,
the family physician’s involvement in
furnishing psychoactive medications for
the treatment of primarily psychological
complaints was largely sub rosa. It
became far more widespread and notorious
in the 1960s. There were two reasons for
this. First, a new, safer class of
sedative hypnotics, the benzodiazepines,
including Librium and Valium, were an
instant sensation, especially among
housewives who called them “mothers’
helpers.” Second, amphetamines had
finally been approved for use with
children (their use up to that point had
been “off-label,” meaning that they were
prescribed despite the lack of FDA
authorization).
Pharmaceutical
companies, coincidentally, became more
aggressive in marketing their products
with the tremendous success of
amphetamines. Valium was marketed
directly to physicians and indirectly
through a public relations campaign that
implied that benzodiazepines offered
sedative/hypnotic benefits without the
risk of addiction or death from drug
interactions or suicide. Within fifteen
years of its introduction, 2.3 billion
Valium pills were being sold annually in
the U.S. (Sample 2005).
So, family physicians
became society’s instruments: the
suppliers of choice for legal
mood-altering drugs. But medical
practitioners required scientific
authority to protect their reputations,
and the public required a justification
for its drug-seeking behavior. The
pharmaceutical companies were quick to
offer a pseudoscientific conjecture that
satisfied both. They argued that
neurochemical transmitters, only
recently identified, were in fact the
long sought after mediators of mood and
activity. Psychological complaints,
consequently, were a function of an
imbalance of these neural chemicals that
could be corrected with stimulants and
sedatives (and later antidepressants and
antipsychotics). While the assertion was
pure fantasy without a shred of
evidence, so little was known about the
brain’s true actions that the artifice
was tamely accepted. This would later
prove devastating when children became
the targets of pharmaceutical expansion.
With Ritalin’s FDA
approval for the treatment of
hyperactivity in children, the same
marketing techniques that had been so
successful with other drugs were applied
to the new amphetamine. Pharmaceutical
companies had a vested interest in the
increase in sales; they spared no
expense in convincing physicians to
prescribe them. Cash payments, stock
options, paid junkets, no-work
consultancies, and other inducements
encouraged physicians to relax their
natural caution about medicating
children. Parents also were targeted.
For example, CIBA, the maker of Ritalin,
made large direct payments to parents’
support groups like CHADD (Children and
Adults with Attention
Deficit/Hyperactivity Disorder) (The
Merrow Report 1995). To increase the
acceptance of stimulants, drug companies
paid researchers to publish favorable
articles on the effectiveness of
stimulant treatments. They also endowed
chairs and paid for the establishment of
clinics in influential medical schools,
particularly ones associated with
universities of international
reputation. By the mid 1970s, more than
half a million children had already been
medicated primarily for hyperactivity.
The brand of
psychiatry that became increasingly
popular in the 1980s and 1990s did not
have its roots in notions of normal
behavior or personality theory; it grew
out of the concrete, atheoretical
treatment style used in clinics and
institutions for the profoundly
disturbed. German psychiatrist Emil
Kraepelin, not Freud, was the God of
mental hospitals, and pharmaceuticals
were the panacea. So the whole
underlying notion of psychiatric
treatment, diagnosis, and disease
changed. Psychiatry, which had straddled
psychology and medicine for a hundred
years, abruptly abandoned psychology for
a comfortable sinecure within its
traditional parent discipline. The
change was profound.
People seeking
treatment were no longer clients, they
were patients. Their complaints were no
longer suggestive of a complex mental
organization, they were symptoms of a
disease. Patients were not active
participants in a collaborative
treatment, they were passive recipients
of symptom-reducing substances. Mental
disturbances were no longer caused by
unique combinations of personality,
character, disposition, and upbringing,
they were attributed to pre-birth
anomalies that caused vague chemical
imbalances. Cures were no longer
anticipated or sought; mental disorders
were inherited illnesses, like birth
defects, that could not be cured except
by some future magic, genetic bullet.
All that could be done was to treat
symptoms chemically, and this was being
done with astonishing ease and
regularity.
In many ways,
children are the ideal patients for
drugs. By nature, they are often passive
and compliant when told by a parent to
take a pill. Children are also generally
optimistic and less likely to balk at
treatment than adults. Even if they are
inclined to complain, the parent is a
ready intermediary between the physician
and the patient. Parents are willing to
participate in the enforcement of
treatments once they have justified them
in their own minds and, unlike adults,
many kids do not have the luxury of
discontinuing an unpleasant medication.
Children are additionally not aware of
how they ought to feel. They adjust to
the drugs’ effects as if they are
natural and are more tolerant of side
effects than adults. Pharmaceutical
companies recognized these assets and
soon were targeting new drugs
specifically at children.
But third-party
insurance providers balked at the surge
in costs for treatment of previously
unknown, psychological syndromes,
especially since unwanted drug effects
were making some cases complicated and
expensive. Medicine’s growing prosperity
as the purveyor of treatments for mental
disorders was threatened, and the
industry’s response was predictable.
Psychiatry found that it could meet
insurance company requirements by
simplifying diagnoses, reducing
identification to the mere appearance of
certain symptoms. By 1980, they had
published all new standards.
Lost in the process
was the fact that the redefined
diagnoses (and a host of new additions)
failed to meet minimal standards of
falsifiability and
differentiability. This meant that
the diagnoses could never be disproved
and that they could not be indisputably
distinguished from one another. The new
disorders were also defined as lists of
symptoms from which a physician could
check off a certain number of hits like
a Chinese menu, which led to
reification, an egregious
scientific impropriety. Insurers,
however, with their exceptions
undermined and under pressure from
parents and physicians, eventually
withdrew their objections. From that
moment on, the treatment of children
with powerful psychotropic medications
grew unchecked.
As new psychotropics
became available, their uses were
quickly extended to children despite, in
many cases, indications that the drugs
were intended for use with adults only.
New antipsychotics, the atypicals,
were synthesized and marketed beginning
in the 1970s. Subsequently, a new class
of antidepressants like Prozac and
Zoloft was introduced. These drugs were
added to the catalogue of childhood drug
treatments with an astonishing
casualness even as stimulant treatment
for hyperactivity continued to burgeon.
In 1980,
hyperactivity, which had been
imprudently named “minimal brain
dysfunction” in the 1960s, was renamed
Attention Deficit Disorder in order to
be more politic, but there was an
unintended consequence of the move.
Parents and teachers, familiar with the
name but not always with the symptoms,
frequently misidentified children who
were shy, slow, or sad (introverted
rather than inattentive) as suffering
from ADD. Rather than correct the
mistake, though, some enterprising
physicians responded by prescribing the
same drug for the opposite symptoms.
This was justified on the grounds that
stimulants, which were being offered
because they slowed down hyperactive
children, might very well have the
predicted effect of speeding up
under-active kids. In this way, a whole
new population of children became
eligible for medication. Later, the
authors of DSM-III memorialized this
practice by renaming ADD again, this
time as ADHD, and redefining ADD as
inattention. Psychiatry had reached a
new level: they were now willing to
invent an illness to justify a
treatment. It would not be the last time
this was done.
In the last twenty
years, a new, more disturbing trend has
become popular: the re-branding of
legacy forms of mental disturbance as
broad categories of childhood illness.
Manic depressive illness and infantile
autism, two previously rare disorders,
were redefined through this process as
“spectrum” illnesses with loosened
criteria and symptom lists that cover a
wide range of previously normal
behavior. With this slim justification
in place, more than a million children
have been treated with psychotropics for
bipolar disorder and another 200,000 for
autism. A recent article in this
magazine “The Bipolar Bamboozle” (Flora
and Bobby 2008) illuminates how and why
an illness that once occurred twice in
every 100,000 Americans, has been recast
as an epidemic affecting millions.
To overwhelmed
parents, drugs solve a whole host of
ancillary problems. The relatively low
cost (at least in out-of-pocket dollars)
and the small commitment of time for
drug treatments make them attractive to
parents who are already stretched thin
by work and home life. Those whose
confidence is shaken by indications that
their children are “out of control” or
“unruly” or “disturbed” are soothed by
the seeming inevitability of an
inherited disease that is shared by so
many others. Rather than blaming
themselves for being poor home managers,
guardians with insufficient skills, or
neglectful caretakers, parents can find
comfort in the thought that their child,
through no fault of theirs, has
succumbed to a modern and widely
accepted scourge. A psychiatric
diagnosis also works well as an
authoritative response to demands made
by teachers and school administrators to
address their child’s “problems.”
Once a medical
illness has been identified, all
unwanted behavior becomes fruit of the
same tree. Even the children themselves
are often at first relieved that their
asocial or antisocial impulses reflect
an underlying disease and not some flaw
in their characters or personalities.
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