Summaries of recent articles
concerning the use of psychopharmacological agents:
Summary: The Effectiveness of Antidepressant
Medications: Results From a Major New Study, . Boren, J. J., The Behavior
Therapist, Vol. 30, No. 5, June 2007. This study was the largest trial of
antidepressant medications ever conducted, 35 million dollars was expended over
a 7 year period with 4000 outpatients enrolled in the Sequenced Treatment
Alternatives to Relieve Depression-STAR*D. The goal of the study was to
determine the effectiveness of several follow-up treatments for depressed
patients who had not responded well to a first course of antidepressant
treatment. One of the study's significant findings was that despite advertised
differing targets of reported brain-biochemical action (i.e., actions affecting
serotonin, dopamine, norepinephrine, gamma amino butyric acid levels), the study
found no difference in depression when medications affecting differing systems
were switched, i.e., they were all equally ineffective/effective. The
study reported a 28% chance of relief from depression following a single 3-month
course of an antidepressant drug (Celexa). 21 % of those who were deemed to have
not responded well to the initial course of treatment achieved relief, and 30%
of those who switched medications or augmented the dose of the initial
medication achieved relief. An estimated 43% to 50% gained remission when
both an initial and second course of treatment occur. An even larger number had
some improvement even though they did not reach the remission criterion. The
study concluded that these results could be good news for those suffering with
depression. However the author reported that there was no way of knowing if any
of the results were attributable to the antidepressant medications. Three other
factors were listed as possible causes of improvement other than response to
medication: (1) spontaneous recovery, i.e., many depressed patients recover on
their own, sometimes with the help of friends, exercise, books, and/or a
deliberate return to normal life activities; (2) large amounts of individualized
psychiatric and medical care patients received throughout the study;
(3)placebo. Separate studies have shown that as much as 82% of the
antidepressant drug effect is attributable to placebo effects, i.e., the
expectation of relief may cause relief. Many drug effect trials have not shown a
significant difference between placebos and antidepressants. The author
stated that it is impossible to tell what portion of the low remission rate was
attributable specifically to antidepressant medications. The author added, "the
pharmaceutical industry may be promoting misguided faith in the evidence
supporting a biological basis for depression." The author referred to "The Myth
of Depression as a Disease, by Leventhal and Martell (2006) which addresses the
issue of the nature of depression with a large array of evidence, which,
accordingly, points to depression not as a brain disease but rather a mood and
behavioral disorder resulting from adverse life situations. Within the proposed
non brain disease model, brain biochemistry may change as the result of the
individual's response to adverse life situations.
Summary: Do Antidepressant Medications Really
Increase Suicide Risk for Adolescents? Reflections on the FDA's Black Box
Warning, Mikula, L., Bronson, A., Reitman, D., The Behavior Therapist,
Vol. 30, No. 5, June 2007. Despite an FDA "Black Box" warning, the empirical
evidence concerning the likelihood that antidepressants increase suicide risk is
equivocal. The authors report a 25% decrease in the suicide rate for adolescents
10 to 19 years of age, between 1992 to 2001 which was accompanied by a sharp
increase in the prescription of antidepressants for this population. The authors
reported a 1% increase in the use of SSRIs among adolescents was associated with
a decrease of 0.23 suicides per 100,000 adolescents per year. The noted
association between reduced suicides and use of SSRIs may be coincidental as the
base rate for suicide is very low. The authors reviewed a study conducted at the
University of Colorado Health Sciences Center (UCHSC) where researchers
identified 24,119 adolescents diagnosed with depressions and/or receiving
antidepressant medications. The UCHSC research team concluded that treatment
with antidepressant medications (either SSRI or non-SSRI) did not result in a
statistically significant increased risk of suicidal attempts. The researchers
reported that adolescents who took anti-depressant medications for at least 6
months were less likely to attempt suicide. Increased risks of suicide attempts
was observed among adolescents with more sever depression however, and among
those who were younger at the time of diagnosis, and among females, and among
those residing within the Midwest or Western part of the US. The researchers
reported that factors such as severity of depression and gender may complicate
estimations of suicide risk for antidepressants. The authors reported a study
sponsored by NIMH, which was designed to evaluate the short and long term
effectiveness of four treatments for adolescents diagnosed with depression. The
research study group adolescents had not been taking antidepressants at the
inception of treatment, nor were they receiving psychotherapy. The authors
reported that based on their observations, the the research team recommended
combined treatment with fluoxetine and cognitive behavior therapy (CBT). CBT was
found to be less effective than fluoxetine, and CBT was not superior to a
placebo pill. Significantly, fluoxetine did not appear to increase risk of
suicidal ideation. However, fluoxetine did appear to increase the risk of
"harm-related adverse events" among depressed adolescents treated with
fluoxetine. The addition of CBT to treatment with fluoxetine appeared to reduce
the likelihood of "harm-related events." The authors report that the lower level
of response to CBT as opposed to findings in other studies may have been due to
greater severity, chronicity and comorbidity in this study's trial participants.
A general decrease in suicidal thinking was found in adolescents taking
fluoxetine. However, 15 of 216 adolescents taking fluoxetine (6.94%) had a
"suicide-related event" such as making a suicide attempt or threat as compared
to 9 of the 223 receiving a placebo pill (4.04%). In a separate trial, the FDA
was reported to have found that twice as many adolescents (4%) receiving
fluoxetine had suicidal ideation or behavior including attempts among the nearly
2200 children as opposed to those receiving placebo pills. No completed suicide
attempts were reported in either study. The authors conclude, " it is extremely
difficult to determine whether or not SSRIs increase the risk of completed
suicide." Additionally, the authors reported that an individual's response to
medication cannot be predicted with confidence, nor can it be predicted on the
basis of the currently available research which individuals may be sensitive to
to the potentially adverse effects of an SSRI. There is some evidence that
SSRI's may increase the risk of of suicide attempts or threats, while other
studies do not reveal an increased risk. The use of SSRIs in adolescents and
children was recommended only with caution. The authors conclude that the FDA's
"Black Box Warning" regarding the use of SSRIs in adolescents and children is
appropriate. Mental health professionals providing treatment to children
receiving SSRIs are recommended to carefully note any indications of an adverse
reaction and report that data to the prescribing professional.
Summary: Antidepressants and
suicide, Harvard Medical School Mental Health Letter Vol. 24
No. 1, July 2007. In view of current research, pediatricians have
appropriately become more cautious about prescribing antidepressants for
children. Pediatricians are more likely to refer children with serious
depression to mental health professionals who appropriately are becoming more
cautious regarding antidepressants and the risk of suicide. The danger should
not be exaggerated as the incidence of contemplation of suicide among college
students (10%), as well as the incidence of attempted suicide (1%) is
significant. Antidepressant medications can make a significant contribution to
reducing the risk of suicide. All risks should be considered in planning for
patient care.
Summary: Preschool attention
deficit disorder, Harvard Medical School Mental Health Letter Vol.
24 No. 3, September 2007. Critics believe the ADHD diagnosis is overused and
drug therapy over recommended. The number of children attending preschool and
day care programs might be making excessive demands on young children for self
control and compliance with rules. Others are reported to believe that ADHD is
not diagnosed as often as it should be. The only two studies conducted in
pediatric clinics found that ADHD was not identified in preschool children even
if their parents were worried about their child's behavior. On the other hand
few children having behaviors consistent with ADHD are actually referred for a
mental health evaluation. It was recommended that the American Academy of Child
and Adolescent Psychiatry's recommendations be followed: "Be slow to make the
diagnosis and consider parent training and specialized day care before resorting
to stimulant drugs."
See:
October/November 2007 Scientific American Mind: "the power of good
therapy is in the lasting benefits that it bestows. As psychologists Hal
Arkowitz and Lilienfeld write in this issue's Facts and Fictions in Mental
Health, empirically supported options such as cognitive-behavior therapy
can create the kinds of positive brain changes associated with the use of
antidepressant medications. Talk therapy may offer other advantages over drugs
as well."
Drugs for ADHD 'not the answer'
November, 2007
From the BBC,
http://news.bbc.co.uk/1/hi/uk/7090011.stmhttp://news.bbc.co.uk/1/hi/uk/7090011.stm
Treating children who have Attention
Deficit Hyperactivity Disorder (ADHD) with drugs is not effective in the
long-term, research has shown.
A
study obtained by the BBC's Panorama program says drugs such as Ritalin and
Concerta work no better than therapy after three years of treatment.
The findings by an influential US study also suggested long-term use of the
drugs could stunt children's growth.
It said that the benefits of drugs had previously been exaggerated.
The
Multimodal Treatment Study of Children with ADHD has been monitoring the
treatment of 600 children across the US since the 1990s.
In
1999, the American study concluded that after one year medication worked better
than behavioural therapy for ADHD. This finding influenced medical practice on
both sides of the Atlantic, and prescription rates in the UK have since tripled.
But
now after longer-term analysis, the report's co-author, Professor William
Pelham of the University of Buffalo, said: "I think that we exaggerated the
beneficial impact of medication in the first study.
"We
had thought that children medicated longer would have better outcomes. That
didn't happen to be the case.
"There's no indication that medication's better than nothing in the long run."
Prof Pelham said there were "no beneficial effects" of medication and the impact
was seemingly negative instead.
"The
children had a substantial decrease in their rate of growth so they weren't
growing as much as other kids both in terms of their height and in terms of
their weight," he said.
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
3-year follow-up of the
NIMH MTA Study
August, 2007
Jensen et.al.
J Am Acad Child
Adolesc Psychiatry. 2007 Aug ;46 (8):989-1002 17667478
available online @
http://www.mdconsult.com/das/article/body/817210442/jorg=journal&source=MI&sp=&sid=/N/599375/s046p0989.pdf
(excerpts
below)
The 3-year follow-up
assessment focused on 5 important outcome domains: parent and teacher ratings of
ADHD and ODD symptoms, reading achievement scores, social skills, and functional
impairment.
In contrast to the results obtained at 14 and 24 months, significant benefits of
intensive medication management - either alone or in combination with behavior
therapy - were not found for any of the key outcomes.
In fact, participants
using medication in the 24- to 36-month period actually showed increased
symptomatology during that interval relative to those not taking medication.
Thus, 2 years after
treatment ended, children who received intensive treatment from MTA researchers
were not doing any better than those who had received routine community care
or behavior therapy.
Antidepressants Under Scrutiny
Over Efficacy
Sweeping Overview Suggests Suppression of Negative Data
Has Distorted View of Drugs
The effectiveness of a dozen popular
antidepressants has been exaggerated by selective publication of favorable
results, according to a review of unpublished data submitted to the Food and
Drug Administration.
As a result, doctors and patients are getting a distorted view of how well
blockbuster antidepressants like Wyeth's Effexor and Pfizer Inc.'s Zoloft
really work, researchers asserted in this week's New England Journal of
Medicine.
A total of 74 studies involving a dozen antidepressants and 12,564 patients
were registered with the FDA from 1987 through 2004. The FDA deemed 38 of
the studies to be positive. All but one of those studies was published, the
researchers said.
The other 36 were found to have negative or questionable results by the FDA.
Most of those studies -- 22 out of 36 -- weren't published, the researchers
found. Of the 14 that were published, the researchers said at least 11 of
those studies mischaracterized the results and presented a negative study as
positive.
For example, Pfizer submitted five trials on its drug Zoloft to the FDA, the
study says. The drug seemed to work better than the placebo in two of them.
In three other trials, the placebo did just as well at reducing indications
of depression. Only the two favorable trials were published, researchers
found, and Pfizer discusses only the positive results in Zoloft's literature
for doctors.
One way of turning the study results upside down is to ignore a negative
finding for the "primary outcome" -- the main question the study was
designed to answer -- and highlight a positive secondary outcome. In nine of
the negative studies that were published, the authors simply omitted any
mention of the primary outcome, the researchers said.
The 'Effect Size'
In this week's study, the researchers found that failing to publish negative
findings inflated the reported effectiveness of all 12 of the
antidepressants studied, which were approved between 1987 and 2004. The
researchers used a measurement called effect size. The larger the effect
size, the greater the impact of a treatment.
The average effect size of the antidepressant Zoloft rose 64% by the failure
to publish negative or questionable data on the drug, the researchers found.
Recent article in the Palm Beach Post
*******************************************************
Regarding Paxil and its effects upon pregnancy:
http://www.medicinenet.com/script/main/art.asp?articlekey=57323
http://bipolarblast.wordpress.com/2009/04/25/vogue-magazine/
http://www.lawyersandsettlements.com/blog/tag/paxil-and-pregnancy
Feds Recommend Warnings on ADHD Drugs
By ANDREW BRIDGES, Associated Press Writer
View PDF Version
WASHINGTON - Ritalin and other stimulant drugs for attention deficit
hyperactivity disorder should carry the strongest warning that they may be
linked to an increased risk of death and injury, federal health advisers said
Thursday.
The Food and Drug Administration advisory panel voted in favor of the "black
box" warning after hearing about the deaths of 25 people, including 19 children,
who had taken the drugs. The vote was 8-7, with one abstention. One committee
member, Dr. Curt Furberg, a professor of public health sciences at the Wake
Forest University Baptist Medical Center, said it would be "inappropriate,
unethical behavior" not to disclose that there was uncertainty about the safety
of the drugs.
The FDA is not required to follow the recommendations of its advisory
committees but typically does.
"The committee plainly wanted to tell us certain things ought to be in
labeling in a more forceful way," Dr. Robert Temple, director of the FDA's
Office of Medical Policy, told reporters after the meeting.
Doctors prescribe the drugs to about 2 million children and 1 million adults
a month. Drugs that would have to carry the warning labels are methylphenidates,
which are sold as Ritalin, Concerta, Methylin and Metadate. The labels for
Adderall and Adderall XR, both amphetamines, have included the warnings since
2004. The Drug Safety and Risk Management advisory committee also recommended
that the drugs include a medication guide for patients and parents. The vote was
15-0, with one abstention.
Adderall is made by Shire Pharmaceuticals; Ritalin by Novartis
Pharmaceuticals Corp.; Concerta by Johnson & Johnson; Methylin by Mallinckrodt
Pharmaceuticals; and Metadate by UCB. Various other companies make generic
versions of Ritalin. Novartis said Ritalin, approved by the FDA in 1955, is safe
and effective. A company review of more than 50 years of records shows no
apparent increase in cardiovascular problems associated with the drug's use,
according to Novartis' medical safety director, Dr. Todd Gruber.
He told the committee that the drug's label advises caution in patients with
certain pre- existing heart conditions.
The FDA had asked the advisers to consider ways of studying the drugs because
agency data suggested the drugs were linked to an increased risk of sudden death
and serious cardiovascular problems, including heart attacks.
The committee, however, quickly began debating whether it should consider new
warnings for the drugs rather than the need for more studies. Dr. Steve Nissen,
medical director of the Cardiovascular Coordinating Center at The Cleveland
Clinic, told fellow committee members they should recommend the black box
warning.
Nissen said his suggestion was meant partly to slow what he characterized as
the "out of control growth" use of the drugs.
The drugs already carry warnings related to the possible risk they could pose
to patients with heart defects.
"We feel this warning is appropriate given our current knowledge of these
drugs," said Dr. Gerald DalPan, a division director in the FDA's Center for Drug
Evaluation and Research.
The FDA review that found 25 reports of deaths among the drugs' users between
1999 and 2003 also uncovered 54 cases of serious cardiovascular problems,
including heart attack, stroke, hypertension, palpitations and arrhythmia. Some
of these ADHD drug- treated patients had pre-existing heart conditions or
hypertension.
"There's smoke. Does that mean there's fire?" asked Dr. David Graham, a
medical officer at the FDA's Center for Drug Evaluation and Research.
"We wouldn't be going through this exercise if we didn't think there was a
real possibility of increased risk," Graham told reporters.
The FDA's review found fewer than one reported death or life-threatening
injury for every 1 million prescriptions filled for the drugs.
"The decision has been apparently made, and if it's been made, I agree with
it, that the reports are not enough to warrant regulatory action," committee
member Sean Hennessy said.
Hennessy, an assistant professor of epidemiology and pharmacology at the
University of Pennsylvania School of Medicine, ended up voting against
recommending additional warnings.
The FDA said the few studies that have looked at longer-term use of ADHD
drugs provide little information on those risks.
Also, the agency's analysis of the reports of death and injury only suggests
a possible link between the drugs and cardiovascular problems, said Dr. Kate
Gelperin, a medical officer in the agency's Office of Drug Safety.
She said the link is not conclusive, nor is it clear whether there is an
increased incidence of death or serious injury among people treated with the
drugs.
That "is really a question we'd like to have answered," she said. Sales of
ADHD drugs rose to $3.1 billion in 2004 from $759 million in 2000, according to
IMS Health, a pharmaceutical information and consulting firm.
About 2.5 million children between age 4 and 17 take ADHD drugs, according to
federal survey data cited by Dr. Andrew Mosholder, a medical officer in the
Office of Drug Safety. The survey found 9.3 percent of 12-year-old boys and 3.7
percent of 11-year-old girls take the drugs, Mosholder said.
Adult use of the drugs alone grew 90 percent between March 2002 and June
2005, he said.
The following
portions were copied from the Harvard Mental Health Letter August 2011
"No
magic pill for autism spectrum disorders"
(snip)
Surveys indicate
that nearly half of children with autism spectrum disorders take some type of
psychiatric medication-most often antidepressants, antipsychotics, or
stimulants. Yet a recent federally funded study concluded that most of these
drugs aren't effective at treating symptoms of autism spectrum disorders.
Although estimates
vary, about one in 110 U.S. children has an autism spectrum disorder. (snip)
While autism spectrum disorders differ in some ways, they all cause impairment
in the ability to communicate, socialize, and build relationships. Individuals
with these disorders may also engage in ritualistic or repetitive behaviors like
constantly tapping their fingers or humming.
Early intervention
behavioral therapy, typically delivered at home or in school, forms the
foundation of treatment for autism spectrum disorders (see Harvard Mental
Health Letter, September 2010). Unfortunately these therapies are labor and
time-intensive, producing modest improvements at best. Parents and clinicians'
often desperate for additional options, have increasingly turned to medications
to alleviate symptoms such as aggression, irritability, and repetitive
behaviors, or to prevent children from injuring themselves.
(snip)
the U.S. Agency for
Healthcare Research and Quality asked investigators at the Vanderbilt University
Evidence-Based Practice Center to conduct a review of research on various autism
spectrum disorder treatments for children 12 and younger.
(snip)
The review found
that no medications improve social skills or communication ability in children
with autism spectrum disorders. Some drugs may modestly improve their behavior.
Antipsychotics.
In two studies of risperidone (Risperdal), for example,
investigators asked
parents to rate their children's behavior using a 48-point checklist (the higher
the score, the worse the behavior). Scores dropped an average of 12 to 15 points
in children treated with risperidone, compared with an average drop of 4 to 7
points in children assigned to placebo. Parents reported that risperidone also
reduced repetitive behavior and hyperactivity in their children. Two studies of
aripiprazole (Abilify) reported similar results.
Both antipsychotics
caused significant side effects, including weight gain, sedation, and
extrapyramidal symptoms (such as muscle stiffness or tremor). The Vanderbilt
reviewers recommended that risperidone and aripiprazole be used only when
children with autism spectrum disorders are severely impaired or at risk of
injuring themselves.
(snip)
The review concluded there is scant evidence that antidepressants help improve
behavior in children with autism spectrum disorders. And they identified only
one good quality randomized controlled study of methylphenidate (Ritalin) in
youths with autism spectrum disorders. Although this study found that the drug
reduced hyperactivity in participants, this benefit was offset by side effects
such as lethargy, social withdrawal, irritability, sleep problems, headaches,
and diarrhea.
(snip)
Most early
intervention therapies used in treating children with autism spectrum disorders
are based on the principles of applied behavioral analysis, which uses positive
reinforcement and other techniques to encourage behavior change. Although the
evidence is limited, studies suggest that high-intensity interventions (at least
30 hours a week for one to three years) improve children's language
skills, behavior, and thinking ability when compared with other (broadly
defined) community treatments. As such, behavioral interventions remain the best
choice for treating children with autism spectrum disorders.
(snip)
The hormone
secretin stimulates the secretion of digestive fluids. More than a decade ago,
case reports of three children with autism spectrum disorders who were given
secretin during medical procedures suggested that secretin improved thinking
ability and communication skills. However, the Vanderbilt reviewers examined
seven randomized controlled studies conducted since then and found that none of
them showed that secretin is helpful for children with autism spectrum
disorders. (An earlier review by the Cochrane Collaboration concluded the same
thing.) As such, there is no reason to use secretin-although some Web sites
still promote it.
McPheeters ML, et
al. "A Systematic Review of Medical Treatments for Children with Autism Spectrum
Disorders;' Pediatrics (May 20ll): Vol. 127, No.5, pp. e13l2-21.
Warren Z, et al. "A
Systematic Review of Early Intensive Intervention for Autism Spectrum
Disorders;” Pediatrics (May 20ll): Vol. 127, No.5, pp. e1303-11.
January 28, 2012
Ritalin Gone Wrong
By L. ALAN SROUFE
THREE million children in this country take drugs
for problems in focusing. Toward the end of last year, many of their parents
were deeply alarmed because there was a
shortage of drugs like Ritalin and Adderall that they considered
absolutely essential to their children’s functioning.
But are these drugs really helping children?
Should we really keep expanding the number of
prescriptions filled?
In 30 years there has been a twentyfold increase
in the consumption of drugs for attention-deficit disorder.
As a psychologist who has been studying the
development of troubled children for more than 40 years, I believe we should
be asking why we rely so heavily on these drugs.
Attention-deficit drugs increase concentration in
the short term, which is why they work so well for college students cramming
for exams. But when given to children over long periods of time, they
neither improve school achievement nor reduce behavior problems. The drugs
can also have serious side effects, including stunting growth.
Sadly, few physicians and parents seem to be aware
of what we have been learning about the lack of effectiveness of these
drugs.
What gets publicized are short-term results and
studies on brain differences among children. Indeed, there are a number of
incontrovertible facts that seem at first glance to support medication. It
is because of this partial foundation in reality that the problem with the
current approach to treating children has been so difficult to see.
Back in the 1960s I, like most
psychologists, believed that children with difficulty concentrating were
suffering from a brain problem of genetic or otherwise inborn origin. Just
as Type I diabetics need insulin to correct problems with their inborn
biochemistry, these children were believed to require attention-deficit
drugs to correct theirs. It turns out, however, that there is little to no
evidence to support this theory.
In 1973, I reviewed the literature on drug
treatment of children for The New England Journal of Medicine. Dozens of
well-controlled studies showed that these drugs immediately improved
children’s performance on repetitive tasks requiring concentration and
diligence. I had conducted one of these studies myself. Teachers and parents
also reported improved behavior in almost every short-term study. This
spurred an increase in drug treatment and led many to conclude that the
“brain deficit” hypothesis had been confirmed.
But questions continued to be raised, especially
concerning the drugs’ mechanism of action and the durability of effects.
Ritalin and Adderall, a combination of dextroamphetamine and
amphetamine, are stimulants. So why do they appear to calm children
down? Some experts argued that because the brains of children with attention
problems were different, the drugs had a mysterious paradoxical effect on
them.
However, there really was no paradox. Versions of
these drugs had been given to World War II radar operators to help them stay
awake and focus on boring, repetitive tasks. And when we reviewed the
literature on attention-deficit drugs again in 1990 we found that all
children, whether they had attention problems or not, responded to stimulant
drugs the same way. Moreover, while the drugs helped children settle down in
class, they actually increased activity in the playground. Stimulants
generally have the same effects for all children and adults. They enhance
the ability to concentrate, especially on tasks that are not inherently
interesting or when one is fatigued or bored, but they don’t improve broader
learning abilities.
And just as in the many dieters who have used and
abandoned similar drugs to lose weight, the effects of stimulants on
children with attention problems fade after prolonged use. Some experts have
argued that children with
A.D.D. wouldn’t develop such tolerance because their brains were somehow
different. But in fact, the
loss of appetite and
sleeplessness in children first prescribed attention-deficit drugs do
fade, and, as we now know, so do the effects on behavior. They apparently
develop a tolerance to the drug, and thus its efficacy disappears. Many
parents who take their children off the drugs find that behavior worsens,
which most likely confirms their belief that the drugs work. But the
behavior worsens because the children’s bodies have become adapted to the
drug. Adults may have similar reactions if they suddenly cut back on coffee,
or stop smoking.
TO date, no study has found any long-term benefit
of attention-deficit medication on academic performance, peer relationships
or behavior problems, the very things we would most want to improve. Until
recently, most studies of these drugs had not been properly randomized, and
some of them had other methodological flaws.
But in 2009, findings were published from a
well-controlled study that had been going on for more than a decade, and the
results were very clear. The study randomly assigned almost 600 children
with attention problems to four treatment conditions. Some received
medication alone, some cognitive-behavior therapy alone, some medication
plus therapy, and some were in a community-care control group that received
no systematic treatment. At first this study suggested that medication, or
medication plus therapy, produced the best results. However, after three
years, these effects had faded, and by eight years there was no evidence
that medication produced any academic or behavioral benefits.
Indeed, all of the treatment successes faded over
time, although the study is continuing. Clearly, these children need a
broader base of support than was offered in this medication study, support
that begins earlier and lasts longer.
Nevertheless, findings in neuroscience are being
used to prop up the argument for drugs to treat the hypothesized “inborn
defect.” These studies show that children who receive an A.D.D. diagnosis
have different patterns of neurotransmitters in their brains and other
anomalies. While the technological sophistication of these studies may
impress parents and nonprofessionals, they can be misleading. Of course the
brains of children with behavior problems will show anomalies on brain
scans. It could not be otherwise. Behavior and the brain are intertwined.
Depression also waxes and wanes in many people, and as it does so, parallel
changes in brain functioning occur, regardless of medication.
Many of the brain studies of children with A.D.D.
involve examining participants while they are engaged in an attention task.
If these children are not paying attention because of lack of motivation or
an underdeveloped capacity to regulate their behavior, their brain scans are
certain to be anomalous.
However brain functioning is measured, these
studies tell us nothing about whether the observed anomalies were present at
birth or whether they resulted from trauma, chronic stress or other
early-childhood experiences. One of the most profound findings in behavioral
neuroscience in recent years has been the clear evidence that the developing
brain is shaped by experience.
It is certainly true that large numbers of
children have problems with attention, self-regulation and behavior. But are
these problems because of some aspect present at birth? Or are they caused
by experiences in early childhood? These questions can be answered only by
studying children and their surroundings from before birth through childhood
and
adolescence, as my colleagues at the University of Minnesota and I have
been doing for decades.
Since 1975, we have followed 200 children who were
born into poverty and were therefore more vulnerable to behavior problems.
We enrolled their mothers during
pregnancy, and over the course of their lives, we studied their
relationships with their caregivers, teachers and peers. We followed their
progress through school and their experiences in early adulthood. At regular
intervals we measured their health, behavior, performance on intelligence
tests and other characteristics.
By late adolescence, 50 percent of our sample
qualified for some psychiatric diagnosis. Almost half displayed behavior
problems at school on at least one occasion, and 24 percent dropped out by
12th grade; 14 percent met criteria for A.D.D. in either first or sixth
grade.
Other large-scale epidemiological studies confirm
such trends in the general population of disadvantaged children. Among all
children, including all socioeconomic groups, the incidence of A.D.D. is
estimated at 8 percent. What we found was that the environment of the child
predicted development of A.D.D. problems. In stark contrast, measures of
neurological anomalies at birth, I.Q. and infant temperament — including
infant activity level — did not predict A.D.D.
Plenty of affluent children are also diagnosed
with A.D.D. Behavior problems in children have many possible sources. Among
them are family stresses like domestic violence, lack of social support from
friends or relatives, chaotic living situations, including frequent moves,
and, especially, patterns of parental intrusiveness that involve stimulation
for which the baby is not prepared. For example, a 6-month-old baby is
playing, and the parent picks it up quickly from behind and plunges it in
the bath. Or a 3-year-old is becoming frustrated in solving a problem, and a
parent taunts or ridicules. Such practices excessively stimulate and also
compromise the child’s developing capacity for self-regulation.
Putting children on drugs does nothing to change
the conditions that derail their development in the first place. Yet those
conditions are receiving scant attention. Policy makers are so convinced
that children with attention deficits have an organic disease that they have
all but called off the search for a comprehensive understanding of the
condition. The National Institute of Mental Health finances research aimed
largely at physiological and brain components of A.D.D. While there is some
research on other treatment approaches, very little is studied regarding the
role of experience. Scientists, aware of this orientation, tend to submit
only grants aimed at elucidating the biochemistry.
Thus, only one question is asked: are there
aspects of brain functioning associated with childhood attention problems?
The answer is always yes. Overlooked is the very real possibility that both
the brain anomalies and the A.D.D. result from experience.
Our present course poses numerous risks. First,
there will never be a single solution for all children with learning and
behavior problems. While some smaller number may benefit from short-term
drug treatment, large-scale, long-term treatment for millions of children is
not the answer.
Second, the large-scale medication of children
feeds into a societal view that all of life’s problems can be solved with a
pill and gives millions of children the impression that there is something
inherently defective in them.
Finally, the illusion that children’s behavior
problems can be cured with drugs prevents us as a society from seeking the
more complex solutions that will be necessary. Drugs get everyone —
politicians, scientists, teachers and parents — off the hook. Everyone
except the children, that is.
If drugs, which studies show work for four to
eight weeks, are not the answer, what is? Many of these children have
anxiety or depression; others are showing family stresses. We need to treat
them as individuals.
As for shortages, they will continue to wax and
wane. Because these drugs are habit forming, Congress decides how much can
be produced. The number approved doesn’t keep pace with the tidal wave of
prescriptions. By the end of this year, there will in all likelihood be
another shortage, as we continue to rely on drugs that are not doing what so
many well-meaning parents, therapists and teachers believe they are doing.
L. Alan Sroufe is a
professor emeritus of psychology at the University of Minnesota’s
Institute of Child Development.