Debate on behavioral drugs and children

Childhood depression is believed to be increasing, based on the rising number of suicides among young people. In 2008, statistics showed that suicide was the third leading cause of death among people aged fifteen to twenty-four, and the sixth leading cause of death among five to fourteen year olds. In 2019, the US Centers for Disease Control and Prevention (CDC) reported that suicide was the second leading cause of death among people age ten to twenty-four for the year 2017, at 19.2 percent.

Antidepressants have been hailed as safe and effective miracle drugs that can cure depression, but critics argue that antidepressants are often given needlessly. Others maintain that depression should be treated by behavioral therapy instead of drugs, and many charge that antidepressants themselves can be responsible for suicides among children and adolescents.

Also increasing is the rate of attention-deficit hyperactivity disorder (ADHD), which makes it hard for children to control impulses or pay attention. Statistics show that more than 6 million children in the United States have been diagnosed with ADHD. Stimulants have been found to have a converse effect in ADHD sufferers, calming them down and helping them to focus. The best-known stimulant is Ritalin; others include Strattera and Adderall. These medications have been given to children as young as fifteen months.

While all experts agree that depression and ADHD must be treated, many are cautious about drug treatment. These critics argue that behavior drugs are often prescribed for children "off-label," meaning that the medications have been approved for adults and older children, but have not been tested for younger ones.

In recent years, the United States Food & Drug Administration (FDA) has mandated warning labels for drugs such as Prozac, Paxil, and Zoloft, to inform doctors and patients of the danger of increased suicidal thoughts in children and adolescents taking these medications. The FDA advisory panel has also recommended a label warning that ADHD drugs can cause heart problems in some patients.

Understanding the Discussion

Attention-Deficit Hyperactivity Disorder (ADHD): Children with this condition have intense, sustained difficulty paying attention and/or controlling their behavior.

Monoamine Oxidase Inhibitors (MAOI): Antidepressants in this category block the activity of monoamine oxidase, the enzyme in nerve cells that breaks down neurotransmitters.

Neurotransmitters: Nerve cells communicate using neurotransmitters, chemicals in the brain that travel from one nerve cell to another, across the synapse (a tiny gap between the cells). An imbalance or lack of neurotransmitters in the synapse is associated with depression. Types of neurotransmitters include dopamine, norepinephrine and serotonin.

Psychotherapy: The process of treating mental and emotional problems with professional counseling, as in cognitive behavioral therapy (CBT) or interpersonal therapy (IPT).

Reuptake: The process by which a receiving nerve cell releases the neurotransmitter back into the synapse, where it is taken up again by the sending cell.

Ritalin: Common name for the stimulant methylphenidate hydrochloride, used to treat ADHD.

Selective Serotonin Reuptake Inhibitors (SSRI): Antidepressants that work to keep serotonin active in the synapse longer.

Tricyclics: These antidepressants are given to inhibit the reuptake of both serotonin and norepinephrine and possibly other neurotransmitters.

History

Both critics and supporters of behavior drugs agree on the importance of treating depression and ADHD in children to prevent serious, and possibly lifelong, harm. But there is wide disagreement on what type of treatment is effective or even safe.

Until the 1990s, it was believed that children and adolescents were not emotionally mature enough to suffer true depression. New drugs as Prozac, developed in 1989, appeared to be much safer than the earlier tricyclic antidepressants, so doctors began prescribing them widely, and soon began prescribing them for off-label use by teens and younger children.

Since then, the use of antidepressants among children, adolescents, and even infants has increased. Critics maintain that medicating such young children is one example of widespread over-prescribing. Further, they worry that many prescriptions are written by medical doctors without psychiatric consultation or treatment. From 1996 to 1998, the number of prescriptions written by non-psychiatrists doubled, while those written by psychiatrists increased by only 18 percent.

Mental health experts maintain that nobody should ever be given behavior drugs without psychotherapy. In fact, some advocate a no-drug approach, preferring cognitive behavioral therapy or interpersonal therapy alone. In addition, critics are concerned because these medications have not been thoroughly tested for children.

Some mental health critics also reject the entire theory of depression as a biological disease. Drugs, they assert, treat only the symptoms; they are not a cure for the problem that caused the depression. Each depression is individual, they argue, so a single drug cannot be generally effective. These critics tend to consider the whole idea of antidepressants as a marketing ploy rather than a source of real help.

In addition, critics of drug therapy argue that even the best antidepressants have unpleasant and even dangerous side effects which can cause lasting damage. Many violent crimes, say some experts, are committed not by depressed people, as reported in the media, but by people under the mind-altering influence of antidepressants.

What is now called ADHD was first described in 1845 by Dr. Heinrich Hoffman, whose son exhibited typical hyperactive behavior. Sir George F. Still undoubtedly relieved the minds of many parents in 1902, when he published a series of lectures on children with behavioral problems that were caused by organic dysfunction rather than by poor parenting. Thousands of scientific papers have been written on the subject since.

While often ADHD appears in early childhood, 70–80 percent of children with the disorder continue to suffer as teens, and 60 percent continue to experience symptoms of the disorder into adulthood. ADHD is often associated with other problems, such as learning disabilities, depression and bipolar disorder. Left untreated, ADHD can increase the risk of other problems, such as substance abuse. As with depression, neurotransmitters are involved.

Proponents of Ritalin, which has been in use for fifty years, maintain that the medication is safe, its side effects are minor and it can prevent later drug abuse. Critics complain that giving children an amphetamine-like substance sends a message that contradicts anti-drug warnings. They also worry about the long-term effects of such strong medication, even if it is necessary. The drugs used to treat ADHD, they point out, have numerous known side effects, including loss of appetite, insomnia and stunted growth. Furthermore, the drugs have not been thoroughly tested for very young children. Even with these problems, Ritalin has been given to children as young as fifteen months.

Most specialists agree that true ADHD is a medical problem and requires medication. The major concern is that many children may be incorrectly diagnosed and given drugs for trivial behavior problems or for problems resulting from trauma such as sexual abuse.

Additionally, many specialists are concerned that physicians prescribe ADHD medications alone, as is often done with antidepressants. The US National Institute of Mental Health (NIMH) reports that combined treatment with drugs and behavioral therapy works best. Combined treatment also often means that drug dosages can be reduced.

In the twenty-first century, FDA actions have added fuel to the debate over behavior drugs and children. In 2005, the FDA mandated warning labels for SSRIs cautioning doctors and patients of the dangers posed to children and adolescents taking Prozac, Zoloft, Paxil, and other drugs. It further recommended that one of the SSRIs, paroxetine (Paxil), not be used for children and adolescents at all. At the same time, the FDA maintains that adolescents can benefit substantially from antidepressants, under careful observation. Only Prozac has been approved for use by children as young as eight. In 2009, Lexapro became FDA-approved for the treatment of depression in individuals ages twelve to seventeen. Most prescriptions for younger children are off-label.

Critics worry about physical and mental problems, such as antisocial and violent behavior, that they say are side effects of antidepressants. At the same time, many parents have become active in opposing ADHD medications. Hundreds of popular books have been written on the subject, warning against hasty diagnosis for children who are simply highly energetic. Critics contend that most of the behavior labeled ADHD actually results from medical conditions, the tensions of modern life, or trauma.

Proponents of drug therapy argue that no study has yet provided convincing evidence that Ritalin causes addiction. Critics, however, say that studies show the use of Ritalin leads to addictive behavior such as smoking. Also, they point out that there have been no studies of the long-term effects of ADHD medications.

Some critics, including medical experts, do not believe that ADHD even exists. The American Medical Association (AMA), on the other hand, charges that groups such as Scientologists have inflamed the debate with colorful public relations campaigns. Critics of ADHD medication were given a boost in late 2006 when an FDA advisory panel recommended that medications for ADHD include a "black-box’ label, the strongest warning, that the drugs present a cardiac risk to some patients.

Behavior Drugs & Children Today

According to the Wall Street Journal, 25 percent of children in the United States were on prescribed medications by the 2010s. Debate on the issue of behavior drugs and children continued through the decade, with various studies lending to support to one side or the other.

Opponents of medicating children for behavioral issues continue to argue that the side effects of popular drugs often outweigh the benefits, especially in young people whose bodies and minds are still developing. They warn that even as research progresses, studies of the long-term effects of behavioral drugs remain largely unknown, and that rising rates of diagnosis reflect ever-increasing pressure on children and their parents to achieve unrealistic standards. Many experts have called for greater attention to factors such as sleep hygiene and heightened screen time that may affect children's behavior before immediately prescribing medication. Fears of the overmedication of children became widespread, and government agencies such as the CDC joined in calls for parents to promote behavior therapy for their children before turning to drugs.

In contrast, proponents of using behavior drugs for children continue to cite the potential quality of life improvement medication can bring to those with conditions such as ADHD or depression. They also suggest that public concerns over the overmedication of children are often played up by the media and not backed up by statistical evidence. For example, a study from the Columbia University Irving Medical Center (CUIMC) published in Journal of Child and Adolescent Psychopharmacology in 2018 found that, despite popular belief, stimulants and antidepressants were not prescribed to children or adolescents at a higher rate than the rate of diagnosis for the conditions they were meant to treat. In fact, the researchers found that some medications may be underprescribed at the population level, based on the steadily growing number of young people diagnosed with psychiatric disorders.

These essays and any opinions, information, or representations contained therein are the creation of the particular author and do not necessarily reflect the opinion of EBSCO Information Services.

Bibliography

Books

Berlinger, Norman T. Rescuing Your Teenager from Depression. New York: Harper Resource, 2005. Print.

Mayes, Rick, Catherin Bagwell, and Jennifer Erkulwater. Medicating Children: ADHD and Pediatric Mental Health. Cambridge: Harvard UP, 2009. Print.

Mondimore, Francis Mark. Adolescent Depression: A Guide for Parents. A Johns Hopkins Press Health Book. 2nd ed. Baltimore: Johns Hopkins UP, 2015. Print.

Periodicals

Arnold, L. Eugene. "New Attention Deficit/Hyperactivity Disorder Medication Options: Advances in Long-Term Treatment for a Chronically Impairing Condition." Current Medical Literature: Pediatrics 20.1 (Mar. 2007): 1–8. Academic Search Premier. Web. 22 June 2009. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=24910243&site=ehost-live.

Cha, Ariana Eunjung. "CDC Warns that Americans May Be Overmedicating Youngest Children with ADHD." The Washington Post, 3 May 2016,www.washingtonpost.com/news/to-your-health/wp/2016/05/03/cdc-warns-that-americans-may-be-overmedicating-two-to-five-year-olds-with-adhd/. Accessed 26 Aug. 2019.

Clavenna, Antonio, and Maurizio Bonati. "Safety of Medicines Used for ADHD in Children: A Review of Published Prospective Clinical Trials." Archives of Disease in Childhood 99.9 (2014): 866–72. Print.

Comstock, Edward J. "The End of Drugging Children: Toward the Genealogy of the ADHD Subject." Journal of the History of the Behavioral Sciences 47.1 (2011): 44–69. Print.

D’Agostino, Ryan. "The Drugging of the American Boy." Esquire Apr. 2014: 120–30. Print.

Isaacson, Goran, and Charles Rich. "Antidepressant Drugs and the Risk of Suicide in Children and Adolescents." Pediatric Drugs 16.2 (2014): 115–22. Academic Search Complete Web. 9 Nov. 2015. http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=95006817.

Kozel, Maggie. "Little Pharma: The Medication of U.S. Children." Huffington Post. TheHuffingtonPost.com, 5 Feb. 2011. Web. 9 Nov. 2015. http://www.huffingtonpost.com/maggie-kozel-md/childrens-health-care%5Fb%5F803167.html.

Mathews, Anna Wilde. "So Young and So Many Pills." Wall Street Journal. Dow Jones, 28 Dec. 2010. Web. 9 Nov. 2015. http://online.wsj.com/article/SB10001424052970203731004576046073896475588.html.

"Psychiatric Medications Are Not Overprescribed for Kids, Finds Study." ScienceDaily, 29 Jan. 2018,www.sciencedaily.com/releases/2018/01/180129181419.htm. Accessed 26 Aug. 2019.

"Psychiatric Medications for Children and Adolescents." Brown University Child and Adolescent Behavior Letter 21.9 (2005): 9–10. Academic Search Premier. Web. 22 June 2009. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=18577222&site=ehost-live.

Rosenberg, Martha. "Should Children Be on These Medications?" Huffington Post. TheHuffingtonPost.com, 26 Feb. 2011. Web. 9 Nov 2015. http://www.huffingtonpost.com/martha-rosenberg/children-on-medication-%5Fb%5F820680.html.

Southammakosane, Cathy, and Kristine Schmitz. "Pediatric Psychopharmacology for Treatment of ADHD, Depression, and Anxiety." Pediatrics 136.2 (2015): 351–59. Academic Search Complete Web. 9 Nov. 2015. http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=108846453.