The practice of medicating children with large doses of toxic and potentially dangerous drugs in response to questionable diagnoses is an international scandal that endangers these vulnerable clients and their long term best interests.

money pillThe Mental Health Capital of a society is enhanced by its equality of opportunity across social groupings, cultural diversity, creative responses to need, levels of support offered, engagement levels in sport or cultural activities and lower levels of use of psychotropic medications.

Due to the risk of harm to our collective mental health capital the time is right to challenge the exponentially growing practice of medicating our children. They are now regularly being prescribed drugs for displaying behaviors and thought processes that, until recently, would have fallen within the normal range as defined by our shared expectations as a society.

The increasing pathologisation of normal responses to often demanding situations for children is, in my view, insidious and pervasive, and threatens to produce a collective societal shift of perspective about childhood, which can only be detrimental in the longer term to our shared ‘ethos’ and values.

There is no definition of a mental disorder. I mean, you just can’t define it.

-Dr. Allen Frances, Editor-in-chief of DSM IV.

 My central thesis, which is shared by an increasing number of prominent academics, educationalists, many disillusioned parents and politicians of all parties is that over the last twenty years there has been a totally unhealthy business alliance forged between pharmaceutical companies, some key researchers and some pediatric medical practitioners to deliberately colonise this region of our common experience purely for financial gain. Questionable pecuniary relationships have been exposed by the work of Dr. Lisa Cosgrove in 2009, who demonstrated conclusively that 70% of the members of the panel members who determined the new diagnostic manual DSM-5 were being paid up to $10,000 (the new reduced maximum amount allowed by law) from the drug manufacturers.

This concerted and driven financial vehicle or business model has been expanding in its remit to meet the ever-widening spectrum of conditions that are felt by the pharmaceutical multinational corporations to warrant medication. There are indeed some prophetic stories of how ailing drug companies have systematically turned round the profitability of their companies by focusing their marketing and advertising machines on such psychotropic drugs as amphetamines, anti-depressants and anti-psychotics for the child market, seeing children as a ‘market expansion opportunity.’ This dangerous profit cycle was illustrated recently by the class action in the U.S. against the manufacturers of Respirdal, an anti-psychotic which is commonly used for treating children with autism. The successful case for criminal injury led to a record payout for liability of $2.3 Billion. It is only one of an increasing number of cases where research was hidden that had indicated potential harm from the psychotropic drug concerned (i.e. boys developing breasts and increased risk of suicide). The financial gains of this expansionism into childhood on a colossal scale is clearly worth the calculated risks of such expensive law suits for hiding research data.DSM-5 Pill

This is not some whacky conspiracy theory, but the current reality as recognised by such august bodies as the USFDA Drug Safety Committee, whose chair Peter Gross in 2006 stated,

It has become clear that drugs are being overused with children.

This issue is particularly relevant at a time of financial crisis, as companies will be desperately looking for pastures new and expanding markets for their products available to treat a plethora of normal psychological conditions such as temporary sleep problems, mild social anxiety, shyness, some excitability of thought processes, temporary mood swings and some need for stimulation. These surely fall within the range that all of us should be creatively dealing with, and not necessitate expensive advertising campaigns to convince us otherwise of the high medication levels that would follow.

These drug companies are indeed in a financially mutually beneficial relationship with all the major stakeholders in this scenario; that is, the researchers, the medical practitioners, the state and indirectly through that to the parents by the payment of such benefits as Disabled Living Allowance. One has to question the ethical stance of key researchers in the field who have produced questionable checklists that claim to have clinically diagnostic potential, when those same researchers are receiving considerable payments for being on the advisory boards of the drug manufacturers that produce the very drugs recommended for these clinical conditions.

One eminent Harvard professor, who has been one of the most active evangelists for the use of amphetamines on children and the diagnosis of juvenile bipolar disorder, was shown by a Congressional inquiry in 2008, led by Senator Charles Grassley to have received $1.6 million for consulting fees, but only declared $200,000 to the university authorities for the period of 2000 to 2007 (New York Times, June 8th 2008). Four other senior academics, at least, have been exposed by the Inquiry to have had similar financial relationships with the drug manufacturers. The former researcher has also published articles in medical journals supporting the diagnostic use of such checklists as the Child Behavior Checklist (CBC) which is a widely used tool amongst health professionals for diagnosing ADHD, juvenile bipolar disorder, etc. Can the eminent professor’s endorsement of these checklists’ diagnostic efficacy be trusted in the light of his questionable financial practice and violations pertaining to conflict of interest with his research? Also the validity of such checklists must be questioned in terms of the small number of items used to identify ‘supposed’ childhood disorders (e.g. only six for ADHD including: fidgety in class and restless).

Even the ‘inventor’ of the term ADHD, Professor Leon Eisenberg, just shortly before his death said he regretted his role in promoting it as a condition, in an interview in the German newspaper Der Speigel, and stated

ADHD is a classic example of a fictitious disease.

It is quite easy to see why such high diagnosis rates might be inappropriately achieved in the population of children we know and professionally work with on a daily basis completing these checklists. Many doctors who have not had the rigorous training needed, that pediatricians and psychiatrists do receive, to prescribe these high-level classes of medication, also provide field trial information to drug companies in batches of 10 patients on a pro-forma designed by the drug company market researchers, for which they are financially rewarded very generously. Drug companies offer lavish conferences in exotic locations. For example, one consultant psychiatrist told me of a conference in Hawaii she had attended, with extensive ‘goody bags’ and free golf options, which she was aware were provided to oil the wheels of the drug companies’ sales machines. It has been common knowledge that there are considerable inducements given by the drug producers to medical professionals in the field. Professionals’ journals, in some countries are part or fully funded by the pharmaceutical companies, which must bring into question their impartiality. All of these dubious business practices are aimed at exponentially boosting sales of psychotropic drugs for children.

line graph When asked if this massive expansion of drugs was just about making money for Big Pharma, the British Psychiatrist Dr Joanna Moncrieff who is author of the much lauded The Myth of the Chemical Cure, published in 2009, replied,

 Psychiatrists push pills because it bolsters their status as doctors. Also governments have supported medical interventions like drugs because they look like simple solutions to otherwise complex and intractable problems. Also we live at a time when big business is very powerful, and governments are unwilling to reign it in.

The saddest element of this sick ‘trade triangle’ is that parents become seduced by the rationales being offered by professionals, especially if they are socially disadvantaged and are told they can benefit financially from one of the two levels of Disability Living Allowance payments, which are then approved by the same professionals. There are very few trade cycles in the modern world where all participants can be so generously rewarded, but we must not forget that the major driver in this process is the profitability of products and the market expansion of the drug companies. Surely investors and shareholders should be asking themselves questions about the ethics behind their drug companies’ marketing, and where their products are targeted.

For vulnerable children in particular, ‘chemically enslaving’ them and creating long-term dependency on drug treatment in turn boosts the massive profits of the drug producers, and so the profit cycle turns.

-Dave Traxson 2013

The statistics in this field are genuinely mind-boggling. According to DHS statistics, there has been a sixty-fold increase in the prescription rate for amphetamines for children in the decade leading to 2004 in the UK. Imagine the furor if there was a sixty-fold increase in the shipments of cocaine or heroin to the same young population in our towns. A similar surge also resulted in eight-and-a-half tons of amphetamines being consumed by young people in that year in the US. Again, one can visualise the ensuing headlines in national newspapers. A consensus is emerging amongst many professionals that enough is enough, and that whilst we can reasonably see that in the very short term, there are undoubtedly some benefits of medication for a few children, we should provide the purported ‘window for opportunity’ for change by using other social and psychological interventions in a very child-specific way. There are now clear long-term concerns about negative effects on anxiety levels, damage to working memory and even increases in Parkinson’s disease in long term users (Higgins, Scientific American, July 2009) as well as increasing concerns about the issues of long-term dependence. This could cause potential physical and psychological damage to broad swathes of the next generation of young people, not least because of increased toxicity levels at a crucial time of early brain maturation. One has to ask if the window of opportunity is being capitalised upon, and whether young people are still on medication at the end of a two-year period, the maximum recommended by The National Centre for Clinical Excellence (NICE).

Research on this question is desperately needed, as many young people are not given alternative interventions in this period as recommended by NICE. Evidence causing concern is mounting from many sources on this, not least from the young people’s own life stories, their close circle of friends and their disillusioned parents whom some of us work with regularly.

Severe adverse drug reactions such as major sleep disturbance, ‘Parkinsonian’ tremors, significant weight loss are commonly reported and sudden heart failure is an increasingly reported side effect in some studies, due to the over-stimulation of the heart by the drugs. For example, Peter Breggin in 2009 stated that any therapeutic effect is a direct result of the drugs’ toxicity, and that they can also inhibit growth and cause cerebral dysfunction. The range of side effects, as might be expected, is considerable and varies greatly in nature and severity depending on the combinations of psychoactive drugs given to young people. They range from loss of appetite and reduced affect at one end, through weight loss and major mood changes, to sudden death from the over-stimulation of the heart at the extreme, and thankfully very rare, end.

I was recently involved with a collaborative team of professionals including child psychiatrists, child clinical psychologists, school nurses, parents and parent partnership officers for local authorities to produce guidance for parents of children who may have ADHD. During this period and since, a range of professional colleagues raised several issues. A regular concern in some areas is that on the basis of parental checklist information only, prescriptions are being made out for this range of strong medications, often at high-dose levels. Of equal concern is that this data is often not triangulated, as it should be, with the views of the school staff. Indeed, in one study, in only 47% of cases did the prescribing doctor check the behavioural pattern existed in school prior to prescribing the medication concerned.

In one authority, a job lot of Connor’s Checklists parental forms were taken to another service’s child psychiatrist, and prescriptions were issued without seeing the children concerned, which is against published guidelines. In the  same period, in one extreme case a child was on maximum levels of Ritalin and a parent asked if their son could also be also prescribed an SRI anti-depressant. This was again done without the doctor seeing the young person concerned. One supervising senior psychiatrist was shocked when this information was shared with her saying it was a matter for the General Medical Council, the regulatory body in the U.K.

Prescribing ‘top up’ doses, given euphemistic names such as ‘a kickstart dose’ in the morning or a ‘booster dose’ at lunchtime, of quick-release Ritalin used for ADHD, when a child is already on a maximum dose of slow release Ritalin capsules, is also common in some areas of the country. This is somewhat confusing for other professionals as the outer casing of Concerta already has a proportionate dose of 41.

Ritalin with quick-release built into it. These additional unnecessary doses often mean the maximum dose is exceeded as stipulated in the manufacturer’s manual, which could significantly increase the risk of harm from the known side effects such as major sleep disturbance.

A key part of the process identified by NICE is regular six monthly monitoring of the child’s weight and response to the medication or any side effects. This is often not done, on the admission of the psychiatrists involved, due to reported shortages of manpower. Professor Tim Kendal, spokesperson for the Royal College of Psychiatrists stated in a BBC interview in 2011 that is there was a shortage of manpower then less prescriptions should be issued in order to guarantee the ability of teams to regularly monitor side effects. Also some practitioners are reported not to follow guidelines in relation to drug holidays at the end of the two years. Many child cases reported by colleagues have in their opinion clearly very high, if not clinical, levels of anxiety, which according to NICE guidelines, is a contra-indicator to treatment with Ritalin. Severe weight loss has been reported in many cases, which when not addressed as a matter of urgency led to further deterioration in one child’s health as a result of compromising her immune system.

One very worrying report from a parent told of a multiple prescription for high levels of Ritalin, an SRI anti-depressant and an anti-psychotic medication to aid relaxation. When the prescription was taken to the pharmacist after consultation he refused to issue the prescription, saying it was “life threatening.” The parent was advised to go back to the prescribing child psychiatrist and get it changed.

kid with pill A number of professionals have grave concerns about the principle of informed consent regarding medication, with some parents saying words to the effect that they don’t understand how they work, particularly the purported ‘paradoxical effect’, but they get their child to take it because they trust the prescribing doctor. This resonates with the famous Milgram experiment where subjects said,

I did it because the man in the white coat told me to.

Milgram’s seminal book, ‘Obedience To Authority – An Experimental View’ (1974), endorsed this strong socio-psychological phenomenon.

As professionals working within Children’s Services, our directors regularly tell us that our shared paramount duty is to ensure the well-being and safety of children. Some independent arbiters may consider that this vital principle has been breached in some of these illustrations.

As a trained conventional and social scientist, one issue I need to draw attention to is the seductive power of the scientific rationalist paradigm. Such have been the huge benefits of science to the world, and to all of us individually, that we take on board the potential benefits that scientific discoveries can bring, easing us into accepting other scientific breakthroughs. Perhaps we also need to use more common sense scientific enquiry methods to dispute the benefits of having 40% of young people being on long-term medication at some point in their early life, or an average figure of 12.5% being on them at any one time, which is currently the situation in America. If we choose not to follow the same route as our transatlantic cousins, we need to act soon and comprehensively to avert escalation of such dubious diagnoses.

From my  research enquiries it is shockingly apparent that even some creditable organisations such as Mind are predicting from the American data and diagnostic criteria that there will be up to 1 in 85 occurrence rates for this condition in this country. In reality, this would mean one or two children in every year group at a secondary school, which is an exponential increase in the levels of this condition that has been the norm for the last twenty years.

Autism is now also undergoing a massive expansion in diagnosis rates added to by the publication of the much broader criteria for it  in DSM-5 in May 2013. Dr Allen Frances feels this is the next fashionable diagnosis promoted by pressure groups and Big Pharma literature or adverts stating,

The most likely cause of the autism epidemic is that autism has become fashionable – a popular fad diagnosis.

What you can be sure of is that the drug companies are ahead of the game and are gearing up for their next massive market expansion into this new field of prescribing in children. We clearly need to reflect on and learn from our shared experience with Ritalin, and generalise our learning to these coming challenges so that we can work collaboratively and holistically as professionals to address children’s sometimes complex needs appropriately and creatively.

A significant variable is that more and more DSM-5 (Diagnostic and Statistical Manual of Mental Disorders – fifth edition) conditions are redefined as ‘spectrum conditions’, which enormously increases the numbers of young people identified as affected, thus automatically expanding the markets open to the pharmaceutical companies for sales. DSM-5, the main American diagnostic criteria at present, promotes a wider range of behavioral and mental health conditions. This has been achieved with the backing of the same researchers who produce the dubious checklists, funded in part by the drug companies. The lack of scientific rigor and validity of the assessments will result potentially in massive increases in diagnoses, much to the satisfaction of the drug manufacturers. Aided by the many ‘sweeteners’ that ‘oil the wheels’ of the drug production machine it is feared that this will lead to a exponential growth in prescribing behavior by pediatricians for children on these spectrums.

DSMS A crazy example of the new terminology is ‘sub-clinical normal variation autism’ which extends the definition of mental health problems clearly into the normal range and massively expands the ‘marketplace available for sales of these toxic products.Hopefully new guidance from NICE (National Institute for Health and Clinical Excellence) will in part clarify the new situation and mitigate against inappropriate diagnosis to some degree. Another tension exists between the Medical and Social Models of understanding human difference and conditions.Some practitioners are heavily wedded to one or the other with the extremes being that some see all problems as ‘within child’ clinical issues and others seeing them as social manifestations of their current circumstances and environment.

UK psychiatrist Dr. Joanna Moncrieff, mentioned above, author of The Myth Of The Chemical Cure: A Critique of Psychiatric Drug Treatment, also stated in the same interview,

Seeing psychiatric medications as treatments for disease misleads the public about how they actually work, and obscures their potential for abuse as tools of social control.

The reality is that the Medical and Social models are not mutually exclusive and by a balanced view of both real progress can be achieved by colleagues willingly crossing the professional boundaries to work creatively with each other  achieving Solution Focused outcomes for children.These will benefit the children avoiding the need for unnecessary compartmentalisation and labeling which can be a life long burden to the recipient.

Professor Peter Kinderman, head of the Institute of Psychology, Health and Society at the University of Liverpool, in an interview with the BBC in January 2013 described the pressures on the health system in the U.K. to use bio-medical approaches in the following way,

In current mental-health systems, diagnosis is often seen as necessary for accessing services. However, it also sets the scene for the misuse and overuse of medical interventions such as anti-psychotic and anti-depressant drugs, which have worrying long-term side-effects. Scientific evidence strongly suggests distressing experiences result not from “faulty brains,” but from complex interactions between biological, but more importantly, social and psychological factors.The diagnosis and the language of biological illness obscure the causal role of factors such as abuse, poverty and social deprivation. The result is often further stigma, discrimination and social exclusion.

Bitterest A final issue I think is pertinent at this time of economic crisis, is the likely swingeing cuts that are expected in all Public Services. In order to best protect our beloved National Health Service surely it is right to review the financial priority given to such contentious treatments as this in order that the savings from the reduced levels of funding are appropriately targeted to maximum areas of need. We surely have a personal, professional and collective responsibility to support such a review for our collective best interests.

Clearly as professionals working with these children, this complex issue causes us great concern, and many professionals feel a Government led review of this worrying practice needs to be undertaken, as a matter of continuing urgency, so we don’t blindly follow the aggressive Big Pharma business model so liberally here in the U.K.

“My position in this article was recently given a huge boost from an unexpected source, when Dr. Conners was speaking in a non triumphalist way at a key conference recently. He spoke, as the developer of the internationally lucrative checklist which is responsible for much of the subjectively based identification of ADHD, around the world. He noted, with alarm, that recent data from the Centers for Disease Control and Prevention show that the diagnosis had been made in 15 percent of high school-age children in the U.S. alone, and that the number of children on medication for the disorder had soared from 600,000 in 1990 to 3.5 million in 2013. He questioned the rising rates of diagnosis and called them “a national disaster of dangerous proportions.”

-Dave Traxson

http://www.nytimes.com/2013/12/15/health/the-selling-of-attention-deficit-disorder.html?ref=health&_r=1& 

Dave Traxson

About Dave Traxson

I am a Chartered Educational Psychologist (BPS),who has seen the questionable practice of over-diagnosis and prescription of psychotropic drugs for children, increase exponentially in my thirty year career. I am a member of the Division of Educational and Child Psychologists Committee of the British Psychological Society. Now is the time to appropriately challenge doctors in cases where psychologists have ethical concerns about the Emotional Wellbeing of the children with whom they work. This is supported by the Health Professionals Council "Duties as a Registrant."(2009) = "You must not do anything or allow someone else to do something that you may have good reason to believe will put the health or safety of a service user in danger." We all therefore have a "Duty of Care to be Aware" of these issues in the schools where we work and to discuss concerns with a linkworker there and with the prescribing doctor. The National Committees of the Association of Educational Psychologists and the Division of Educational and Child Psychology of the British Psychological Society actively support my position of raising concerns about the impact of psychotropic drugs on the Safeguarding of Children in the U.K. from the potential short and longer term physical and psychological harm. I believe this is a key issue in promoting wellbeing of children within a progressive society. I was pleased to contribute to the BPS response to the American Psychiatric Association's consultation on DSM-5 and the paper was called "The Future of Psychiatric Diagnosis," (BPS 2012.)