Are Psychiatric Disorders Over-diagnosed in Children? Are Medicines Over-prescribed? 13 Myths & Facts
(Originally appeared in Four Winds Hospital Mental Health News-Fall, ‘09)
Headlines scream that too many kids are taking Ritalin or Adderall or whatever the latest ADHD medicine du jour is. TV’s talking heads complain that we’re drugging our kids with Prozac, Zoloft and other “dangerous drugs.” But your child’s teacher recommends your child be “evaluated”-a code word that tells you to consider medicine. And mental health professionals tout medicine’s benefits. What’s a parent to do? Parents are understandably confused and frustrated. Are these medicines over- prescribed? If I consent to medicine, will my child become a statistic? If I don’t, am I withholding needed treatment? Let’s trash the myths and examine the facts. Myth #1 Children do not suffer with psychiatric disorders. Fact: While we like to think of childhood as a simple time, a bastion of happiness, it is not for all children. Research has shown that about 20% of children and adolescents have a psychiatric disorder and about half of these have a disorder which disables them. Myth #2 Psychiatrists invent psychiatric disorders at the drop of a hat. Fact: Psychiatric disorders are based on years of research and much debate. Even with all the research, are these disorders evolving concepts? Absolutely. Research is painstaking and takes years, so our understanding of these disorders changes slowly. Some doctors are more liberal in applying the criteria for a particular disorder and others more conservative. This can frustrate parents who receive different opinions from different physicians. Bipolar Disorder is a perfect example. What Bipolar Disorder looks like in children has been debated for the past decade or so. Some doctors apply a broader set of criteria and others a narrower set. The final word has yet to be determined. Myth #3 When I was a boy, nobody had these disorders.
Fact: When I was a boy, children had these disorders, they simply were not recognized or the kids were labeled “bad seeds” and the like. Truth is, if I look back to elementary school, even decades later, I can pick out at least some of the kids who would have been given a diagnosis today. Myth # 4 Psychiatric disorders are not real illnesses with real bad consequences. Fact: Psychiatric illnesses carry what doctors call significant morbidity and mortality. That is they can be debilitating and deadly. For example, 5-10% of depressed adolescents will commit suicide over the next 15 years. If your child’s doctor told you that there was a 5-10% chance that your child’s illness could be fatal before they were 30, you would not hesitate to pursue treatment aggressively. Other disorders, like Anxiety disorders, while less lethal, also adversely affect a child’s functioning. Some of my patients are unable to attend school, go to a friend’s house or even leave home because of anxiety. And, ADHD is associated with higher rates of Emergency Room visits, medical costs, traffic accidents among teens, cigarette smoking, early pregnancy, divorce, job changes, and dropping out of high school. While some of these risks are probably higher among youth with ADHD combined with certain other disorders, I’d say ADHD could be a fairly nasty disorder. Myth #5 Anyone can have a little bit of ADHD or OCD. Fact: We all have characteristics that make us who we are. Some of us are a bit more fidgety and others more slow moving. Some are fastidious and others are a mess. But, for those with a disorder, the characteristic has become a symptom, something that significantly interferes with the person’s life.
Myth #6 Psychiatric disorders are caused by bad parenting. Fact: Parenting has an important and unique impact on child development, but children also come into the world with biological propensities and risks. For example, researchers at NYU showed that about 15% of children were characterized as being Slow to Warm. That is, when a stranger was present, they clung to their mothers, eyes open wide and saying nothing. Researchers at Harvard showed that similar children had faster heart rates and more dilated pupils during a problem solving task and that about 1/3 of them would go on to have Social Anxiety Disorder as teens. More recent research is demonstrating that a part of the brain called the amygdala is also different in children with anxiety disorders. Myth #7 More kids are using psychiatric medicine than ever before. Fact: Just want to keep you awake. That last one is actually a fact. Over the past 20 years, the number of prescriptions given to children and adolescents has increased considerably, perhaps 2, 3, or 4 times the rate in the 1980’s. But, the number of children using cell phones and laptops has also increased dramatically. Like these other innovations, other than Ritalin, most of the medicines used in child psychiatry were not around until the very late 1980’s or even later. Myth #8 Most kids today take a psychiatric medicine. Fact: The overwhelming majority of children do no take any of these medicines. National studies demonstrate that about 5% of children are given a prescription for a stimulant, such as Ritalin or Adderall. About 2% of children are treated with antidepressants. And about 1% or fewer are treated with other psychiatric medicines. Myth #9 Children become addicted to psychiatric medicines Fact: While some of the medicines used in psychiatry, such as stimulants, like Ritalin, or the anti-anxiety medicines, like Xanax, are addictive when used inappropriately, such as used at too high a dose, the responsible, physician-managed use of these medicines does not lead to addiction in children. In fact, research suggests that taking stimulants lowers the risk of drug and alcohol abuse among young people with ADHD. Myth #10 Never take a medicine that isn’t FDA approved for the condition you’re treating. Fact: The FDA approves of medicines for a specific age group and a specific condition. If the patient is not in that age group or does not have the specified condition, the use of the medicine is called “off-label.” Medicines are used off-label everyday by all physicians. This is legal and ethical. In fact, about 70% of all medicines (including non- psychiatric medicines) prescribed to children are off-label. A medicine can be very effective, but still off-label. For example, the use of the SSRI’s, such as Prozac, for anxiety disorders in children is off-label. There are many reasons a medicine might not have FDA indication for a specific disorder for a specific age group. But, over recent years, the government is trying to encourage pharmaceutical companies to research the use of medicines in children and apply for FDA approval for children. Myth #11 Never take a medicine that has the FDA’s Black Box warning!
Fact: A Black Box warning is the FDA’s strongest way of pointing out that a medicine has a certain risk. The FDA still approves of the use of the medicine for treating a specific age group with a particular disorder. Some of the side effects that are given black box warnings are rare. The specifics must be discussed with one’s physician. Myth #12 If medicine helps, it’s the only treatment my child needs. Fact: Research has shown that while medicine is effective for the treatment of ADHD and Depression, treatment with medicine combined with a behavioral treatment, such as Cognitive Behavioral Therapy (CBT), is more effective. For disorders such as Obsessive Compulsive Disorder, CBT has been shown to be at least equally effective as medicine and perhaps more effective in the long run. For OCD, a combination of these treatments seems best of all. Many parents also benefit from counseling that teaches them how to deal with their child’s difficulties, regardless of whether their child takes medicine. Myth #13 Too many children are taking medicines, like Ritalin and Prozac. Fact: Some children are given psychiatric medicine too quickly when another treatment might be indicated. For example, cognitive behavioral therapy should always be considered for children with anxiety disorders or Obsessive Compulsive Disorder. However, other children would benefit greatly from medicine and never receive it. For example, about half of children with ADHD are not treated with stimulants which could be very effective. In short, medicines are probably over prescribed to some and under prescribed to others. However, parents should be neither fearful, nor cavalier, about psychiatric medicine. Rather, with their physician, they must weigh the risks and benefits of medicine against those of other treatments and against those of not treating at all. Then, with their child in the balance, they will decide on the best course.
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