Why are so many poor kids taking risky psychiatric medications? A front-page story in Tuesday’s New York Times offers one surprising answer: some pediatricians are prescribing drugs — medications to treat ADHD — to try to boost kids’ grades and give the most disadvantaged students an edge in school.
Unfortunately, however, while well-intentioned, such prescribing may ultimately do more harm than good, as the Times’ Alan Schwarz illustrates in his story about Dr. Michael Anderson, a Georgia pediatrician, and some of his young patients.
Although A.D.H.D is the diagnosis Dr. Anderson makes, he calls the disorder “made up” and “an excuse” to prescribe the pills to treat what he considers the children’s true ill — poor academic performance in inadequate schools.
“I don’t have a whole lot of choice,” said Dr. Anderson, a pediatrician for many poor families in Cherokee County, north of Atlanta. “We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”
While taking amphetamine-like drugs to improve academic performance is typically seen as a vice in richer children, Anderson considers it a virtue for poor kids, helping level the playing field. And there is little disagreement among child psychiatrists that lack of funding and resources means that giving drugs is often seen as the only option to help many children, even in cases where the evidence shows that talk therapies are not only safer but more effective.
But the story of some of Anderson’s patients should give pause to those who promote this approach. Schwarz interviewed the Rocafort family in Ball Ground, Ga., whose four children have received prescriptions for medication from Anderson. Quintn, 11, experienced harrowing side effects from the amphetamine Adderall, which he was prescribed starting around age 6 because of his disruptive behavior at school.
As Schwarz puts it:
When puberty’s chemical maelstrom began at about 10, though, Quintn got into fights at school because, he said, other children were insulting his mother. The problem was, they were not; Quintn was seeing people and hearing voices that were not there, a rare but recognized side effect of Adderall. After Quintn admitted to being suicidal, Dr. Anderson prescribed a week in a local psychiatric hospital, and a switch to [the antipsychotic medication] Risperdal.
Yet despite this extremely severe and dangerous turn of events — a previously healthy child winding up in a psychiatric hospital hallucinating and feeling suicidal — the Rocaforts continued to medicate Quintn and the rest of their children. Quintn’s twin brother is taking Risperdal, too, and despite Quintn’s experience with Adderall, the Rocaforts give it to their 12-year-old daughter, Alexis, and 9-year-old son, Ethan, despite insisting that they don’t actually have ADHD (according to Anderson, however, who checked the children’s charts, the Rocaforts had marked a five out of five on nearly every item on a parent questionnaire assessing their children’s severity of behaviors associated with ADHD):
The Adderall is merely to help their grades, and because Alexis was, in her father’s words, “a little blah.”
“We’ve seen both sides of the spectrum: we’ve seen positive, we’ve seen negative,” the father, Rocky Rocafort, said. Acknowledging that Alexis’s use of Adderall is “cosmetic,” he added, “If they’re feeling positive, happy, socializing more, and it’s helping them, why wouldn’t you? Why not?”
There are many possible reasons. For one, the side effects of drugs like Adderall include growth suppression, raised blood pressure, possible increases in heart attack and stroke risk and, rarely, psychosis. (In 2005, Canada briefly banned the extended-release form of Adderall because of 20 deaths, 14 of them in children, but it was put back on the market and never pulled in the U.S. because the connection between the deaths and drug was not clear.) The treatment of children with stimulant drugs for ADHD has also raised concerns about risks of later drug misuse and addiction. Although data suggest that it actually reduces or at least doesn’t increase this risk — children with genuine ADHD are already at higher risk of later drug problems — much of this data has been published by researchers with ties to stimulant manufacturers. Indeed, last year the researchers, from Harvard, were sanctioned by the university for failing to disclose large sums of money received from drug companies and for violating the school’s conflict of interest policies.
For children who don’t have ADHD but are taking stimulants simply to improve mood and grades, the risks of later drug abuse would intuitively seem far higher, but there is no data on the question.
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As for antipsychotic drugs like Risperdal, the harms are much clearer. Risperdal’s maker, Johnson & Johnson, is involved in a $2 billion settlement with the government for hiding data on the serious harms the drug can cause and for promoting it for children despite lack of evidence of benefit. Data show that the drug typically causes weight gain of 5 lbs. to 13 lbs. and increases the risk of diabetes by 50%. It is linked with increased risk for heart disease, stroke and sudden death. Because of its effects on a hormone called prolactin, it can cause some teenage boys and men to grow breasts.
“I’m almost speechless,” says the normally loquacious Dr. Bruce Perry, a leading expert in child trauma who has spent much of his career working with poor children, regarding the Times story. [Full disclosure: Perry and I have written two books together.]
Perry notes that the potential for stimulants and antipsychotic medications to alter the development of key neural networks — especially those that affect the neurotransmitter dopamine and, therefore, the ability to feel excitement, desire and motivation — in children’s growing brains is “very real.”
For example, research in rats has shown that exposure to the ADHD medication Ritalin during adolescence not only reduces the enjoyment the animals derive from cocaine, but also lessens pleasure from sex and sugar. It is not known whether the same changes would occur in humans or, if so, whether such alterations would be large enough to cause the pleasurelessness and amotivation that often accompany depression. But the possibility alone suggests the wisdom of restricting use of the drugs only to the most severe cases in which other approaches have failed.
Further, Perry says, there’s little reason to support the use of the antipsychotic Risperdal in children with ADHD at all. “Quality data about the use of Risperdal for these problems is scant to nonexistent, while the known adverse effects of all of these medications are significant,” he says. “The balance between potential benefits versus potential risks does not seem to be in favor of this cavalier form of prescribing.
“It is sad that our field has deteriorated to the point where clinicians would essentially give up on therapeutic efforts that are enduring and much more likely to cause meaningful changes in the brains of developing children and retreat to the use of non-specific and questionable psychopharmacology,” Perry adds.
Poor children need better schools and less chaotic neighborhoods and homes. Perhaps the money from the $2 billion settlement with J&J can be directed toward providing the education, parenting training and therapy that could really make a difference. If drug companies are going to profit by fraudulently selling medications for use on vulnerable children, shouldn’t they be made to pay for treatment that would actually help them?