Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Friday, April 18, 2008

Children, Adolescents and Mental Health Problems: Psychiatric Drug Cocktails Are not the Answer—Elizabeth Clarke

According to the National Institutes of Mental Health (NIMH), 1 in 10 children and adolescents in the United States suffers from mental illness serious enough to warrant psychiatric treatment (1). The most common diagnoses include Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum, Bipolar Disorder, Borderline Personality Disorder, Depression, Eating Disorders, and Schizophrenia (1). The prevalence of these diagnoses has increased markedly in recent years. Nationwide, the diagnosis and pharmaceutical treatment of bipolar disorder, for instance, has increased 40-fold over the last 10 years (2). The prevalence of severe, incapacitating psychiatric illnesses has tripled over the last ten years in the U. S. (3).
That the incidence of these diseases is increasing this rapidly is alarming but what is more concerning from a public health perspective is the widespread overuse and even abuse of psychiatric medications in treating these disorders. Drug-based interventions for psychiatric conditions are flawed and ineffective. These disorders are grounded in psychology, society and culture yet the current intervention approach does not consider the social and behavioral theories of public health.
Indeed, psychiatric drug interventions ignore the underlying psychological, social, and cultural roots of mental health problems in adolescents. Furthermore, pharmacologic treatments fall short in terms of their poor safety, sustainability, and comprehensiveness.
Drug Interventions stigmatize children and adolescents with mental health disorders.
Because pharmaceutical treatments are far from comprehensive, they are not sensitive to the emotions of adolescents and children with mental health disorders. Overlooking mental health patients’ feelings simply makes the problem worse, since many aspects of mental health deal with emotional health (4). Instead of addressing the disorders comprehensively, pharmaceutical interventions effectually label patients as “defective” and in need of drug treatment to remedy their problems. In this way, psychiatric drug interventions stigmatize the plight of children and adolescents who are suffering from mental health problems (4). In fact, recent data from the National Stigma Study-Children (NSS-C) indicates that many parents feel the psychiatric medication itself stigmatizes their children “delays solving ‘real’ behavior-related problems” (5).
Stigmatization of mental illness is proven to decrease an already low quality of life for children and adolescents suffering from mental health problems (6). One study found that people experiencing high degrees of stigmatization were seven to nine times more likely to have low self-esteem than those experiencing low degrees of stigmatization (7). Pharmaceutical treatment of child and adolescent mental health problems encourages stigmatization and is therefore a poor choice for treatment among children and adolescents.
Drug interventions do not empower children and adolescents.
Social cognitive theory emphasizes individual characteristics of self-efficacy, behavioral capability, expectations, and coping and reinforcement, context, and reciprocal determinism as environmental factors in health behavior (8). Children and adolescents who are prescribed psychiatric medications for their mental health problems are effectively being told that they cannot make progress without the pills they are prescribed. This is a tremendously discouraging message to send. Instead of empowering these children and adolescents with self-efficacy, drug treatments alone communicate a general sense of hopelessness and chemical dependency (3, 4). The result is that patients may act less confidently or more defensively, or just avoid interactions with people completely (7).
In many cases, the reality is that physicians are evaluating simplistic and superficial outcomes in lieu of the full psychosocial context in response to treatment (9). Reportedly, drug interventions can also numb patients’ thoughts, emotions, and behaviors (10). This is the reverse of empowerment. By ignoring psychological complexities in prescribing psychiatric medications, physicians are not only ignoring important causes and catalysts for mental health problems, but they are making the illnesses worse.
Pharmaceutical treatments do not account for culture, environment or socioeconomic status.
Drug interventions do not take into account the environment in which the children and adolescents are raised, and therefore ignore important sources and catalysts of mental health conditions. Socioeconomic factors include the culture and opportunities which the affected children and adolescents encounter daily, and these factors must be considered when evaluating both the cause of illness and its treatment. Many children of low socioeconomic status live in abusive households with one or both parents absent and/or abusive most or all of the time (10). Such maltreatment is proven to seriously and dramatically impact the children’s mental health for the worse (11). However, pharmaceutical interventions do not address child abuse and therefore miss a huge cause of the illness.
Evidence from environmental health studies suggests that environmental toxicants are directly involved in adolescent mental health problems (12). Furthermore, the relative concentrations of these toxicants are higher in neighborhoods of low socioeconomic status. This leads to a markedly higher risk of acquiring mental health problems at a chemical level (13). However, this can also be exacerbated in an indirect fashion. The stress experienced during exposure to pollutants can promote anxiety and learned helplessness (13).
Additionally, access to community resources is limited for children and adolescents of low socioeconomic status. Without these resources, the stress of having pollutants in the neighborhood can lead to a greater vulnerability to the environmental toxicants (13). Interventions for children and adolescents should consider socioeconomic status. Drug-based treatments, however, fail to do this.
Even beyond socioeconomic stratification, the contemporary U.S. culture is generally harsh, discouraging, and distracting. Children of all socioeconomic strata are growing up in an increasingly emotionally distant, fast-paced culture (3, 14). The widespread and frequent use of videogames, television, and the internet brings children into close contact with violence, gore, and other disturbing imagery and concepts (15). A meta-analysis review indicates that aggressive behavior, cognition, and affect, as well as cardiovascular arousal and a decrease in empathy are a certain and causal result of videogames (16). Moreover, among children suffering from ADHD, those who play video games are substantially more likely to experience a greater intensity of the disorder than children with ADHD who do not play video games (17).
Television can have damaging effects on adolescent mental health, as well. Eating disorders in particular are correlated with television watching. For instance, adolescent anorexia nervosa and bulimia nervosa incidences have increased directly in response to television viewing (18).
The internet, too, has some profound effects on mental health, especially ADHD, depression, social phobia, and hostility (19). Psychiatric drug interventions fail to address the important role of video games, television, and the internet in child and adolescent mental health disorder progression.
Implications for children and adolescents.
Pharmaceutical interventions present a one-dimensional solution to a complex problem and ultimately fail to address the numerous causes and catalysts of child and adolescent mental health problems. In short, the drug-based interventions simply do not solve the underlying causes of adolescent mental health problems (20). Besides, the current treatments can create more problems than they solve, since the prescribed drugs have a very narrow clinical window (11). Moreover, on many occasions the drugs cannot confer benefit because the diagnosis for which the drugs are indicated is not accurate (3, 11).
Furthermore, the medication has only been tested on adults. Children and adolescent dosing has not been clinically evaluated, so it is not only ineffective but also dangerous to administer psychiatric drugs to this population (21). Many of these drugs have a very narrow clinical window, and a number of deaths have resulted from careless prescribing to children (21).
Additionally, physicians are making a self-admitted uncertain and sketchy diagnosis. There are no blood tests, brain scans, or silver-bullet questions that provide conclusive evidence for diagnosing children and young people. The practitioners have to rely on an inflexible set of diagnostic criteria. This process results in inherent ambiguity and overlap between diagnoses. Adolescents are diagnosed with many different disorders as they grow up (3, 22), which only leads to their own loss of identity, self-efficacy and discouragement regardless of the chemical effects of multiple dosing.
Future Directions.
Given that pharmaceutical treatment of childhood and adolescent mental health is disparagingly ineffective and potentially harmful, research and development of alternative treatment is imperative. Such treatments include exercise, psychotherapy, and group activity. These therapies present safer, more suitable, and more comprehensive solution to issues of psychiatric illness in children and young adults (22, 23, 24, 25, 26).
Exercise in particular has been shown to be an emphatic strategy in preventing and attenuating mental health complaints in children (25, 26). One study found that exercise works on dopamine level balance, which is askew in many mental health disorders (27). Furthermore, physical activity demonstrably improves cognition and performance in children and adolescents (28). Performing well boosts self-efficacy and empowers individuals to succeed.
Psychotherapy has also been shown to improve the mental health of children and adolescents (22). Among children and adolescents with ADHD, parent-child interaction and management training, classroom behavior modification methods, and special educational placement dramatically improve symptoms (29). In adolescents with clinical depression, the evidenced-based technique of interpersonal therapy (IPT) has proven to be an effective solution in a many different contexts (30).
The “Social Empowerment Training and Responsibilities for Students with ADHD (STARS)” intervention uses group concept based peer support, directed dynamic conversation, and participant-initiated creative problem solving to work through mutual difficulties (31). This program has been highly successful in helping children with ADHD cope with their symptoms. Other group activity-based interventions have had dramatic effects as well, including a trial of family-focused therapy for bipolar disorder (32). In this 9-month randomized clinical trial, those receiving the therapy had improved relationships and greater satisfaction with activities, work and recreational activities.
It is clear that these alternative treatments have resounding success in attenuating a diverse range of mental health problems in children and adolescents. From a public health perspective, therefore, future treatment of adolescent and child mental health must include these non-pharmaceutical interventions to be not only successful but also to not be damaging or deleterious.
References
1. National Institutes of Mental Health: Child and Adolescent Mental Health
http://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/index.shtml
2. National Institutes of Mental Health: Rates of Bipolar Diagnosis in Youth Rapidly Climbing, Treatment Patterns Similar to Adults
http://www.nimh.nih.gov/science-news/2007/rates-of-bipolar-diagnosis-in-youth-rapidly-climbing-treatment-patterns-similar-to-adults.shtml
3. The New York Times: Troubled Children: A Series
http://nytimes.com/ref/health/troubled-children.html
4. Salovey, P. and Meyer, J.M. Emotional Intelligence (pp 313-320). In: Jenkins, J., Oatley, K., Stein, N. Human Emotions: A Reader. San Francisco, CA: Wiley and Sons, Inc., 1998.
5. Pescosolido BA, Perry BL, Martin JK, McLeod JD, and Jensen PS. Stigmatizing attitudes and beliefs about treatment and psychiatric medications for children with mental illness. Psychiatric Services 2007; 58:613-8.
6. Klassen AF, Miller A, Fine S. Health-related quality of life in children and adolescents who have a diagnosis of attention-deficit/hyperactivity disorder. Pediatrics 2004; 114:541-7.
7. Link BG, Struening EL, Neese-Todd S, Asmussen S, Phelan JC. Stigma as a barrier to recovery: The consequences of stigma for the self-esteem of people with mental illnesses. Psychiatric Services 2001; 52: 1621-6.
8. Edberg, M. Social, Cultural, and Environmental Theories Part I (pp 51-54). In: Essentials of Public Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
9. Abraham C , Conner M, Norman, P, ed. Understanding and Changing Health Behaviour: From Health Beliefs to Self Regulation (374 pp). New York, NY: Harwood Academic Publishers, 2000.
10. Cicchetti D, Rogosch FA, Sturge-Apple ML. Interactions of child maltreatment and serotonin transporter and monoamine oxidase A polymorphisms: depressive symptomatology among adolescents from low socioeconomic status backgrounds. Developmental Psychopathology 2007; 19: 1161-80.
11. Manning, N. Psychiatric diagnosis under conditions of uncertainty: personality disorder, science and professional legitimacy. Sociology of Health and Illness. 2000; 22: 621-639.
12. Braun JM, Kahn RS, Froehlich T, Auinger P, Lanphear BP. Exposures to Environmental Toxicants and Attention Deficit Hyperactivity Disorder in U.S. Children. Environmental Health Perspectives. 2006; 114: 1904–1909.
13. Gee GC, Payne-Sturges DC. Environmental health disparities: a framework integrating psychosocial and environmental concepts. 2004; 112: 1645-53.
14. K A Dodge. Social-Cognitive Mechanisms in the Development of Conduct Disorder and Depression. Annual Review of Psychology 1993; 44: 559-584.
15. Porter G, Starcevic V. Are video games harmful? Australas Psychiatry. 2007; 15:422-6.
16. Anderson CA. An update on the effects of playing violent video games. Journal of Adolescence: 2004; 27:113-22.
17. Bioulac S, Arfi L, Bouvard MP. Attention deficit/hyperactivity disorder and video games: a comparative study of hyperactive and control children. European psychiatry: 2008; 23:134-41.
18. Guerro-Prado D, Barjau Romero JM, Chinchilla Moreno A. The epidemiology of eating disorders and the influence of mass media: a literature review. Archives of Specialized Psychiatry (Spanish): 2001; 29:403-10.
19. Yen JY, Ko CH, Yen CF, Wu HY, Yang MJ. The comorbid psychiatric symptoms of Internet addiction: attention deficit and hyperactivity disorder (ADHD), depression, social phobia, and hostility. Journal of Adolescent Health: 2007; 41: 93-8.
20. Corrigan, PW. Mental Health Stigma as Social Attribution: Implications for Research Methods and Attitude Change. Clinical Psychology: Science and Practice: 2000; 7: 48–67.
21. Freeman MP, Stoll AL. Mood stabilizer combinations: a review of safety and efficacy. American Journal of Psychiatry: 1998; 155: 12-21.
22. Zazzali JL, Sherbourne C, Hoagwood KE, Greene D, Bigley MF, Sexton TL. The adoption and implementation of an evidence based practice in child and family mental health services organizations. Administration and Policy in Mental Health: 2008; 5: 38-49.
23. Weisz JR, Sandler IN, Durlak JA, Anton BS. Promoting and Protecting Youth Mental Health Through Evidence-Based Prevention and Treatment. American Psychologist: 2005; 60: 628–648.
24. Effects of physical exercise on depression, neuroendocrine stress hormones and physiological fitness in adolescent females with depressive symptoms. Chanudda Nabkasorn, Nobuyuki Miyai, Anek Sootmongkol, Suwanna Junprasert, Hiroichi Yamamoto, Mikio Arita and Kazuhisa Miyashita. The European Journal of Public Health 2006 16(2):179-184.
25. Strong WB, Malina RM, Blimkie CJ, Daniels SR, Dishman RK, Gutin B, Hergenroeder AC, Must A, Nixon PA, Pivarnik JM, Rowland T, Trost S, Trudeau F. Evidence Based Physical Activity for School-age Youth. The Journal of Pediatrics. 2005; 146: 732-737.
26. Burnsa J, Rapee, RM. Adolescent mental health literacy: Young people's knowledge of depression and help seeking. Journal of Adolescence: 2006; 29: 225-239.
27. Tantillo M, Kesick CM, Hynd GW, Dishman RK. The effects of exercise on children with attention-deficit hyperactivity disorder. Med Sci Sports Exerc.: 2002; 34:203-12.
28. Hillman CH, Erickson KI, Kramer AF. Be smart, exercise your heart: exercise effects on brain and cognition. Nat Rev Neurosci. 2008; 9:58-65.
29. Barkley RA. Psychosocial treatments for attention-deficit/hyperactivity disorder in children. J Clin Psychiatry. 2002; 63:36-43.
30. Mufson L, Sills R. Interpersonal Psychotherapy for depressed adolescents (IPT-A): an overview. Nord J Psychiatry. 2006;60(6):431-7.
31. Frame K. The STARS program: social empowerment training for preadolescents with attention deficit hyperactivity disorder (ADHD). J Sch Nurs. 2004; 20:257-61.
32. Miklowitz DJ, Otto MW, Frank E, Reilly-Harrington NA, Kogan JN, Sachs GS, Thase ME, Calabrese JR, Marangell LB, Ostacher MJ, Patel J, Thomas MR, Araga M, Gonzalez JM, Wisniewski SR. Intensive psychosocial intervention enhances functioning in patients with bipolar depression: results from a 9-month randomized controlled trial. Am J Psychiatry. 2007; 164:1340-7.

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1 Comments:

  • At April 24, 2008 at 9:12 AM , Anonymous kerin said...

    I fully agree that over medication is a huge problem for children with psychiatric disorders. However, many mental health disorder have a strong genetic component. If a sibling or parent is diagnosed with a certain disorder the likelihood of the child developing the same disorder or a similar mental health disorder can be very high. You mentioned that the root of mental disorders are social and cultural but I think you are neglecting to consider the genetic component. Perhaps for cases of familial mental disorders, there is truly a biomedical problem in the way neurons communicate with each other. If this is the case, prescribing medication seems appropriate. It doesn't seem much different than prescribing drugs for a patient with a somatic health problem.

     

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