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Dave Traxson at a Birmingham University Symposium in 2008 Talking on the Ethics of Over-prescription of Psychotropic Drugs for Children and the Risks to Young People of Prescribed Amphetamines re:later in life consequences.e.g long-term stimulant addiction / usage (nicotine,cocaine,caffeine,"Speed"etc.)
user/Humanagement2011
For more information on this issue and the BBC Radio programmes on the over-prescription of drugs for kids.
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Professional Practice Essay: "The Medicalisation of Normal Healthy Childhood."
Please see post: "Twenty Questions for Educational Professionals" (March 2010) for "Top Ten" Posts on this Blog.
"There is clearly a growing willingness to offer young people drugs which have profound effects on the way they think and behave," and also, "We should give more thought to changing the shape of our classrooms to fit our children, rather than trying to medicate our children to fit the classroom!" Baroness Susan Greenfield, Professor of Pharmacology, Oxford University and ex- Director of the Royal Institution.
(Times Educational Supplement January 8th 2007)
I feel the time is right to challenge the exponentially growing practice of medicating our children for displaying behaviours and thought processes that until recently would have fallen within the normal range as defined by our shared expectations as a society and certainly by the pastoral care staff in schools. This pathologisation of normal responses to often demanding situations for children is in my view insidious and pervasive at this time and threatens to produce a collective societal shift of perspective about childhood which can only be detrimental in the longer term.
My central thesis which is shared by an increasing number of prominent academics and educationalists is that over the last twenty years there has been a totally unhealthy business alliance forged between pharmaceutical companies, some key researchers and some paediatric medical practitioners. Their aim is to deliberately colonise this region of our common experience purely for financial gain. This orchestrated and driven financial vehicle or business model has been expanding in its remit to meet the ever widening spectrums of conditions that are felt by the multinational pharmaceutical corporations to warrant medication.
"The pharmaceutical industry is primarily responsible to its shareholders so making profit is its primary motivation. The industry's techniques affect not only prescribing habits of doctors but also concepts of mental health," Sammi Timmi, Advances in Psychiatric Treatment(2008)14:3-9. There are indeed some prophetic stories of how ailing drug companies have turned round the profitability of their companies by focussing their marketing and advertising machines on such psychotropic drugs as amphetamines (psycho-stimulants with a similar effect to cocaine) for the child market. This is not some conspiracy theory but the current reality as recognised by such august bodies as the United States Federal Drugs Agency(USFDA), Drug Safety Committee. Its chair Peter Gross stated ,"It has become clear that drugs are being overused with children."(Hackensack University Medical Center, New Jersey 2006)
"The pharmaceutical industry has popularised the idea that many problems are caused by imbalances in brain chemicals. This message helps to further the aims of neoliberal economic and social policies by breeding feelings of inadequacy and anxiety. These feelings in turn drive consumption, "Dr Joanna Moncrieff, editorial, The British Journal of Psychiatry (2006),188,301-302.
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, some need for stimulation at a rapid rate which as we know as parents our children have become acclimatised to in the current frenetic culture. These surely fall within the range that all of us should be creatively dealing with in our families and schools and not necessitate expensive advertising campaigns to convince us otherwise or the high medication levels that would follow.
These drug companies are indeed in a financially mutually beneficial relationship with all the major stake holders in this scenario, the researchers, the medical practitioners, the state and indirectly through that to the parents by the payment of such benefits as Disabled Living Allowance ( DLA). 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 with children was shown by a Congressional Inquiry in 2008 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) This same researcher has published articles in medical journals supporting the diagnostic use of such checklists as a child behaviour checklist which is a widely used tool amongst health professionals. Can the eminent professor's endorsement of these checklists diagnostic efficacy be trusted in the light of his questionable financial practice and reported violations pertaining to conflict of interest with his research? Indeed when as an independent psychologist you scan the domains in these supposed diagnostic checklists item by item, where often scaled answers (1-5 or 10) are expected or even just a yes-no response are expected. It is quite easily 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 by completing these checklists. If six positive responses are achieved to items like "Is the child very restless?" then a clinical level of ADHD is obtained. How many children do we all know who are naturally very restless and happily creative with it a lot of the time?
In relation to ADHD researchers at Mc Master University have identified five features of ADHD that contribute to its controversial nature:
-It is a clinical diagnosis for which there is no laboratory or radiological confirmatory tests or specific features.
-Diagnostic criteria have changed frequently.
-There is no curative treatment, so long term drug therapy is required.
-Therapy often includes stimulant drugs that are thought to have abuse potential.
-The rates of diagnosis and treatment substantially differ across countries.
From an editorial in Every Child Journal(2010)1.4,p 1.
This view is reinforced by Emeritus Professor Steven Rose of the Open University, neuropsychologist, in a paper entitled, "Prospects and Perils of the New brain Sciences."A Royal Society Science Policy Lab Paper 20th October 2009. He asks, "Is ADHD a disease and if so why is it on the increase? Despite some weak claims for a genetic link no biochemical tests can detect the condition and its diagnosis ,in the vast majority of cases, is entirely based on educators' and parents' accounts of the child's behaviour and response to the drug.(e.g. by checklists) This response was once thought to be anomalous(paradoxical) but is now recognised as no different from that of "normal" children." Profoundly he adds, "What is clear is that we are moving into a world in which psychopharmalogical adjustment of an individual's behaviour to fit within prescribed norms is becoming common and can only become increasingly so with advances in the sophistication of the available pharmaceuticals.
Many doctors who have not had the rigorous training needed, that paediatricians and psychiatrists do receive, to prescribe these high level classes of medication also provide field trial information to drug companies in batches of ten patients on a proforma designed by the drug company market researchers for which they are financially rewarded. Another training concern is that some nurse practitioners are now being authorised to prescribe amphetamines for children.
Again ask any National Health Service (NHS) child psychiatrist what their personal training budget is for their worthy requirements and you will find it is paltry from the NHS itself and yet drug companies offer lavish conferences in exotic locations. For example one consultant psychiatrist told me of one 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 rafts of professionals in the field, which include hotel receptions with a la carte meals, expenses paid trips, personalised stationery, vintage wines, rare whiskeys etc. Even professionals' journals are part funded by the pharmaceutical companies which must bring into question their impartiality.
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 (level 1 being £75 a week, level 2 is £150 per week) 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 and market expansion of the drug companies. For vulnerable children in particular "enslaving" them and creating long term dependency on long term drug treatment in turn boosts the massive profits of the drug producers, and so the profit cycle turns. Surely investors and share holders should be asking themselves questions about the ethics behind their drug companies marketing machines and where their products are targeted.
The statistics in this field are genuinely mind boggling e.g. a sixty fold increase in the prescription rate for amphetamines("speed") for children in the decade leading to 2004 in the U.K.(Department of Health statistics), imagine the furore if there was a sixty fold increase in the shipments of cocaine or heroine 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 U.S. again one can visualise the ensuing headlines. 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 to provide the "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 ( Dr Edmund Higgins Scientific America Mind, July 2009) and we have 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 or are the young people still on medication at the end of say a two year period, the maximum recommended by National Institute of 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 that some of us work with regularly. Severe Adverse Drug Reactions (ADR's) such as cardiological reactions e.g.sudden heart failure is an increasingly reported side effect in some studies due to the overstimulation of the heart by the drugs in "Psychostimulants in the treatment of children diagnosed with ADHD : Risks and mechanism of action." (P.Breggin ,International Journal of Risk and Safety in Medicine, 12(1999) 3-35) He also states that any therapeutic effect is a direct result of the drugs toxicity, they can also inhibit growth and cause cerebral dysfunction. The range of side effects, as might be expected, are considerable and vary 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 overstimulation of the heart at the extreme and thankfully very rare end.
Professor Steve Baldwin states, "There is no reliable scientific criteria for an ADHD diagnosis. Judgements are made by parents ,teachers and medical personnel using unreliable and invalid checklists. In "The Cult of Methylphenidate: clinical update," Critical Public health 2000(10)81-86.
This was reinforced by accounts from colleagues when
I was involved in co-writing a publication for the West Midlands Regional Partnership entitled, "A Parent Resource Pack for A.D.H.D between 2005 -2006, with a team of professionals including child psychiatrists, child clinical psychologists, school nurses, parents and Parent Partnership Officers for local authorities in the area. During this period and since a range of professional colleagues have raised the following 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 issuing the medication.
_In one authority illustrating this issue, 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.
_On this same issue in one extreme case a child was on maximum levels of
Methylphenidate and a parent asked if their son could also be prescribed a Seratonin Reabsorption Inhibitor (SRI) antidepressant, which it duly was without the child being seen. One senior psychiatrist was shocked when this information was shared with her.
_Prescribing "top up" doses of quick release Methylphenidate when a child is already on a maximum dose of the slow release drug, is also common in some areas. A morning dose is called a "kick start" and a lunchtime dose is called a "booster" in explanations given to parents. This is somewhat confusing for other professionals as the outer casing of Concerta already has a proportionate dose of Methylphenidate quick release built into it. These additional doses often mean the the maximum dose is exceeded as stipulated in the manufacturers manual.
-A key part of the process indentified 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 due to reported shortages of manpower. Also some practitioners in the area not 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 contraindicator to treatment with methylphenidate.
_Severe weight loss has been reported in at least one case which was not addressed as a matter of urgency and lead to further deterioration of the child's health.
_One very worrying report from a parent told of a multiple prescription for high levels of methylphenidate, an SRDI anti-depressant and an antipsychotic 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.
-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 takes 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." His seminal book was, "Obedience to Authority- an experimental view."(1974),which endorsed this strong socio- psychological phenomenen.
Clearly as professionals also working with these children this causes us great concern, and many professionals feel a national review of this worrying practice needs to be undertaken, as a matter of urgency, so we don't blindly follow the American business model. Obviously as a professionals working within Children's Services our Directors regularly tell us that our shared paramount duty is to ensure the wellbeing and safety of children .i.e. Safeguarding children. Some independent arbiters may consider this vital principle has been breached in some of these illustrations.
As a trained conventional and social scientist one issue I want to raise 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 in sales terminology we are "hooked" as to the potential benefits that scientific discoveries can bring which eases us into accepting other scientific "breakthroughs". But recently the vox pop has drawn a line in the sand on GM crops, for obvious reasons of food safety. 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 the situation in America at the current time. If we choose not to follow the same route as our transatlantic cousins we need to act soon and comprehensively to avert escalation of diagnoses. Another reason for prompt action is that we have been through the "Ritalin wave" of impulsive prescribing by medics and we may yet to be heading for a "Tsunami" of identification of Bi- Polar disorder in children which is heading our way across the pond soon. From my recent research 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 high school which is an exponential increase on what I have come across and helped to identify in my thirty year career. 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 DSM4 conditions are being redefined as "spectrum conditions" which enormously increases the numbers of young people indentified as affected thus automatically expanding the markets open to the pharmaceutical companies for sales. DSM4 is the main American diagnostic criteria at present for a wide range of behavioural and mental health conditions and is about to be revamped as DSM5. One illustration alone shows the power of this process where a new category of sub clinical normal variation Autism/Bi polar Disorder is proposed. This loosening of the criteria will have huge implications on diagnosis rates. This has been achieved with the backing of the same researchers who produce the dubious checklists and their lack of scientific rigour will result potentially in massive increases in diagnosis 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 behaviour by paediatricians for children on these spectrums. Hopefully new guidance from NICE 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. The reality is that these models are not mutually exclusive and by a balanced view of both real progress can be achieved where colleagues who willingly cross the professional boundaries can work creatively with each other to achieve Solution Focussed outcomes that benefit the children avoiding the need for unnecessary compartmentalisation and labelling which can be a life long burden to the recipient.
A final issue I think is pertinent at this time, 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 in order that 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.
So to conclude I would like to pose some questions or dilemmas that educational professionals particularly Pastoral Care Staff need to address as: "Pastoral Care Staff have a duty of care to be aware":
What are the ethical and test validity issues that result from using diagnostic checklists designed by researchers who have a vested financial interest in the diagnosis and medication of the children they are used on? Can academics receiving large financial payments from drug producers be relied upon for ethical probity?
What are the ethical and moral constraints on the drug manufacturers to realise the social costs of the triangle of trade that they are engaged in? (I would urge them to consider the massive profits that they are reaping from these legal narcotics will have huge potential damage to very young people their adverts claim they want to help.) Should shareholders also be examining the ethical rationale of unregulated and unlicensed experimental drug treatments on children and how they profit from shares dividends for these companies.
Are professionals and the general public seduced by the power of scientific rationalism and the inducements of the pharmaceutical industry and what needs to be done to achieve a balanced holistic perspective? Is a more holistic approach more valid?
How far should educational professionals cooperate or maybe even collude with medical professionals intent on diagnosing mental health problems in children we jointly work with and then prescribing psychotropic medication for these conditions? How can we best challenge this practice in cases we, education professionals, are concerned about, often where we have listened to the "child's voice" about their worries?
Is it ethical for schools to regularly administer these drugs and possibly act as agents of the medical professionals involved ? Is this a legitimate loco parentis role or is it making decisions beyond their professional remit?( especially when the treatment exceeds recommended guidelines) How can it be right that schools don't give Paracetamol for headaches but give high strength psycotropic drugs for unsubstantiated mental health conditions?
Does the, GOLDEN RULE, " Would I want this intervention for my own child" test criterion help in selecting the appropriate response for each case?
Is doing nothing the most harmful or the least risky option for the long term best interests of the child concerned? ( Remember about the normal 60% spontaneous remission rate which is standard across a wide range of conditions in medical and mental health conditions i.e. where the condition improves on its own.)
Why are boys four times more likely to be identified than girls and prescribed drugs and how does this relate to their later drug usage/ dependence and adult life outcomes e.g. illicit drug use and / or time in prison as a result of crime to fund drug habit? ( Could it be due to their traditionally activity based focus in early childhood for boys as against a more person centred focus for girls?) Does this further accentuate the gender imbalance in our prison population for example?
Is the influence of the pharmaceutical companies coercive in nature and does it constitute an abuse of their commercial influence and power?
And last but certainly not least when does over-prescription or inappropriate prescription of drugs mean that a concerned educational professional has to ask appropriate questions about ensuring the safeguarding of the children concerned? Should a Common Assessment Framework or Child Protection Meetings be convened in these cases where educational professionals have these significant concerns?
Are we all committed to principles of Beneficence (promoting the clients well being) and non-malificence ( avoiding direct or indirect harm to the client) as our shared Paramount Objective.
To end with a very timely quote from a radical thinker of the 1970's Ivan Illich in his seminal book " Medical Nemesis"(1974) London, Calder and Boyars.
Has "the medical system become a major threat to public health"? in this case for our children.
Certainly we must avoid a "Pharmageddon" the title of a prophetic recent book by Dr Paul Clayton the renowned Oxford Brookes University epidemiologist ( Royal Society of Medecine Press, 2009).
Written to stimulate debate on this major issue of our times and for our society
By Dave Traxson ,Chartered Educational Psychologist.
Further Reading:
"Is Psychiatry For sale?" Joanna Moncrieff, Published by The Institute of Psychiatry, London as an ocassional paper,2002.
"The Myth of the Chemical Cure." Dr. Joanna Moncrieff ,Palgrave/Macmillan , 2009 . Nominated for Mind Book of the year,2009.
"The Plan to Drug American Children", by George Stone, MA, paper for Conference
"The Human Rights of Children," Oxford University 2005.
"Prospects and Perils of the New Brain Sciences: a twenty year timescale." Professor Steven Rose,Open University,2009.
"Child Psychiatry and its relationship with the pharmaceutical industry:theoretical and practical issues." Dr.Sammi Timmi,Consultant Child Psychiatrist.
"Overdosed America- How the Pharmaceutical Companies are Corrupting Science." Dr John Abramson.Harper - Perennial,New york,2004.
"Good Work - when Excellence and Ethics Meet," Howard Gardner et al. Basic Books (Perseus) New York,2001.
"Madness Explained," Richard Bentall. Penguin, London,2003.Winner of the B.P.S. Book Award 2004.
"Solutions in Schools - Creative Applications of Solution focussed Brief Thinking with young People and Adults." Edited by Jasmin Ajmal and Ioan rees, BT Press.London.2001.
"Smart Drugs :do they work? Are they Ethical? will they be legal?" Nature reviews,Neuroscience.Prof.S.Rose,2002.
