A Delicate Brain: Ethical and Practical Considerations for the Use of Medications in Very Young Children
A Delicate Brain: Ethical and Practical Considerations for the Use of Medications in Very Young Children
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The debate is growing. Amidst federal inquiries into financial ties to pharmaceutical companies by researchers, decreasing interface between academic institutions and pharmaceutical companies, and decreasing research funding available from the NIH, the use of psychotropic medications—particularly atypical antipsychotics and stimulants—remains mired in controversy.1
Absent significant changes to the current system of care and political climate and more research into the efficacy and long-term safety of psychotropic medications in children, this controversy will continue to grow.
Our youngest and most vulnerable children—those with significant mental health concerns for whom psychotropic medications are prescribed—are most affected by this controversy. The historical context for this controversy, the ethical implications of the current state of care for young children in the mental health care system, and the limited knowledge of the developmental neurobiological impact of these medications provide the background for a much-needed critical discussion.
Current prescribing practices compared with evidence-based treatments
Empirical research has shown that preschoolers can and do experience debilitating mental health problems that interfere with normal development and cause significant suffering for them and their families.2 The concurrent and predictive validity of ADHD, major depressive disorder, PTSD, and disruptive behavior disorders are well established in preschool children. Early childhood mental health problems stabilize over time; however, they are associated with substantial impairment in multiple developmental domains.
There is evidence that early psychological disorders increase the risk of mental health problems across the person’s life span. Although awareness of early childhood mental health problems has increased, this awareness has not translated into substantial empirical support for psychopharmacological interventions in this age-group or into increased access to nondrug interventions.
A substantial body of literature supports the efficacy of nonpharmacological treatments for young children. For example, there are more than 100 randomized controlled trials of parent-child interaction therapy—a training program that assists parents of children with disruptive behaviors. Parents are taught effective child management skills to improve both disruptive behaviors in their children and their relationship with their children. These trials show that effects are maintained up to 6 years after treatment has ended.3
Cognitive-behavioral therapy, with developmental modifications, has been found to be effective in decreasing anxiety symptoms in trauma-exposed preschoolers, with sustained results at 12-month follow-up.4 Child-parent psychotherapy—an attachment-based intervention—is effective in decreasing child and parent trauma-related symptoms following partner violence.5
The following comment is by Manuel Mota-Castillo, MD:
There is lot to say about this well-written paper that touches a very important issue. I would bet on the side of good intentions inspiring the authors to present the facts (and several myths) in a way that, unfortunately could lead the readers to make false assumptions.
Since I stated the inclusion of myths I will start with the first one: Severe Mental Illness goes away.
We certainly can cure obsessions and phobias with CBT but this effective technique only helps the treatment of major mental disorders such as schizophrenia, autism and bipolar spectrum disease. Furthermore finding a psychotherapist specialized in CBT that accept Medicaid patients is as difficult as wining the Power Ball lottery.
The authors also use "revealed truths"elevated to such a distinguished status by the old trick of repetition. One example is the assertion that "when two medications are combined the risk of developing…"in reference to the possibility of harming a developing brain with psychotropic drugs. This is true if we look at the issue as mathematicians, but what happens when we walk down to the trenches and face a patient that has more chances of developing side effects from 2 milligrams of risperidone than if we only prescribe 1 mg and add lamotrigine, lithium or valproic acid to treat the symptoms of bipolar illness?
They also refer to the "lack of efficacy for the use of psychotropic medications in children" in complete disregard of the fact that this perceived failure in the pediatric population is due to the widespread misdiagnosis of disruptive behaviors, anxieties, elevated moods and even psychosis as reason to label a child with the flavor of the decade, ADHD.
Here is a real case: 50 pounds boy on 80 mg of amphetamine salts having auditory hallucinations, displaying a very aggressive behavior and staying up all night. His pediatrician referred him to a psychiatrist when the doctor discovered that his patient is adopted and that his biological parents have severe mental illness. The C & A psychiatrist that treated him before me kept the ADHD diagnosis (and the astronomical dose of amphetamine) and added a small amount of risperidone at night, clonidine in the morning and a twice a day dosing of valproic acid. The poor child, who never had ADHD was biting his lips and showing serious facial tics…but the stimulant was continued. How can we call this a failure of the mood stabilizers?...how come the experts in this field trust statistics that rely on studies of bipolar patients treated for years with antidepressants as cases of Treatment-Resistant Depression and continued on these drugs after the real diagnosis was made? How the MTA became so relevant when its data is contaminated with cases of Oppositional-Defiant Disorder which is not a real disease but a symptom?
In the past I used to say that when I practiced pediatrics I never heard a mother complaining of the "terrible side effects of chemotherapy" when her child was in treatment for Leukemia. Now, with my youngest daughter with Lupus it really feels close to home when I hear about side effects from "dangerous drugs." Still, what are my choices?
I wonder if society in general has ever considered that a serious mental illness can be as lethal as a major physical condition and it should be treated as such.
A few hours ago I said to one of my new patients "for the past 20 years doctors have been aiming at the wrong target." You don't have fatigue; you are tired because, as you just told me, you never had a full-night sleep. She is another "failure" of medications to control her anxiety and depression because her real problem is a racing mind, poor anger control and impulsivity.
I would like to conclude with a simple question: Could it be more productive to worry about making a correct diagnosis than getting anxious about side effects that, when present are the necessary price to pay for keeping a life-threatening illness at bay?
Manuel Mota-Castillo, MD
Lake Mary, FL
www.psychiatricanswers.com
Youtube video: ADHD a real disease but a false epidemic