Two recent articles in the New York Times make clear that the controversy over whether to medicate the very young with powerful psychiatric drugs is not going away. If anything, it is just heating up. In yesterday's paper, Duff Wilson's article "Child's Ordeal Shows Risks of Psychosis Drugs for the Young" reads as a bookend to Pamela Paul's troubling (and question-begging) article, "Can Preschoolers Be Depressed?," which ran in last week's magazine section of the paper.
As is customary with journalistic pieces on psychiatry, both articles opened with case studies featuring distraught children with behavioral issues, using each example to build a case for the child's welfare. The issue driving both articles--whether underdiagnosis should trump the risks of overmedication--will leave readers more informed, but almost certainly more troubled and disturbed.
In Paul's article, a Midwestern 4-year-old nicknamed "Kiran" is diagnosed with "preschool depression" largely because "guilt and worry suffused [his] thoughts." "It was painful," his mother says, "but also a relief to have professionals confirm that, yes, he has had a depressive episode. It's real."
In Wilson's article, by contrast, we learn that Louisianan Kyle Warren, prone to "severe temper tantrums," had been put on a course of antipsychotics from the age of eighteen months. By the age of 3, his drug regimen had expanded to include "the antipsychotic Risperdal, the antidepressant Prozac, two sleeping medicines and one for attention-deficit disorder." The pediatrician prescribing the Risperdal made his diagnosis "within five minutes of sitting with him." He "looked at [Kyle's mother] and said, ‘He has autism, there's no doubt about it.'"
Kyle's mother had been at her wit's end over his tantrums, but when her son grew sedated, overweight, and started drooling, her fears turned instead to the drugs' effects on his altered personality. "All I had was a medicated little boy," she is quoted as saying. "I didn't have my son. It's like, you'd look into his eyes and you would just see just blankness."
Before focusing on each example, let's look for a moment at the broader picture both represent.
"More than 500,000 children and adolescents in America are now taking antipsychotic drugs," Wilson reports, "according to a September 2009 report by the Food and Drug Administration. Their use is growing not only among older teenagers, when schizophrenia is believed to emerge, but also among tens of thousands of preschoolers."
He continues, "A Columbia University study recently found a doubling of the rate of prescribing antipsychotic drugs for privately insured 2- to 5-year-olds from 2000 to 2007. Only 40 percent of them had received a proper mental health assessment, violating practice standards from the American Academy of Child and Adolescent Psychiatry."
"There are too many children getting on too many of these drugs too soon," according to Dr. Mark Olfson, professor of clinical psychiatry and lead researcher in the government-financed study. Adds Dr. Ben Vitiello, chief of child and adolescent treatment and preventive research at the National Institute of Mental Health, "This is a recent phenomenon, in large part driven by the misperception that these agents [antipsychotics] are safe and well tolerated."
"Texas Medicaid data obtained by the New York Times," notes Wilson, "showed a record $96 million was spent last year on antipsychotic drugs for teenagers and children--including three unidentified infants who were given the drugs before their first birthdays." That data should be viewed alongside a 2009 report by Florida's St. Petersburg Times, which found that in 2007 23 infants in the state, less than one year old, had been prescribed antipsychotics through Medicaid.
The same year, and through the same program, no less than 39 one-year-olds in Florida were prescribed the same medication, with the numbers rising each year the children aged, all the way to 1,801 five-year-olds. In 2008, after the state began requiring approval for such prescriptions for children under the age of six, the numbers dropped significantly, but still remained disturbingly high: 5 one-year-olds were prescribed the drugs; and 26 two-year-olds; all the way to 437 five-year-olds. Indeed, according to Wilson's article, "a Rutgers University study last year found that children from low-income families, like Kyle, were four times as likely as the privately insured to receive antipsychotic medicines."
Then there's the matter of Pharma throwing huge amounts of money at a largely untapped market. As Wilson notes, "Even the most reluctant prescribers encounter a marketing juggernaut that has made antipsychotics the nation's top-selling class of drugs by revenue, $14.6 billion last year, with prominent promotions aimed at treating children. In the waiting room of Kyle's original child psychiatrist, children played with Legos stamped with the word Risperdal, made by Johnson & Johnson. It has since lost its patent on the drug and stopped handing out the toys." (A photo of the toys in question appears below.)
"I will never, ever let my children be put on these drugs again," Kyle's mother is reported as saying as she chokes back tears. "I didn't realize what I was doing." Yet in the comments section for the article, facing intense criticism from readers, she insists that "early detection does work," despite clear evidence that both her son's behavioral problems and his medical side effects greatly improved when he was taken off the antipsychotic and antidepressant (he now takes Vyvanse for attention deficit). Indeed, as Wilson writes in the article: "Ms. Warren and Kyle's new doctors point to his remarkable progress--and a more common diagnosis for children of attention-deficit hyperactivity disorder--as proof that he should have never been prescribed such powerful drugs in the first place."
By contrast, in Pamela Paul's magazine article, "Can Preschoolers Be Depressed?," Kiran's mother says it was "a relief to have professionals confirm that, yes, he has had a depressive episode." It isn't hard to imagine that relief, especially when it gives troubling behavior a scientific name. But with professional disagreement diverging so radically among Kyle's physicians, was confidence in her son's diagnosis misplaced--indeed, unwarranted?
Despite the authority she gives to two studies in her article, neither of which is remotely conclusive about "early-onset depression," Paul's article is full of unanswered questions: "Is it really possible to diagnose such a grown-up affliction in such a young child? And is diagnosing clinical depression in a preschooler a good idea, or are children that young too immature, too changeable, too temperamental to be laden with such a momentous label?" For some, those questions almost answer themselves, especially as we're talking about an 18-month infant and antipsychotics thought too dangerous to give the elderly. "When the rate of development among children varies so widely and burgeoning personalities are still in flux," Paul continues, "how can we know at what point a child crosses the line from altogether unremarkable to somewhat different to clinically disordered?"
How indeed? We also learn from Paul's article that in the late '90s, "the study of early childhood entered a kind of vogue among academics and policy makers. That was the era of President Clinton's White House Conference on Early Childhood Development and Learning," she reminds us, "and there was a wave of interest in the importance of what was termed ‘0 to 3.' Researchers took a closer look at how sophisticated feelings like guilt and shame emerge before a child's third birthday."
But among the experts Paul interviews, "guilt and shame" turn out to be virtual synonyms for early depression--a distressing and imprecise slip, given the key role that limited forms of both play in child development. The mid-to-late 1990s were also, we recall, a time when well-positioned physicians at Harvard and Mass General Hospital pushed bipolar disorder in children so aggressively, they argued that roughly half of all mood disorders should be redefined as bipolar disorder. A few years earlier, bipolar disorder in children was thought a medical impossibility. (For many experts and researchers, it still is.)
Finally, and despite the obvious delicacy of the subject, both articles give crucial airtime to the environment and the parental dynamics shaping Kyle's and Kiran's lives. Writes Paul, "Elizabeth says she does wonder if her behavior exacerbated some of Kiran's negative tendencies. 'Sometimes I worry that we were too critical of Kiran,' Elizabeth told me over the phone in January. 'I was exasperated with him all the time. I wasn't intentionally trying to make him feel guilty, but the way I was interacting with him was providing a guilt trip.' Elizabeth's own moods sometimes played a role. 'If my mood was low, his got even lower.'" With Kyle, meanwhile, we learn from Wilson's article: "Ms. Warren conceded that she resorted to medicating Kyle because she was unprepared for parenthood at age 22, living in difficult circumstances, sometimes distracted. ‘It was complicated,' she said. ‘Very tense.'"
Appropriately, neither article implies any wrongdoing on the part of these caregivers. What's striking, though, is the complex picture that emerges--parental dynamics included--when the diagnoses both mothers trusted as watertight are revealed as open-ended, even erroneous, while the high-potency drugs they gave their toddlers create a litany of health-related problems, putting their overall efficacy very much in doubt.
In short, we're left with a deeply unsettling picture: Pediatricians, after five-minute consultations, urging the use of antipsychotics to infants as young as 18 months. Other physicians trying to placate anxious parents wanting medication for their child at any price. Researchers hyping inconclusive results because studying toddlers is the new vogue. Parents regretting their decision and rethinking the family messages their children may be imbibing. Drug companies doing all they can to exploit the confusion, including by advertising their antipsychotics on toys available in doctors' waiting rooms.
The net effect? Half-a-million American children and teenagers on drugs thought too dangerous to give the elderly, but known to cause obesity and diabetes. Welcome to child-rearing in twenty-first century America.