October 2019, Volume XXXIII, No 7
Labeling and medicating children
A new epidemic
rior to my election to the Minnesota House of Representatives in 2010, I served on my local school board for 16 years. During that time, I developed an interest in the increasing practice of labeling and medicating children who showed signs of Attention Deficit Hyperactivity Disorder (ADHD). I learned that the procedure used to diagnose these children was primarily based on a series of questions from educators, which then resulted in a subjective judgment call and a recommendation to a physician to prescribe psychotropic medications. In almost all cases where students are diagnosed and subsequently labeled with a disorder, there is no objective medical evidence to determine this diagnosis.
Special education programs—which include children labeled as having ADHD—is financed at about 80% of actual costs through state and federal funds, which creates major funding problems for local school districts that must fund the remaining 20%. In addition, schools are under increasing pressure to improve their metrics on grades and standardized test scores. These two factors can lead schools to turn to what appears to be a quick fix: medicate in hopes of managing behavior—and, potentially, improving test scores—all the while contributing to a dramatic increase in drug sales involving kids.
The pharmaceutical industry promotes the value of this approach, visiting school boards and educators to stress the benefits of psychotropic medications to manage behavioral health concerns and increase test scores. Pharmaceutical representatives can no longer promote their products to physicians, but they can visit educators—and increase their profits, with estimates ranging as high as $7 billion annually for psychotropic drugs. Educators and counselors pass these messages on to parents, resulting in visits to physicians who may trust the recommendations of non-physician educators and write prescriptions without conducting a thorough assessment of the child’s needs. The result is a steep and rapid increase in psychotropic prescriptions.
Spotting trends and concerns
In 2006 I obtained a book coauthored by Nicholas A. Cummings, PhD, ScD, a former president of the American Psychological Association, entitled, “Destructive Trends in Mental Health: The Well Intentioned Path to Harm.” Two chapters piqued my interest: “Warning, Psychiatry can be Hazardous to your Health” and “The Diseasing of America’s Children.”
Ten percent of all school-aged children are now labeled with ADHD.
A March 2012 Psychology Today article, “Why French Kids don’t have ADHD,” stated that only one-half of one percent of French kids are labeled and medically treated for ADHD, compared to over 9% of American children. In France, diagnosis of ADHD takes into consideration the underlying causes in the child’s social context, addressing these through psychotherapy or family counseling, whereas the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders does not specifically include these underlying causes. The result is a much larger number of medicated American children. A recent article on the front page of the Minneapolis Star Tribune reported that 10% of all school-aged children are now labeled with ADHD.
Then in November 2018, FEE (Foundation for Economic Education) published an article titled “Harvard Study Shows the Dangers of Early School Enrollment,” which warned about the dangers of labeling and medicating pre-school children. The article stated that the Centers for Disease Control and Prevention estimated approximately 11% of children are diagnosed with ADHD in the U.S. It also included numerous other concerns of early school enrollment.
Another disturbing fact is that the use of psychotropic drugs on the developing brains of children seriously impairs their ability to serve in the military. I have visited with several military recruiters over the last several years who confirmed that the use of psychotropic drugs can result in denial into our military branches. The reason they are denied is that one of the negative side effects of long-term use of psychotropic drugs is violent out-bursts of uncontrollable rage. It should be evident why the military has serious concerns regarding the use of these drugs on developing children.
In addition, there is a crisis of young people committing suicide. It would be interesting to study how many were on psychotropic drugs at the time of death.
Finally, probably the most serious concern is the growing evidence of the connection between young mass shooters, both in and out of our schools, who also have a history of long-term use of psychotropic drugs.
I am aware that this is an extremely controversial issue with psychiatrists and pharmaceutical companies who deny that there is any possible connection—however it is one of the primary reasons I authored a bill (HF713) in the Minnesota House of Representatives, which would create a study group of experts to research some of the previously mentioned concerns.
My concerns are also partially based on the 2013 report of the OLA (Office of the Legislative Auditor), which identified that Minnesota has more than 170 additional laws and regulations over and above the federal requirements on special education. These additional laws have never been evaluated for costs or effectiveness!
During the 2019 legislative session, I also offered an amendment (A173) on the House floor with additional language specifically addressing the excessive labeling and medicating of children. The amendment passed on a strong bipartisan vote; however, this language did not make it into the final educational omnibus bill signed by the governor. I intend to try again in 2020.
A personal note
Whether you agree or disagree with the above information, I think we should all agree that an in-depth study should be done on the costs and effectiveness of Minnesota’s special education requirements.
Let me stress that I do not want to hurt any special education students. I have relatives who were in special education programs, but I am committed to finding factual answers to the above concerns.
Part Two: a physician’s concerns
s a general internist with a special interest in pharmacology, nutritional and botanical medicine, and complex illness, I have grown especially concerned with the misapplication of drugs—often many in the same patient. The rapid evolution of the physician (and other provider) workplaces with computerized medical records and the compulsion to practice medicine by “drop down menu” has added to the propensity to overprescribe. Nowhere is this more apparent than in the inappropriate overprescribing of psychotropic drugs for children—often by physicians who have not adequately examined the child.
Questions about effectiveness
Many drugs used to manage mood and behavior in children either have very little scientific basis (never tested thoroughly in youth under 18) or have a very undesirable risk-to-benefit ratio. This latter item is rarely, if ever, fully disclosed to the patients or their legal guardians in the spirit of informed consent. Examples include medications like Risperidone, a drug now in relatively common use for schizophrenia and other related thought disorders that has profound implications when given long term. It can actually cause permanent brain damage, resulting in irremediable tardive dyskinesia (an involuntary movement disorder that is both humiliating and disabling).
Many drugs used to manage mood and behavior in children ... have a very undesirable risk-to-benefit ratio.
The so-called “serotonin reuptake inhibitors,” long in use for the management of depression and anxiety (Prozac, Zoloft, etc.) in fact have very little scientific basis for their action. They are routinely given for anxiety and depression, particularly in children who suffer various types of posttraumatic stress disorder from abusive homes, injuries, medical conditions, and other factors. There is very little validated evidence that they are safe or effective in children. In fact, there is a boxed warning regarding both homicidal and suicidal ideations on several of these drugs that are commonly used. A recent expose disclosed that a majority of mass shootings have been perpetrated by individuals taking these drugs. The breathtaking element here is the utter lack of scientific scrutiny for safety and efficacy, particularly when given on a long-term basis (longer than six months).
Trends in diagnoses
Another overriding concern is the growing number of individuals using these medications. Much of this goes back to the publication of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in 1994. When this now-revised fourth version came out, reported rates of ADHD, autism, and childhood bipolar disorder increased dramatically, largely because of the then-new DSM definitions. Some have called this “diagnostic inflation,” a phenomenon that is strongly promoted by pharmaceutical companies in concert with the psychiatry profession and those who write the DSM revisions. As soon as an illness is codified this way, spending for pharmaceutical solutions skyrockets.
The current DSM-V was published in 2013, and, predictably, started a new epidemic of childhood mental disorders by introducing a new diagnosis: Disruptive Mood Dysregulation Disorder (DMDD). A recent editorial in the Journal of the American Academy of Child and Adolescent Psychiatry goes to great lengths to distinguish between ADHD, childhood manic-depressive disorder, and DMDD in order to help distinguish specific treatments that should be studied and applied in each individual illness.
What I find astonishing is that doctors are taking the advice of school employees with no medical training and writing prescriptions without demanding more evaluation by trained professionals. Arguably, it is a bit more work for the medical team to look at nutrition, specific biomarkers such as vitamin D, toxins in the environment, subtle infections including Lyme disease, and even exposure to specific frequencies of light (especially near-infrared and red light). There is scientific evidence that many of these factors are related to the prevalence of adolescents with severe mental illness.
When physicians prescribe psychotropic medications that could do harm based on a recommendation from educators, without conducting their own assessment of the child’s needs and home life or seeking a second opinion from a behavioral health specialist, the result is the current explosion of labeling and medicating—creating a situation not unlike the opioid epidemic. Parents may not have the resources to seek second opinions, or may live in areas with shortages of psychiatrists, but this follow-up would serve schoolchildren best.
Recommendations for evaluation and treatment
It was not that long ago when many practitioners failed to test children with behavioral disorders for a condition called PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections). This condition is of a neuro-immune nature, much like rheumatic fever, but the brain is the target, instead of the heart and joints. It can result in profound mood changes, night terrors, enuresis, and severe obsessive-compulsive tendencies. I have seen many children with this illness who are treated quite quickly and incorrectly with Zoloft or some similar drug with no appropriate investigation. Rarely is such detective work performed when a child is referred by a teacher to a psychiatrist for evaluation and treatment. That consultation almost always results in a prescription based solely on the educator’s assessment.
The issue is that thoroughly evaluating a child for underlying causes of aberrant behavior is simply more labor-intensive than writing a prescription. However, that should not deter physicians from finding a better way to evaluate and treat rather than contribute to yet another explosion of psychotropic drugs that are poorly studied in children—many of which can have lifelong side effects and implications. A growing number of physicians, including myself, are doing such detective work, often coming up with solutions that obviate the need to use psychotropic drugs. This needs to be encouraged, studied much more extensively, and, as a policy, prioritized as a healthier way to approach childhood neuropsychiatric problems rather than just reaching for a prescription pad.
Glenn Gruenhagen (R) represents District 18B in the Minnesota House of Representatives and served on the Glencoe-Silver Lake school board for 16 years. He owns an independent insurance agency and is a Chartered Financial Consultant and CLU. A USMC veteran, he also participated in prison ministry for 13 years.
© Minnesota Physician Publishing · All Rights Reserved. 2019
cover story One
Christopher M. Foley, MD, ABIM, has practiced internal medicine since 1979 and pioneered one of the first integrative medical clinics in the Midwest in 1995. He is a former instructor in the University of Minnesota Medical School and lecturer in the College of Pharmacy at the University of Minnesota.