Some public health fads, sensationalized by the media, come and go rather quickly. Others take root and significantly change the way Americans view the health and wellness needs of their children. Take, for example, wisdom teeth extraction. You’ve probably heard the old tale that because wisdom teeth cause all sorts of problems, young people should have them extracted as a preventive measure. After close examination of the evidence, you will find that this simply is not true. According to an article in the American Journal of Public Health, wisdom teeth extraction is a public health hazard and should be avoided (Friedman,1554). Wisdom teeth extraction, however, continues to be a big money maker for the dental industry at around a billion dollars a year.
Another public health fad that has changed American culture, became a public health hazard and continues as a big money maker for the behavioral health industry: using psychostimulants to treat hyperactivity and inattentiveness in children. Yet, hyperactivity and inattentiveness are expected behaviors of an undeveloped brain and do not necessarily indicate ADHD (attention deficit hyperactivity disorder). Over the last twenty years America’s children, some diagnosed with ADHD and some only presenting associated symptoms, have been prescribed stimulants at increasing and alarming amounts.
Since 1990, the number of America's children taking stimulants has soared from 600,000 to about four million (Safer, 1084). These numbers which appear to represent a burgeoning ADHD epidemic actually only reflect the pharmaceutical companies’ marketing skills.“Big pharma” moved into a booming children’s market by funding multiple studies that show psychostimulants to be the most efficacious treatment for ADHD in kids. According to analysis of CDC data, ADHD is now one of the most frequent long term diagnoses of children.
Funded by pharmaceutical companies, the prominent Harvard child psychiatrist, Dr. Joseph Biederman, produced multiple research articles embracing the use of stimulants in children. Dr. Biederman has been called by other physicians, “unequivocally the most published psychopharmacology maven for ADHD.” Frequently cited by pharmaceutical representatives, his work delivers three messages: ADHD is underdiagnosed, stimulants are safe and effective treatment for ADHD, and unmedicated ADHD poses significant risks. Although investigated by Congress and sanctioned by Harvard for conflict of interest violations, Dr. Biederman has produced research that has drastically changed the way American physicians both diagnose ADHD and treat ADHD with psychostimulants in children.
Stimulants will indeed make an inattentive child pay attention. Parents almost overnight will see an improvement in school work. Teachers, who previously called daily about a disruptive child, stop calling. For a few months, the medication works like a miracle pill. Gradually the calls start again as behavior slips back to what is was before the start of medication. Another trip to the doctor and the dose is increased due to a phenomenon known as “tolerance,” repeated use that results in diminished returns. Dosage is increased gradually over months to the maximum recommended, but even at levels this high, tolerance continues to reduce efficacy. The child is later switched to a different stimulant in a different class and once again the dosage climbs the tolerance ladder. It is not uncommon for me to evaluate a child and hear the caregiver state, “Oh, my child has tried every medicine there is for ADHD.”
The long term impact of stimulants on the developing brain of a child is unknown. Pertinent unanswered questions include the following:
1. How does the stimulant affect dopamine (a neurotransmitter which neurons use to communicate with each other)?
2. Does the stimulant increase the risk for a substance abuse disorder later in life?
3. Will the stimulant affect a child’s physical growth?
Presently, no one can supply precise answers to these questions for few long-term studies addressing them have been completed.
Certainly, ADHD is a real disorder. Its existence has been supported by sound scientific research. It legitimately disables those who suffer from it at school and in their interpersonal relationships. Since no definitive test exists, final interpretation of symptoms is left up to the diagnosing clinician. Rating scales should be completed by parents and teachers before and throughout the management of a child’s treatment with stimulants for ADHD. Examples of these scales include the Conners’ Parent Rating Scale, the Conners’ Teacher Rating Scale and the Child Behavior Checklist.
A ten-year-old patient, whom I will refer to as John, was doing a lot better in school after nine months on stimulant medication. Concerned about potential side effects, his mom asked that his medication be tapered down and discontinued. After three months off medication, John was failing subjects again, and he was no longer getting invited to birthday parties. Because of the decline in his academic performance and in his social standing, John’s self esteem also took a blow. For children who legitimately have ADHD, stimulants may be a necessary risk to advance academically and to maintain social relationships. Their use, however, but must be carefully considered and closely monitored.
An increasing number of parents are seeking to have their children evaluated for ADHD. Poor grades, absent mindedness, and class disruption are now being used as grounds for a stimulant prescription rather than a diagnosis of ADHD based on more objective data such as rating scales or direct observation. The pharma advertising leaves physicians reasoning that if a stimulant helped children with ADHD, then perhaps it can also help children without ADHD who are struggling with the same issues. Physicians will claim to be uninfluenced by pharmaceutical marketing, but years of research, however, suggest otherwise. We are all influenced by advertising and other social pressures to at least some degree.
The FDA has cited “big pharma” for false and misleading advertising regarding the use of stimulants many times. Shire, a leading producer of stimulants, has gone as far as subsidizing the production of comic books that market directly to children. On these pages, superheroes encourage children to take medicine to control their behavior. Given the high abuse potential of stimulants, regulations that allow such marketing does not afford enough protection. Instead, direct consumer marketing of controlled substances, especially to children, should be illegal.
Many risks are involved in the use of stimulants. The FDA has labeled stimulants with a black box warning (their strictest warning) because of their high abuse potential, cardiovascular complications, and association with sudden death. Other side effects include loss of appetite, weight loss, insomnia, irritability, anxiety, abnormal involuntary movements, and hallucinations. Children frequently require additional medications just to address the side effects associated with stimulants.
I evaluated a child in the emergency room of a large pediatric hospital for hallucinations. The seven-year-old girl, whom I will call “Sarah,” stated tearfully, “I feel bugs crawlin’ on me! Look! See!” Despite her mom’s reassurance that she didn’t have bugs on her, Sarah continued to talk incessantly about them. The worried mother brought Sarah to the emergency room. The emergency physician examined her carefully and found no bugs and no evidence left by any bugs. Her mother stated that Sarah had started taking a stimulant, Adderall XR, about three weeks prior.
The diagnosis that I wrote in Sarah’s chart that night was “stimulant-induced psychotic disorder.” Sarah’s mother was instructed to discontinue Adderall as it was the likely cause of the Sarah’s psychosis which had manifested as visual hallucinations (seeing bugs) and tactile hallucinations (feeling bugs). Methamphetamine (the illicit substance sold by drug dealers) and Dextroamphetamine (the primary substance in many ADHD meds) differ in only one molecule. This molecule allows methamphetamine to act faster and stronger, but both types of amphetamine do the same thing: They increase the amount of dopamine available to neurons in the brain. It might appear confusing to give a stimulant to a child who already appears overly stimulated. However, the areas of the brain that control attention are, in fact, stimulated by the increased dopamine, thus allowing a child with ADHD to have more focus.
Pediatricians and family practice doctors are the ones who write most stimulant prescriptions despite being much less educated on diagnosing and treating ADHD. Managed care companies further restrict access to child psychiatrists by refusing reimbursement for visits to specialists. Clearly, stimulants are being prescribed to children who do not have ADHD. Stimulant overuse is a serious public health concern that poses significant and unnecessary risks to the safety of America’s children.
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