From the NIMH Director's Blog
The National Institute of Mental Health
By Thomas Insel
June 6, 2014
A recent symposium at the Carter Center featured a report by the Centers for Disease Control and Prevention (CDC) that as many as 10,000 toddlers may be receiving psychostimulant medication, like methylphenidate (Ritalin). (1) The media reports of this, like many past reports, decried the overmedication of children. The numbers are notable.
The latest estimate from the National Center for Health Statistics reports that 7.5 percent of U.S. children between ages 6 and 17 were taking medication for “emotional or behavioral difficulties” in 2011-2012. (2) The CDC reports a five-fold increase in the number of children under 18 on psychostimulants from 1988-1994 to 2007–2010, with the most recent rate of 4.2 percent. (3)
The same report estimates that 1.3 percent of children are on antidepressants. The rate of antipsychotic prescriptions for children has increased six-fold over this same period, according to a study of office visits within the National Ambulatory Medical Care Survey. (4) In children under age 5, psychotropic prescription rates peaked at 1.45 percent in 2002-2005 and declined to 1.00 percent from 2006-2009. (5)
Taken together, what do these numbers mean? A common interpretation: children with behavioral or emotional problems are being overmedicated by psychiatrists too busy to provide therapy, at the request of parents too busy to provide a healthy home environment.
A corollary of this interpretation is to blame schools too busy to provide recess or activities for fidgety boys. And usually the blame extends to the pharmaceutical companies that market medications in pursuit of profits.
While blaming psychiatrists, parents, schools, or drug companies might seem legitimate, some of the facts just don’t fit. First, most of the prescriptions for stimulant drugs and antidepressants are not from psychiatrists. (6) In fact, outside of a few major cities, families in much of the nation have very limited access to child psychiatrists.
Blaming parents is easy, but as Judith Warner argues in her book, We’ve Got Issues, most parents resist medication rather than request it. (7) Schools in many parts of the country have reduced unstructured time, but the increase in medication is now seen in toddlers, years before children begin school. And drug companies, while frequently maligned, have reduced, not increased, their marketing budgets in the US. (8)
If psychiatrists, parents, schools, or drug companies are not the culprit, who is?
The answer is potentially more complicated and more worrisome. Is it possible that the increased use of medication is not the problem but a symptom? What if more children were struggling with severe psychiatric problems and actually the problem was not over-treatment but increased need?
Surely, if we discovered more children were being treated for diabetes or immune problems, we wouldn’t blame the providers or the parents. We’d be asking what drives the increase in incidence. And, there actually are large increases in the incidence of Type I diabetes and food allergies. (9, 10, 11)
Skepticism regarding increased rates of emotional and behavioral difficulties as opposed to increases in other medical disorders can be attributed in part to the absence of biomarkers or laboratory tests for psychiatric diagnosis comparable to glucose tolerance tests for diabetes or anaphylactic reactions for allergies. Absent these kinds of consistent, objective measures for mental disorders, we cannot distinguish between a true increase in the number of children affected or simply changing values or trends in diagnosis.
Clearly, context matters. What one parent might consider hyperactivity, another parent might consider healthy exuberance. What physicians once called attention deficit hyperactivity disorder (ADHD), often now elicits a diagnosis of childhood bipolar disorder, leading to a 40-fold increase in prevalence from 1994-1995 to 2002-2003. (12)
No question, in a field without biomarkers, there is a risk of over-diagnosis. No question, subjective diagnosis could invite unnecessary treatment and over-medication. But what if the increased use of medication reflected more children with severe developmental problems and more families in crisis? What if the bigger problem is not over-medication but under-treatment?
Hearing that 7.5 percent of children are on medication (4.2 percent on psychostimulants) seems stunning, but knowing that 11 percent of children have a diagnosis of ADHD raises a possibility of under-treatment.
In fact, evidence from nationally representative surveys of youth in the U.S. challenges recent concerns regarding widespread overmedication and misuse of medications, at least in adolescents. (13, 14, 15) Among those with current mental disorders, only 14.2 percent of youth reported psychotropic medication use, and the majority who had been prescribed medications had a mental disorder with severe consequences, functional impairment, suicidality, or associated behavioral or developmental difficulties.
In light of the evidence that about 1 in every 12 youth suffer from a severe developmental, behavioral or emotional disorder, under-treatment remains a serious problem.
Of course, the problem may be both over-treatment and under-treatment. It is possible that children with issues that would be resolved by psychotherapy alone are receiving medication. It seems very likely, given the data in adolescents, that many who would benefit from medication and psychotherapy are receiving neither intervention.
It is also worth considering that the rates of childhood mental disorders could be stable, but that more children are getting the treatment they need and, for many, detection and intervention is at an early age. If it is your child suffering acutely from anxiety, autism, anorexia, or depression, the problem is certainly not over-treatment. The CDC report showed that parents of more than one-half of those children who used a prescribed medication for emotional or behavioral difficulties had reported that this medication helped the child "a lot.” (16)
What I hear from families in crisis is lack of access, poor quality care, and a desperate need for answers. In the media reports on over-medicating children, this perspective is missing. The possibility that there is a real increase in the number of children suffering with severe emotional problems, just as there is a real increase in the number of children with diabetes and food allergies, is not even considered.
Shouldn’t we be asking why so many children, at younger ages, are being seen for emotional and behavioral problems?
1 Schwartz A. Thousands of Toddlers Are Medicated for A.D.H.D., Report Finds, Raising Worries. New York Times, May 14, 2014.http://www.nytimes.com/2014/05/17/us/among-experts-scrutiny-of-attention-disorder-diagnoses-in-2-and-3-year-olds.html
2 Howie LD, Pastor PN, Lukacs SL. Use of medication prescribed for emotional or behavioral difficulties among children aged 6-17 years in the United States, 2011-2012. NCHS Data Brief. 2014 Apr;(148):1-8.
3 National Center for Health Statistics. Health, United States, 2013: With Special Feature on Prescription Drugs. Hyattsville, MD. 2014.
4 Olfson M, et al. National trends in the office-based treatment of children, adolescents, and adults with antipsychotics. 2012 Dec;69(12):1247-56.
5 Chirdkiatgumchai V, et al. National trends in psychotropic medication use in young children: 1994-2009. Pediatrics. 2013 Oct;132(4):615-23.
6 Olfson M, et al. Trends in office-based mental health care provided by psychiatrists and primary care physicians . J Clin Psychiatry. 2014 Mar;75(3):247-53.
7 Warner J. We’ve Got Issues: Children and Parents in the Age of Medication. 2010. Riverhead Books, New York.
8 FiercePharmaMarketing. (2014). CEGEDIM STRATEGIC DATA: Worldwide Pharma Industry Marketing investment flat in 2013. [Press release]. Retrieved from http://www.fiercepharmamarketing.com/press-releases/cegedim-strategic-data-worldwide-pharma-industry-marketing-investment-flat
9 Dabelia D, et al. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. 2014 May 7;311(17):1778-86. doi: 10.1001/jama.2014.3201.
10 Clark S, et al. Frequency of US emergency department visits for food-related actue allergic reactions. J Allergy Clin Immunol. 2011 Mar;127(3):682-3.
11 Branum AM, Lukacs SL. Food allergy among U.S. children: trends in prevalence and hospitalizations. NCHS Data Brief. 2008 Oct;(10):1-8.
12 Moreno C, et al. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007 Sep;64(9):1032-9.
13 Merikangas KR, et al. Medication use in US youth with mental disorders. JAMA Pediatr. 2013 Feb;167(2):141-8.
14 Hacker K, et al. Referral and follow-up after mental health screening in commercially insured adolescents. J Adolesc Health. 2014 Feb 11. pii: S1054-139X(13)00832-X.
15 Jonas BS, Gu Q, Albertorio-Diaz JR. Psychotropic medication use among adolescents: United States, 2005-2010. NCHS Data Brief. 2013 Dec;(135):1-8.
16 Howie LD, et al, op. cit.