Use of Psychotropic Medications for School Children

Abstract

Large numbers of school children nationwide take psychotropic drugs as treatment to manage demands for daily living. Over time and in later life, the psychotropic drug use among school children has a negative impact on quality of life. Prescription conditions for such psychotropic drugs range from general but chronic mal-adaptive behaviors to full blown psychiatric diagnoses. A societal shift from psychiatric to primary care for addressing mental issues in the family, coupled with a profit driven pharmaceutical industry lobby create a spiral effect which makes it difficult to redress children’s drug dependency and ultimately addiction. Inner city school districts, especially those serving families subsisting in sub-economic or disadvantaged conditions are most likely to suffer the hardest impact of the increasing spiral of psychotropic drugs prescriptions. Limited involvement of parents or guardians in the children’s school life creates a void for decision making on critical mental and general health care issues when same children come up for evaluations before School Based Support Teams or later on when they are already in trouble before adjudicatory panels in impartial hearings.

Studies of Psychotropic Treatment or Prescription Among Children

A recent total population register-based study within the United States performed a systematic evaluation of the psychotropic drug Benzodiozepine (BZD) in the seven-year period between 2006 and 2013. (Anna Sidorchuk, et al., 2018, Benzodiozepine Clinal Report). The study reported among its findings a 22 % increase in the prevalence of BZD dispensation in the population aged 0 to 24. (Anna Sidorchuk, et al., id). While the study found that the increase among children under 11 within the identified group was modest, there were other findings which indicated a growing trend to have prescriptions originating from non-traditional mental care centers or facilities. In that respect, the study distinguished between traditional or specialized psychiatric services and primary care or non-psychiatric specialist services. According to the study, 65% of all prescriptions from the study period came from primary care or non-psychiatric specialist service centers. (Anna Sidorchuk, et al., id).

Just as important, and according to the researchers--“most alarming”, was the finding on the prescribing patterns which indicated that a high proportion of individuals across all ages were prescribed psychotropic medication for longer than 6 months. The evidence showed long-term psychotropic medication at a rate of “every fifth child under 11 and every third adolescent.” (Anna Sidorchuk,et al., id).

When you analyze this data in the context of school children in inner city school given the prevalence of behavioral and mental health referrals for such children to primary care or non-psychiatric specialist services, the implications for the future are very frightening.

Outside the US

The increasing alarm and concern about rampant psychotropic prescriptions for children is not limited to the United States. Aprajita Dhami, et al., address this issue in the article “Psychotropic medication profile in a community youth mental health service in Australia”. (Children and Youth Service Review Journal, Vol. 90, 2018, pp 8-14). There, besides raising the caution about psychotropic medications for children, the authors observe that 60% of “young people without psychosis” received psychotropic medications. The analysis by Dhami, et al, posited that internationally, “around one in four young people experience symptoms of mental illness,” (Dhami, et al., p 8, quoting Lawrence et al., 2015; Mission Australia, 2017; Mojtabai, Olfson, & Han, 2016; UK National Health Service, 2016). The connection which these authors seek to draw in their article is that when children are exposed at an early age to long term psychotropic drug prescriptions, that sets them on the path to developing actual symptoms of mental illness, even though the antecedent reasons for prescription may not be have been a psychiatric diagnosis.

Dhami, et al., have not been alone in sounding off the alarms. In a much earlier study conducted at Dallhouse University Psychiatry Department in Canada, C. Binder and V. Kusumakar explored the attitudes of family physicians, pediatricians, and child psychiatrists towards the treatment of children with disruptive behavior disorders using with psychotropic medications. The study sorted disruptive behaviors along a continuum that went from “(1) uncomplicated attention deficit hyperactivity disorder (ADHD), (2) ADHD with disruptive disorders (DBD), and (3) DBD without ADHD.

While the results from this study were not uniform, the study concluded that “a significant number of pediatricians, child psychiatrists and family physicians in Canada need more education about existing and new evidence of efficacy and safety of psychotropic and psychosocial treatments, and training in the practical use of these treatments in routine clinical practice in children with ADHD and DBD.”

Whether in the United States, Australia, Canada or any other part of the world, that does not change the likelihood that the financially stressed or economically disadvantaged sectors of communities are among those most vulnerable to overprescription among children. Tending to worsen the problem is a confluence of factors relating to family structure and socio-economic background on the one hand, and the influence and power of the pharmaceutical industry lobby.

Impact of family structure and socio-economic background

In a recent study conducted by Eirini Florini and others, the group investigated how disadvantaged socio-economic family background affected development of ADHD and similar behavior disorders among school children. The researchers cautioned against the use of that study to discount the genetic or heritability factors which are well documented and confirmed in other research (Florini, et al., p732). Nonetheless, their study developed the understanding of the role played by the environmental factors such as economic disadvantage in a child’s family. (Florini, et al., id).

The correlation between economic disadvantage for the family and mal-adaptive behavior for the children is, while it is never a given fact, is not a difficult mental leap. Studies show that, especially in inner cities for large and sprawling metropoli such as New York City, severe economic disadvantage often goes hand in hand with depression, substance abuse, and crime. Again there is not a single study to establish that poverty or economic struggle necessarily translates to a prevalence of these social ills: there simple exists a significant correlation. So, not surprisingly, Florini et al.’s study came to the conclusion that “family socio-economic disadvantage puts children with ADHD at an increased risk of developing emotional and conduct problems.” (Florini, et al., p. 730).

Florini et al and similar studies contributes to the understanding of overprescription of psychotropic drugs among school children especially those with ADHD and similar behavioral problems. The same parents who suffer economic disadvantage, depression, substance abuse and mental issues are the ones most likely not to be critical about, or to fight and resist prescription of psychotropic drugs to control or regulate the behavior of their school-going children. The moment for parents to make that decision is at an evaluation conference in an office of their primary care provider after a child was referred for behavioral problems either at the parent’s initiative or through complaints from the school. The parent will often not be prepared to ask the right type of questions to fully investigate about the appropriateness or long term effects of the prescription of a psychotropic drug to manage the child’s undesirable behaviors. To the contrary, the ethics of such conduct notwithstanding, some parents are relieved to get a psychotropic prescription for their child.

Impact of Pharmaceuticals

The pharmaceutical industry invests a lot of resources in making sure that they have a ever growing market for the psychotropic stimulants which are predominantly used to treat ADHD and related anxiety ills among school children. While itself “not a psychotic diagnosis, antidepressants and atypical antipsychotics specifically sertaline and risperidone are utilized as the most common non-ADHD therapies in the pediatric Medicaid population.” (Xinyue Liu, et al., Psychotropic drug utilization in children with concurrent attention-deficit/hyperactivity disorder and anxiety, p. 536).

The ethics question which begs asking is how do pharmaceutical drugs specially designed to treat conditions that belong to the psychotic end of the spectrum under the Diagnostic and Statistical Manual of Mental Disorders end up being used to treat school age children who do not have such diagnoses? This paper obviously does not allow for a full discussion of political power and monetary influence dynamic between the pharmaceutical industry lobby, politicians in Washington, D.C., and the every increasing number of non-psychiatric primary service providers burdened with dispensing the drugs put at their office steps by aggressive pharmaceutical drug manufacturers.

Pros for Psychotropic Treatment for Children

The use of psychotropic drugs for treatment of children in not without supporters. To be sure there is extensive literature and research which justifies their use among school children. On a practical level, when students a diagnosed with ADHD and other concommitant behavioral disorders, they can be extremely impulsive, and or have aggressive tendencies, and or exhibit acute oppositional defiant behaviors, all of which are very unpleasant to deal with at home in the classroom.

Irene Joy et als., describes the condition as follows: “patients with ADHD are often classified as (1) predominantly hyperactive-impulsive, (2) predominantly inattentive, and (3) combined type. (Progress in Neuro-Psychopharmacology and Biological Psychiatry, Vol 88, Jan 2019, pp. 311-319). When the parent at home or the teacher in the classroom can bring that child to settle down and relax or focus for half a day or longer, it bring mental relief to the parent, the teacher, and arguably the child as well. Thus popularity of psychotropic drugs such as Methylphenidate, commonly known as Ritalin and Dopamine is, in a way, not misplaced. (See, e.g., C. J. Jordan and S. L. Anderson, Encyclopedia of Neuroscience, 2009, pp 625-631).

Conclusion

There has been a significant increase in the use of psychotropic prescriptions to treat behavioral disorders among children of school going age. Several factors come into play to perpetuate the continuance of this practice globally. Although not exclusively, evidence based on studies indicates that the impact of that practice tends to disproportionately affect school children from economically disadvantaged backgrounds such as we find in the inner city schools of the City of New York. The problem is, however not regional or limited to certain demographics or races, but instead a global issue. Pharmaceutical industry’s power and influence also comes to play when studying the contributing factors to this problem, but no single factor requires to be seen or studies in isolation as the problem is, because of its ethics components, a large one that require care and attention to fully address.

References

1. Anna Sidorchuk, Kayoko Isomura, Yasmina Molero, Clara Hellner, Paul Lichtenstein, Zheng Chang, Benzodiazepine prescribing for children, adolescents, and young adults from 2006 through 2013: a total population register-linkage study. Clinical Report (Education & Treatment of Children, Aug. 2017, Volume 40, p. 425+.)

2. Aprajita Dhami, Dominiek Coates, Psychotropic medication profile in a community youth mental health service in Australia. (Children and Youth Service Review Journal, Vol. 90, 2018, pp 8-14).

3. Lipschultz J, Wilder D, Behavioral Assessment and Treatment of Noncompliance: A Review of the Literature. (Education & Treatment of Children, May 2017, Vol 40. Iss. 2, p. 263-297)

4. C.Binder, V. Kusumakar, Physican attitudes towards psychotropic treatment for children with disruptive behaviors and ADHD. (European Neuropsychopharmacology Journal, Vol. 12, Sup. 3, Oct 2002)

5. Eirini Flouri, Emily Midouhas, Alexandra Ruddy, Vanessa Moulton, The role of socio-economic disadvantage in the development of comorbid emotional and conduct problems in children with ADHD. (Eur Child Adolesc Psychiatry Vol. 26, Jan 2017, pp 723-732)

6. Xinyue Liu, Paul Kubilis, Dandan Xu, Regina Bussing, Almut G. Winterstein, Psychotropic drug utilization in children with concurrent attention-deficit/ hyperactivity disorder and anxiety. (Journal of Anxiety Disorders, Vol. 28, Issue 6, Aug. 2014, pp 530-536)

7. C.J. Vaidya, P.S. Lee, Attention Deficit Hyperactivity Disorder (ADHD): Methylphenidate (Ritalin) and Dopamine. (Reference Module in Neuroscience and Behavioral Psychology, 2017, pp 625-631

8. Lembke A, Papac J, Humphreys K. Our other prescription drug problem. N Engl J Med. 2018; 378 (8) 

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