Rob: Starting with stimulants, and if you could give a bit of the history of how the...it's not just the drugs, it's also the diagnosis that is part of the problem...a big part of the problem. So if you can give a bit of the history and background that has led to over 2 million children being on stimulant medication...or it's even more than that now.
RW: Well I think it is over...I think it's around 2 million, maybe a little bit more. I'm not quite sure of these numbers...the numbers sometimes are a little bit...depending on which source you use. But let's...it's a number, okay...it's an extraordinary number. So how did this happen? And I think, by the way, that this is a topic if you wanted to list the topics of...which should be at the top of our list as a society as a moral concern, I think this is number one, personally. I think medicating of children is such a national moral question, an ethical question -- we should be having congressional hearings and the society as a whole should be saying -- is this a good thing to do?
So let's start with the stimulants. You know, if you go back, basically, as early as the 1930s...late 1930s, which is when amphetamines were first synthesized, you know, college students began using them to stay up at night and study. But they were...when they were given to kids at a small, sort of, facility for disturbed kids with maybe even some organic brain dysfunction, it was found that it would quiet those kids...it would sort of still their behaviors for whatever reason. And so there was some sense that maybe we can use stimulants for severely disturbed kids to sort of quiet them a little bit, and maybe it would help them focus on schoolwork. So when it was first used in this setting...child setting -- I think it was in Wisconsin...
Rob: Wait, wait, wait...
RW: What's that?
Rob: You used the term organic brain function as a diagnosis...
RW: Dysfunction -- organic brain dysfunction. In other words there was a thought that these kids had a real neurological problem, a very small percentage of kids. This was the thought in the early 1930s/1940s.
Anyway going forward -- and I can jump forward here, and I really should jump forward -- up until, you know, thorough the 60s, kids were not being medicated because there was a thought that it was too dangerous to be giving kids psychotropic drugs, alright? And Ritalin got introduced initially for...to help people stay awake, if I remember, as a treatment for narcolepsy in adults. But then in the 1970s they began...there was a little bit of use of...the thought was -- Okay, we'll use stimulants...and I think that the term was minimal brain dysfunction -- kids that are really agitated in class and, again, the idea was here that there's a small, small group of kids that may have something organically wrong and maybe we'll use these drugs to help quiet them in class and still their movement.
Then in 1980 there was what opens the floodgates to really using stimulants in a big fashion. And what happens is in DSM-III -- this is the Diagnostic and Statistical Manual prepared by the American Psychiatric Association meeting -- and in DSM-III they said, let's create a manual that basically uses the medical model for psychiatric disorders, and we'll say that these are brain disorders and therefore they need, basically, drug treatments much like insulin for diabetes. Well when they did...in 1980 when they did this new manual, they identified Attention Deficit Disorder as a discrete disorder for the first time, so that now enters the national, sort of, consciousness...Attention Deficit Disorder; and once they have that as a medical disorder -- meaning any kid that is fidgeting too much in class and just isn't paying enough attention -- is now said to be, you know, have a psychiatric condition and how are you going to treat that....you're going to treat that with a stimulant. So this opened the floodgates to (a) a new disorder to be treated with stimulants in a wide percentage of people, a broad percentage of people, particularly boys; and then by 1987 that got redefined as Attention Deficit Hyperactivity Disorder, and that further sort of expanded the boundaries of who should be treated with stimulants.
Now going a step forward, at the same time, the drug companies are starting to become very good at marketing things...helped fund a group called CHADD -- and I forget exactly what that acronym stands for -- but they help fund it and CHADD becomes a mechanism for informing the public and getting out marketing materials saying this is a real disease, it's a brain disease, it's caused by a chemical imbalance -- and even though there had been no sign that it...there was no understanding of any sort of pathology underlying this diagnosis at all...and that these kids needed to take amphetamines like insulin for diabetes -- so the marketing machinery began to crank up.
So this is how we got this explosion of stimulant use in the 1980s, and continued in the 1990s. Now what's interesting is as that happened, were they finding that this was really helping kids? Well they would find that over the short term that the use of stimulants would help kids...they would quiet kids, it would still their behaviors in class, so that meant that kids behavior was more, sort of, acceptable to the teacher in that classroom setting. But they were having a hard time finding as they did even short term studies that it was helping the kid in any way. So were they finding that it was really helping the kid do better in, sort of, in his studies -- getting better grades? No. Did it help them socialize better? No, in fact they would find that the kids tended to become a little bit isolated. How about their sense of self? Well they found that kids said -- Oh I must be a little bit defective if I have this disorder...I'm not quite normal. So that was even bad a little bit for the self-image. How about in terms of creative thinking, creative problem solving -- did they find stimulants helped that? No, they did not. So they weren't really finding, time and time again, that this medication was helping the kids.
Now going forward a little bit on this efficacy story....in the early 1990s, the NIMH, that's the National Institute of Mental Health, says -- Wow, we really don't have any evidence that this is helping kids at the long term...over the long term at all, so let's mount a long term study. It was called the MTA study and the NIMH said -- this is first real good study of any, sort of, child psychiatric disorder of any length of time -- so this is going to be the definitive study. Now they biased the study by design against, you know, in favor of the medication group. I'm not going to go into it but there was a huge bias in favor of the drug. Anyway, at the end of 14 months, they announced that it did seem that the drugs was providing a little bit of benefit. The "ADHD symptoms" -- this fidgetiness, this movement, sort of, maybe talking too much in class -- those ADHD symptoms did seem better in the drug treated group than in the behavioral group. And there was some sense that maybe the drug treated group was doing better on reading. So big announcement -- see, aha, we now have evidence that this helps kids over the long term. But what happened at the end of 3 years? By the end of 3 years being on drug was not a marker of benefit but a marker of deterioration. In other words, their ADHD symptoms were worse...those on medication; they actually...there was some growth suppression; there was no benefit in school at all; unfortunately we didn't hear about that result -- and now go forward at the end of 6 years what did they find? Well they found, again, there was some growth suppression, there was actually worse ADHD symptoms for the kids on medication, there was some functional impairment for the kids on medication...
Rob: What do you mean by functional impairment?
RW: Well there was some sense in terms of, you know, cognitive performance I think is what they were talking about. Unfortunately they didn't...they basically have a scale for that and they really didn't blow out in their report the things exactly what they're talking about, but it's the ability to do certain tasks whether it be homework tasks or maybe it's even some physical tasks...I'm not quite sure all of what that scale, you know, encompasses -- great question and I should know that answer.
But anyway, they weren't showing benefit, you know, greater delinquency...that sort of thing...in other words more likely to get in trouble with the police...the kids on drugs. So as William Tellam, the lead investigator from Buffalo said is we had expected that the kids on medication would do better over the long term -- we did not find that to be the case; there was no benefit, none. So if you have a form of care that provides no benefit, what you have left is all the risk with taking the medications....right? And by the way, there's been a study that was done now by Western Australia -- they also found no benefit. There was a big review of all the, sort of, studies that was done by the Oregon and Health Sciences, a group at Oregon Health Sciences School in Oregon...the state of Oregon -- they found that there's no good quality evidence that these drugs are either safe or effective for kids over the long term. So time and time again we did not find that these drugs were helping kids long term.
So the questions is then why are we still doing it? Because there are risks -- the risks are many, both sort of physical risks or growth suppression; there's a risk that kids will have a psychotic episode; risk that the kids will have a manic episode. And so for example, somewhere between 10 and 25 percent of all kids placed on stimulants today now convert to bipolar illness, and when they convert to bipolar illness because of a, sort of, drug induced psychotic episode, drug induced, sort of, mood swings every day. Now they're put onto a cocktail of drugs and they're really on a pathway to a career as a mental patient. So you see in that data alone, this capacity to do great, great harm, but no one talks about that and we're exposing kids to this risk even though our studies showed no long term benefit. And so that's part of this tragedy that is unfolding today.
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