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Understanding the agreements and controversies surrounding childhood psychopharmacology
Erik Parens and Josephine Johnston
Erik Parens parense@thehastingscenter.org
The Hastings Center, 21 Malcolm Gordon Road, Garrison, New York 10524, USA
an excerpt:
As Benedetto Vitiello observed, we can all agree that, to the extent that medicalizing childbirth saves the lives of women and children, it is good; similarly, we can agree that labeling political dissenters as mentally ill (a form of medicalization that occurred in the former Soviet Union) is bad. It was religious studies scholar, Sidney Callahan, who articulated the group's widely shared view that we need to get clearer about the difference between "good" and "bad" forms of medicalization.
As Benedetto Vitiello observed, we can all agree that, to the extent that medicalizing childbirth saves the lives of women and children, it is good; similarly, we can agree that labeling political dissenters as mentally ill (a form of medicalization that occurred in the former Soviet Union) is bad. It was religious studies scholar, Sidney Callahan, who articulated the group's widely shared view that we need to get clearer about the difference between "good" and "bad" forms of medicalization.
Again, though, different WPs emphasized different points. Psychiatrist John Sadler, for example, argued that medicine's primary focus should be to treat non-moral problems and that other social institutions (education, religion, criminal justice) should address the moral problems that too-often have crept into DSM's and psychiatry's ambit (e.g., Conduct Disorder): As he put it, "The mental health field should draw stricter boundaries between mental disorders and vice." Sadler believes that, as we define more and more moral problems as medical problems, we confuse the public about what he takes to be the fundamental difference between "badness" and "madness," between wrongful or criminal conduct and mental illness. Philosopher Bonnie Steinbock suggested that, whatever the conceptual difficulties with the distinction between "bad" and "mad," it would be pragmatically impossible to give it up entirely, since a criminal justice system requires us to be able to distinguish between criminal behavior – which is generally deserving of punishment – and behavior that, because it is the product of mental disorder, may not be deserving of punishment.
Some WPs, however, emphasized that we should use medicine if it helps achieve our aims, regardless of whether those aims are traditionally within the purview of medicine. Along the lines of psychiatrist Michael First above, psychiatrist Benedetto Vitiello argued: "Our society has decided that pain, suffering, murder, aggression are bad. Getting along with others, respecting the law are good. And these are the same values that medicine has to pursue. In some ways it's irrelevant if disorders are classified as illness or vice." here
It would be funny if it weren't so tragic...
Can the psychiatric profession engender respect for the law without demonstrating that respect for the law is valued by the psychiatric profession? Psychiatrists have been active and a passive participants in a vast criminal enterprise. Participating in illegal marketing, research fraud, and then defrauding the American people of billions of dollars through the publicly funded Medicaid program, while using fraudulent claims as a means to coerce "treatment compliance." Psychiatrists have been misinforming patients, parents of children with behavioral and emotional difficulties and the general public about what is and is not known about mental illnesses; and were dishonest about the serious and even fatal risks of the psychotropic drugs they prescribe. Although the drugs are effective for some people, it does not justify prescribing dangerous drugs without significantly benefits to offset the serious risks.
The massive amount of illegal marketing and Medicaid fraud would never have been possible without the complicity of the NIMH, the APA and the AACAP; particularly the individual psychiatrists who ignored the standards for scientific research, medical ethics, i.e. duty to do no harm; when implementing treatment protocols and algorithms that are then marketed as "evidence-based" Standards of Care. The standards of care recommend the drugs being illegally marketed simultaneously.
The standards of care facilitate fraud.
The widespread dissemination of psychiatry's treatment standards may be WHY so many children are being drugged for emotional and behavioral issues. FDA approved or off-label prescriptions how did the drugs recommended in treatment algorithms, practice paramenters and clinical care standards, become "standard" without robust evidence?
Abuse, neglect, poverty, trauma and violence all exacerbate and cause emotional and behavioral problems. Problem behaviors are often misguided attempts to meet unmet needs, a tauma reaction, or attempts to cope with traumatic harm.
Pills can't fix poverty, pills do not prevent or treat the effects of malnutrition, pills do not heal traumatic injuries, pills do not give children the attention, concern, and compassion they deserve, or the consistent respectful guidance they require. Some may believe that psychopharmacological treatment helps children cope with the adverse effects of environmental and social stressors and the negative emotional and behavioral impact on children; there is no evidence that this is the case. Researchers may pursue a pill that can treat children's emotional and behavioral symptoms with environmental causes; but would such a pursuit be a political endeavor not a medical one.
Would it be ethical? I think not...
Video: Hastings researchers Erik Parens and Josephine Johnston introduce their report on children and psychiatry
More and more children in the United States receive psychiatric diagnoses and psychotropic medications — this is not news. With those increased rates of diagnosis and pharmacological treatment come sometimes intense debates about whether those increases are appropriate, or whether healthy children are being mislabeled as sick and inappropriately given medications to alter their moods and behaviors.
- Why have the numbers of children diagnosed and treated increased, and what does this increase mean?
- Are children being overmedicated?
- Are sick children getting the care they need?
To better understand theses controversies, The Hastings Center, an independent bioethics research institution, with a grant from the National Institute of Mental Health, conducted a series of five workshops over the course of three years that brought together clinicians, researchers, scholars, and advocates from a variety of disciplinary backgrounds with widely diverse views. In this report, we will describe many of the complexities, paying close attention to the ineradicable role that value commitments play not only in decisions about the appropriate modes of treatment, but also in diagnosis.
Erik Parens and Josephine Johnston, “Troubled Children: Diagnosing, Treating, and Attending to Context,” Special Report, Hastings Center Report 41, no. 2 (2011).
Acknowledgements
We are deeply grateful to Alison Jost for her research assistance.
Workshop participants (institutional affiliations are in USA unless otherwise noted) were the authors, Erik Parens and Josephine Johnston, and:
Marcia Angell, Senior Lecturer in Social Medicine, Department of Social Medicine, Harvard Medical School;
Sidney Callahan, Distinguished Scholar, The Hastings Center;
William B. Carey, Clinical Professor of Pediatrics, University of Pennsylvania School of Medicine, Division of General Pediatrics, The Children's Hospital of Philadelphia;
Carol Caruso, Board of Directors, National Alliance on Mental Illness;
Peter Conrad, Harry Coplan Professor of Social Sciences, Department of Sociology, Brandeis University;
Elizabeth Jane Costello, Professor of Psychology, Duke University Medical Center;
Jörg Fegert, Professor and Chair of Child and Adolescent Psychiatry and Psychotherapy, University of Ulm, Medical Director of the Department of Child and Adolescent Psychiatry and Psychotherapy, Ulm University Hospital, Germany;
Michael B. First, New York Psychiatric Institute, Department of Psychiatry, Columbia University;
Sara Harkness, Professor of Human Development, Pediatrics & Anthropology, Director, Center for the Study of Culture, Health, and Human Development, University of Connecticut;
Steven E. Hyman, Provost, Harvard University, Professor of Neurobiology, Harvard Medical School;
Peter S. Jensen, Professor of Clinical Psychiatry, Columbia University, Research Psychiatrist, New York State Psychiatric Institute;
Kelly J. Kelleher, Professor of Pediatrics, Public Health, and Psychiatry, Colleges of Medicine and Public Health, and Department of Psychiatry, The Ohio State University, Vice President for Health Services Research, Director, Center for Innovation in Pediatric Practice, Columbus Children's Research Institute;
Julia Kim-Cohen, Assistant Professor, Department of Psychology, Yale University;
Roy P. Martin, Professor Emeritus, Department of Educational Psychology, University of Georgia;
Jon McClellan, Associate Professor, Department of Psychiatry, University of Washington;
John Z. Sadler, Daniel W. Foster Professor of Medical Ethics, Professor of Psychiatry & Clinical Sciences, Director, UT Southwestern Program in Ethics in Science and Medicine, Director, Center for Values in Medicine, Science, & Technology The University of Texas at Dallas, Co-Editor:Philosophy, Psychiatry, & Psychology, Department of Psychiatry, University of Texas Southwestern;
Kenneth F. Schaffner, University Professor of History and Philosophy of Science, Professor of Psychiatry, University of Pittsburgh;
Ilina Singh, Wellcome Trust University Lecturer in Bioethics and Society, London School of Economics and Political Science, United Kingdom;
Bonnie Steinbock, Professor, Department of Philosphy, University at Albany/SUNY;
Charles M. Super, Professor of Human Development and Family Studies, Co-Director, Center for the Study of Culture, Health, and Human Development, University of Connecticut;
Benedetto Vitiello, Chief, Child & Adolescent Treatment & Preventive Intervention Research Branch, National Institute of Mental Health;
Julie Magno Zito, Associate Professor of Pharmacy and Psychiatry, University of Maryland.
Funded by grant U13 MH78722 of the National Institute of Mental Health to the Hastings Center (Principal Investigator: Erik F. Parens, Ph.D.)
