Excerpts

CHAPTER 1 The High Cost of Labeling A terrible epidemic is sweeping our country, and it's gaining momentum at a frightening pace. It's causing our children to suffer greatly, and it shows no signs of abating. No one can predict what long-term effects this trend will have on our kids' overall quality of life, but it's clear that the cost to their health and overall well-being right now is staggering. Our kids--millions of them--are being blighted every day. Their health, their self-esteem, their ability to thrive and fit in, and their capacity for joy and success are being undermined by a crippling foe called labeling. LOST TO A LABEL Labeling is what happens when our children show signs of distress and trouble and we, the well-meaning adults in their lives, intervene. On the face of it, we do the right thing when we are able to identify the symptoms of "disease" in our children and turn to experts for help. But something curious happens when we defer--with the best of intentions--to doctors, psychologists, health care providers, educators, and other "experts" in order to help our children. Too often, the relief of symptoms becomes the sole goal of treatment, and our children wind up labeled and medicated but feeling no better. I don't mean to be the voice of doom and gloom about this, and of course, it can be useful--even crucial--to first aggressively treat the symptoms a child exhibits. What does alarm me, however, is how many of our children are being treated only on a symptomatic level and thus become lost to their labels. When this happens, the true source of the upset often remains unidentified and unaddressed. From 1987 to 1996, the number of children who were prescribed psychiatric medications in this country tripled. If this ominous trend continues, within a generation fully half of all American children will be on some kind of psychiatric drug. Everywhere you look the numbers of American children being prescribed psychiatric medications is reaching a crescendo that draws concern. In one study published in 2006, called the National Ambulatory Medical Care Survey, researcher Mark Olfson, MD, of Columbia University found that the use of psychotropic medications for teenagers increased 250 percent between 1994 and 2001. More specifically they found the proportion of physician visits resulting in a prescription for a psychiatric medication rose from 3.4 percent to 8.3 percent. Sadly, by 2001 one in every 10 office visits by a boy resulted in a prescription for a psychotropic medication. One issue that concerned the researchers was a finding that about 25 percent of the cases that involved psychotropics did not have a mental health diagnosis. "That should alert physicians to the possibility of a trend toward casual prescribing of psychotropic medications to young people," Dr. Olfson commented. Some of the most comprehensive current data comes from Medco Health Solutions (part of the drugmaker Merck). In 2004, it released its annual analysis of prescription drug users. In that report these startling facts were revealed: There was a 369 percent increase in spending on ADHD drugs for children under the age of 5 between 2000 and 2003. The number of prescriptions for autism and behavioral disorders rose by 71 percent. Spending for all psychotropics in children rose 77 percent in 3 years. Psychiatric medications for children were the fastest-growing prescriptions. Express Scripts Inc. published the results of 5 years of study in 2004. These findings are no different: The use of antidepressant medications rose 100 percent in preschool girls and 64 percent in preschool boys (all kids under the age of 5). The Archives of General Psychiatry published a study in 2006 that showed a sixfold rise in the use of antipsychotic medications in children between 1993 and 2002. Anywhere from 3 to 10 percent of American children have ADHD, and this figure increases at an alarming rate each year. Why? I attribute it to a phenomenon known as diagnosis creep, which clinically captures our overwillingness to label and diagnose our children. Diagnosis creep has even been documented by the National Institute of Mental Health (NIMH). In a survey conducted from 2001 to 2003 and released in 2005, the NIMH postulated that more than 46 percent of the American population would meet the criteria used by the psychiatric industry for a mental illness. As the definitions we use for emotional and mental disorders expand, it seems inevitable that the range we allow for normalcy will shrink. In 2003, the Medco study also pointed out, 65 percent of children and adolescents taking behavioral medicines were also on antidepressants. This is one of the most frightening aspects of overlabeling: More and more kids are on two or more psychiatric drugs at a time. This is true despite there being little or no research on what the effects of combining such drugs has on children. In late 2005, Medco Health released the alarming news that the fastest-growing population of prescription sleeping pill users in this country is made up of children between the ages of 10 and 19. The number of children taking sleeping pills is up a whopping 85 percent in just 4 years, despite the fact that the FDA has approved most popular sleep aids only for use in adults. This points up one of the scariest facts of the labeling epidemic: There is no body of scientific research to prove that these drugs are safe for our children over the long term. In fact, in early 2004, the FDA insisted that manufacturers include warning labels on many antidepressants about their potential dangerous side effects, including increased risk of suicidal impulses in teens. (There is some slowdown in prescribing one category of these drugs, however. In late 2005, nearly a year and a half after drug companies were forced to include a "black box" warning on the labels of antidepressants, the number of prescriptions for antidepressants written for children dropped 20 percent.) Other commonly prescribed drugs are finally coming under similar close scrutiny. In early 2007, the FDA directed the manufacturers of stimulants-- including Ritalin (methylphenidate), Adderall (amphetamine- dextroamphetamine), Strattera (atomoxetine), and other brands--to issue guidelines alerting parents and patients to the serious risks involved in taking these medications, including psychiatric problems (hearing voices, manic behavior, and increased anxiety and suspiciousness) and heart problems (elevated blood pressure and even sudden cardiac death). These are big, serious, crucial steps in finally breaking the doctor-diagnosis-drug cycle, which will, I hope, lead to a decline in labeling. Instead of spending my time diagnosing most kids I see, I try to undiagnose them, to free them from the labels that are hurting more than helping them. I work to figure out what leads to the symptoms and the label. Paradoxically, I often have to taper kids off medications to determine what is wrong. How did we get into this situation of overlabeling our kids? I believe it's a problem of well-intentioned parenting colliding head-on with a rigid and label-oriented medical culture. Parents have kids who are suffering, and they want to find relief for them. They turn to a medical system that rewards quick diagnosis over thoughtful and reflective care and prizes the myth of "silver bullet" treatment over accurate understanding. This tendency to favor the "quick fix" is rapidly spreading into other areas of our culture, too. Look at our schools, for instance, where a child who prefers to move rather than sit still is flagged as a potential problem. Look into our homes, and you may find parents who are so temperamentally at odds with their own children that they can't resist seeing them as somehow being not quite normal. Labels, to many parents, appear at first glance to be a kind of lifeboat. Who wouldn't be relieved and hopeful when whatever ails their child is quickly and succinctly identified? But the long-term cost of labeling outweighs any short-term relief of symptoms. Instead of stopping to contemplate what brain stressors might be undermining a child's ability to enjoy emotional and mental well-being, we parents have a tendency to panic at the signs of upset in our children, to become fearful in the face of serious symptoms. When this happens, our good parental intentions go bad. How do I know this? First, I am a parent who has had to resist the urge to label my own kids whenever the going gets tough for them--or for me. Second, I am a child psychiatrist whose practice is bursting at the seams with children who have been aggressively (and often erroneously) diagnosed with and treated for major psychiatric problems but who are not getting better. Third, I speak to professional groups around the country, and I hear firsthand how frustrated and concerned my colleagues are with the current situation. Labeling our children often cripples them instead of liberating them. The very labels that we turn to in order to help our children can actually do more harm than good. PSYCHIATRIC LABELS: HARD SCIENCE? Unlike most branches of medicine, psychiatry does not rely on objective data to diagnose and treat illness. It is a soft science, not a hard science. There is no blood test or brain scan we can use to diagnose a condition like ADHD. Psychiatric diagnosis is based on the personal observation and judgment of the practitioner, which are colored by temperament, interest, skill, level of knowledge, degree of training, and innumerable other factors. In 2006, the journal Psychiatry explored this topic and found that despite much improvement over the past 50 years, "the reliability of psychiatric diagnosis among practicing clinicians remains poor," and this was in terms of diagnosing adults. Psychiatry does very little research into the reliability of our diagnostic system in actual clinical practice. One reason may be that the results are so embarrassing and destructive to psychiatry that no one wants to consider them. Here is one such example reported in May 2006 in Clinical Psychiatry News. In this study 376 patients at a large psychiatric hospital in Tucson, Arizona, were readmitted within 30 days of their initial discharge, and very few received the same diagnosis. Fewer than half of the patients with bipolar disorder were given the same diagnosis. Ninety percent of patients with schizoaffective disorder got a new and different diagnosis. In this study 255 people had two admissions; only 50 of these (less than 20 percent) were given the same diagnosis. If they had three admissions, only 7 of 82 patients (9 percent) received the same label. When they were readmitted four times, only 2 of 27 (7 percent) got the same tag. The poor souls who were sick enough to be admitted more than four times batted zero for 12. The researcher who did this study gave this advice: "Take the prior diagnosis with a grain of salt because other diagnosticians may not be as careful as you." I don't think I could have said it better. Can you imagine what the diagnostic reliability would have been if these patients had been children? Everyone in the field of psychiatry knows that kids are much harder to diagnose, simply because they are "moving targets" as they constantly grow, change, and mature. We psychiatrists have some understanding of how the human brain functions, but we have very little understanding of what causes the brain to malfunction in ways that cause emotional or mental disorders. In order to organize and "codify" the way we think about mental disruptions, psychiatry has evolved around an ever-expanding encyclopedia of terminology that gives a diagnostic name to a symptom or cluster of symptoms. These psychiatric terms are the labels I've been referring to, and they can be found in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders), which is the official handbook created by and for psychiatrists that names and defines mental disorders. The DSM, which has been in existence for roughly a half century, is updated periodically (we're currently using the fourth edition, hence DSM-IV). When it was first published in 1952, the DSM contained 106 mental disorders. When it was updated in 1968, there were 182. Now, based on the most current edition, which was edited in 1994, there are more than 300 mental disorders identified in the DSM. Even I, a psychiatrist, must ask: Could the numbers of serious mental and emotional disorders really have tripled in 42 years? The answer is no. I believe the proliferation of mental and emotional disorders as created by the editors of the DSM reflects our tendency toward "diagnosis creep," toward our willingness to find illness where there may be simply difference. The labels we most frequently give to kids include the acronyms for and names of some complex and serious mental, emotional, and social disorders. These disorders, though once thought to be very rare in children, are being diagnosed (and misdiagnosed) at alarming rates. (In the 1970s, ADHD was considered quite rare, and only about 150,000 American children were thought to have it. Today, nearly four million American kids are labeled with ADHD, and most of them are also being given very powerful drugs to "control" it.) Before I begin to sound as though I am rigidly against all labeling, I must say that diagnostic labels do play an important role in terms of helping us identify what a child is experiencing. It would be foolhardy of me to say that I don't use the DSM-IV and the definitions it provides on a daily basis. I do use labels as insurance companies, other doctors, and many parents require them. But I always use them to the child's greatest benefit. THE ADVANTAGES OF LABELS Diagnostic labels were designed to facilitate healing. There is no doubt about this. Using such labels is not only crucial to guiding appropriate treatment, it also provides a source of much-needed relief for the parents of any child who is suffering. Once a diagnosis is made, parents experience an immediate sense of reassurance that the problems that plague their child are understood and will be addressed. With a diagnostic label in hand, parents can often break out of the isolation that comes with having a seriously troubled child. They can then find support among parents with kids who have been similarly diagnosed. They can also do research and learn more about the diagnosis, which, one hopes, will help them learn more about their child. As a physician, finding a suitable diagnosis gives me a departure point, an entree into treating a child, and this is a crucial first step in any good treatment. I turn to diagnostic labels daily in my own practice and use them to get a handle on the symptoms that may be debilitating a child under my care. I use these labels cautiously, however, as I'm aware of the tendency (even in myself) to become persuaded that the diagnosis--or the label--is the end point of treatment. THE DISADVANTAGES OF LABELING Of course, there are negative consequences of diagnostic labeling, even when the diagnosis is correct. Excerpted from Please Don't Label My Child: Break the Doctor-Diagnosis-Drug Cycle and Discover Safe, Effective, Choices for Your Child's Emotional Health by Scott M. Shannon, Emily Heckman, Linda B. White All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.