Judith Warner's We've Got Issues.

Reading between the lines.
Feb. 22 2010 9:28 AM

To Drug or Not To Drug

Judith Warner misses the real questions about medicating children.

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But everything about human beings, cultural or individual, innate or learned, is in our brains. Loss and humiliation change our serotonin levels, education transforms our brain connections, social support affects our cortisol. Neurological and psychological and social processes are inextricable. The work of psychological science is to identify causes at many levels of description—social, cultural, individual, and neurological.

Well, do the drugs help or not? The answer, like most scientific answers, is complicated—it's different for different problems and for different children. The enormous success of some aspects of medicine—antibiotics, vaccinations, aseptic technique—has led to what you might call the Pasteur paradigm: You identify the cause of a problem, then you eliminate it and the problem goes away. Recently, we've had a few Pasteur-paradigm successes in psychology. Serotonin reuptake inhibitor drugs and, to a lesser extent, anti-psychotic drugs, have undoubtedly saved lives and alleviated the human misery of major depression and schizophrenia. Cognitive behavioral therapy is very effective for panic attacks and insomnia.

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But most psychological medicine (for that matter, most physical medicine) isn't like that. And the "issues" for which we treat children certainly aren't like that. The problems the drugs are supposed to solve are complicated and varied. Syndromes like autism, ADHD, or dyslexia are like "fever" or "dropsy," rather than like malaria or polio. They are names for somewhat incoherent collections of symptoms rather than clearly identified causes. Other "diseases" like "childhood bipolar disorder" or "sensory integration disorder" are even less clearly defined and may exist only in the minds of the therapists.

Moreover, in the psychological case even more than the physical one, what counts as a problem depends on the context. When nobody read, dyslexia wasn't a problem. When most people had to hunt, a minor genetic variation in your ability to focus attention was hardly a problem, and may even have been an advantage. When most people have to make it through high school, the same variation can become a genuinely life-altering disease. To say this doesn't imply, as Warner seems to think, that these are made-up problems, rather than real neurological ones. But it does suggest that changing the social context in which children grow up can be as important as directly changing their brain chemistry.

You can sympathize with the impulse of parents to do something, anything at all, to help their children. But that doesn't alter the fact that the scientific evidence just isn't clear about what to do. On balance, though, the evidence suggests that we should be conservative about prescribing drugs to children, and much more conservative than we actually are. Even the scientists who advocate some use of drugs acknowledge that they are overprescribed and badly managed. Brains are complex enough, children's developing brains are even more complex, and determining the long-term effects of drugs that alter those brains is especially difficult. Children are different from adults, often in radical ways, and many childhood problems resolve just as part of development.

On top of that, each generation of doctors discovers that the last generation was disastrously misguided in its medical interventions, from lobotomies to estrogen replacement, at the same time that they assure the patients that this time is different. Throw in the machinations of big pharma and surely the "First, do no harm" principle applies. At the least, we could apply the principle that we should prescribe drugs only when there are clear, randomized, controlled trials that show they are safe and effective over the long run.

Moreover, even where there is the most scientific evidence in favor of drugs, as in the case of ADHD, it turns out that some kinds of behavioral therapy are also effective. In the popular imagination the alternatives to drugs are "talking cures" like psychoanalysis. In fact, there is very little empirical evidence for such therapies. But there is good evidence that cognitive behavioral therapy can be effective for a wide range of psychological problems. And at least these treatments, unlike drugs, do no harm. The trouble is that these therapies take time and attention and funding, and they are actually discouraged by the American health care system: It is almost always easier to get reimbursed for drug treatments than for behavioral ones. Some of the best scientific studies also suggest that the most important factor of all is whether families have enough money and social support to cope with the inevitable ills that children suffer. We do nothing to help provide that support.

In this book, as in her previous book, Warner spends a lot of time being indignant about the fact that parents are made to feel guilty about their children. But guilt and anxiety go with the territory, the inevitable flip side of the responsibility, risk, and moral weight of having children. It would surely be better to apply our indignation and energy to the task of using both science and social policy to make children's lives better.

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