To Drug or Not To Drug
Judith Warner misses the real questions about medicating children.
It's a truth verging on a truism that journalism is about telling stories. But what exactly is it that narratives—good stories—do for us? Stories work because they explain important or unusual or compelling events in terms of our everyday psychology—the causal principles that we all understand by the time we are 4. A good journalist explains why the health care bill failed, for example, by telling us about the beliefs, desires, and emotions of the wavering senators.
But science isn't about applying the causal principles we know about. It's about discovering causal principles we don't know about. Psychological science, in particular, is about using evidence to find new and unexpected causal explanations for our actions and experiences. It's not about using our everyday psychological knowledge to explain what we do. When psychologists do that, we rightly accuse them of just telling us what we already know.
This is especially true when scientists are trying to explain the conditions we vaguely call "clinical" or "dysfunctional" or "pathological." After all, people aren't pathological when they are angry or frustrated or sad because of what they want or believe. They are pathological precisely when we can't explain their miseries in the normal way—when the successful author suddenly kills himself, or when the bright child with loving and concerned parents just can't read no matter how hard she tries. Clinical scientists try to use evidence to discover the less than obvious causal principles (his serotonin level was too low, she can't process language sounds) that can explain these events.
Human beings do love stories, but, fortunately, they can also appreciate the interest and fascination of scientific problem-solving. Good science journalists think like scientists. They don't just tell stories. Instead, they understand and explain how new evidence can lead to surprising and counterintuitive conclusions. And they study and evaluate the scientific journals and peer-reviewed articles—the currency of science.
Judith Warner's book illustrates the perils of preferring stories to science. We've Got Issues takes off from an unquestionably important set of events. Within the past few years more and more children have been given powerful brain-altering drugs to deal with a wide range of problems. Many of the traditional journalistic parts of Warner's book are interesting and engaging. She tells some compelling stories about desperate parents, about the absurdly dysfunctional American health care system, and about the greed of the big pharmaceutical companies. The everyday psychological explanations that underpin these stories work very well. The companies want to make a lot of money, so they manipulate the data. Poor children don't have health care, so their problems are left untreated until they become emergencies, and so on.
The book is also written as a story about Warner herself. She started out thinking, from talking to people and reading blogs and newspapers and magazines, that overambitious parents and unfeeling doctors were pressuring children to succeed at all costs and callously using drugs to help. Then she talked to more people, particularly the parents and doctors who were giving children the drugs, and she read more blogs and newspapers and magazines. She had her epiphany and changed her mind. Actually, the children had real problems, and the parents and doctors were trying to help them.
That, quite explicitly, is the main point of the book, and much of it is devoted to Warner's emotional recounting of these discussions and her reactions to them. You have to wonder a little, even from a purely journalistic perspective, about whether Warner really expected that the parents she talked to would say to her, "Yes, actually my child doesn't have real problems; I'm just medicating him because I'm an overambitious neurotic." But surely the real question is not, "Are the parents and doctors good or evil?" but "Do the drugs make the children better?"
You may be able to answer the first question with journalistic narrative, but to answer the second question you need scientific evidence. Sometimes, at least, Warner seems to think that her epiphany licenses the conclusion that we should indeed be giving children drugs for this range of psychological problems (though she's fuzzy about this). But nowhere in the book does she explain or evaluate the scientific evidence that could actually help answer this question. In fact, there are far more references to newspapers than to scientific journals, and she consistently treats an anecdote or an interview as if it has the same weight as a meta-analysis or a randomized clinical trial.
Warner's book also reflects a common confusion in popular writing about psychology. She writes as if there are just two kinds of explanations for human behavior. Either the everyday narratives are right—so that children are unhappy because their parents don't care about them, or they fail at school because they are lazy. Or else the right answer is that the children's problems are the result of "something in their brains." Warner's logic seems to be that since the parents do care about their kids, the problem must be in the children's brains and therefore drugs will fix it.
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.
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.