The Ethics and Science of Medicating Children
Jacqueline A. Sparks
The University of Rhode Island Kingston, RI
Barry L. Duncan
Institute for the Study of Therapeutic Change Ft. Lauderdale, FL Prescriptions for psychiatric drugs to children and adolescents have skyrocketed in the past 10 years. This article presents evidence that the superior effectiveness of stimulants and antidepressants is largely a presumption based on an empirical house of cards, driven by an industry that has no conscience about the implications of its ever growing, and disturbingly younger, list of consumers. Recognizing that most mental health professionals do not have the time, and sometimes feel ill-equipped to explore the controversy regarding pharmacological treatment of children, this article discusses the four fatal flaws of drug studies to enable a critical examination of research addressing the drugging of children. The four flaws are illustrated by the Emslie studies of Prozac and children, which offer not only a strident example of marketing masquerading as science, but also, given the recent FDA approval of Prozac for children, a brutal reminder of the danger inherent in not knowing how to distinguish science from science fiction. The authors argue that an ethical path requires the challenge of the automatic medical response to medicate children, with an accompanying demand for untainted science and balanced information to inform critical decisions by child caretakers.
uring the 1990s, prescriptions for psychiatric drugs to children and adolescents skyrocketed (Olfson, Marcus, Weissman, & Jensen, 2002; Zito et al., 2003). Evaluating the records of almost a million Medicaid and HMO youths, one of the largest and most comprehensive studies to date concluded that child and adolescent psychotropic utilization rates nearly tripled from pre-1990s levels (Zito et al., 2003). Total psychotropic prevalence for youths reached as high as 6.3%, rivaling adult rates. According to an IMS Health survey, between 1995 and 1999, the use of antidepressants increased 151% in the 7-12 age group and 580% in the under-6-years-old population. Children under 18-years-old saw a nearly 300% increase in the use of antipsychotic medications such as Risperdal (Diller, 2000). Drug Enforcement Administration records and national physician practice surveys indicate that approximately 4 million children took stimulants in 1998 (Diller). Even more alarming rates cluster in certain groups. Zito and colleagues found that children in foster care were 16 times more likely to receive a prescription than their non-foster care counterparts (2003). The Boston Globe reported that 1 in 8 teens in the state’s Medicaid © 2004 Springer Publishing Company 25
Sparks and Duncan
program was taking psychotropic medications, and 1 in 9 aged 6 to 12 years (8% and 13%, respectively; Barry, 2003). Between 1991 and 1995, pediatricians and psychiatrists wrote record numbers of stimulant, tricyclic antidepressant, clonidine hydrochloride, and SSRI prescriptions for preschoolers (Zito et al., 2000). Prescription rates for methylphenidate (Ritalin) for 2- through 4-year-olds grew by 169%. Zito and associates called such dramatic increases “remarkable in light of the limited knowledge base that underlies psychotropic medication use in very young children” (2000, p. 1026). In most major surveys of child and adolescent psychotropic use, stimulants are ranked as most popular, and antidepressants are ranked second. The research also points to an increasingly commonplace trend, polypharmacy, prescribing two or more medications simultaneously. According to one study, the rate of co-prescription rose significantly from 4.7% to 11.6% during 1987-1996 (Olfson, Marcus, Weissman, & Jensen, 2002). Children on stimulants for diagnoses of attention-deficit hyperactivity disorder (ADHD) are frequently prescribed...