Just Say 'No' to Drugs as a First Treatment for Child Problems
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Just Say ‘No’ to Drugs as a First
Treatment for Child Problems
Barry L. Duncan, Jacqueline A. Sparks,
J o h n J . M u r p h y AN D S c o t t D . M i ll e r
When children and teens present with behaviour and emotional problems the lure of a quick fix is
understandable and drugs present a ready-made solution. Therapists are often hesitant to talk about
medication and defer to medical professionals. In this paper DUNCAN, SPARKS, MURPHY and MILLER
highlight the explosion in the use of psychotropic medications for children and teens. This trend flies in the
face of the American Psychological Association’s recommendation of the use of psychosocial interventions
as the first intervention of choice with children and teens. The reliability and validity of psychiatric diagnoses is
questioned, in particular against a background of fluctuations in child development and social adaptations,
and a compelling critique is provided of the current research findings on the effectiveness of psychotropic
medications including antidepressants and ADHD medications. Therapists are urged to shed their timidity
and discuss openly the risks and benefits of medication with the knowledge that there is empirical support
for psychosocial interventions as a first line approach. Recommendations are offered to engage clients as
central partners in developing solutions—medical or non-medical—that fit each child and each situation.
A mother has a moment of panic,
spying her daughter’s arms
crisscrossed with red cuts.
medication with the families they see,
choosing instead to defer to medical
professionals. But to not talk about
Aren’t we stepping out of our expertise
and professional role to discuss
medications with clients?
A harried teacher does a double psychiatric drugs in today’s world of While we may be stepping out
take when the behaviour of a typically ubiquitous chemical imbalances and of our comfort zones, we are not
disruptive middle schooler takes a glossy advertising remedies is to ignore travelling beyond the boundaries of our
bizarre turn. Young parents are at a the proverbial elephant in the living expertise to discuss options regarding
loss to explain the uncontrollable rages room. Prescriptions of psychotropic treatment approaches for young people
of their five-year old. In each case, drugs for children and adolescents have in distress. We need not fear these
the spectre of mental illness hovers, skyrocketed. To skip a discussion of conversations or feel timid in the face
whispering an urgent command to “get medication is to disregard a growing of medical opinion; the data speak
professional help!” Psychotherapists are reality that impacts on children clearly about just how safe and effective
often the first stop for help—we, like and their families. The Rx (medical psychiatric drugs are for children. The
our clients, feel the pressure to solve the prescription) elephant won’t go away empirical evidence supporting the
problem rapidly with the best standard just because we don’t talk about it. benefit of child medication is far from
of care. And, more and more, that Our reticence is mirrored in parents substantial, while concerns about safety
standard has become synonymous with and children who are reluctant to offer continue to surface. Therapists can use
psychiatric medication. an opinion or ask a question about this knowledge to confidently assist
With daily pressure on therapists other options or side effects. The end with medication decisions—they can
to manage youth behaviour and result is that children, parents, and help children and parents get the facts
emotional problems, the lure of a therapists are often shut out of the about risks and benefits, and make
quick fix is understandable, and loop—their questions, ideas, and clear the take-home message that there
drugs seem a ready-made solution. solutions take a back seat. But how are many paths to preferred ends.
But beyond referring families for can therapists broach this topic—after It is not our aim to discredit
psychiatric consultations, therapists all, we are not medical experts, or as individual preferences for or
are often hesitant to talk about the joke goes, we are not ‘real’ doctors. experiences with medication, or to
32 PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007claim that psychiatric drugs are not Explosion in the use of a psychiatrist is made and Jess is
ever helpful. We are not wide-eyed psychotropic medication prescribed an antidepressant.
anti-drug zealots. Instead, we are for children and teens Jess is not alone. The past decade
anti-privileging drugs as a first-line Jess, a 15-year old girl enters school has seen an explosion of psychotropic
solution—especially for children and through the front door, proceeds down medication prescriptions for children
adolescents. And while we are adamant the hallway and out the back, another and teens (Zito et al., 2003). In
about putting clients in charge of the no-show for the day. Jess finds it the United States prescriptions for
decision to medicate and have been difficult to attend to classroom work, antidepressants have increased at a
writing passionately about the lack preferring to hang out with the pony rate of 11 per cent each year from 1994
of demonstrated efficacy of drugging she helps care for as a part-time job. At to 2000, and five per cent each year
children for nearly ten years, we are the school meeting, Jess’s mother states since, a total of over eleven million
actually in the mainstream of current that she found marks on her daughter’s prescriptions written annually. The
scientific thinking, The American arms, apparently self-inflicted with number taking antipsychotic medicines
Psychological Association Working Group her father’s pen knife. A referral to soared 73 per cent in the four years
on Psychotropic Medications for Children
and Adolescents, 2006 states:
‘It is the opinion of this working group
that…the decision about which treatment
With daily pressure on therapists to manage
to use first…should be guided by the
balance between anticipated benefits
youth behaviour and emotional problems,
and possible harms of treatment choices… the lure of a quick fix is understandable,
For most of the disorders reviewed herein,
there are psychosocial treatments that are and drugs seem a ready-made solution.
solidly grounded in empirical support
as stand-alone treatments. Moreover,
the preponderance of available evidence
indicates that psychosocial treatments
are safer than psychoactive medications.
Thus, it is our recommendation
that in most cases, psychosocial
interventions be considered first’.
(p. 175, emphasis added)
The report further points out:
‘Ultimately, it is the families’ decision
about which treatments to use and
in which order. A clinician’s role is to
provide the family with the most up-to-
date evidence, as it becomes available,
regarding short- and long-term risks
and benefits of the treatments.’ (p. 175)
The APA is hardly an organization
known for going out on a limb or
taking risky liberties with the data!
This knowledge means that when
children experience difficulties,
discussions about solutions can be
open, creative, and evolving, and
encompass a range of views about
change based on each person’s
concerns, circumstances, and
preferences. While medication may
be useful for some children, it does
not have to dominate intervention
strategies or monopolize talk about
change. Therapists can expand the
range of options, and their clinical
roles, even in circumstances that
typically trigger prescriptions.
Illustration: Shannon Rose
PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007 33ending in 2005, far outpacing the to neuro-imaging research as proof Yeah…I told my mom about Nick (Jess’s
increase in adults—over 2.5 million positive of the biology of behavioural boyfriend). She knows we broke up.
youth in the US per year are prescribed and emotional problems. A highly Therapist: Is that what’s bothering you
antipsychotics (dosReis, Zito, Safer, publicized study claimed to show the most now?
Gardner, Puccia & Owens, 2005). that the brains of ADHD-diagnosed Jess: Yeah. That, and school sucks.
Spending on drugs like Ritalin for children were smaller than their non- Jess, her mom and the therapist
behavioural problems exceeds any other ADHD counterparts (Castellanos et talk about how Jess cuts herself to help
category for the first time, including al., 2002). However, anatomy Professor with the emotional hurt. They also
antibiotics. The number of kids taking Jonathan Leo and researcher David talk about Jess’s boredom with her
one or more prescription medicines to Cohen report that the control group classes and her desire to work more
treat mental health-related conditions was two years older, heavier, and taller to earn money and not ‘waste time’ at
has hit nearly nine per cent. If Jess than the ADHD diagnosed children, school. They listen to Jess and value
that she feels comfortable enough to
let them into her world. All agree that
We are not wide-eyed anti-drug zealots. the first order of business is for Jess to
be safe. Since Jess is adamant about
Instead, we are anti-privileging drugs not wanting medication, they agree to
set up a safety plan. The practitioner
as a first-line solution—especially ensures that Jess is the primary
architect of the plan, prompting her to
for children and adolescents. identify strategies that she believes will
work. Instead of cutting at night when
she felt down, Jess planned to listen to
lived in a foster home, she would be 16 undermining any conclusion about music, get in her mom’s bed or call her
times more likely to be medicated; if brain size and ADHD (Leo & Cohen, friends. Jess writes the strategies down
the diagnosis ended up bipolar disorder 2003). Despite fifty years of efforts to and signs an agreement to tell her mom
or ADHD, her chances of being on find one, no reliable biological marker or call the therapist if she feels like it is
more than one medication at the same has ever emerged as the cause of any not working.
time would be as much as 87 per cent psychiatric ‘disease’. There are many ways to reach desired
(Duffy et al., 2005). Knowing there is no irresistible ends. Not every child is Jess and not
The push to medicate young people scientific justification to medicate, the every parent will react the same way.
is fueled partially by the belief that therapist is free to put other options on What will work can only be known one
problems are biological and require the table and draw in the voices of Jess child and one family at a time after an
medical intervention. Web pages, and her mother. open consideration of options.
doctor’s office brochures, magazine Mother: Jess, you can’t keep doing this.
Validity and reliability of
articles and TV advertisements I don’t want you to hurt yourself.
psychiatric diagnosis
describe depression, ADHD, What’s wrong? What do you want?
mood swings, and the like as brain Jess: (Shrugs shoulders and Michael, age 13, is home from
dysfunctions. Even when we know they looks down.) residential treatment and recently
are promotions from drug companies, Therapist: Jess, we just want to make reunited with his mother who is
pictures of neurotransmitters or talking sure you’re safe? What do you think now attending regular Narcotics
serotonin cartoons are powerful, lasting will help? Anonymous meetings. When
images. This biological perspective is Jess: I don’t know. confronted about his ‘clowning’
also backed up by impressive sounding (Everyone just sits for a while. in math class, Michael makes a
clinical studies. Social explanations There is genuine puzzlement and beeline for the door and is found
and solutions are not accorded the same concern from everyone in the room— hanging halfway up the flagpole
weight in the media as medical ones there does not seem to be a way out o like a frightened monkey. In short
and are a distant second when it comes f the dilemma.) order, Michael’s diagnosis is changed
to research funding and marketing. As Mother: Jess, do you want to take the from ADHD to early onset bipolar
a result, claims are rarely questioned medicine that Dr. Stevens gave you? He disorder. His medication is changed
and the assumption that child and said you were clinically depressed and from stimulants to anticonvulsant and
adolescent problems have a biological that it would help. antipsychotic medications.
basis has become accepted fact. Jess: No! I don’t want to take any pills. ‘Early onset bipolar disorder’ has an
Cartoons notwithstanding, I’ve got to do this myself. ominous ring to it. At first glance
biochemical imbalances and other Mother: Okay. medication seems the most logical
so-called mind diseases remain the Therapist: Jess, do you want to talk with intervention for preventing a slide
only territory in medicine where me and your mom, or maybe just one of us into more distress and coping with
diagnoses are permitted without a alone, about some of that stuff we talked the disorder. Diagnosis, as the sole
single confirmatory test (Duncan, about last week? gateway to medications, provides
Miller & Sparks, 2004). Many point Jess: (after a lengthy pause, thinking) the official rationale for medical
34 PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007intervention. The belief that diagnosis like the old ones, but these are even worse. as making sense within the context of
can provide accurate identification of Mom says I should take them, but they the child’s life. And if medication is a
discreet disorders is a key assumption make me feel weird! part of treatment, children can monitor
that underlies medication prescription. Therapist: I saw what the doctor said in whether medication is useful and, with
Therapists may feel that they have the report he sent me. It says that it seems the help of adults, can be in the driver’s
little choice but to assume that a like your moods kind of go up and down. seat in medication decisions.
diagnosis explains what is wrong Does that seem right to you?
Are research findings on the
and provides a solution. Michael: Yeah. Kind of. I never know if
effectiveness of psychotropic
In spite of its widespread mom is going to, you know, go off again.
medication reliable?
acceptance, the validity and reliability It’s hard to sit there in class when I keep
of psychiatric diagnosis is suspect thinking about that, so I just start joking Six-year old Kyle, according to his
(Duncan et al, 2004; Sparks, Duncan around. Then Mr. Riley gets on my case, parents, ‘flies into a rage at the drop of a
& Miller, 2006). In particular, and I haven’t even done anything so I say hat.’ They note that Kyle’s rages occur
diagnostic validity is questionable ‘I’m outta here!’ when playing with his three-year
when it comes to children. According Therapist: Wow. That makes a lot of old sister and they fear that he may
to the World Health Report, ‘Childhood sense. No wonder you wanted to do hurt her. Kyle’s mother shares with a
and adolescence being developmental something to get that thought out of your therapist her concern that Kyle might
phases, it is difficult to draw clear mind for a while. have a mental illness and wonders
boundaries between phenomena that are Michael: So, you mean I’m not crazy? whether medication could help. When
part of normal development and others It was important for Michael to parents hear that even young children
that are abnormal’ (World Health make sense of his own experience can be mentally ill and that problems
Organization, 2001). The notion of and actions, and to understand these result from undiagnosed disorders, it
stable, fixed psychiatric syndromes as reactions to stressful events. The makes sense that they may adopt this
does not fit the fluctuations of child therapist refused to allow the diagnosis point of view when other explanations
development and adaptation to social or his situation at home to get him and options are not readily available.
environments—children change off the hook. They brainstormed The decision to pursue psychotropic
continually with age and context. ways that Michael could deal with drugs is based largely on the belief that
Reliability has to do with whether or his stress without getting in trouble. they work. People assume that Prozac
not clinicians looking at the same array The therapist returned to the pills and similar drugs are the intervention
of symptoms will come up with the because Michael expressed discomfort of choice for child and adolescent
same diagnosis. If there is independent with them. Referring to the outcome depression, and that stimulant
agreement on a diagnosis amongst measure the therapist was using, the medications are consistently effective
professionals, it is considered reliable. practitioner suggested that Michael for children labeled with ADHD.
Robert Spitzer, the primary architect monitor his response to the medication Pediatricians and family doctors also
of the DSM, commented on the ability to determine whether it was working or endorse such assumptions based on
of the DSM to provide consistent making him feel worse. published evidence from clinical trials.
agreement in clinical diagnosis: ‘To say Instead of certain diagnoses The clinical trials most often cited
that we’ve solved the reliability problem resulting in knee-jerk prescriptions, for medication effectiveness include:
is just not true…It’s been improved. But troubling behaviour can be validated the two clinical trials that gained
if you’re in a situation with a general
clinician it’s certainly not very good. There’s
still a real problem, and it’s not clear how to
solve the problem’ (Spiegel, 2005, p. 63).
In other words, Michael might well be
diagnosed with depression if he were
seen by a different clinician, or may
not have received a diagnosis at all.
A bipolar diagnosis can last a lifetime;
out-of-the ordinary child behaviours
tend to be time-limited. Recognizing
the potential negative effects, the
American Counseling Association’s
Ethical Code supports counsellors who
refrain from making a diagnosis.
Returning to Michael, consider the
therapist’s response to his diagnosis:
Therapist: Hey, Michael, how’s it going?
Michael: Not so good. The doctor says I
have some kind of…I forget. Anyway, he
gave me these new pills to take. I didn’t
PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007 35Prozac FDA approval for childhood inactive pill takers easily, effectively between medication and placebo
depression conducted by psychiatrist un-blinding the study and skewing groups tend to dissolve by 16 weeks.
researcher Graham Emslie of the results. In support of this theory, a Without longer term follow-ups,
University of Texas Southwestern meta-analysis conducted by psychiatrist researchers cannot make accurate
Medical Center and colleagues researcher Joanna Moncrieff of the conclusions about effectiveness in
(1997, 2002) (hereafter called the University College of London found everyday life. The Emslie studies were
Emslie studies); and the Multimodal that when studies used active placebos, of eight weeks duration, calling into
Treatment of ADHD (MTA) little or no differences were found question their usefulness in real-world
examining the efficacy of Ritalin versus between the dummy pill and the drug decision making.
behavioural and combined intervention (Moncrieff, Wessely & Hardy, 2004). A key component of evaluating
(MTA Cooperative Group, 1999, The Emslie studies used inactive, sugar any drug trial is learning who
2004ab). pill placebos drawing into question paid for it and what the authors’
The gold standard for research is the integrity of the study’s double potential conflicts of interest are. The
the randomized, double blind, placebo blind. Evidence of the compromised pharmaceutical industry’s influence
controlled trial. In this design, two double blind were apparent in the drug over scientific inquiry has, in some
groups are formed, presumably similar manufacturer’s own records where ways, become almost a cliché. In
since they are selected randomly from ‘it was not uncommon to see notations May of 2000, the editor of the New
the initial pool of applicants. One defining the patient’s blinded treatment, England Journal of Medicine, Marcia
group gets the drug being tested; the or in some cases to find fluoxetine (Prozac) Angell called attention to the problem
other, a placebo. In this design, neither plasma concentration results’ (FDA, of ‘ubiquitous and manifold…financial
study participants, researchers, nor 2001, June 25, p. 19). associations’ of authors to the companies
assisting clinicians, should know who The instruments chosen as primary whose drugs were being studied
is in which group—that is, who is measures in drug trials are clinician- (Angell, 2000, p. 1516). Why is it
taking the real drug and who is getting rated. Frequently, client ratings of important to know who sponsors a
the dummy pill. This helps eliminate improvement differ from clinician’s, study? One recent review (Heres,
the bias that comes when participants often in ways that run counter to Davis, Maino, Jetzinger, Kissling &
and researchers know who is in each findings of drug effectiveness. In Leucht, 2006) looked at published
group, and weeds out factors like hope both clinical trials that resulted in head-to-head comparisons of five
and expectancy that could interfere FDA approval of Prozac, no client- popular antipsychotic medications. In
with determining what is actually rated measures indicated superiority nine out of ten studies, the drug made
responsible for any differences found of the drug over placebo. However, by the company that sponsored the
between groups. The validity of the both studies concluded that Prozac study came out on top.
trial depends upon the ‘blindness’ of outperformed placebo. How valid Without an appreciation of the
participants who rate the outcomes. can an assessment of improvement role industry influence plays in how
However, most studies do not use be if the client does not agree with the study is designed, carried out,
active placebos—pills that mimic the it? In the first Emslie study, two and disseminated, it would be easy
effects of real drugs. Rather, they use out of four clinician-rated measures to accept bottom line conclusions as
inert sugar pills as the placebo which indicated a difference between the fact. However, recent regulations now
makes it possible for most participants placebo and SSRI groups. Two client- require authors to fully disclose their
and clinicians to tell who is getting rated measures found no difference. affiliations, allowing a more critical
the medication. Inert sugar pills, or Similarly, the primary measure of appraisal of any study’s conclusions.
inactive placebos, do not produce the the second study failed to show a The first Emslie study, published prior
standard side effect profile of actual significant difference—all client- to disclosure requirements, did not
drugs—dry mouth, weight loss or gain, rated and two clinician-rated scales identify author affiliations. However,
dizziness, headache, nausea, insomnia showed no difference. Out of seven, FDA data indicate that Eli Lilly
and so on. Study participants are likely three clinician-rated measures showed sponsored the study. The second and
to be on the alert for these types of significant differences between the approval-clinching trial of Prozac for
events and, since most have been on experimental drug and placebo. If child and adolescent depression lists
medications before, many are familiar children and their parents do not author affiliations on the first page.
with these effects. As a consequence, detect improvement over placebo, how Here, readers learn that Emslie is
these subjects are likely to identify effective are the drugs? a paid consultant for Eli Lilly, who
correctly which group they are in Standard time frames for clinical funded the research and whose product
(Fisher & Greenberg, 1997; Sparks & drug trials are 8 to 12 weeks. In was being investigated. The remaining
Duncan, in press). contrast, most prescriptions for youth authors are listed as employees of
Researchers interview participants psychiatric medication assume that the Eli Lilly and ‘may own stock in that
throughout the study to collect drug will be taken for much longer. company’ (p. 1205). Combining this
information about change and side Assessing how well a drug does in an information with the ‘unblinding’
effects. On-going interviews that listen 8 to 12-week period cannot portray that results from inactive placebos
for or are active in asking about side an accurate picture of the drug’s seriously calls into question whether
effects can reveal the active versus performance in real life. Differences the researchers, either employees or
36 PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007consultants of the company whose drug (the 7–9 year old children) rated MTA authors have significant ties to
was under investigation could, with so themselves as no more improved when drug companies. Specifically, Jensen
much at stake, remain objective. using medication than when using is listed as a consultant to Novartis,
Recent pooled analyses of both behavioural or community alternatives. the makers of Ritalin, the drug under
published and unpublished trials of Of interest, peer ratings concurred investigation in the MTA.
SSRIs for the under-18 age group with this assessment. The fact that When practitioners know what to
reveal that, as far as how well they neither blinded classroom observers, look for—does the study have a true
work, these drugs, plain and simple, the children themselves, or their peers double blind, are outcome measures
do not deserve a blank cheque. An found that medication was better than clinician or client rated, how long
did the study last, who funded the
study and what are the authors’
The notion of stable, fixed psychiatric industry affiliations—they realize that
medication should not be privileged
syndromes does not fit the fluctuations over other psychosocial options
(Sparks & Duncan, in press). Equipped
of child development and adaptation to with this information, therapists also
have a powerful method for evaluating
social environments—children change future studies without having to take
the word of the latest headline or sound
continually with age and context. byte on the evening news.
Kyle and his family are at a
crossroads. It would not be hard
analysis by researcher Jon Jureidini behavioural interventions suggests that to start down a path that saw his
found that, out of 42 reported measures stimulant drugs offer no advantages difficulty as the early signs of mental
in six published trials, only 14 showed over non-medication alternatives. illness. Through this lens, a proactive
a statistical advantage. None of the With regard to time frames, the approach might make sense, warding
youth and parent measures in this MTA surpassed its predecessors off a potential downward spiral before
sample indicated any advantage of because it evaluated outcomes at 14 it becomes entrenched and intractable.
the drug over a sugar pill—only the months instead of the customary 8–12 However, knowing also that such an
doctors reported improvement. They weeks. The assessment occurred at approach most likely means medication
also discovered that the effect size for the 14-month endpoint while subjects with its attendant risk and unproven
the drug over placebo was quite modest were actively medicated. However, efficacy, it also makes sense to explore
(0.26), amounting to only a 3 to 4 point behavioural intervention had long since other ways to understand and to resolve
difference on scales which had ranges stopped—endpoint measures were his and his family’s dilemma.
from 17 to 113 as possible scores. This taken four to six months after the last Therapist: I can certainly see that you
may be statistically significant, but fails face-to-face contact. Thus, the endpoint have some concerns here. I really appreciate
the test of clinical significance—that MTA comparison was between how you’re trying to make sure that you
is, fails to tells us anything meaningful active medication and withdrawn know what’s going on so that you can take
about the client sitting in front of us, behavioural intervention. This made action sooner rather than later. Usually,
much less serve as a mandate, or ‘best the comparison hardly a head-to-head it’s a lot easier to head things off at this
practice’. Unpublished trials fared contest, making the slight superiority age, rather than wait until the child is 8 or
much worse—only one in nine showed of medication (on 3 of 19 unblinded 9 when it is a lot harder.
a statistical advantage for the drug over measures) a foregone conclusion. A Mother: Exactly! That’s what we [with
placebo (Jureidini, Doecke, Mansfield, 24-month follow-up of the MTA Kyle’s dad] thought too. That’s why I
Haby, Menkes & Tonkin, 2004). shows that the improvements of wanted to speak to you. You know, since
The Multimodal Treatment Study children on medication deteriorated (up we moved here, and the new baby came,
of Children with ADHD (MTA), to 50 per cent) while the behavioural and starting the business and all, we
the major trial supporting the intervention group retained their gains. hardly have time to sleep.
superiority of ADHD medication, All advantage of the combined group Therapist: Well, it says a lot about you
not only didn’t use an active placebo, over the behavioural intervention also that you could make the time to get in
it lacked a pill placebo control group dissipated (MTA, 2004a). here today!
altogether (MTA Cooperative Group, Finally, consider the conflicts of Mother: Thanks. What you said about
1999). As a consequence, it relied on interest. For those studies conducted doing something now rather than later,
evaluations made by teachers, parents, before the disclosure requirement, a did you think we should have him see a
and clinicians who were not blinded to little sleuthing can help. An online doctor, or have some kind of evaluation,
the intervention conditions. The only database published by a non-profit maybe some medication or something?
double-blind measurement (made by health advocacy group (Integrity in Therapist: Well, that is certainly
classroom raters) found no difference Science, www.cspinet.org/integrity/) something that could be done. But, we
among any of the intervention groups. reveals that lead MTA investigator don’t really know if that will be needed
In fact, the subjects themselves Peter Jensen and at least five other at this point. Most of the time, we can
PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007 37work with the schools and also recommend children are prescribed ‘off label’. participants receiving Prozac in this
things at home, that can move things in This means that the majority of drugs study attempted suicide (FDA, 2001,
a better direction. Children of Kyle’s age prescribed frequently do not have the June 25).
typically respond well to behaviour plans. requisite two clinical trials that show After a review of published
We can observe what’s working for him they are safe and effective. Included and unpublished trials, the FDA
and what we can do to build in some in off label medications are the new issued a black box warning for
rewards for when things are going well. antipsychotics and all anticonvulsants. all antidepressants for children,
It would be helpful if you could do the Additionally, there are no studies alerting consumers and providers
same—see what is working or what isn’t to support the efficacy or safety of to increased risk of suicidality and
at home. Would you note the times that
Kyle is getting along with his sister and
when things are going well? (Mother
nods in agreement) If we can meet again
In both clinical trials that resulted in FDA
next week, we might have some better
ideas of what’s going on and where to go
approval of Prozac, no client-rated measures
with things. Does that make sense? indicated superiority of the drug over
Mother: Yes, it does. Problem is, his dad
and I are so busy, and the baby takes up placebo. However, both studies concluded
so much of my time, we hardly pay much
attention to Kyle these days except to tell that Prozac outperformed placebo.
him to do things, like get ready for bed or
to stop doing things. Come to think of it,
we don’t even have time to get him in prescribing multiple medications. All clinical worsening (FDA, October, 15,
bed like we used to, with his favorite antidepressants, with the exception of 2004). The Medicines and Healthcare
game and story. Prozac, are prescribed off label for child Products Regulatory Authority
Kyle’s mother and the therapist and adolescent depression. The window (MHRA) in the United Kingdom took
detailed concrete steps that could of approved drugs for children is very it further, banning all antidepressants
be implemented at school and home. narrow—more narrow than what (except Prozac, which can only be used
A follow-up meeting was scheduled might justify the robust prescription with children over eight years when
to review progress and develop a rates. Even approved medications often talk therapies have failed). Growth
behavioural plan based on the mother’s have risks that are minimized in the suppression and adverse cardiac effects
and the teacher’s observation of decision-making process. have been noted as well (FDA, 2001,
what was working. Diagnosis and As the APA report noted, a June 25; FDA, 2003, January 3).
medication, while not discounted, thoughtful weighing of risk versus ADHD drugs also have troubling
were not the primary discussion benefit is at the heart of any medication records when it comes to side effects.
topics. Instead, other ways to view decision. Much of the data that has Sixty four percent of the children
and address the problem emerged been collected raises concern. A in the MTA reported adverse drug
from a therapeutic partnership to systematic evaluation of 82 medical reactions: 11 per cent were rated
explore options. charts of children and adolescents as moderate and three per cent as
treated with SSRIs found that 22 severe. In March of 2006, an FDA
Safety
per cent experienced some type of safety advisory committee called for
Jess’s mother was torn. On one psychiatric adverse event (PAE), stronger warnings on ADHD drugs,
hand, she feared for her daughter’s typically a disturbance in mood citing reports of serious cardiac risks,
life and would do whatever it took to (Wilens, Biederman, Kwon, Chase, psychosis or mania, and suicidality.
protect her. On the other, she was leery Greenberg & Mick , 2003). Estimates Stimulant medications have also been
of medications and, in particular, ones of PAEs in child and adolescent associated with increased emergency
not approved for children. Michael studies is complicated by inconsistent room visits. A recent study conducted
was placed on an antipsychotic and an collection methods for side effects by the U. S. Centers for Disease
anticonvulsant. All he knew was that data, and benign or misleading Control and Prevention found
he didn’t feel right. His teacher noted assessments of data actually reported. that thousands of children taking
that Michael no longer disrupted class, In the first Emslie study, six per cent stimulants wind up in the ER with
but instead put his head on the desk a of participants taking Prozac dropped chest pain, stroke, high blood pressure,
good portion of the day. Many popular out due to manic reactions compared fast heart rate, and overdose (Johnson,
drugs are viewed as safe for children. with two per cent in the placebo 2006, May 25). Finally, the MTA
However, safety is often tied to a group. If extrapolated to the general also revealed that the average height
lesser-of-two-evils argument. Many are population, for every 100,000 children suppression for older children was
willing to accept certain risks when the on Prozac, as many as 6,000 might about 1 cm per year, while younger
possible alternative is a child’s school be expected to experience this serious children averaged 1.4 cm per year
failure, drug abuse, crime or suicide. adverse effect. In addition, according height loss with a 20 per cent reduction
Most psychiatric medications for to FDA documents, at least two in growth rate.
38 PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007Children like Michael, diagnosed systematic feedback on an outcome C. L., Walter, J. M., Zijdenbos, A., Evans,
with pediatric bipolar disorder, are measure that is understood easily A. C., Giedd, J. N. & Rapoport, J. L. (2002).
Developmental trajectories of brain volume
taking antipsychotic medications in by all (like the Child Outcome abnormalities in children and adolescents
record numbers (Duffy et al., 2005; Rating Scale—free download with attention-deficit/hyperactivity disorder.
Staller, Wade, & Baker, 2005). Side at www.talkingcure.com.) If JAMA, 288(14), 1740––1748.
effects for these drugs in adults are medication is part of the plan, dosReis. S., Zito, J. M., Safer, D. J.,
well known, including irreversible invite the youth and others to Gardner, J. F., Puccia, K. B., Owens,
movement disorders, obesity and the monitor the effects and use the P. L. (2005). Multiple psychotropic
risk of diabetes. Given that one in five results as a basis for discussion medication use for youths: a two-state
visits to a psychiatrist by a young person with medical professionals. Invite comparison. Journal of Child & Adolescent
Psychopharmacology, 15(1), 6877.
results in an antipsychotic prescription, the youth and others to view
a six-fold increase in recent years, it’s positive change as resulting from Duncan, B., Miller, S., & Sparks, J. (2004).
hard not to be alarmed at what these their efforts—‘Given that some The Heroic Client. San Francisco:
Jossey-Bass.
risks might mean for children (Olfson, take meds and they don’t work, how
Blanco, Liu, Moreno & Laje, 2006). is it that you made them work for Duffy, F. F., Narrow, W. E., Rae, D. S., &
West, J. C., Zarin, D. A., Rubio-Stipec,
you?’ These kinds of questions
Conclusion M., Pincus, H. A. & Reiger, D. A. (2005).
encourage people to take ownership Concomitant pharmacotherapy among
The decision of whether or not for successful outcomes. youths treated in routine psychiatric
to medicate a child is one of the Lack of critical awareness takes practice. Journal of Child and Adolescent
most difficult any family can face. A on greater weight where children Psychopharmacology, 15(1), 12–25.
medical path is always a choice, and are concerned because children trust Emslie, G. J., Heiligenstein, J. H.,
its pros and cons can be explored with adults to make good decisions on Wagner, K. D., Hoog, S. L., Ernest, D. E.,
medical and non-medical professionals. their behalf. We hope that knowing Brown, E., Nilsson, M. & Jacobson, J. G.
Therapists can feel free to shed their about the APA recommendations, (2002). Fluoxetine for acute treatment of
timidity and discuss openly the risks depression in children and adolescents:
the lackluster empirical support for A placebo-controlled, randomized clinical
and benefits of medication, with the drugging children as a first-line trial. Journal of the American Academy of
knowledge that there is empirical intervention, and the attendant safety Child and Adolescent Psychiatry, 41(10),
support for psychosocial intervention risks has bolstered your confidence to 1205–1215.
as a first line approach. The following talk about medication, raise concerns Emslie, G.J., Rush, A.J., Weinberg, W. A.,
are recommendations for engaging about robotic prescription practices and Kowatch, R. A., Hughes, C. W., Carmody,
clients as central partners in developing side effects, and offer alternatives. An T. C. & Rintelmann, J. R. (1997). A double-
solutions—medical or non-medical— awareness of the relationship between blind, randomized, placebo-controlled trial
that fit each child and each situation. of fluoxetine in children and adolescents
a profit-driven industry and science, with depression. Archives of General
• Gather input from multiple sources and what that science actually reveals, Psychiatry, 54(11), 1031–1037.
including the child, parents, enables therapists to assist families
teachers, school records, and Fisher, S., & Greenberg, R. P. (1997). From
to make intervention decisions—not Placebo to panacea: Putting psychiatric
other community care-givers. only permitting a fuller picture from drugs to the test. New York: Wiley.
• Develop multiple frameworks which to construct solutions, but also
of understanding the problem Heres, S., Davis, J., Maino, K., Jetzinger,
an appreciation that a child constantly E., Kissling, W., & Leucht, S. (2006). Why
based on the perspectives of the changes with the ebb and flow of life, Olanzapine beats Risperidone, Risperidone
youth, parents, teachers, and and is indeed like a river. You cannot beats Quetiapine, and Quetiapine beats
significant others. Include step in the same river twice. Olanzapine: An exploratory analysis
developmental, familial and of head-to-head comparison studies
environmental explanations. References of second-generation antipsychotics.
American Journal of Psychiatry, 163(2),
• Develop a concrete plan of action. American Psychological Association
185–194.
Working Group on Psychoactive
If medication is part of the plan,
Medications for Children and Adolescents. Johnson, L. A. (2006, May 25). ADHD
make sure that all involved, (2006). Report of the working group on drugs linked to scores of ER visits. Chicago
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Jureidini, J. N., Doecke, C. J., Mansfield,
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for childhood disorders: Evidence base, P. R., Haby, M. M., Menkes, D. B., &
and the lack of studies supporting Tonkin, A. I. (2004). Efficacy and safety
contextual factors and future directions.
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teachers and others to implement Jeffries, N. O., Greenstein, D. K., Clasen, L. Moncrieff, J., Wessely, S., Hardy, R. (2004).
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AUTHOR NOTES
BARRY DUNCAN, Psy.D. is co-director of the Institute for the Study of Therapeutic Change.
Dr. Duncan is the author or co-author of over one hundred publications, including fourteen books.
The latest: The Heroic Client (Jossey Bass, 2004), Brief Intervention for School Problems (Guilford, 2007),
and the self-help book, What’s Right With You (HCI, 2005).
JACQUELINE A. SPARKS, Ph.D. is an Assistant Professor of Family Therapy in the Department of
Human Development and Family Studies at the University of Rhode Island. She is co-author of The
Heroic Client (2004) and Heroic Clients, Heroic Agencies (ISTC Press, 2002). Her numerous publications
and trainings advocate for a transformation of ‘business as usual’ in mental health to put clients at
the forefront of their own change.
JOHN J. MURPHY Ph.D., Professor of Psychology at the University of Central Arkansas (US), is an
internationally recognized author and trainer on collaborative approaches with young people and
school problems. He has authored (with Barry Duncan) the recent book, Brief Intervention for School
Problems: Outcome-Informed Strategies.
SCOTT D. MILLER, Ph.D. is co-director of the Institute for the Study of Therapeutic Change, a private
group of clinicians and researchers dedicated to studying ‘what works’ in mental health and substance
abuse treatment. As a therapist he provides clinical services pro bono to traditionally under-served
clients. He is author or co-author of numerous articles and books: Escape from Babel, (with Barry
Duncan & Mark Hubble, 1997), The Heart and Soul of Change (with Mark Hubble & Barry Duncan,
1999), The Heroic Client (with Barry Duncan & Jacqueline Sparks, Revised, 2004), and the forthcoming
Making Treatment Count: Outcome-Informed Treatment (with Michael J. Lambert & Bruce Wampold).
For more information and recent articles visit www.talkingcure.com
Comments: barrylduncan@comcast.net
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