JustSayNo

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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.

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JustSayNo

  1. 1. Just Say ‘No’ to Drugs as a FirstTreatment for Child ProblemsBarry 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 armscrisscrossed 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 outtake when the behaviour of a typically ubiquitous chemical imbalances and of our comfort zones, we are notdisruptive middle schooler takes a glossy advertising remedies is to ignore travelling beyond the boundaries of ourbizarre turn. Young parents are at a the proverbial elephant in the living expertise to discuss options regardingloss to explain the uncontrollable rages room. Prescriptions of psychotropic treatment approaches for young peopleof their five-year old. In each case, drugs for children and adolescents have in distress. We need not fear thesethe spectre of mental illness hovers, skyrocketed. To skip a discussion of conversations or feel timid in the facewhispering an urgent command to “get medication is to disregard a growing of medical opinion; the data speakprofessional help!” Psychotherapists are reality that impacts on children clearly about just how safe and effectiveoften the first stop for help—we, like and their families. The Rx (medical psychiatric drugs are for children. Theour clients, feel the pressure to solve the prescription) elephant won’t go away empirical evidence supporting theproblem rapidly with the best standard just because we don’t talk about it. benefit of child medication is far fromof care. And, more and more, that Our reticence is mirrored in parents substantial, while concerns about safetystandard has become synonymous with and children who are reluctant to offer continue to surface. Therapists can usepsychiatric 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 canto manage youth behaviour and result is that children, parents, and help children and parents get the factsemotional problems, the lure of a therapists are often shut out of the about risks and benefits, and makequick fix is understandable, and loop—their questions, ideas, and clear the take-home message that theredrugs 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 discreditpsychiatric consultations, therapists all, we are not medical experts, or as individual preferences for orare often hesitant to talk about the joke goes, we are not ‘real’ doctors. experiences with medication, or to32 PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007
  2. 2. claim that psychiatric drugs are not Explosion in the use of a psychiatrist is made and Jess isever 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 decadeanti-privileging drugs as a first-line Jess, a 15-year old girl enters school has seen an explosion of psychotropicsolution—especially for children and through the front door, proceeds down medication prescriptions for childrenadolescents. And while we are adamant the hallway and out the back, another and teens (Zito et al., 2003). Inabout putting clients in charge of the no-show for the day. Jess finds it the United States prescriptions fordecision to medicate and have been difficult to attend to classroom work, antidepressants have increased at awriting passionately about the lack preferring to hang out with the pony rate of 11 per cent each year from 1994of demonstrated efficacy of drugging she helps care for as a part-time job. At to 2000, and five per cent each yearchildren for nearly ten years, we are the school meeting, Jess’s mother states since, a total of over eleven millionactually in the mainstream of current that she found marks on her daughter’s prescriptions written annually. Thescientific thinking, The American arms, apparently self-inflicted with number taking antipsychotic medicinesPsychological Association Working Group her father’s pen knife. A referral to soared 73 per cent in the four yearson Psychotropic Medications for Childrenand Adolescents, 2006 states: ‘It is the opinion of this working groupthat…the decision about which treatment With daily pressure on therapists to manageto use first…should be guided by thebalance 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 supportas stand-alone treatments. Moreover,the preponderance of available evidenceindicates that psychosocial treatmentsare safer than psychoactive medications.Thus, it is our recommendationthat in most cases, psychosocialinterventions be considered first’.(p. 175, emphasis added) The report further points out: ‘Ultimately, it is the families’ decisionabout which treatments to use andin which order. A clinician’s role is toprovide the family with the most up-to-date evidence, as it becomes available,regarding short- and long-term risksand benefits of the treatments.’ (p. 175) The APA is hardly an organizationknown for going out on a limb ortaking risky liberties with the data!This knowledge means that whenchildren experience difficulties,discussions about solutions can beopen, creative, and evolving, andencompass a range of views aboutchange based on each person’sconcerns, circumstances, andpreferences. While medication maybe useful for some children, it doesnot have to dominate interventionstrategies or monopolize talk aboutchange. Therapists can expand therange of options, and their clinicalroles, even in circumstances thattypically trigger prescriptions. Illustration: Shannon Rose PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007 33
  3. 3. ending in 2005, far outpacing the to neuro-imaging research as proof Yeah…I told my mom about Nick (Jess’sincrease 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 youantipsychotics (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 therapistbehavioural problems exceeds any other ADHD counterparts (Castellanos et talk about how Jess cuts herself to helpcategory for the first time, including al., 2002). However, anatomy Professor with the emotional hurt. They alsoantibiotics. The number of kids taking Jonathan Leo and researcher David talk about Jess’s boredom with herone or more prescription medicines to Cohen report that the control group classes and her desire to work moretreat mental health-related conditions was two years older, heavier, and taller to earn money and not ‘waste time’ athas 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 tolived in a foster home, she would be 16 undermining any conclusion about music, get in her mom’s bed or call hertimes more likely to be medicated; if brain size and ADHD (Leo & Cohen, friends. Jess writes the strategies downthe diagnosis ended up bipolar disorder 2003). Despite fifty years of efforts to and signs an agreement to tell her momor ADHD, her chances of being on find one, no reliable biological marker or call the therapist if she feels like it ismore 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 oneproblems are biological and require the table and draw in the voices of Jess child and one family at a time after anmedical 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 ofarticles and TV advertisements I don’t want you to hurt yourself. psychiatric diagnosisdescribe 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 fromdysfunctions. Even when we know they looks down.) residential treatment and recentlyare promotions from drug companies, Therapist: Jess, we just want to make reunited with his mother who ispictures of neurotransmitters or talking sure you’re safe? What do you think now attending regular Narcoticsserotonin cartoons are powerful, lasting will help? Anonymous meetings. Whenimages. 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 aclinical studies. Social explanations There is genuine puzzlement and beeline for the door and is foundand solutions are not accorded the same concern from everyone in the room— hanging halfway up the flagpoleweight in the media as medical ones there does not seem to be a way out o like a frightened monkey. In shortand are a distant second when it comes f the dilemma.) order, Michael’s diagnosis is changedto research funding and marketing. As Mother: Jess, do you want to take the from ADHD to early onset bipolara result, claims are rarely questioned medicine that Dr. Stevens gave you? He disorder. His medication is changedand the assumption that child and said you were clinically depressed and from stimulants to anticonvulsant andadolescent 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 glancebiochemical imbalances and other Mother: Okay. medication seems the most logicalso-called mind diseases remain the Therapist: Jess, do you want to talk with intervention for preventing a slideonly territory in medicine where me and your mom, or maybe just one of us into more distress and coping withdiagnoses are permitted without a alone, about some of that stuff we talked the disorder. Diagnosis, as the solesingle confirmatory test (Duncan, about last week? gateway to medications, providesMiller & Sparks, 2004). Many point Jess: (after a lengthy pause, thinking) the official rationale for medical34 PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007
  4. 4. intervention. The belief that diagnosis like the old ones, but these are even worse. as making sense within the context ofcan provide accurate identification of Mom says I should take them, but they the child’s life. And if medication is adiscreet disorders is a key assumption make me feel weird! part of treatment, children can monitorthat underlies medication prescription. Therapist: I saw what the doctor said in whether medication is useful and, withTherapists may feel that they have the report he sent me. It says that it seems the help of adults, can be in the driver’slittle 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 theand 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 keepof 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 occurdiagnostic validity is questionable ‘I’m outta here!’ when playing with his three-yearwhen it comes to children. According Therapist: Wow. That makes a lot of old sister and they fear that he mayto the World Health Report, ‘Childhood sense. No wonder you wanted to do hurt her. Kyle’s mother shares with aand adolescence being developmental something to get that thought out of your therapist her concern that Kyle mightphases, it is difficult to draw clear mind for a while. have a mental illness and wondersboundaries between phenomena that are Michael: So, you mean I’m not crazy? whether medication could help. Whenpart of normal development and others It was important for Michael to parents hear that even young childrenthat are abnormal’ (World Health make sense of his own experience can be mentally ill and that problemsOrganization, 2001). The notion of and actions, and to understand these result from undiagnosed disorders, itstable, fixed psychiatric syndromes as reactions to stressful events. The makes sense that they may adopt thisdoes not fit the fluctuations of child therapist refused to allow the diagnosis point of view when other explanationsdevelopment 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 psychotropiccontinually 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 Prozacnot clinicians looking at the same array The therapist returned to the pills and similar drugs are the interventionof symptoms will come up with the because Michael expressed discomfort of choice for child and adolescentsame diagnosis. If there is independent with them. Referring to the outcome depression, and that stimulantagreement on a diagnosis amongst measure the therapist was using, the medications are consistently effectiveprofessionals, 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 alsoof the DSM, commented on the ability to determine whether it was working or endorse such assumptions based onof 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 citedthat 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 gainedif you’re in a situation with a generalclinician it’s certainly not very good. There’sstill a real problem, and it’s not clear how tosolve the problem’ (Spiegel, 2005, p. 63).In other words, Michael might well bediagnosed with depression if he wereseen by a different clinician, or maynot have received a diagnosis at all.A bipolar diagnosis can last a lifetime;out-of-the ordinary child behaviourstend to be time-limited. Recognizingthe potential negative effects, theAmerican Counseling Association’sEthical Code supports counsellors whorefrain from making a diagnosis. Returning to Michael, consider thetherapist’s response to his diagnosis:Therapist: Hey, Michael, how’s it going?Michael: Not so good. The doctor says Ihave some kind of…I forget. Anyway, hegave me these new pills to take. I didn’t PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007 35
  5. 5. Prozac FDA approval for childhood inactive pill takers easily, effectively between medication and placebodepression 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 accurateMedical 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 wereEmslie studies); and the Multimodal that when studies used active placebos, of eight weeks duration, calling intoTreatment of ADHD (MTA) little or no differences were found question their usefulness in real-worldexamining 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 who2004ab). 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. Thethe randomized, double blind, placebo blind. Evidence of the compromised pharmaceutical industry’s influencecontrolled trial. In this design, two double blind were apparent in the drug over scientific inquiry has, in somegroups are formed, presumably similar manufacturer’s own records where ways, become almost a cliché. Insince they are selected randomly from ‘it was not uncommon to see notations May of 2000, the editor of the Newthe initial pool of applicants. One defining the patient’s blinded treatment, England Journal of Medicine, Marciagroup gets the drug being tested; the or in some cases to find fluoxetine (Prozac) Angell called attention to the problemother, a placebo. In this design, neither plasma concentration results’ (FDA, of ‘ubiquitous and manifold…financialstudy participants, researchers, nor 2001, June 25, p. 19). associations’ of authors to the companiesassisting clinicians, should know who The instruments chosen as primary whose drugs were being studiedis in which group—that is, who is measures in drug trials are clinician- (Angell, 2000, p. 1516). Why is ittaking the real drug and who is getting rated. Frequently, client ratings of important to know who sponsors athe 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 publishedgroup, and weeds out factors like hope both clinical trials that resulted in head-to-head comparisons of fiveand expectancy that could interfere FDA approval of Prozac, no client- popular antipsychotic medications. Inwith determining what is actually rated measures indicated superiority nine out of ten studies, the drug maderesponsible for any differences found of the drug over placebo. However, by the company that sponsored thebetween 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 theparticipants 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 easyeffects of real drugs. Rather, they use out of four clinician-rated measures to accept bottom line conclusions asinert sugar pills as the placebo which indicated a difference between the fact. However, recent regulations nowmakes it possible for most participants placebo and SSRI groups. Two client- require authors to fully disclose theirand clinicians to tell who is getting rated measures found no difference. affiliations, allowing a more criticalthe 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 priorstandard side effect profile of actual significant difference—all client- to disclosure requirements, did notdrugs—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 Lillyand so on. Study participants are likely three clinician-rated measures showed sponsored the study. The second andto be on the alert for these types of significant differences between the approval-clinching trial of Prozac forevents and, since most have been on experimental drug and placebo. If child and adolescent depression listsmedications 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 isthese subjects are likely to identify effective are the drugs? a paid consultant for Eli Lilly, whocorrectly 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 remainingDuncan, 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 thatthroughout the study to collect drug will be taken for much longer. company’ (p. 1205). Combining thisinformation 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 placebosfor or are active in asking about side an accurate picture of the drug’s seriously calls into question whethereffects can reveal the active versus performance in real life. Differences the researchers, either employees or36 PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007
  6. 6. consultants of the company whose drug (the 7–9 year old children) rated MTA authors have significant ties towas under investigation could, with so themselves as no more improved when drug companies. Specifically, Jensenmuch 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 underpublished 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 toreveal that, as far as how well they neither blinded classroom observers, look for—does the study have a truework, these drugs, plain and simple, the children themselves, or their peers double blind, are outcome measuresdo 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 hardanalysis by researcher Jon Jureidini behavioural interventions suggests that to start down a path that saw hisfound that, out of 42 reported measures stimulant drugs offer no advantages difficulty as the early signs of mentalin six published trials, only 14 showed over non-medication alternatives. illness. Through this lens, a proactivea statistical advantage. None of the With regard to time frames, the approach might make sense, wardingyouth and parent measures in this MTA surpassed its predecessors off a potential downward spiral beforesample 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 andoctors reported improvement. They weeks. The assessment occurred at approach most likely means medicationalso discovered that the effect size for the 14-month endpoint while subjects with its attendant risk and unproventhe 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 resolvedifference 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 youmay be statistically significant, but fails face-to-face contact. Thus, the endpoint have some concerns here. I really appreciatethe test of clinical significance—that MTA comparison was between how you’re trying to make sure that youis, fails to tells us anything meaningful active medication and withdrawn know what’s going on so that you can takeabout 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 thispractice’. Unpublished trials fared contest, making the slight superiority age, rather than wait until the child is 8 ormuch 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 [withplacebo (Jureidini, Doecke, Mansfield, 24-month follow-up of the MTA Kyle’s dad] thought too. That’s why IHaby, 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, wethe 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 younot only didn’t use an active placebo, over the behavioural intervention also that you could make the time to get init 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 about1999). 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 aand 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 certainlyclassroom raters) found no difference Science, www.cspinet.org/integrity/) something that could be done. But, weamong any of the intervention groups. reveals that lead MTA investigator don’t really know if that will be neededIn 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 37
  7. 7. work with the schools and also recommend children are prescribed ‘off label’. participants receiving Prozac in thisthings 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 publishedWe can observe what’s working for him they are safe and effective. Included and unpublished trials, the FDAand what we can do to build in some in off label medications are the new issued a black box warning forrewards 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 providerssame—see what is working or what isn’t to support the efficacy or safety of to increased risk of suicidality andat home. Would you note the times thatKyle is getting along with his sister andwhen things are going well? (Mothernods in agreement) If we can meet again In both clinical trials that resulted in FDAnext week, we might have some betterideas of what’s going on and where to go approval of Prozac, no client-rated measureswith things. Does that make sense? indicated superiority of the drug overMother: Yes, it does. Problem is, his dadand I are so busy, and the baby takes up placebo. However, both studies concludedso much of my time, we hardly pay muchattention to Kyle these days except to tell that Prozac outperformed placebo.him to do things, like get ready for bed orto 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 Healthcaregame 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 tookdetailed concrete steps that could of approved drugs for children is very it further, banning all antidepressantsbe implemented at school and home. narrow—more narrow than what (except Prozac, which can only be usedA follow-up meeting was scheduled might justify the robust prescription with children over eight years whento review progress and develop a rates. Even approved medications often talk therapies have failed). Growthbehavioural plan based on the mother’s have risks that are minimized in the suppression and adverse cardiac effectsand 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 troublingwere 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 childrenand address the problem emerged been collected raises concern. A in the MTA reported adverse drugfrom a therapeutic partnership to systematic evaluation of 82 medical reactions: 11 per cent were ratedexplore 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 FDASafety 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 beenof medications and, in particular, ones of PAEs in child and adolescent associated with increased emergencynot approved for children. Michael studies is complicated by inconsistent room visits. A recent study conductedwas placed on an antipsychotic and an collection methods for side effects by the U. S. Centers for Diseaseanticonvulsant. All he knew was that data, and benign or misleading Control and Prevention foundhe didn’t feel right. His teacher noted assessments of data actually reported. that thousands of children takingthat Michael no longer disrupted class, In the first Emslie study, six per cent stimulants wind up in the ER withbut 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 MTAHowever, safety is often tied to a group. If extrapolated to the general also revealed that the average heightlesser-of-two-evils argument. Many are population, for every 100,000 children suppression for older children waswilling to accept certain risks when the on Prozac, as many as 6,000 might about 1 cm per year, while youngerpossible alternative is a child’s school be expected to experience this serious children averaged 1.4 cm per yearfailure, 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 2007
  8. 8. Children 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 volumetaking antipsychotic medications in by all (like the Child Outcome abnormalities in children and adolescentsrecord 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 psychotropicrisk of diabetes. Given that one in five results as a basis for discussion medication use for youths: a two-statevisits 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 viewa 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, howBlanco, 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 questionsConclusion 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 psychiatricto medicate a child is one of the Lack of critical awareness takes practice. Journal of Child and Adolescentmost 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 oftimidity and discuss openly the risks depression in children and adolescents: the lackluster empirical support for A placebo-controlled, randomized clinicaland benefits of medication, with the drugging children as a first-line trial. Journal of the American Academy ofknowledge 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 trialthat 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 including the youth, are aware of psychoactive medications for children & Tribune, p. 6. potential risks, adverse events, the adolescents. Psychopharmacological, Jureidini, J. N., Doecke, C. J., Mansfield, meaning of off label prescription, psychosocial, and combined interventions 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. combining medications. Suggest Washington, DC: American Psychological of antidepressants for children and resources for obtaining additional Association. Retrieved Sept. 22, 2006 from adolescents. British Medical Journal, information about risks and http://www.apa.org/pi/cyf/childmeds.pdf. 328, 879–883. benefits. Include discussion of a Angell, M. (2000). Is academic medicine Leo, J., & Cohen, D. (2003). Broken brains time frame for discontinuation for sale? The New England Journal of or flawed studies? A critical review of ADHD of medication. Medicine, 341(20), 1516–1518. neuromimaging research. The Journal of Mind and Behavior, 24(1), 29–56. • Work with the child, parents, Castellanos, F. X., Lee, P. P., Sharp, W., teachers and others to implement Jeffries, N. O., Greenstein, D. K., Clasen, L. Moncrieff, J., Wessely, S., Hardy, R. (2004). the plan and modify it based on S., Blumenthal, J. D., James, R. S., Ebens, Active placebo versus antidepressants for PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007 39
  9. 9. depression. The Cochrane Database of Sparks, J. A. & Duncan, B. L. (in press). U. S. Food and Drug AdministrationSystematic Review: The Cochrane Library, Do no harm: A critical risk/benefit analysis (2004, October 15). FDA launches a2, Oxford: Update Software. of child psychotropic medication. Journal of multi-pronged strategy to strengthen Family Psychotherapy. safeguards for children treated with MTA Cooperative Group. (2004a) 24-month antidepressant medications. Retrievedoutcomes of treatment strategies for Sparks, J. Duncan, B. & Miller, S.(2006). October 30, 2004 from http://www.fda.gov/attention deficit/hyperactivity disorder Integrating psychotherapy and bbs/topics/news/2004/NEW01124.html(ADHD): The NIMH MTA follow-up. pharmacology: Myths and the missingPediatrics, 113, April, 754–761. link. Journal of Family Psychotherapy, Wilens, T. E., Biederman, J., Kwon, A., 17, 83–108. Chase, R., Greenberg, L. & Mick, E. (2003).MTA Cooperative Group (2004b). Changes A systematic chart review of the nature ofin effectiveness and growth during Spiegel, A. (2005). The dictionary of psychiatric adverse events in children andthe follow-up phase of the multimodal disorder: How one man redefined adolescents treated with serotonin reuptaketreatment study of children with psychiatric care. The New Yorker, January inhibitors. Journal of Child and Adolescentattention deficit/hyperactivity disorder. 3, 56–63. Psychopharmacology, 13, 143–152.Pediatrics, 113, April, 762–769. Staller, J. A., Wade, M. J., & Baker, M. (2005). Current prescribing patterns World Health Organization (2001). WorldMTA Cooperative Group (1999). A 14- in outpatient child and adolescent Health Report, 2001. Available at http://month randomized clinical trial of treatment psychiatric practice in central New www.who.int/whr/2001/en/strategies for attention-deficit/hyperactivitydisorder. Archives of General Psychiatry, 56 York. Journal of Child and Adolescent Zito, J. M. & Safer, S. J. (2005). Recent(12), 1073–1086. Psychopharmacology, 15(1), 57–61. child pharmacoepidemiological findings. U. S. Food and Drug Administration Journal of Child and AdolescentOlfson, M., Blanco, C., Liu, L., Moreno, C. & (2001, June 25). Medical review. Psychopharmacology, 15(1), 5–9.Laje, G. (2006). National trends in outpatienttreatment of children and adolescents with Retrieved July 3, 2004 from http://www. Zito, J. M., Safer, S. J., dosReis, S.,antipsychotic drugs. Archives of General fda.gov/dcer/foi/nda/2003/18936SO64_ Gardner, J. F., Magder, L., Soeken, K.,Psychiatry, 63(6), 679–685. Prozac%Pulvules_medr .pdf Boles, M., Lynch, F. & Riddle, M. A. (2003). Psychotropic practice patterns for youth: A 10-year perspective. Archives of Pediatric & Adolescent Medicine, 157(1), 17–25. 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.net40 PSYCHOTHER APY IN AUSTR ALIA • VOL 13 NO 4 • AUGUST 2007

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