There is, in America, an epidemic of
children being diagnosed with mental illness. The
Surgeon General?s Report of 1999 states that
“Approximately one in five children has a DSM-IV
disorder (mental health problem) during the course of a
year”.1 The most common diagnosis is Attention Deficit
Hyperactivity Disorder(ADHD), but Oppositional Defiant
Disorder(ODD), conduct disorder(CD), anxiety, bipolar
disorder, and depression are also diagnosed frequently,
and often several ‘co-morbid’ diagnoses are made at the
same time.2 Moreover, all these ‘illnesses’ are said to
be due to disorders within the child’s brain, rather
than to environmental stresses or the normal vagaries of
childhood. We will see how this trend reflects the
current bias in psychiatry towards bio-determinism,
which in turn reflects the state of the world in which
we live.
The prevailing model within the
psychiatric profession today is that mental illness is
predominantly biological in origin. “Brain chemistry is
believed to be not only the cause of mental disorders,
but also the explanation of the normal variations in
personality and behavior.” 3 This view applies not only
to severe psychoses such as schizophrenia, but to
maladaptive behavior or swings in mood, which used to be
viewed as responses to the stresses and losses of life
or neurotic at worst.
This biological model developed in large
part because of the discovery of drugs in the last 50
years which could improve psychotic symptoms, mood and
behavior. Most of these beneficial effects were
discovered serendipitously, but the drugs were later
found to affect neurotransmitters such as serotonin or
dopamine. Thus it was theorized that abnormalities in
these substances were the cause of mental illness,
although very little is actually known about the
pathways between neurochemistry and behavior. There is
no doubt that emotions, ideas and actions are all
reflected in the brain, but how these pathways work,
what is cause or what is effect, what is inborn and what
is environmental remain largely unknown. However, by
assuming that neurochemistry explains so many
psychological problems, psychiatrists can treat nearly
all patients with medications without dealing with their
life circumstances.4 This is not only a huge boon to the
drug industry, but removes any pressure to investigate
how our society may be making so many people unhappy or
nonfunctional.
Another significant movement within
psychiatry is the expansion of the list of problems
which are characterized as illnesses.5 All kinds of
personality traits, such as shyness, separation anxiety,
distractibility, or hyperactivity have come to be seen
as diseases or symptoms of disease. If one looks at the
diagnostic criteria for ADHD (Table1)6, they are
characteristics that may be exhibited by almost any
child in trying circumstances or may simply represent a
part of the spectrum of childish behaviors. In fact,
what is labeled as disease may be said, in many cases,
to represent a mismatch between the child and the
expectations that are placed on him or her. We require
our children to attend schools with ever larger classes,
fewer and more inexperienced teachers, with less time
for play and the arts, to master skills at an ever
earlier age, and to be subject to constant testing and
rigid curricula. It is not surprising that ever more
children find it hard to conform to the expectations of
the schools. More and more children are also dealing
with the stresses of poverty and broken homes. Even well
to do children are under increasing pressure to pass
tests, get into college, and compete in a shrinking job
market.7 But instead of questioning the wisdom of our
social and educational choices, we blame the difficulty
of children in living up to our expectations on them, by
labeling more and more of them as
ill.
The diagnosis of ADHD has increased
dramatically in the last 30 years, from an estimated
150,000 in 19708 to 5-10% of American children
today.9,10 Over 85% of Ritalin in the world is
manufactured and prescribed in the United States,
causing the United Nations to caution against this
excess.11(Figures 1&2) There is also a major
variation between areas of the country in the frequency
of its use. In some areas of eastern Virginia, over 1/3
of boys in fifth grade are diagnosed with ADHD.12 In
other states, such as Hawaii, almost no one is on
Ritalin. As publicity about the over or under-diagnosis
of the condition has influenced public opinion, the
rates of Ritalin prescriptions in a single place have
changed dramatically in a short period of time. For
example, there was a 2.5 fold increase in Maryland from
1990-5, a similar decrease in Wisconsin, and there is up
to a 10 fold variation in prescription rates in counties
within the same state.13,14 If ADHD were truly a disease
with a medically necessary treatment like insulin, this
could never occur.
Ritalin, the main drug prescribed for
ADHD, is a stimulant similar to amphetamines and
cocaine. It was first approved for use in hyperactive
children by the Drug Enforcement Agency (DEA) in 1961,
and in 1970 it was made a Schedule II drug because of
its potential for psychic addiction.15 Although it is
commonly thought that Ritalin has a paradoxically
calming effect in children, this is not the case. It
enables anyone who takes it to improve performance on
various tasks, especially those requiring attention to
detail and repetition, like many school exercises. There
is no evidence that Ritalin, or similar drugs like
Concerta, improves complex skills like reading or social
behavior16 or overall long term outcome for users, in
terms of graduation rates, school suspensions or legal
encounters.17 The drug has few dangerous side effects in
many who take it, but it often causes trouble sleeping
or loss of appetite. In rare cases, it can lead to
severe tics or cardiovascular problems. Most worrisome
is that Ritalin has become a common drug of abuse, with
16% of college age students selling their Ritalin for a
concentrated high and an increasing number of overdose
hospitalizations and deaths.18
The age at which children are being
medicated has also continued to decrease. Recently, a
survey of toddlers in both a Medicaid and an HMO
documented that 1.5% of them are on psychiatric
medications,19 and many of these are on multiple
medications. Other studies of drug prescriptions in this
age group have shown that the use of drugs and drug
combinations is totally haphazard, and that many of
these children are not receiving close follow up either
medically or psychologically.20,21 Not only are
psychiatric drugs not approved for this age group, but
this is the time of life when neuroreceptors in the
brain are developing the most rapidly, and there us an
unknown potential for long term toxicity of drugs
targeting neuroreceptors.22 The response of the
psychiatric community and regulatory agencies to this
expose, however, was not to ban the use of drugs in such
young children but to study them further. The problem is
that we do not have the tools to assess long term
effects of stimulants, nor the inclination to delve into
the causes of children’s difficulties or alter the
environments in which they live.
In the case of Ritalin, the National
Institutes of Mental Health(NIMH) is now sponsoring a
study of its use in 3-5 year olds at seven medical
centers. 23 The study assumes that one can draw a line
between normal and abnormal behavior at this age. One
way children’s response to Ritalin is assessed by
observing their performance at various nursery school
tasks, like building with blocks, for which Ritalin
would improve the ability of any child. By definition,
only children whose parents would be willing to place
their child on medication are enrolled, but those same
parents will be part of assessment of success. Thus
there is no doubt that this study will be said to prove
the safety and usefulness of Ritalin. However, the short
36 month term of the study will not address the possible
long-term toxicity of the drug in such young children,
nor are parents made aware of this potential danger. It
is not unexpected that the researchers at New York State
Psychiatric Institute/Columbia Presbyterian Department
of Child Psychiatry, who proposed this study to NIMH,
are largely supported by the drug companies who
manufacture Ritalin and its
congeners.24
The spectrum of children diagnosed and
treated with Ritalin over the years has also changed.
Several decades ago, white middle class youngsters were
the main consumers, perhaps reflecting the pressure on
such children to do well academically and the faith of
their parents in medical science. The use of the drugs
was always voluntary and was often sought by parents.
However, there is now marked narrowing of the gap in
Ritalin usage between poor and middle class children and
between whites and blacks .The ratio of stimulant use
between white and African-American children fell from
2.9 in 1987 to 1.4 in 1996.25 Moreover, when ADHD is
diagnosed and drugs prescribed for poor and minority
children, the process is much more likely to be
coercive. Often the diagnosis is suggested by a teacher
who is having trouble dealing with a child in class
either behaviorally or academically. The schools may
then suggest that the parent see a doctor to prescribe
medicine for ADHD, and the parent is then likely
referred to a medical center like Columbia or a
pediatrician who is biased in favor of medications and
performs only a cursory evaluation of the child. If
parents object to medication, they may be forced to
remove the child from school or be threatened with being
reported to child welfare agencies for ‘medical
neglect’. When a recent series of articles on such cases
was published in the New York Post, over a hundred local
parents called to describe such abuses.26 In response to
similar cases, several states, including Colorado,
Texas, and Rhode Island, have passed laws forbidding
schools from making medical diagnoses or requiring
medication for children in order to attend
school.
It is important to say that psychiatric
medications, including Ritalin, are not always against
the interest of the child. Some children have extreme
behavioral or emotional problems that require intensive
investigation and treatment, and medication may be a
part of an overall treatment plan. What is alarming,
however, is that huge and escalating numbers of children
are being labeled as ill and medicated. Many of these
children may have no problem at all -- they are simply
active or dreamy in situations where adults want them to
sit still and pay attention. Other children may have
more significant problems, but their problems may
reflect stresses within the family, ineffective
schooling, learning disorders, medical conditions, poor
diet or sleep patterns, or a myriad of other
possibilities. It is a time consuming and difficult
process to assess a child and his or her environment and
develop a plan to improve the situation. Many schools
and families do not have the resources to do this, and
so they resort to a quick fix with drugs. Unfortunately,
many educators and medical professionals are promoting
this approach.
We cannot, however, attribute the steep
rise in the diagnosis and medication of children to just
a fad or a wobble in the nature-nurture debate, for more
profound forces are at work. One factor is the power of
the pharmaceutical industry. Psychiatric medicines like
Prozac have become some of the biggest selling drugs on
the market and accounted for $8 billion in profits in
the US in 1998.27 Ritalin alone showed a 5 fold increase
in profits from 1990-1996.28 Certainly the drug
companies are eager to sell to the largest untapped
market for their mind altering drugs -- children. But
they could not do this if the society was not already
primed to accept a biodeterministic view of life. This
outlook says that a person’s social position and success
are largely predetermined by his genetic makeup, and it
has been used to explain social inequality for hundreds
of years. Under slavery, blacks were said to be inferior
to whites and attempted escape was said to result from a
disease called drapetomania. The eugenics movement of
the early 20th century was born in America and purported
to prove the inferiority of various minority groups.
Eugenics laws were enforced to limit immigration and
even to force sterilization. The Nazis imported eugenic
‘science’ from the US to justify the slaughters of Jews,
Slavs, the mentally retarded, the physically handicapped
and others. The perpetrators of the Tuskegee experiments
declared the physical difference of African Americans to
explain how they contracted syphilis and why it was all
right not to treat them.
Biodeterminism has always flourished
when societies exhibit both great inequality and are at
risk of upheaval. It is an outlook which explains
inequity and blames the most oppressed and weakest
members of society for their own disadvantages. It takes
the onus off society to change since it declares that it
is the inborn endowment of each individual that
determines his or her condition. In the present day
United States, we are living in an era of great and
increasing inequality between the rich and the
poor--poverty is increasing for the first time in 12
years and unemployment has not been so high since the
last recession. Moreover, the aftermath of 9/11 and the
impending war in Iraq have allowed the government to
impose fearsome new limits on civil liberties. From
arrests based on racial profiling to secret trials to
encouragement of spying on one?s neighbors, a climate of
intimidation and jingoism is growing and bears a
startling resemblance to regimes called fascist in the
past.
To make this new order acceptable to
people, the state relies on fear and ideology, which
includes patriotism, racism and biodeterminism. That is,
we are urged to believe in our fundamental difference
from those of other nationalities or backgrounds, who
are branded as ?evil?, and to accept the stratification
in our own society as based on natural assortment by
ability and temperament. The growing percentage of
Americans who believe themselves to be mentally ill,
many of whom are on an array of psychiatric drugs, have
not only bought into the idea that they are damaged
goods but have been rendered unable to struggle to
change their situation or conditions in society. Imagine
the harm that is done to children, who from an early age
are labeled ‘ill’ and who will suffer as yet unknown
physical and psychic harm from decades on mind-altering
drugs. This is truly medical fascism, carried out in the
name of biomedical progress.
Several groups around the country are
fighting this trend to over-drug our children. One such
effort is by The Coalition Against the Violence
Initiative in New York City, a group of parents,
community activists, and health workers affiliated with
The Riverside Church. We have had informational forums,
leafletted schools and PTAs, spoken on radio, held
demonstrations and published literature for teachers and
parents. If you would like to know more about us or find
about a group in your area, call 212 330-8677 or write
to CAVI , c/o Social Justice Ministries of The Riverside
Church, 490 Riverside Dr., New York, NY
10027.
Contact Dr. Isaacs at eisaacs@pol.net
REFERENCES
1. Mental Health: A Report of the Surgeon General,
Chapter 3:Chilren
and Mental Health, 1999
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H, Psychotropic
Medication Use in a Population of Children with
Attention-Deficit/Hyperactivity
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3. Valenstein E, Blaming the Brain. The Free Press,
New York, 1998, p. 1
4. Rethinking Ritalin, The Congressional Quarterly
Researcher. 1999;9:905-28
5. Ralph D, Work and Madness, The Rise of Community
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7. Diller L, Running on Ritalin. Bantam Books, New
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8. Ibid., p.22
9. Attention Deficit Hyperactivity Disorder, National
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10. Biederman J, Are Stimulants Overprescribed for
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11. Woodworth T, Deputy Director Office of Diversion
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12. Griffith D, ADHD Alert Spurs Reform in Virginia,
The Sacramento Bee, June 23, 2002
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14. Parry, M, letter to Dr. Roger Lindeman, publisher
Virginia Mason, March 31, 1998
15. Woodworth T (see 11)
16. Diller, p. 314
17. Lefever, G, presentation at National Convention
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18. Press Release, Drug Enforcement Administration,
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