Psychology Today Blogs - The Last Normal Child

ECGs, ADHD, Ritalin...Oh My!

Lawrence Diller, M.D. — Sat, 10 May 2008 17:40:08 -0700

On April 21st, the American Heart Association (AHA) shocked families and professionals alike when it recommended that all kids that take or may take Ritalin should have an electrocardiogram (ECG). Stimulant drugs like Ritalin, Concerta and Adderall have been used in children for ADHD for 70 years. Why this recommendation now -- and should you get one for your child if he/she takes one of these drugs?

I read and reread the article in Circulation (the official journal of the AHA) four times trying to make sense of the main points and recommendations. I’ve spoken to two high up academic child psychiatrists. I am awaiting a call back from my contact pediatric cardiologist. We’ve consulted before on a boy with severe ADHD whom I’ve treated with Concerta who also has had surgical repair of his heart that was missing his left ventricle when he was born.

The AHA evaluation and recommendations were prompted by reports two years ago of the sudden deaths of 18 children while taking a prescription stimulant drug over a five year period (1999 to 2004). Only seven of these children were found not to have structural heart problems. Their deaths were felt to be caused by severe irregular heart beats associated with their basic cardiac condition and exacerbated by taking the medication.

For six months the Canadian equivalent of the FDA banned Adderall (felt to be the drug of most concern) for children in Canada. However, after considering all the numbers (how many children take the drug) and the relative risk, the ban was rescinded. Now come the AHA recommendations that include obtaining an ECG for any child (even those without any cardiac symptoms or family history) being considered for a prescription stimulant. The AHA recommends that all children currently on stimulants also get an ECG. Also if the first ECG was obtained before the age of twelve a second ECG should be performed when the child is a teenager.

I commented on this problem of sudden death two years ago. Most of you aware of my writing and stance know that I’ve been prescribing stimulant medication to children for thirty years even as I feel we over prescribe and don’t sufficiently pursue effective non-drug interventions for problems of children’s behavior and performance (at school). I’ve never felt that stimulants were dangerous and I believe they are effective in the short term. My calls for caution were based more for ethical than medical reasons.

Two years ago I tried to figure the risk for a child without heart disease of dying suddenly while taking a stimulant. I used seven as the numerator – the number of kids who died without heart disease present -- and four million as the denominator for my estimate of the number of kids under the age of eighteen taking stimulant drugs in America in 2006. I came up with a number with five zeroes after the decimal point (.00000175) or 0.000175 per cent, approximately two ten thousandths of a per cent chance of dying suddenly if the child is taking a stimulant drug. This represents what I call an “existential” level of risk.

I am not certain of my numbers but suggested the likelihood of getting killed on the local freeway on a Saturday night by a drunk driver was probably higher – and still we take freeways because it gets us from one place to another faster. I’m not sure what the accident rate on surface roads are but it’s all meaningless in terms of real risk – much like debating how many angels dance on the head of a pin.

Even taking eighteen as the numerator and lowering the denominator to 2.5 million (the CDC estimate of the number of children taking stimulants) one gets about four times the risk – now seven ten thousandths per cent – but still infinitesimal. So why did the AHA make their recommendation?

I could answer cynically as say this was a real CYA move so that the AHA and pediatric cardiologists could tell child psychiatrists, pediatricians and family physicians, “See we gave you our warning,” should the public mood ever change over the propriety of the widespread use of stimulant drugs in children. But the AHA recommendation brings up an ethical dilemma for parents (and doctors) who want to feel that they took every possible precaution in the unlikely event (and we’re talking on the level of lightning strikes or lotto winners) of a catastrophe.

The AHA acknowledges that an abnormal ECG alone does not represent a complete contraindication towards using a stimulant drug for a child. Rather AHA experts suggest the family and pediatric cardiologist discuss the relative risks. I suppose in a truly borderline decision it might psychologically (because scientifically, the risk is so so low) have a family lean towards not using the medication for the child. As someone who feels the medication is generally over prescribed, I suppose I should be pleased with this result but I’m not, if the basis is a hysteria over existential risk.

I am planning to let parents decide for themselves. I will give them my opinion that I am willing to assume the theoretical added risk in not knowing whether or not a child has asymptomatic cardiac disease. However, if the family wants to obtain an ECG for their child I will support it. I suspect some of the more anxious parents will opt to get the ECG for their kid. Has anyone in this imbroglio figured in the slightly higher rates of suicidality when one prescribes an SSRI to an anxious child? Confronting hypocrisy and propaganda has routinely been my motive for speaking out and writing. Overreaction and hysteria even in well thought out scenarios require my challenging the “authorities” again.

Mr. Rogers Was Wrong

Lawrence Diller, M.D. — Sun, 20 Apr 2008 10:32:15 -0700

He closes his review with the following quote," It stands to reason, though, that parents must be part of the problem. Some of us have raised dummies and the disengaged not on purpose, surely, but perhaps because we listened to Mr. Rogers and told them (the kids) too often that we liked them just the way they were."

I've watched with concern, helplessness, frustration and bemusement the fruits of our culture's over emphasis on feelings in general and its fixation over children's self-image and self esteem. These are huge cultural trends (read the first essay in my book, The Last Normal Child) that are now playing themselves out, as children raised under these "rules," are now maturing into their mid-twenties.

A rash of books, including my own, is documenting the untended consequences about all this concern and fussing. They include in no particular order Perfect Madness: Motherhood in the Age of Anxiety by Judith Warner, The Price of Privilege by Madeline Levine, One Nation Under Therapy by Sally Satel and most recently, A Nation of Wimps by Psychology Today's Hara Marano. I'm not sure what else is happening out there in media land (TV documentaries pending or websites etc.) but these books could be signalling a tipping point (finally) in our culture's over obsession with feelings and feeling good -- at least on how it can harm our children.

I've been thinking for years that if you want kids to feel good about themselves (and in a moment I'll tell whether that's even all that important) there have to be three ingredients. First and foremost, you've got to get those kids to perform. Here I'm not calling for pre-Harvard/Stanford performance in pre-school. But rather if a kid only listens to his/her parents once out of five times and the parents on the fifth time congratulate the kid for his excellent behavior I can tell you that kid is still going to feel lousy about himself because four of five times, he didn't do what his/her parents said and internally to kids that means "I'm bad." (No matter how much you say "It's not you, Johnny, that's bad -- it's what you did," kids until about age eight cannot intellectually make the distinction -- ask Piaget.) So you've got to get that kid to comply whether through using positives or dare I say discipline (punishment lights up in red on my email screen every time I use the word which I find totally amusing and apropos).

Next, when the kid does perform you've got to acknowledge it otherwise the kid never knows what's good enough. This in general I don't find a problem with the families I work with in that parents are saying "good job" these days for kids' who handle breathing and blinking well enough.

Finally -- and this comes much later for most kids -- is an acknowledgment of difference -- meaning everybody's different and you can't be good at everything. This point hits kids particularly in early adolescence and may not get worked out until one's twenties (that long ain't that bad by the way). However a kid with learning differences may experience this crisis in elementary school so acknowledgment of difference and finding areas of relative competency (everyone has at least one or two) can be helpful.

Still and all the whole self-image/self-esteem concern is blown way out of proportion in terms of long term outcomes. Baumgarten has show quite strongly that self-esteen under the age of thirteen has no predictive value on how kids turn out in their mid-twenties. There are minimal correlations for teen's self-esteem and young adult outcomes. So all this worry about how children feel -- and of course we'd prefer as parents that our kids feel good -- if it leads to weird and untoward outcomes (like wimps or increased diagnoses of ADD/ADHD) should be challenged.

So now we're getting all these books. Ironically, the only thing that hasn't changed is parents' readiness to forego their own common sense and the wisdom of grandparents (yeah, our parents in the 50s and 60s didn't seem to do all that bad after all) and continue to turn to experts who are now reversing 180 degrees their advice from twenty-five years ago.

And you know, it really all doesn't matter in the end. Judith Rich Harris was pilloried ten years ago with her book, The Nurture Assumption, because she was interpreted by critics as saying it's all genetic and parenting doesn't matter. Well, if you look at identical twins reared apart by different families you're impressed with how similar they are by the time they reach thirty. But Harris never said parenting doesn't matter.

If you married your spouse with the idea that you could fundamentally change his/her personality and behavior most of us would consider that naive. However how you act with your spouse on a day to day basis could make a big difference in the quality of that on going relationship. Harris uses that example to try to get parents to chill some in their worry and interventions over their kids. Hey, it'll mostly all work out -- even those kids who've been babied and pampered and worried over by those helicopter parents. It'll all work out. Mr. Rodgers wasn't wrong. He doesn't matter.

MDs Under Pharmarchy: Cooperation or Resistance?

Lawrence Diller, M.D. — Thu, 17 Apr 2008 20:29:19 -0700

On Tuesday in the science section of the New York Times, long time reporter Gina Kolata interviews former chief editor of the New England Journal of Medicine, Jerome Kassirer about his views on doctors facing ethical dilemmas taking drug company money for research or expert speaking. Then she interviews three doctors who have chosen to no longer accept drug money and wonders whether this will be a growing trend in academic medicine.

On Wednesday, in the business section of the Times, Stephanie Saul, reports on an article that appears in this week's Journal of the American Medical Association on scientific journal articles ghostwritten by pharmaceutical industry hired writers then signed by doctor-leaders in the respective field of expertise. The article comes from legal documents obtained during the Vioxx trials and suggests that the practice is quite widespread. The doctors implicated offer weak defenses ("The fact that the draft was written by a Merck employee for later discussion does not in and of itself constitute ghostwriting"). The editor of JAMA that accepted one of the article was not so charitable, "I consider that being scammed."

Danny Carlat, a psychiatrist, who publishes an independent review of psychiatric drugs and therapeutics, The Carlat Newsletter, has been complaining about ghostwritten articles for a couple of years now and it's good that it is getting the attention in mainstream medical journals and newspapers.

What's at stake here apart from good or bad research is the hardwon credibility of doctors as scientists and advocates for their patients. One hundred years ago in this country doctors were considered little more than hucksters for various patent medicines and many neer do well sons of rich scions were sent off to medical school where diplomas could be bought. The professional self-reform efforts led by William Welch of Johns Hopkins and the effects of Flexner Report on medical education created a firewall between the drug companies of old and the medical education of new doctors that was strongly based upon the German/European model of the time. Doctors once again are on the verge of losing their credibility, after nearly 30 years of the Bayh-Dole act passed during the Reagan administration which encouraged financial ties between industry and medical academia.

I have never received money from drug companies but twenty years ago I worked briefly for a start up venture capital firm out to develop educational toys and programs for toddlers to five years old children. I was on the science board and it was my job to vet the product but especially manage the very aggressive marketing set up for these products. I remember saying "You can't say this. You can't say that. Okay you can say this." I often felt that if there was any way I could stretch what I believed to be true to cover what the marketers wanted to say I would try. It was natural. They were paying me. I wanted to help. There were stock options. I wouldn't lie but short of lying if there was some version of the truth that would work I would allow the marketers their version. P.S., the product line failed in part because the marketing never clicked.

I'm neither angel nor devil but I believe that process that worked on me works on all doctors taking money from drug companies today. One doctor in the article said things have changed from 20 years ago. I agree, 20 years ago the doctors had more control (interestingly when the profession separated 100 years ago the drug companies became quite beholden to the doctors). Now we live in a Pharmarchy so any doctor on the Pharma dole faces ethical challenges and scrutiny. The doctors who choose to turn down drug money decided it was no longer worth it to them. Unless, the bulk of my profession makes the same choice, the image and credibility of doctors in our country will inevitably fall.

The Coronation of Pharmarchy

Lawrence Diller, M.D. — Sat, 12 Apr 2008 09:53:33 -0700

The last consensus conference on ADHD in 1998 was meant to trumpet the initial findings of the government's MTA study which at that time was indicating that Ritalin (meaning all the prescription stimulants) worked. This was no great news to most of us in the field but enough controversy remained about Ritalin that the leaders in child psychiatry research (funded primarily by drug companies - though not this particular study) wanted once and for all to end questions about Ritalin.

But in fact the conference was a disappointment to the establishment as the neutral (non experts in the field of chlid psychiatry - doctors, lawyers, parents, etc.) found the evidence that ADHD was simply a brain based disorder not convincing and in not being clear about etiology, did not want to advocate one treatment over another. Nor could the panel recommend preventative strategies. The conference acknowledged the problems of behavior and performance in children and recognized the barriers to getting effective interventions.

Ten years later the triumph of our "pharmacrocy" is nearly complete. The venerable radical avatar of anti-psychiatry, Thomas Szasz, coined this term in a 2001 book. Since he gets credit for that neologism I propose my word "pharmarchy" to mean the absolute power a monarch wields over his/her subjects alluding to the power the drug industry in league with medical researchers now influences our thinking about children and mental health in our country.

If the NIMH bites and convenes another conference I predict the public will be inundated with industry financed experts (each one of them are good men and women who sincerely believe in their research but data and common sense show that they are influenced by their financial sponsors) who will declare the solely biological basis of ADHD trotting out genetic and brain scan data as evidence. The "nature" aspects of this "disorder" in this setting will overwhelm the "nurture" (read family, school, social, economic, and political aspects) with all the usual implications: it's no one's fault (very appealing but then also denies responsibility) and that medication makes the most sense in treating a biological disorder.

I am so tired and weary of this reductionistic, simplistic ultimately unethical view of children's behavior. I've been at this for nearly 15 years (30 years in practice) and recognize society's own responsibility in devouring this propaganda. Anyone who has read my stuff over the years know that I believe there is a biological/genetic/chemical component to all behavior but that's only the beginning of understanding and treating ADHD.

Phenylketonuria deficiency of PKU deficiency is a genetic disorder that all babies are screened for with a heel-stick blood test shortly after birth. Why? Because if you eliminate phenylalanine from a child's diet right at birth, the child grows up to be entirely normal. Untreated, severe mental retardation ensues. Here is a clearly genetic disorder but is "treatable" with a environmental intervention.

I'm not making the case for changing children's diets for ADHD (the evidence for the effectiveness of such interventions is rather weak unfortunately). But I want to nail this reductionistic approach for everyone -- not that it matters. My blog's point will overwhelmed daily by countless drug company ads suggesting to parents "It your child's brain, stupid!"

So we will have this conference if the AACAP has it's way. The government generally caves to industry. I suspect I will even be invited as one of the token heretics. The last time William Carey was the stand-in. He began his presentation with a slide of St. Stephen at the Cross (apparently a saint who after crucifixion also had arrows shot through him). My favorite slide these days is that of Sisyphus. You know that guy in the loin clothe condemned by the gods (by the way what he do wrong to deserve such a fate?) to push the boulder uphill only to have it roll down and start over again. These days I find the slope of that hill becoming steeper and steeper. Oh my.

Pleased To Be Here

Lawrence Diller, M.D. — Mon, 07 Apr 2008 21:07:44 -0700

I just want to say hello to everyone out there in cyberland. While I've had a website for over ten years (docdiller.com) but I've never blogged so I'm intrigued with the idea and honored that the editors of Psychology Today would have me join their elite list of contributors. Many of you probably have never even heard of my subspeciality, behavioral-developmental pediatrics. I evaluate and treat children (and their families) who struggle with behavior and performance problems at home and at school. I have a medical degree (so I can and do prescribe drugs). I finished a pediatrics residency (and am board certified in pediatrics). But I also completed a fellowship in behavioral-developmental pediatrics in the 1970s when there were only three such extant programs (now there are over 50). I did all my training at the University of California, San Francisco (I'm originally from New York and got my M.D. from Columbia). There are now about 1000 behavioral-developmental pediatricians in a board certified subspecialty of pediatrics compared to about 7000 child psychiatrists nationally. My training in mental health was oriented towards family systems rather than a psychoanalytic or stictly biological approach. So after my fellowship I received additional training from the Mental Research Institute in Palo Alto. They were willing to train non-psychiatrist MDs in family therapy.

That said, most of you have probably never heard of Michael White, a very gifted therapist and innovator from Australia who promoted the "narrative" approach to psychotherapy. White, died suddenly in San Diego, while giving a seminar last Saturday of a heart attack. I believe he was only 62 years old. His insights and optimism will be sorely missed. I'm also, according to my patients and reviewers of my books an optimist apparently -- at least I appear to regularly give parents hope that things will work out okay for their kid. Anyway, this is enough for my first ever blog. I'm no longer a virgin.