Letters

Medicating our children

REBECCA CLAY?S ARTICLE ?Are children being overmedicated?? (December Monitor) should have been entitled ?Why are children being overmedicated?? When highly general, descriptive criteria from the DSM are used to make psychiatric diagnoses of depression, anxiety and attentional problems it is no wonder that we are labeling children in near-epidemic proportions with a ?mental disorder.?

In my experience, many of these medicated children are simply responding with normal sadness, worry and acting out behavior because their childhoods are hurried, overloaded with stimulation, marked by constant pressure to achieve, and their families are finding it increasingly difficult to have the time necessary to nurture their growth and development. The medicalization of children?s problems in late 20th-century America, further propelled by the twin currents of managed care and the pharmaceutical industry, does not seem to be abating. And what role does our own profession play in the proliferation of medicating children? As we lobby hard toward achieving prescription privileges, I fear that there will be an even greater availability of ?magic pills? and quick fixes on the horizon.

Anthony V. Rao, PhD
Boston

?ARE CHILDREN BEING OVER medicated?? raised an important question. Unfortunately, the discussion that followed was misleading. The article relied heavily on quotes from Dr. Dan Egli and Dr. Fredrick Frese. Egli is a paid consultant to the pharmaceutical industry and actively promotes prescription privileges for psychologists. Frese is affiliated with NAMI, an organization underwritten by the drug industry.

Egli is quoted as saying that it would be ?borderline malpractice? to not add medication to treatment for seriously depressed children. Frese is quoted as saying that our only choice is to let anxious or depressed children suffer or to ?use biochemical interventions.? Their opinions rely on anecdotal evidence and are not based on the current scientific literature.

Recent literature reviews conclude that there is no credible evidence that tricylic antidepressants are more effective than placebo for depressed children or adolescents (Ambrosini et al., 1993; Dujovne et al., 1995; Fisher & Fisher, 1995; Fisher & Fisher, 1997; Hazell et al., 1995; Sommers-Flanagan & Sommers-Flanagan, 1996). Regarding SSRIs, we were able to find one controlled study that showed no advantage to fluoxetine over placebo in adolescent depression (Simeon et al., 1990), while another controlled study found fluoxetine superior to placebo in children (Emslie et al., 1997) on some clinician-rated measures but not on any patient-rated measures.

Given the serious risks for side effects in children, it might be ?borderline malpractice? to add such drugs to treatment before controlled research supports their safety and efficacy, especially since psychotherapy has been shown to be a safe, effective alternative (e.g., Lewinsohn et al., 1994).

David Antonuccio, PhD
Bill Danton, PhD
Reno, Nev.

CHEERS TO THE MONITOR for the article on overmedication of children. Schoolteachers who put pressure on parents to obtain a Ritalin prescription and case managers who encourage the medication quick fix instead of therapy create real problems for child psychologists. Thank you for emphasizing this.

Jeers to the Monitor for the medical misinformation in the article. Fisher?s statement that Ritalin works paradoxically because of expectations blithely ignores 25 years of research. On the other hand, Fisher?s excellent comment about the placebo nature of antidepressant is based on the best available current research, but Clay places this in the middle of her article and then undercuts it at the end by quoting Egli that to not prescribe is ?borderline malpractice.?

The dramatic and controversial quote without underlying evidence is the hallmark of a tabloid, not the Monitor.

Richard Rubes, PhD
Clarksville, Tenn.

IT?S STRANGE THAT THE ARTICLE on the use of antidepressants with children and adolescents could accurately report that the vast majority of the evidence shows that they don?t work in such populations and that the long-term effects of such medications are unknown, and yet the gist of the article is ?do you let children with depression?suffer, or do you use biochemical interventions that have produced good results in adults?? One would be truly sadistic to withhold drugs from children, if those were our only options!

And talk about a split between ?practitioners? and ?researchers?! On one side is an isolated private practitioner who boasts that he ?does as much ?prescribing? in the form of collaborating with physicians as he would if he actually had prescription privileges himself? and a PhD who runs what might be described as the public relations advertising arm of the pharmaceutical companies. On the other side we have established researchers who cite nearly 30 years of research showing that any amelioration of symptoms is probably due to placebo.

And the ?zinger? at the end quotes our ?prescribing? PhD as saying ?I couldn?t imagine in good conscience not adding medication to treatment. That would be borderline malpractice?.? In other words, those who disagree are morally degenerate and legally at risk! It seems unbelievable to me that even when the evidence is overwhelmingly against using antidepressants, APA is still grinding the prescription privileges ax in its quest for money and status.

Mack B. Stephenson, PhD
Jacksonville, N.C.

Editor?s note

We thank the members who wrote in response to ?Are children being overmedicated.? The Monitor seeks to cover all issues from a variety of angles and as objectively as possible. In this case, we regret that we did not know that Dan Egli, PhD, is a consultant to the pharmaceutical industry. If we had known that, we would not have used him as a source.

It?s also important to note, however, that the views expressed in the Monitor do not reflect APA policy, they are simply a snapshot of the field of psychology today.

Is forgiveness good for the soul?

THE NOVEMBER ARTICLE ON the benefits of forgiveness cites research showing that offender apology leads to empathy with the offender, and empathy in turn mediates forgiveness.

The article extols empathy and forgiveness as psychological qualities to be enhanced for their contribution to our mental health. This conclusion is appealing to many, if not most, people and is politically and spiritually correct. Who can argue with the virtues of empathy and forgiveness?

I can. I am concerned that blanket endorsement of forgiveness will encourage therapists and their clients to forgive actions, even criminal actions, that should not be forgiven and to absolve those who harm us of the proper consequences (i.e., punishment, restitutive behaviors) of their actions.

Support for my view may be found in the article on empathy appearing in the same issue and written by the same Monitor staff member (Beth Azar). This second article cites the dark side of empathy when excessive empathy becomes maladaptive and induces children to blame themselves for the suffering of others, when they are in no way responsible. The dark side of the empathy-forgiveness relationship may induce victims who have suffered physical or emotional torment to forego ?righteous indignation,? the moral impulse to see that prosocial behavior is rewarded and antisocial behavior punished.

If we create an 11th commandment, ?Thou shalt forgive those who harm you, ? and apply it without regard to circumstances, we will be harming some clients. Will we then ask them to forgive us for the harm we have caused them by our good intentions, but ill-advised practices?

Noach Milgram, PhD
Kochav Yair, Israel

Recognizing faculty merit

ONE PROBLEM WITH ?an expanded definition of scholarship??as discussed in your December issue?is that in its extreme application all members of a department are likely to receive similar ratings. The resulting schedule of communistic reinforcement dilutes the recognition of merit. Moreover, this leveling of criteria is likely to lead to blanket, across-the-board raises. That being the case, why do the faculty evaluation at all?

Granted, the other extreme for rewarding merit?the ?beancounting mentality? based solely on the number of publications?is problematic also, yet the ultimate solution will not be found by spreading the meritous effect across any and all pedagogical activities. Indeed, teaching ?loads? and functions form the bases of typical university contracts. Their (teaching functions) development and improvement are expected under contract. Whereas, evidence of original, research (broadly defined) and its objective evaluation continues to be a sensible focus for recognizing merit.

William F. Vitulli, PhD
Mobile, Ala.

Collective inferiority

I WAS FASCINATED by the ?Science directions? column by William Howell, PhD in November on the Monitor?s stylistic commandments regarding the mention of psychologist?s degrees. Early on, he states: ?Most academic psychologists I know considered it embarrassing, feeling that it made us appear to suffer from a collective inferiority complex.? Soon, he reveals the history: The dictate was proposed by a board member, ?who worked in a medical school?a setting in which the MD was flaunted at every turn, while doctorates earned in fields like psychology were often snubbed.?Confront-ed with this outrage, the practitioner-dominated board was understandably sympathetic to a proposal for ensuring that we at least give proper recognition to our own.?

I take it that this means that that theory?the one about the collective inferiority complex?should be considered confirmed.

Steven M. Kemp,
(and, yes, it is) PhD
Chapel Hill, N.C.

Unwarranted victim-blaming

The article in the August Monitor, ?Women unwittingly uphold wage gap between the sexes,? discusses some interesting studies, but both the title and the article appear to us, the members of APA?s Committee On Women in Psychology, to imply unwarranted victim-blaming.

Yes, women should be taught to negotiate better, but this is probably only a small part of the gender-wage disparity (and no research is cited in the article specifically linking this tendency to outcome variability.) The wage gap is persistent, illegal and has actually increased from 28 percent in 1995 to 29 percent in 1996. In order for women to earn what a comparable man earns, she would need a 30 percent raise, so the income lost is considerably more than the amount cited in the article.

Many studies have been done by other social scientists and economists attempting to account of this disparity and no matter how many possible explanations are included, discrimination remains clearly apparent. If it were simply a matter of undervaluation, one would expect that executives would be less likely to perpetrate such activity. In fact, the statistics on experienced executives and managers (not just those entering the field, as the article reports) show that the wage gap is even higher for this group, and women at higher levels earn only 65 percent of what their male counterparts do.

We believe the article, as written, does a disservice to women by suggesting that it is somehow their own behavior that is responsible for their lower economic status rather than the discriminating behavior of the male decision-makers who control most corporations. Accurate diagnoses of problems are more helpful than inaccurate ones in working toward effective remedies.

Phyllis A. Katz, PhD
for the Committee on Women in Psychology
Boulder, Colo.

Too simplistic

I WAS DISMAYED WITH THE December article ?What triggers our penchant for overzealous shopping?? This appears to be the most outlandish attempt to date by the mental health profession to reduce complex and multidetermined social problems to simplistic neurophysiological causes.

The world is increasingly becoming paved over in pursuit of bigger supermalls to provide outlets for mindless purchasing of goods, to fill the growing spiritual and emotional void of many of its citizens. We live in an increasingly disposable and ecologically destructive climate in which rampant consumerism has become the unshakable panacea for such real problems in post-modern living as the loss of community and an increasing sense of personal alienation, manifested each day by random violence and abuses of all kinds.

Indeed, our social relations and responsibilities are increasingly marked by a rise of hostility towards the ?other? as seen by the advent of new ?private? walled communities, the push to restrict immigration and end affirmative action, the rise of racist separatist movements and the prevailing view of government as ?the enemy.?

To attribute a primary symptom of this condition to abnormal levels of serotonin is at best, shortsighted and misguided, or just downright mean-spirited. However, this line of reductionistic, blaming-the-victim mentality is certainly advantageous for the status quo and those who benefit accordingly. As long as our attention is deflected from the context from which these problems emanate, we will continue to see the symptoms continue unabated.

Ross Levin, PhD
Brooklyn, N.Y.

Ethnocetric ignorance

THIS IS MY THIRD ATTEMPT to respond to the August front page article on political correctness. My two previous letters contained the key sentence ?Human physical variation is clinal, not racial.? Both times, the Monitor changed the word ?clinal? to ?clinical,? rendering the sentence meaningless.

Human physical traits vary gradually across geographical space; this gradual variation of a trait is called a cline. For example, skin color gets gradually darker from Scandinavia to Southern Europe to North Africa to Central Africa. There is no sharp break between light and dark as there would be if distinct races existed. Also, clines for different traits do not co-vary. That is, the spatial distribution of skin color differs from the spatial distribution of hair form, which differs from the varied spatial distributions of different facial features which differ from the varying geographical distributions of blood groups etc., etc. If races existed, the geographical distribution of multiple so-called racial traits would coincide with one another.

Physical anthropologists have long known that they do not?information that psychologists seem impervious to. This is why ?Human physical variation is clinal, not racial.?

Since there are no ?Caucasoid,? ?Negroid,? or ?Mongoloid? races (American beliefs to the contrary notwithstanding), attempts to compare them are pseudoscience. When the article dismissed criticism of pseudoscience as ?politically correct? it demonstrated ethnocentric ignorance.

Jefferson Fish, PhD
Great Neck, N.Y.

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