December 03, 2009

Study Touts Depakote For ADHD Kids Who Are Disruptive

A new study is out in the American Journal of Psychiatry, a small pilot study, touting the use of Depakote in combination with various ADHD stimulants in children and adolescents aged 6 to 13 years of age with both ADHD and a so-called disruptive disorder. The study involved so few children--14 in the Depakote arm--that its findings aren't robust at all, statistically. And yet the study is accompanied by an editorial trumpeting the future of child psychopharmacology.

Let's deal with the editorial first. Its author Hans Steiner is a professor of psychiatry at Stanford and the author of a 2003 study in the Journal of Clinical Psychiatry reporting good results using Depakote to treat conduct disorder in adolescents. He and his Stanford colleague Niranjan Karnik write in the editorial accompanying the study:

"[M]ost experts in the field agree that aggression, especially emotionally hot, impulsive aggression, forms a legitimate target for intervention across a spectrum of psychopathology, including attention deficit hyperactivity disorder (ADHD), bipolar mood disorder, and posttraumatic stress disorder."

OK, then.

"The future of psychopharmacology in childhood aggression and its underlying disorders is an important area of great need for more work along the lines demonstrated in this study. It is unrealistic to assume, as we have been for some time, that complex behaviors, such as aggression, will respond robustly to single psychopharmacological agents in all patients and all types of comorbidity, and yet the bulk of clinical trials are done with single agents. A more realistic assumption is that a careful blend of activating (like stimulants) and inhibiting (arguably valproic acid) agents will ultimately result in controls of main and downstream effects of neurotransmitters that produce remission of symptoms. This is especially likely in children and adolescents in whom development generates rapid shifts in neurosystems underpinning instrumental behavior such as aggression.

"This study points the way to a more complicated, but ultimately more realistic, polypharmacology in developmental psychiatry that should produce better results for our patients, rather than some of the unfortunate 'polypsychopharmacology,' where a high number of agents is combined in suboptimal doses in hopes of producing desired results."

Look, I'm all in favor of getting away from the wild polpharmacy advocated by the Harvard child psychiatry crowd and others, which has resulted in tons of aggressive kids on antipsychotics for non-psychotic issues, but it is more than a little Pollyannaish to suggest that a little old pilot study is as suggestive for the future of child psychiatry as the editorial pretends.

What's more, I'm really concerned that aggression in children is becoming such a defining issue in how our culture views children that aggression has become a force of evil to be stamped out. Much of this is driven by the culture of American schools these days, where behavioral calmness is everything and boys are to be firmly affixed to their chairs in class. I think we all know where Huck Finn and Tom Sawyer would be these days--headed to the nurse's office for their noon-time meds. OK, I know I'm overstating things a bit there, but something has changed so dramatically in how we address childhood aggression these days that someone has got to push back a bit, even if it seems unreasonable.

The study itself comprises 14 youngsters on stimulants whose aggression didn't abate and who were then put on various dosages of Depakote or were given a placebo (13). After eight weeks researchers reported that 57 percent (8 of 14) of the Depakote kids had improved on aggression scores while only 15 percent (2 of 13) had on placebo. That's a sizable effect size of 42 percent, but with such a small sample size (and the researchers admit this) the statistical power is limited. This could be a result of chance or something else.

Joseph Blader, a professor psychiatry at Stony Brook University School
of Medicine in New York led the study. His and other study researchers' pharma-funding conflicts are listed at the end of the study and they are epic: J&J, Lilly, Schering-Plough, Abbott Labs and so on. I'm concerned that this study blends funding from NIH and Abbott Labs. I wasn't aware that it was common practice to mix funding that way.

So who are some of these kids? The study includes a case profile of one 6-year old boy:

"'Freddy' was a 6-year-old boy whose mother related a long history of attention deficit hyperactivity disorder (ADHD) symptoms and behavioral dyscontrol. She characterized his present difficulties as being 'verbally and physically abusive.' She stated that 'he destroys property, defies authority, has no friends, hurts animals, and constantly annoys others.' He was in frequent conflict with family members, peers, and school authorities. When not acutely upset, he was an affectionate, articulate, pleasant boy. His ingenuity and engaging character attracted other kids initially, but subsequent interactions discouraged them, owing to his inflexibility in accommodating other children’s desires over his own....

"At a 54-mg dose [of a stimulant], attention and appropriate participation in school improved, but aggressive outbursts persisted, including
incidents of throwing his desk over in response to directions to
conclude an activity....

"By his fourth week after randomization [meaning he was getting Depakote], his mother reported that he was 'great,' with 'no problems at all.' She stated, 'He shows a lot less anger and is a lot more relaxed.'"

Poor Freddy is all I can say. I certainly cannot remember when not having friends at school and turning over desks counted as a psychiatric disorder. My entire elementary school in California should've come under suspicion for all the fights, kids flipping out, kids getting stabbed with a pencil in the arm (poor Ted Looney) and getting their hands slammed in windows (that'd be me, thanks to a little girl named Beth). How did we manage to survive and evolve into adults?

Posted by Philip Dawdy at December 3, 2009 12:01 AM
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Comments

What?
Depakote for ADHD? I took it and felt many side effects.
How scientific of them trying old drugs instead of researching.
I believe that they don't research new drugs because they know quite well that they don't have enough knowledge to create anything new.
It's useless creating new drugs when nothing has changed.
So... old drugs even if they don't work.
I am amazed by the news I see here everyday.
I believe things are getting worse and worse.

Posted by: Ana at December 3, 2009 01:43 AM

Between the destruction of property, hurting of
animals, and what would appear to be persistent
obstreperous and antisocial behavior (hard to
tell for certain from the details given), it seems
that there IS something wrong with the kid.
Whether or not it is a "psychiatric disorder",
whether or not said disorder is best addressed
psychopharmacologically, and indeed precisely what
the phrase "psychiatric disorder" MEANS, are
different questions. But let's not allow those
thorny questions to obscure the obvious.

Posted by: Alan at December 3, 2009 03:03 AM

"How did we manage to survive and evolve into adults?"

I for one have no trouble believing that
aggressive, "conduct-disordered," and even
sociopathic/psychopathic kids grow up to be
aggressive, "conduct-disordered" and even
sociopathic/psychopathic adults. Society
is filled with such adults. The financial
and economic structures of society are
currently in the process of disintegration
and collapse on account of the actions of
such adults.

Posted by: Alan at December 3, 2009 03:09 AM

I completely agree. I work in the school system and I have a child with issues that the schools love to medicate. And we have medicated him twice now at their request with horrendous results and won't do it again. The public school system as it is set up now is completely unnatural for children and especially boys. Kids at many schools almost literally have no real breaks to run around and be normal kids and get their energy out. Even PE these days is often completely controlled (he used to have organized, silent track walking for PE in elementary school, if you can imagine). It's so sad that as a society we are ok with drugging the children rather than changing the schools to allow kids to be kids. I feel certain that this choice will hurt, and is hurting, our society in the long run. And someday as we have to build more and more prisons we will look back on all of this and wonder, what the heck were we thinking? It also makes a very strong case for homeschooling - which we have done as well - and if you are able to do it is a great alternative to drugging your child. You rarely meet an angry, raging homeschooled child. Most of those kids feel very safe, secure and nurtured - and it shows.

Posted by: Meg at December 3, 2009 05:59 AM

There is a new documentary out called The War on Children (I think) that addresses some of the issues you mention re: the repressive atmosphere at schools and pathologization of negative behaviors. The doc's creator was on John Stewart the other night and I look forward to seeing this film.

Posted by: Miranda at December 3, 2009 08:07 AM

Listen if I were 6 and my mother was thinking of me as someone with a "long history of attention deficit hyperactivity disorder," I'd be acting out in some pretty major ways myself. It is just tragic to think that a mother can look at her child and all she sees are the 4 big capital letters A-D-H-D. And aggression "didn't abate" on stimulants -- is that really a surprise? It probably gets worse. It's just staggering to me that no one is bringing up some kind of behavioral therapy for both the mother and the kid. But no, just add to the cocktail. Sedate the life out of the kid. It's really tragic.

Posted by: Sara at December 3, 2009 09:09 AM

I don't remember any kids stabbing people with pencils (other than my brother when he was like 10 yrs old - which was impulsive and out of character), and I don't remember kids throwing over desks either. I did once turn my desk around in school when I was 10, but then again I was/am fucked up. NO other kids did that.
I remember fights in school, but those were rare, isolated, and not impulsive. Meaning, a school fight is something that happened after a long standing conflict between two students... it wasn't some crazy kid flipping out because he doesn't want to sit down after lunch.

I do remember one kid flipping out in gym class when I was like 9 or 10. This kid was a weirdo, and one day in gym class he started hysterically crying and beating the floor with a wiffle bat because his team lost. We all thought he was insane. Whole class stood there watching him freak out. He probably was insane. It was markedly abnormal behavior. Normal kids don't fly into aggression and tears for no reason at all (something as trivial as your team losing in gym class).

It's true normal kids sometimes do impulsive aggressive things (e.g. my brother stabbing me in the leg with a pencil once) but normal kids don't do that all the time, and they don't have massive melt downs that make everyone stop and stare (as described above).

If a small dose of depakote helps the kid I don't see the big deal. Babies take depakote for seizure disorders. If someone is acting like a little sociopath (hurting animals destroyiong property etc) and if depakote stops that, I would say, : stay on the depakote.

Posted by: noone at December 3, 2009 03:45 PM

"Noone" your pattern is starting show again.

It was the wonderful Lithium makes me "GOOD" and pointing your fingers at all those "idiots", "animals", "Cultist", "irrational", and if you happen to question this deeply flawed and dangerous drugging medical modality you call them anti-psychiatry scientologists.

How many times are you going to beat that dead and buried horse to death. To quote you "I'm real tired of this"

Now your touting that depacote is good for kids and babies.

Are you going to pull out a factious son, while bringing us your Geodon is candy kid "good" presentation next.

I believe you fit your own words quite perfectly:
"IDIOT"
"IRRATIONAL"
"quack brigade"
"bullshit"

Posted by: MadMan at December 3, 2009 05:16 PM

The thing I don't understand is at 6 years old how long of a history of ADHD behaviors could he have had? He's 6.

Posted by: Meg at December 3, 2009 08:07 PM


Freddie sounds disturbed, but before putting kids on drugs, I think the parents should be checked out VERY thoroughly, including surprise visits from social workers and random drug testing. We only have the mother's word that this child really is "abusive." What if she's the abusive one?

If the parents are abused or addicted, then drugging up the kids isn't going to fix the problem.

Posted by: A at December 5, 2009 08:41 AM

The mother's word is a key item today in child psychiatry that I have a feeling contributes to over pathologizing and over medicating of kids. The idea of "The mother reports...", that is. Child psychiatry today is based almost wholly on the mother's (or father's) interpretation of her child with no checks and balances to see whether that perception is at all consistent with how others see the child. And the mother is a part of her child's world so if you consider "The Observer Effect" of physics it is nearly impossible for someone actively involved in the environment of a subject of analysis to see that subject objectively.

Posted by: Meg at December 5, 2009 01:11 PM

Personally, I question very deeply the "flawed
and dangerous drugging medical modality" (or
medical mentality), while AT THE SAME TIME it
is evident to me that there exists a bunch of
hysterical, irrational anti-psychiatry zealots.
It is unfortunate that this whole discussion is
so polarized. I can see WHY it is polarized, and
there is some (fair) reason for the polarization,
but it is unfortunate nonetheless.

Posted by: alan at December 6, 2009 07:43 AM

Alan- I'm not sure what zealots you are talking about. For me personally, my son sees a psychiatrist regularly who I think the world of and he has also been on meds in the past and he will get meds in the future if he really needs them. But there are dangers in the meds and flaws in the psychiatric model that's currently used and it's good for people to be aware of those so that they can make informed decisions and question situations that don't feel right or aren't working. That's not to say though that the meds and psychiatrists haven't also helped a lot of people because I know many people who they have helped. In our case, even our psychiatrist questions all the issues that we question here on this site and I appreciate him for that. It means he feels like he doesn't have all the answers and that put me at east because it is very honest.

Posted by: Meg at December 6, 2009 02:19 PM


Meg wrote: "Alan- I'm not sure what zealots
you are talking about."

They are easy to spot. Just cruise
furiousseasons.com comments for a while. Or
many other sites of like nature. Look for a
deep, VISCERAL hatred of drugs, pharmaceutical
companies, etc., insufficiently checked, or
unchecked, by rational considerations of the
whole picture.

And: "For me personally, my son sees a
psychiatrist regularly who I think the world
of and he has also been on meds in the past
and he will get meds in the future if he
really needs them."

Good! IF HE REALLY NEEDS THEM. Anti-psych
zealots of an extreme sort might have you
renouncing said meds no matter what. That's
irrational and potentially destructive.

And: "But there are dangers in the meds and
flaws in the psychiatric model that's currently
used and it's good for people to be aware of
those so that they can make informed decisions"

YES, OF COURSE! The whole system is deeply
flawed, Big Pharma is filled with greedy pigs
(and worse), psychiatrists are FAR too itchy
to prescribe crappy drugs or whatever drugs
Big Pharma has currently spent 80 bazillion
dollars advertising, blah blah blah. I agree
with all of that. And none of that means that
an individual may not do well on (and even,
in practice, require) a given med made by Big
Pharma. Paradoxical, and difficult to accept,
but true.

Posted by: Alan at December 10, 2009 08:28 AM
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