A question that has recently exercised my mind since reading a bestselling and much applauded book by Atul Gawande, ‘The Checklist Manifesto – How to Get Things Right’ (2011), is “Could the use of some carefully formulated questions in a short checklist by themselves actually change practice, in terms of the increasingly common practice of prescribing of psychotropic drugs for children, following a clinical assessment, by child mental health practitioners?
There is indeed some (at present anecdotal) evidence that the use of such checklists to promote good practice and mindful responses in doctors could also work in this field. This approach of a team following a simple checklist has had a huge positive impact on many areas starting with the aircraft safety exemplar that Gawande first drew on before he developed one for his own field of surgery. Few predicted that following simple protocols and having simple clarifying conversations, as a team, before a scalpel is used would boost the survival rates in operating theatres so dramatically.
He believes that one of the key concepts underpinning such approaches is that
”Under conditions of complexity, people need room to act and adapt. They require a seemingly contradictory mix of freedom and expectations. This process requires balancing of several virtues – freedom and discipline, craft and protocol, specialized ability and group collaborations.”
So doctors prescribing psychotropic drugs to children and adults need the freedom to act according to their considered professional opinion whilst operating within the clear expectations of ‘at least no harm’ or the paramount principle of Safeguarding children.
The idea behind the checklist that I have developed is to promote ‘ethical mindfulness’ and therefore more responsible prescribing to meet these above requirements. It should also provide a reflective structure that does not censure action. It rather encourages a child mental health professional to Pause – Reflect and Review some of the complex interacting variables that might be impacting on a child to create their current pattern of presenting behaviours, before they take the significant step of prescribing psycho-active drugs to a child whose brain is still in the process of development. If they feel, having considered the questions posed, that issuing a drug is the right way ahead then that process may indeed have enhanced the appropriateness of that course of action. On the other hand, it may also reduce erroneous and ‘overzealous prescribing by some colleagues,’ as raised by Sir Simon Wesseley, the President of the Royal College of Psychiatrists, when interviewed for a Times editorial in the summer of 2014. He shared his concerns and said the current position represented ‘a perfect storm’ of the over-diagnosis of children with normal behavioural patterns, and an under-diagnosis of children with genuine mental health conditions.
Another related issue is the growing number of diagnostic categories that have been included in the most recent ‘Diagnostic Bible,’ as practitioners refer to it, DSM-5 which was published in 2013. Many child mental health feel that there is an increasing tendency to pathologise normality. Professor Peter Kinderman, head of the Institute of Psychology at the University of Liverpool and President elect of the British Psychological Society stated, ‘It will pathologise a range of problems which should never be thought of as mental illnesses. Many who are shy, bereaved, eccentric, or have unconventional romantic lives will suddenly find themselves labelled as ‘mentally ill.’
An internationally renowned psychiatrist Professor Allen Frances (Duke University) who was Editor in Chief of DSM-IV the American Psychiatric Association’s previous international diagnostic manual, in a recent article on the PsychiatricTimes website, on July 31st 2015, endorsed such a checklist approach and also used the ‘perfect storm’ theme saying,
” A perfect storm of interacting detrimental factors has resulted in the recent massive overuse of psychotropic medication in children. Drug companies started to focus their marketing campaigns on kids when the adult market was saturated. “
He then went on to say in the same article that I “had come up with a terrific suggestion to help contain the epidemic of careless medication in kids.” He also kindly stated,” We simply don’t know what will be the long-term impact of bathing a child’s immature brain with powerful chemicals. We are now conducting an uncontrolled experiment without informed consent with unknown consequences for millions of our kids.
There are childhood problems that certainly do require medication, but this should only be a last resort after careful consideration of less invasive interventions. Medication should never be, as it now too often is, a first and careless reflex. Dave Traxson’s Checklist is an excellent guide to more responsible practice.”
This is indeed my main hope that a reduction of prescribing will be a measurable outcome once the checklist is introduced to prescribers. More research will need to be undertaken to determine which the most discriminating questions are in terms of a doctor re-evaluating what a child needs and then influencing their decision so as not to prescribe a psychotropic drug.
The Reflective Checklist is to help clinicians think through the necessary steps that should be part of every careful prescription of medication for children.
- Does the child have a classic presentation that closely conforms to an approved indication for this particular medication?
- Is there well documented research on efficacy and safety with children of the same age, gender, and social grouping?
- Are the child’s problems pervasive, occurring in a wide range of social settings and observed by many different individuals?
- Are the child’s problems severe, enduring, and impairing?
- Do the child’s parents and involved professionals see the problems as significant enough to require medication?
- Are there stresses in the child’s relationships, social context, and recent history which might explain this pattern of behaviors?
- Has a psychological or social intervention been tried prior to prescribing medication?
- Have there been any significant adverse side effects from any medications in the past which may influence your decision and have children with a similar profile had adverse reactions to the proposed class of drugs?
- Have you carefully weighed short- and long-term risks and balanced them against possible benefits?
- Have you received informed consent from the parent and (where appropriate) the child?
And, perhaps the most telling question
- If a child in your immediate family or circle of friends had the same presenting problems as the child you are considering psychotropic drugs for, would you be prescribing medicine now?
Since this article was published I have received many positive comments from practicing mental health professionals around the world highlighting the following points:
- That applying such a reflective approach would improve the Safeguarding of vulnerable children who may possibly be harmed by overzealous prescribing.
- That they would expect the prescription rates to fall considerably due to the reflective process involved reducing the likelihood of the doctor going on to sign the prescription.
- That valuable resources within their health services may be released for higher priority interventions, with more needy clients, especially in poorer developing countries.
- That young people have the chance to mature and pass through transient problems without them being pathologised as having mental health disorders.
- That psychological and social interventions would be more likely to be tried first which complies with the guideline issued by such regulatory bodies as the National Institute of Health and Clinical Excellence (NICE) in the U.K.
- That younger children in a year group are not singled out as having behavioural difficulties just for being what they are, the youngest and therefore less mature children in that year. One Canadian study recently showed this was a legitimate concern.
The study author, Dr Richard Morrow, a research analyst at University of British Columbia, said in a written statement:
“Our study suggests younger, less mature children are inappropriately being labelled and treated. It is important not to expose children to potential harms from unnecessary diagnosis and use of medications.”
For the study, published in the March 5 issue of the Canadian Medical Association Journal, researchers examined data on nearly 938,000 children from British Columbia. The researchers found children born in December were 39 percent more likely to be diagnosed with ADHD, and 48 percent more likely to be treated with a medication for ADHD than their counterparts.
This demonstrates clearly the systemic madness that is potentially harming our children due to the rising trend to pathologize normality.
Professor Peter Kinderman, the current President-elect of the British Psychological Society supported the existing NICE guideline for using psychological interventions first, in a press release at the time of DSM-5 publication in 2013, which was published contemporaneously in The Psychologist (BPS Magazine):
“Clearly, it is important to evaluate and assess behavioural and psychological problems fully, and to invest in proper, expert, therapeutic approaches. We would be very concerned if children were being prescribed medication as a ‘quick fix’ rather than accessing the full psychological therapies which may take longer and cost more but ultimately are likely to be better value in the long run.”
Other NICE Guidelines which are regularly breached but are being challenged by many Educational and Clinical Psychologists are :
- To utilise a ‘drug holiday’ if the child has been on a psychotropic drug for longer than two years. Some psychiatrists say they haven’t got enough manpower to operate this but one leading psychiatrist told me that if they haven’t got enough doctors to do this then they should not be prescribing so many drugs.
- Not to prescribe drugs to children under the age of 5 years old. This is regularly being ignored and my ‘worst case scenario’ was a senior psychiatrist who got one of his team to prescribe a psychostimulant to his own child.
- Not to use a psychostimulant if a child is presenting as having high levels of anxiety. This too is breached regularly but again psychologists are professionally challenging psychiatrists about it to good effect.
The reality is that these NICE Guidelines, as we are often told by psychiatrist colleagues, are only guidelines and as a Society we are reliant on the self-monitoring and self-regulation of the rate of prescribing psychotropic drugs to children by the doctors themselves. My two professional bodies the Association of Educational Psychologists and the Division of Educational and Child Psychologists (BPS) are both keen to urge the government to trigger a review of all prescribing of psychotropic drugs issued to young children within the U.K. and to encourage Reflective Thinking before prescribing. There are a variety of reasons for this ranging from a prime concern of many that we do not know what the long term harm is of putting toxic compounds, at varying concentrations, into the developing brains of younger and younger children. We are also aware of a scary new development across ‘the pond’ that the abuse of legally prescribed psychotropic drugs has for the first time in history exceeded the abuse of illegally obtained drugs. We do not want to import this trend to the U.K.
Let’s send a more positive message forward to future generations about how we can better Safeguard our children and our childrens’ children. For as Nelson Mandella rightly stated, “There can be no keener examination of a society’s soul than the way it chooses to treat their children.” Or as Professor Sami Timimi, a practicing child and adolescent psychiatrist in the U.K., said in a recent article in the Independent newspaper, “ADHD is a cultural barometer of how we treat our children.”