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Psychotropic medicines conference at Florida International University -- Miami

The text of a speech given by David Lawrence Jr., president of The Early Childhood Initiative Foundation, on June 11, 2008 before a conference on psychotropic medicines at Florida International University in Miami.

I am accustomed to starting off speeches with words that begin something like: “Thank you for the privilege of speaking with you." This is not such an occasion, though I am fully respectful of everyone here.

Do not be insulted. I am only confessing that you happen to have before you someone with a lifelong habit that gets me into a fair amount of difficulty -- that being the habit of saying, "Yes." People -- in this case Professor David Cohen -- ask me to do all sorts of things, and I agree. Partly that is because I live in some sort of semi-perpetual Catholic guilt and feel compelled to say, “Yes” every time I even marginally can. Partly because people ask me weeks, even months, before I might have to do something...and so the calendar looks clear back when I am first asked. And, hence, I can fit this in “easily”. And then the time to do it comes to be, and I wonder how I get myself into these fixes. Like today when later this morning I Ieave for a meeting in New York.

Anyhow, you are stuck with me for the next short while! In this audience are all sorts of knowledgeable people with a wealth of expertise. So many of you could be -- perhaps should be -- at the front of this room speaking right now. Instead, you have me, speaking on a topic about which I knew very little just weeks ago. However, I do love to learn, and that is among the compelling energies of my life. The pursuit of learning seems to me to be one of life’s most essential joys, and I constantly find myself delighted and fascinated by what I have learned. So it is on this topic, too. (As an aside, and in that spirit, I note that Mark Twain is among my most favorite Americans, not only for his great works of literature, but also because his was a life of lifelong growth and learning. And I've always loved what Mark Twain once revealed about himself: ¡§When I was a boy of 14, my father was so ignorant I could hardly stand to have the old man around. But when I got to be 21, I was astonished at how much the old man had learned in seven years. So however much I have learned about this topic these past few weeks, no telling what I might learn in the next seven years. What I have learned already is how much more I still need to know.)

These past few weeks, in pursuit of my own understanding of what clearly is a most vital topic, I talked at length with Professor Cohen and spent time with his "Critical Think" binder focused on "a critical skills curriculum for psychotropic medications" (which I found useful and illuminating). I also watched an alarming PBS special called "The Medicated Child"...met with a former legislator deeply concerned about the overuse of psychotropic medicines...skimmed through my wife's social-work-master's-degree textbook on "The Social Worker and Psychotropic Medication"...met with the president of the South Florida Council on Child and Adolescent Psychiatry, a fellow of wisdom and decency...scanned the website for the American Academy of Child and Adolescent Psychiatry. ..and read the Newsweek cover story called "Growing Up Bipolar," described "as an elusive disease that no parent fully understands, that some doctors do not believe exists in children, that almost everyone stigmatizes."

Wiser, more knowledgeable people than I have tackled this topic, and so it is a bit arrogant of me to tell you what I think -- but I will anyway. I start with the wisdom of the distinguished former surgeon general, Dr. David Satcher, who argued for three basic steps:

1: Improve early recognition and appropriate identification of mental disorders in children within all systems serving children.

2: Improve access to services by removing barriers faced by families with mental health needs, with a specific aim to reduce disparities in access to care.

3: Close the gap between research and practice, ensuring evidence-based treatments for children.

I come away from reading and asking and listening and watching both alarmed and enlightened.

Alarmed about the power of marketing and the influence of the pharmaceutical industry¡Kalarmed about the potential long-term effects -- the so-far unknowns ¡V of medications¡Kalarmed and wondering about how much we truly know about the efficacy ¡V and the not infrequent overuse -- of psychotropic medicines with very young children, alarmed about anti-psychotic drugs often prescribed to children for non-psychotic conditions, such as ADHD.

Enlightened about the benefits-to-risks ratios, enlightened to the vulnerability of young children and still-developing brains to medications, enlightened about the much higher rate of these medications being used with foster children who, unsurprisingly so, tend to be often very emotionally damaged, enlightened as to how much more these medications are used with children of color, enlightened to nomenclature I had never heard before -- for example, the term "polypharmacy" -- that is, the use of many psychiatric medicines to treat a child.

My intent is not to figure out who's to blame. These matters are complex, as the mind is complex, and not subject to absolutes -- or at least absolutes that can yet be proved. However tempting it is to fasten on the ¡§absolutes,¡¨ life is nowhere near so simple. Thus, it cannot be so simple that today¡¦s topic of medications and over-medicating can be traced ultimately to the power of the Almighty Dollar (though I certainly think the power of money is driving all those TV ads). Here, by way of example of the power of money, is the first paragraph of a front-page story in last Sunday’s New York Times: A world-renowned Harvard child psychiatrist whose work has helped fuel an explosion in the use of powerful antipsychotic medicines in children earned at least $1.6 million in consulting fees from drug makers from 2000 to 2007 but for years did not report much of this income to university officials, according to information given Congressional investigators.¨

Now, having used this example, I also want to say that for 35 years at seven newspapers, I was a paid skeptic, but I never was, nor ever will be, a cynic. In my experience in journalism and in life good people struggle all their lives to find the truth and never quite get there. Generally, only the self-righteous and the misguided actually presume to know the final answer.

So, like you and others, I continue searching. As I parse all this through my still-learning mind, I come away thinking this controversy, this debate tells us at least these half-dozen most vital things:

1: Parents frequently lead tough, even desperate lives, but they surely love their children, and are so often literally desperate to help their children. Some help turns more than it should toward ¡§controlling¡¨ behavior. Meanwhile, teachers, too, want classrooms where they are in control, classrooms where the children have a sense of self-discipline or, failing that, discipline however achieved classrooms where children can learn.

2: Parents -- most certainly loving and caring parents -- turn to professionals whom they believe know far more than they know. Sometimes no one knows enough. While many professions no longer have the public image they once did, doctors still are generally regarded in America as people who ¡§know more than I do¡¨ and many, many people assume they “must” be right. (Yes, we also have countless examples of the power and wisdom and common sense of the informed parent, the informed consumer, but too many parents seek the simple and “perfect” answer. Those answers frequently are not possible. Moreover, the science of psychiatry contains many more unknowns than other medical disciplines.) Doctors and other health professionals held in such high regard have a great responsibility to listen and explain in the simplest king¡¦s English. And parents have a great responsibility to ask every possible question so that they truly understand and can make the wisest decisions.

3: Science and medicine have much more to learn about our bodies -- even more about our minds. There remains a powerful stigma about psychiatry -- e.g., “He’s crazy” -- that is not close to departing in these early years of the millennium. That stigma is even worse than the way cancer was regarded a century ago.

4: What might seem to work today might not work a month or six months or a year from now. A prescription today needs to be constantly monitored and frequently altered, and might need to be quite different some time from now. We are not talking about an “exact science” here.

5: Medication is part of the path to helping other people. But it is not the only path. Genuine ¡§talk therapy¡¨ is part of the path. Finding that right blend, and keeping in mind the medical ethos that says ¡§Do no harm¡¨ should be paramount in the minds of all professionals.

6: Finally, we all turn to pills far too often. I probably take too many myself ¡V every one of them prescribed. We ought to talk more about this and spend some real effort on public awareness (Professor Cohen¡¦s course and curriculum being one good example). Our children ask us to do right by them.

It is our children -- all our children -- we are talking about. The theme I strike everywhere these days speaks to such -- that is, reauthorization of The Children’s Trust this Aug. 26. Pass this, and we will have The Trust forever. Should you and I fail, I do not expect to be alive when another generation seeks to bring it back.

The Children’s Trust is not a panacea for all the challenges of our community. But at a reasonable price, it makes an extraordinary set of investments in early intervention and prevention and, hence, a difference in tens of thousands of children¡¦s lives and futures. Just think of our topic this morning, and the health teams -- including a master¡¦s in social work -- that will be in 164 public schools this coming school year. Just think of the $15 million we are investing in programs this year for special-needs children. Just imagine our community without The Children’s Trust. I would weep if we lost this -- not for myself, but for the children and their futures.

Our mutual mission must be about all children ¡V my child, your children, our children. Hence, I close with a couple of quotations.

Go back with me eight centuries to the wisdom of one of England¡¦s greatest kings, Henry II. His obsequious attendants would tell him frequently that the very realm depended on him. He could take this line no more, and one day reminded them that “in my kingdom there is a town, and in the town there is a street, and on the street there is a house. In the house is a cradle with a child in it.” And on that child, Henry would say, all else depends. And so it is, and always will be.

And it that is not blunt enough, I give you the practical wisdom of the great psychiatrist Karl Menninger, who told us a half-century ago: “What we do to children, they will do to society.”

Thank you, in advance, for voting in August. Most of all, thank you for caring and listening and learning.

God bless you all.