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F I S C A L I M P A C T R E P O R T

SPONSOR Beffort

DATE TYPED 3-02-05

HB

SHORT TITLE Study Prescription Drugs for Child Behavior

SB SJM 52

ANALYST Collard

APPROPRIATION

Appropriation Contained Estimated Additional Impact Recurring

or Non-Rec

Fund

Affected

FY05

FY06

FY05

FY06

Minimal

(Parenthesis ( ) Indicate Expenditure Decreases)

SOURCES OF INFORMATION

LFC Files

National Institute of Mental Health

http://www.nimh.nih.gov

Parents Med Guide

Responses Received From

Department of Health (DOH)

Regulation and Licensing Department – Pharmacy Board

Children, Youth and Families Department (CYFD)

Public Education Department (PED)

SUMMARY

Synopsis of Bill

Senate Joint Memorial 52 requests DOH to convene a taskforce to study the potential misuse and

overuse of prescription drugs in dealing with children's behavioral problems in school, with the

following instructions for the taskforce:

•

Include representation from PED, the children's health program of the University of New

Mexico, pediatricians, child psychiatrists, pharmacists and others with special knowledge and

experience in child health and welfare;

•

Identify alternative approaches to prescription medication, including nutrition and vitamin

supplementation, and evaluate the safety and effectiveness of these approaches;

•

Identify approaches to promote regular exercise and participation in sports in schools as a

way to channel disruptive behavior in more positive directions;

Senate Joint Memorial 52 -- Page 2

•

Develop public outreach efforts to better educate physicians, parents, classroom teachers and

school counselors about the potential dangers of prescription drugs, and alternative ap-

proaches to disruptive behavior;

•

Recommend appropriate observation and examination of children prior to suggesting treat-

ment with pharmaceutical agents;

•

Present the findings and recommendations of the task force to the legislative Health and Hu-

man Services Committee and the legislative Education Study Committee at their respective

October 2005 meetings.

The joint memorial also asks that copies be sent to DOH, PED and statewide organizations rep-

resenting pediatricians and psychiatrists.

Significant Issues

DOH notes the joint memorial addresses the issue of increasing numbers of children in New

Mexico being diagnosed with a variety of behavior disorders and subsequently being prescribed

medications to control behavior problems such as hyperactivity, inattention, impulsivity and de-

pression. The joint memorial states that the unintended side effects of these drugs can have very

serious side effects.

DOH research shows the prevalence of mental illnesses in children and adolescents is significant

and on the rise. About 1 in 10 children in the United States suffers from a mental illness severe

enough to cause impairment. Research shows that reaching children with mental illnesses early

with appropriate treatment significantly improves their long-term prognosis. Conversely, the

failure to provide treatment has tragic consequences. Research shows that early identification

and comprehensive treatment (multidisciplinary) can improve the long-term prognosis of chil-

dren with mental illnesses. The long-term consequences of untreated mental illnesses in youth

are staggering. Nationally, suicide is the third leading cause of death in adolescents aged 15 to

24. Evidence strongly suggests that as many as 90 percent of those who commit suicide have a

diagnosable mental disorder. Youth with untreated mental illnesses often end up in the criminal

justice system. Their inability to succeed in school can result in their failure to complete their

education, obtain meaningful employment and ultimately in the chance to lead an independent

and productive life. Youth with untreated mental illnesses have a greatly diminished future as

citizen and worker. The negative impact on our youth also affects their families, who report ex-

periencing enormous stress, divorce, loss of housing, and excessive absenteeism from work.

PED research shows a significant number of children are being diagnosed with a variety of be-

havioral problems ranging from mildly disruptive behavior to serious disorders such as autism

and depression. Prescription drugs such as Ritalin, Adderall, Prozac, Accutane and Zoloft are

being given to children with behavioral problems. Unintended side effects of these can have se-

rious consequences, such as agitation, insomnia, psychosis and social withdrawal. According to

the Journal of School Nursing, it is estimated that 21 percent of youths ages nine to 17 are af-

fected by a mental health or addictive disorder.

FISCAL IMPLICATIONS

There is no appropriation contained in this joint memorial; however there is the possibility of

each agency paying per diem and/or mileage costs for the members on the taskforce.

Senate Joint Memorial 52 -- Page 3

ADMINISTRATIVE IMPLICATIONS

DOH indicates staff would need to be identified to convene this taskforce.

TECHNICAL ISSUES

CYFD is not identified as a representative agency on the taskforce.

OTHER SUBSTANTIVE ISSUES

DOH notes the joint memorial primarily raises the issue of the safety of psychotropic medica-

tions and their use by children and adolescents, which received considerable attention in June

2003. At that time, the British Medicines and Healthcare Products Regulatory Agency (the Brit-

ish equivalent of FDA) and the United States Food and Drug Administration (FDA) issued for-

mal warnings advising against the use of Paxil (an antidepressant) to treat depression in children

and adolescents. In 2004, the FDA reviewed 23 clinical trials involving more than 4,300 child

and adolescent patients who received any of nine different antidepressant medications. No sui-

cides occurred in any of these studies. These studies included "Adverse Event Reports," which

are reports made by the research clinician if a patient (or their parent) spontaneously shares

thoughts about suicide or describes potentially dangerous behavior. FDA found that such “ad-

verse events” were reported by approximately 4 percent of all children and adolescents taking

medication compared with 2 percent of those taking a placebo, or sugar pill. One of the prob-

lems with using this approach is that most teenagers do not talk about their suicidal thoughts

unless they are asked, in which case no report is filed. In 17 of the 23 studies a second measure

was also available. These were standardized forms asking about suicidal thoughts and behaviors

completed for each child or teen at each visit. In the views of many experts, these measures are

more reliable than event reports. FDA's analysis of the data from these 17 studies found that,

medication neither increased suicidality that had been present before treatment, nor did it induce

new suicidality in those who were not thinking about suicide at the start of the study. In fact, on

these measures, all studies combined showed a slight reduction in suicidality over the course of

treatment.

An important recent study, Treatment for Adolescents with Depression Study, funded by the Na-

tional Institute of Mental Health (NIMH), examined the effectiveness of three different treatment

approaches for adolescents with moderate to severe depression. The researchers found that 71

percent, or nearly three in four, of the young patients who received the combination treatment of

SSRI medication plus cognitive behavioral therapy improved significantly. Of those receiving

medication alone, slightly more than 60 percent improved. The combination treatment was

nearly twice as effective in relieving depression as the placebo or psychotherapy alone

There is no current evidence that antidepressants increase the risk of suicide. There is much evi-

dence that depression significantly increases a child or adolescent’s risk for suicide. Children

with a mood disorder such as depression are five times more likely to attempt suicide than chil-

dren who are not affected by these illnesses. FDA reported an increase in spontaneous reports of

suicidal thoughts and/or behavior among children receiving medication, but there is no evidence

that these suicidal thoughts or behaviors lead to an increased risk of suicide. Research further

demonstrates that the treatment of depression – including treatment with antidepressant medica-

tion -- is associated with an overall decrease in the risk of suicide. Data collected by the Centers

for Disease Prevention and Control (CDC) show that between 1992 and 2001, the rate of suicide

Senate Joint Memorial 52 -- Page 4

among American youth ages 10 – 19 declined by more than 25 percent. It is noteworthy that the

same ten-year period was marked by a significant increase in the prescribing of antidepressant

medications to young people.

In 2002, suicide was the second leading cause of death among 15-24 year-old New Mexicans and

was the third leading cause among youth nationally. Only 36 percent of youth at risk for suicide

receive treatment for their problems. New Mexico’s suicide rates for all ages combined have

historically been nearly twice the national rate, ranking highest among the states in 2001 and ex-

ceeded only by Wyoming, Alaska and Montana in 2002. Notably, the mental health problems

that underlie suicide also underlie homicide and accidents—the two leading killers of young

people. In 2001 NM ranked twelfth of all states in youth deaths due to accidents, homicides, and

suicides. Youth suicide merits additional attention in New Mexico since over 31 percent of the

state’s population is under age 20, the fifth highest proportion in the nation.

The Office of School Health in DOH currently conducts behavioral health screening and assess-

ment pilot programs in 11 schools in the state. These screens are effective at identifying youth at

risk for depression, suicide, and other mental disorders. The value of high-school screening in

identifying troubled and suicidal individuals extends beyond the high-school years, with screen-

ing identifying 65 percent of those who will go on to experience recurrent depression or become

suicidal in young adulthood. Because the screening now only takes 10-15 minutes for the major-

ity of students, and a maximum of an hour for those who go on to the clinical interview segment

of the screening process, screening costs are very low.

DOH also notes the joint memorial identifies Attention Deficit Hyperactivity Disorder as epi-

demic throughout the country, with more than 5 percent of children being diagnosed with the

disorder. Research shows that the origins of ADHD are complex and include genetic and envi-

ronmental factors. Factors implicated as possible contributing causes in ADHD generally fall

into a small handful of categories: (1) differences in brain structure/function, (2) family and ge-

netic factors, (3) prenatal/perinatal factors, (4) chemical toxins, and (5) exacerbating psychoso-

cial stressors and combined factors. Various explanations for ADHD have been put forth involv-

ing diet, allergic food sensitivity, vitamin and mineral deficiencies, environmental pollutants, or

all of the above. Such theories usually carry with them their own untested prescriptions for rem-

edy in the form of special diets, supplementation, and others.

DOH research shows a large body of evidence supports the efficacy of psycho-stimulant medica-

tion in the treatment of ADHD. No studies to date have demonstrated long-term hazards associ-

ated with their use, even though they have been used for more than 40 years. While all forms of

therapy should be used judiciously and cautiously, there are no data suggesting that these treat-

ments do harm, compared to the large amount of evidence indicating that untreated ADHD does

a great deal of long-term harm.

DOH indicates the type of study requested in the joint memorial requires significant research

support such as that available to FDA or CDC. The type of taskforce described in the joint me-

morial would have the expertise and could review already published studies addressing these is-

sues and recommend a range of evidence-based strategies for supporting children with behavior

disorders.

Senate Joint Memorial 52 -- Page 5

ALTERNATIVES

RLD – Pharmacy Board notes the scope of the memorial is limited to the potential misuse and

overuse of prescription drugs in dealing with children’s behavioral problems in school. RLD

indicates accutane, listed on page 2, line 7 is a drug used to treat acne which is not a behavioral

problem. Perhaps the scope of the task force should be expanded to include a review of all

medications typically prescribed for children. The task force then would be able to review weight

loss medications, drugs for memory enhancement, performance enablers, and others.

KBC/yr