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Kids on drugs
A behavioral pediatrician questions the wisdom of medicating our children.
By Lawrence H. Diller, M.D.
[03/09/00]

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[03/08/00]

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[03/07/00]

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[03/07/00]

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By Michael Alvear
[03/06/00]

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Calls from academic and professional organizations for "proper diagnosis" and adherence to treatment protocols often go unheeded by frontline physicians. And the lack of objective biological or psychological diagnostic markers, such as blood tests or brain scans, leaves psychiatric diagnosis very much within the eye of the beholder.

In the real world, prescription practices are symptom-driven, with doctors trying to use the safest medications with the fewest side effects first and changing or adding medications when old symptoms persist or new ones arise, sometimes from the other medications themselves.

In the schoolyard, Tommy gets into frequent fights with his second-grade classmates; he also hits his mother. He is likely first to receive a stimulant like Ritalin, Dexedrine or Adderall. He is only slightly less impulsive and continues arguing at home, so clonidine or Tenex may be added. If problems persist, the doctor, invoking an underlying "atypical" depressive disorder as his reason, may try Prozac, Paxil, Zoloft or Wellbutrin. There's not a great deal of difference between the first three drugs except for their length of action.

But if Tommy doesn't improve or gets worse, especially if he goes after an adult at school or breaks the law, serious consideration will be given to using a "mood stabilizer." These drugs purport to treat the greatly expanded bipolar diagnosis. The anticonvulsants, Depakote and Neurontin, are often tried first. Some doctors prefer to prescribe lithium carbonate but its reputation as an adult drug that has frequent side effects decreases its popularity for use in children. Ultimately medications initially used to treat psychosis are used. They are categorized as novel or atypical anti-psychotics because their chemical structure is different from the first drugs like Thorazine or Mellaril used for schizophrenia. Risperdal and Zyprexia are the current "hot" anti-psychotics that are now being used to treat bipolar disorder.

Children like Anna, 9, take another medication route. She's afraid to be alone at night, asks for constant reassurance and insists on wearing the same outfit every day to school. Anna will start with a Prozac-type drug for her anxiety and obsessive behavior. If she doesn't improve, a Zoloft or Paxil may be tried before another class of drugs is employed. Some doctors continue to prescribe the older antidepressants like imipramine (Tofranil), desipramine (Norpramin) or nortriptyline (Pamelor).

These drugs were not found to be effective in childhood depression but still may be employed for other childhood symptoms. An anti-anxiety agent like Ativan or Klonopin may be offered to Anna especially to help her fall asleep at night. A mood stabilizer or anti-psychotic might be added if she begins talking about death or pulls off all her eyelashes.

All these drugs have side effects. Some are frequent and minor, at least to doctors, while others are quite serious but occur only rarely. The Ritalin-stimulant class has been studied most extensively. The drugs cause temporary loss of appetite and, if given too late in the day, insomnia. In general they are considered relatively safe when used properly. Children do not abuse the stimulants, though teens and adults may. Children under 5 seem to have more side effects on drugs like Ritalin. Clonidine and Tenex are sedating, which may explain their popularity for use in the late afternoon and evening. Children can experience rebound high blood pressure if they are abruptly taken off higher doses of these drugs. Children on Prozac drugs seem to experience a state of "hypomania" far more frequently than their adult counterparts. They act agitated, too happy or bizarre. Mark, 14, had taken Prozac for a week. His father and I had to literally sit on him when he became violent in my waiting room. He had never acted this agitated before.

I was surprised by Claire, a 10-year-old girl I knew, who placed about 10 of her pet salamanders on the sweater she wore as she waited to see me. Claire walked into my office and spent about 20 minutes picking imaginary "warts" off the salamanders as she talked with me. I finally asked her to stop because I thought she was abusing the animals. She had been on Prozac for two months and had never before acted so strangely. Both children's medications were stopped.

Most of the other drugs cause sedation. In rare cases, Depakote can cause a fatal anemia. In women it causes cysts to form in the ovaries. Lithium commonly causes tremor and requires blood tests every six months to monitor kidney and thyroid function. The newer anti-psychotics are said to be less sedating but do cause significant weight gain for many children. They are touted as causing fewer involuntary muscle movements -- called tardive dyskinesia -- abnormalities that can persist even after the drug is discontinued.

However, over the years, many new anti-psychotics have been introduced with the claim that they have fewer side effects. With time and widespread use, their superiority over the older medications becomes questionable. It remains to be seen how much safer Risperdal will be over Mellaril or Thorazine.

Several drugs that had been frequently prescribed by child psychiatrists and pediatricians plummeted in their use when catastrophic side effects were discovered. Desipramine, imipramine and clonidine have all been associated with episodes of sudden death in children. Even though some researchers, Joseph Biederman among them, have questioned the frequency and association between these tragedies and the drugs involved, many doctors simply stopped prescribing them. Apparently, there are enough alternatives. And doctors found it difficult to tell parents that there existed even a small increased risk of their child dying from these drugs.

Similarly, the stimulant Cylert, once used commonly to treat ADHD, was voluntarily removed from the Canadian market and is hardly used in this country anymore. The manufacturer was compelled by the FDA to announce in a letter to all physicians that 11 cases of severe chemical hepatitis developed in children using the drug leading to their deaths or liver transplants.

This is a short list of only the known side effects of these drugs in children or adults. None of these medications except the stimulants have been studied for more than a few months in any children. The increased theoretical risk of long-term side effects exists especially for young children who continue to develop physically and neurologically and will live for 70 to 80 years after taking the medication. For example it is not known whether drugs like Prozac, which frequently cause sexual dysfunction in adults (decreased sex drive, difficulty with ejaculation or orgasm), will have any negative effects on sexually maturing children and teens.

I believe a child's symptoms must be severe and the benefits of taking the medication must be quite clear to justify their use. A couple of kids I've seen have gotten better while taking a drug other than a stimulant. Timothy, 5, was already in a special kindergarten for emotionally disturbed children and his parents were at their wits' end in handling his temper outbursts and defiance at home. He had already been on Ritalin, Dexedrine and clonidine without success. I was working with the parents, who were highly stressed by a suit they were pressing against a petrochemical company whose toxic wastes they believed caused their son's problems. They were going from one doctor to the next.

The parents had Timothy on Zyprexia because of his rage episodes at home. They switched him to Risperdal after a new psychiatrist thought that the better choice. On low-dose Risperdal things did seem to improve for Timmy. His parents reported that his temper tantrums decreased in intensity and frequency and he was more obedient.

As is often the case, however, two other things changed at about the same time. The family finally sold the home they believed was contaminated and moved. Also, I coached the parents, especially the mother, to be more immediate and firm with their discipline of Timmy. It was hard to say if it was only the medicine that made the difference; it's possible it allowed the other interventions to be more successful. The parents were convinced the medication made a crucial difference. I was content to see the improvement and did not challenge them with the possibility that the other changes had been more important.

Sam's temper and school defiance improved considerably when he began taking Depakote. Sam previously had tried two stimulants and Prozac to help stop his angry outbursts at home and his defiance at school. At about the same time he started the Depakote the school assigned Sam, who also had severe learning problems, a full-time aide who shadowed him constantly, giving him immediate positive and negative feedback for his actions. The experience in school turned Sam around. However, neither the parents nor I could deny the possibility that the medication had also helped him.

Next page | Was Bobby simply misdiagnosed or were his doctors "chasing symptoms"?