The opposing voices in the "debate" over the use of psychotropic medications in children veer toward hyperbole. One reviewer likened the process to "dueling grade-B movies," where supporters of drug therapy view doctors as noble knights freeing children and their families from the tyranny of a biologically based mental illness, and the other side has physicians, especially psychiatrists, as evildoers who sedate and control children's behavior by drugging them at the behest of their parents and teachers.
This dichotomy, while appealing to TV talk shows and tabloid journalism, doesn't do justice to the motives of nearly everyone involved. Nor does it describe the economic, bureaucratic and social realities that can lead to an 8-year-old boy taking three psychiatric drugs simultaneously.
The discussion is complicated by the fact that children are dependent on their caregivers and are not allowed to make the final decision about their own care. At best, children are offered informed choice but not consent. Also, because children are in a developmental stage, the stakes are higher when they take medication. Parents and doctors are concerned that the medications may affect normal physical and developmental growth, leaving, in essence, permanent side effects.
Doctors genuinely desire to ease suffering. But they are also strongly influenced by economic factors. The profit motive affects whether and in what manner doctors offer treatment. The traditional fee-for-service arrangement encourages interventions. A capitated system of payments to doctors common in health maintenance organizations (HMOs), which sets a limit on how much money physicians receive regardless of what services are offered, discourages interventions that are deemed costly or result in only marginal benefits to the patient.
Our current systems of care and payment for children's emotional problems, in tandem with often desperate parental expectations that the doctor will supply the "answer" to the problem, place inexorable pressure on the doctor to do something quickly.
Typically today under managed care the doctor must make a judgment about the diagnosis and a decision whether to medicate in a 50-minute meeting with the child and parents (usually just the mother). The doctor is then allowed two follow-up meetings of about 20 minutes each to review the child's behavior on the medication.
Such was the case with Peter, a 5-year-old I was asked to evaluate. Peter's developmental milestones were those of a 3-and-a-half-year-old. His language development was that of a 2-year-old. However, no one could be really sure about Peter's intelligence because he was in constant motion and ignored his parents' commands.
Peter lived too far away to receive ongoing treatment from me so I called Dr. Murrow, a child psychiatrist who had previously worked with Peter and his family in their community. Murrow had already tried a number of medications with Peter. I thought to offer a couple of ideas on Peter's medications but also wanted to address his parents' ineffective approach to limits with Peter.
I asked the doctor if he was doing anything else these days besides prescribing drugs. He sounded resigned and apologetic: "Nope. I see a kid every 15 minutes. It's the only way I can make an income under managed care." But he promised that, for Peter, he would try to include some of my ideas about the family the next time he saw the child and his mother.
Parents and schools complete the chain that squeezes the system toward a rapid medication intervention. I've never met a parent who, at least initially, wasn't ambivalent about giving their kid a medication. However, parents today, when pondering their children's problem behavior, begin to consider medication much sooner than parents did just 10 years ago. These days, after only several weeks of feeling like "We've tried everything," moms and dads think, "Maybe Johnny can't help what he's doing. Maybe he does have a 'chemical imbalance.'"
Imperceptibly at first, people go from believing that a child or parent has influence over a behavior problem to believing that the behavior is involuntary and that something biological is the cause. Medication becomes the reluctantly arrived-at solution. This kind of thinking is powerfully reinforced by much of American psychiatry and the media. Now when I meet parents who strongly believe that their child has "a disorder," I find that they aren't interested in considering other interventions unless I also write a prescription for their kid.
Teachers and schools are the final pressure point. Teachers are faced with a broad curriculum that today includes much more than the three Rs. Poorly educated students and social passing have led to increasing use of standardized tests. Not only are students more scrutinized, but so are their teachers. The demands on a teacher's time and attention in a crowded classroom make managing behaviorally difficult children harder.
Teachers, like parents, consider a medication option much sooner these days. Few teachers come right out and make that suggestion, but the message is unmistakably clear to parents, and to the doctor, when a teacher suggests that the child get a medical evaluation to address problems of behavior and performance at school.
In fact, the Colorado State Board of Education recently passed a resolution urging teachers to first use discipline and educational resources before referring a child for a medical evaluation. They believed that teachers in Colorado were too quick to move to a "medication fix."
Parents and doctors sometimes have to choose between giving a child medication and having the child attend a more restrictive classroom environment. Steven, 9, still couldn't write a coherent sentence and instead hid under his desk. Would adding another medication allow him to remain in the regular class? Or should he be sent to "Special Day Class," where there are fewer children but where they all have similar or more severe problems?
The costs and benefits of such choices are often clouded by an inefficient, overworked public education system that pushes parents toward choosing medication over special education. One can't medicate a school system.
What about the medications themselves and how they are used? Are they effective? What do they do to children? In psychiatry, like the rest of medicine, doctors are supposed to first diagnose a disorder and then treat it. However, the specific psychiatric diagnostic categories for children become less clear in real life situations, and the effects of various medications are neither particularly specific nor reserved for particular diagnoses. ADHD blurs with oppositional defiant disorder, the category used to describe young angry, disobedient children. Ritalin helps treat both. Anxiety disorders merge with depression. Calling Prozac an antidepressant belies its use for obsessive-compulsive disorder or anorexia.
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.
It's not that I'm against using medication in children. On average, in 1999, I wrote one prescription a day for Ritalin or its equivalent. But I've also tried to carefully explore with parents and teachers alternative strategies within the home and school. Many doctors, out of ideological, economic or time constraints, don't bother. I'm much more worried about all these other drugs being offered to kids these days. Their short-term benefits are far less visible to me. They have the possibility of much more serious immediate side effects, and because none of them have been studied for more than a few months, I'm also uneasy about the unknown long-term side effects.
I resist using more drugs with children, despite the pressures on me, which are at times immense. I suspect I approach children's problems with a different point of view and emphasis from many of my colleagues. Psychiatry over 30 years has changed in its perspective from the environmental to the biological but its focus remains on the pathological -- what's wrong with the child or family. Evaluations become a widespread and systematic search for symptoms and problems.
I probe with equal vigor for the competencies and strengths of the child and family. Since children do not exist in isolation, I find it impossible to view children's behavior without considering their families, schools and culture. And it is more effective than considering the child alone. Some children do benefit from some time alone with the doctor. But mostly I work with those who have influence and control over the child's world. After some weeks or months, if the situation hasn't improved, I consider prescribing a medication to the child (or to a parent).
But once I move beyond Ritalin and the stimulants and think about the other medications employed for children today, I know that the family and I are facing the very difficult choice of dramatically altering a child's environment or trying a different medication. Typically questions arise like, "Is this the right classroom or school for Joey?" "Maybe Don and I should separate to decrease the tension and fighting at home?" "Should I call the cops the next time Ian breaks something in the house?"
Families deal with these decisions only with great reluctance. The uncertain benefits and risks of a medication begin to seem worth taking. Proponents for children's psychoactive medication say why not try a medication that may help? Medication is often much cheaper and might work faster.
But medication alone for children's problems is not the moral equivalent of a better home or school environment for children. I object to the frequent current practice of early and multiple medication interventions because, too often, minimal effort has been made to address the children's environment.
A 2-year-old boy on three psychiatric drugs, a 5-year-old trying eight different medications -- these situations and many others like them leave me feeling confused, inadequate and angry. I continue to question my own competency and instincts about psychiatric drugs for kids. Sometimes I think I'm old-fashioned. But the reassurance I get from colleagues and families helps me believe I'm not alone in my concerns.
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By the time I met Bobby in July 1999, the 8-year-old on three medications, much had changed from when his parents first began fighting. Pierre had always been unhappy about Bobby's medications, but Carol typically prevailed. After six years of a costly post-divorce battle over finances and custody, the parents had finally settled some of their issues and were getting along better. A new therapist for Bobby also worked closely with each parent and eventually had them meeting together with him about Bobby, whose behavior and performance improved dramatically at school with the help of a private tutor. Bobby now had average grades and a bevy of friends.
Pierre had never had many problems with Bobby. He attributed their getting along to a mutual love of dogs. In fact, in the process of divorcing, Pierre had lost a kennel and training facility he owned. This was without a doubt, Pierre believed, the single greatest loss for him and his son. Pierre also felt he was more direct than Carol with his affection and discipline of his son. Even Carol admitted that things were better at school for Bobby but she still worried about the possibility of problems at home should Bobby stop taking his medications. She fully accepted the hereditary and long-term nature of Bobby's bipolar diagnosis and was reluctant to stop the medications that she believed had been so helpful. She was a much less confident parent who had battled her own depression and relied quite heavily on trying to talk Bobby through his noncompliance and rages.
I saw Bobby alone and with each parent. He seemed like a pretty normal, cute, lively brown-haired boy to me. He could talk freely about his past problems, his current set of friends and pleasures, his preference for his father's home but also of his continuing loyalty and caring for his mother. He acted a little bit silly and immature in his mother's presence. I spoke with his teachers and tutor, who were aware of some of his medications. They said they could not distinguish Bobby's behavior from that of the other children in the class.
Bobby's therapist felt that Pierre was finally finding his voice as a parent in the family. He also thought Bobby and his parents overall were working better together.
I met Carol and Pierre together and suggested they try a "tapering trial" -- first slowly stopping the Neurontin and then the Anafranil. I was concerned with the sedating effects of both drugs. I tried to acknowledge both parents' positions on the medication. I said that Carol would need a lot of support from Pierre in parenting Bobby, maintaining similar standards and responses.
Pierre wanted Bobby off all medicines but could accept this compromise. Carol remained apprehensive but was willing to try a trial discontinuation as long as she had backup support from the therapist and Pierre.
Bobby continued to be successful with only the Ritalin and perhaps in the near future could try life without any psychiatric medication.
Was all this medication necessary or useful for Bobby? He didn't seem much worse off because of the drugs. They may even have helped him through a difficult time in his family's life. No one knows if the possible benefits outweigh any future harm. Only time will tell.
From my perspective, Bobby's family -- his parents' battles and relative reconciliation -- was the biggest influence on Bobby's behavior. Was Bobby misdiagnosed by his doctors or were they just "chasing symptoms"? Even if the pills helped, was it really necessary to tag Bobby with a psychiatric label of bipolar disorder that may haunt him and his family the rest of his life?
The only thing I know for sure is there are several million children like Bobby in America taking psychiatric drugs today without much certainty about their present value and long-term consequences.