Psych meds for kids: Too much, too soon?

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.

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