Simon's mother, Rachel, did not mince words. Over the telephone in our first conversation she told me point blank that she was wanted Simon on medication. "Would you medicate a two year old?" she asked me point blank.
For the past twenty years I've evaluated and treated children with behavioral and school problems. I'd like to think that when I use medication in a child I've considered many other strategies before reaching for the rx pad. Over the past five years, I've seen the age at which parents and doctors consider psychiatric medications considerably shrink. Some parents and preschools are hoping I consider using Ritalin in children as young as four. But Simon was only 29 months old.
I did meet Rachel one time without Simon. Insurance problems kept us from meeting again. I don't know if I could have helped this family but I'm virtually certain I wouldn't have prescribed any medication to Simon. I was flabbergasted when I later learned from his mother that Simon saw a highly respected child psychiatrist and was now taking Lithium, Zoloft and Risperdal -- three psychiatric drugs at once. I didn't know who felt crazier, Simon or me. It's a feeling I get pretty often these days when I learn of another young child taking two or three psychiatric drugs simultaneously. These combined treatments are not the random ravings of one aberrant mad doctor but are reflective of a system wide change in how psychiatry now deals with problem resistant children.
Quietly yet steadily, the trend to use multiple psychiatric drugs in children has grown raising alarm among mental health professionals, pediatricians and school nurses who dispense many of these meds at school. About four million children under eighteen take one of the stimulants, Ritalin, Dexedrine or Adderall.. Probably more than a million, the majority of whom are teenagers, have used Prozac or one of its sister drugs, Zoloft and Paxil. The rate for children under nine taking anti-depressants has soared by 1200% in half a decade. A survey of Michigan Medicaid children found 223 toddlers, three or younger, were prescribed psychiatric drugs. Forty-four children were taking two or more drugs simultaneously. No one has any idea, nationwide, how many children take more than one psychiatric drug at the same time. However, combined pharmacotherapy (or polypharmacy as it's known pejoratively) is strongly recommended by some of the leading child psychiatry researchers as the most sensible approach to children with difficult mixed psychiatric problems.
More than 150,000 prescriptions for the anti-hypertensive drug, clonidine, were issued in 1996 to children to treat Attention Deficit-Hyperactivity Disorder (ADHD). Anti-convulsant medicines like Depakote or Neurontin are routinely employed to manage a new form of manic-depression, now called bi-polar disorder, supposedly identifiable in children as young as three. However, the newest anti-psychotic drug, Risperdal, is catching up to the anti-convulsants in popularity among doctors for the bi-polar disease. Of the more than two dozen psychiatric drugs used in children only the stimulants and two anti-depressants (Zoloft and Luvox) have met the FDA's tough approval standards for pediatric use. Another handful has been evaluated less rigorously in children for either effectiveness or safety. Most have only been studied and approved for use in adults -- often for non-psychiatric conditions.
Yet child psychiatrists and behavioral pediatricians these days are commonly prescribing these medications. Both the professionals and public have come to believe most serious childhood emotional problems have a biological basis which therefore should be addressed with a medication. Parents are generally feeling desperate by the time they are willing to consider a psychoactive drug for their child. They expect the doctor to provide an answer. Managed care adds to the pressure to do something quickly (usually after one 50 minute visit) about the kid's problem.
Many of these children have extremely tense or chaotic family lives. The kids often have learning problems that are inadequately addressed by overcrowded underfunded classrooms. The absence of any definitive research on the value and safety of these psychiatric drugs for children is compounded by the minimal efforts made to address these children's environments. The problems of these children's lives seem just too great and overwhelming. No one says these children are easy to raise. They are often at risk physically for abuse or self-injury. Something begs to be done for them yet that something too often is only a medication or two or three. We desperately need more research to evaluate the efficacy and safety of these drugs in children. But we also need some balance between our zeal for changing the environment of Johnny's synapses compared to changing the environment of Johnny.
I keep on wondering whether I'm still competent and ìwith itî when it comes to children's behavior and psychiatric drugs. I wonder whether I've missed something in my persistence at working with children's parents and schools. I feel very old-fashioned by my relatively conservative stance on the newer psychiatric medications for children. I'm not against using medication in children. I just believe in primum non nocere "first do no harm." I asked a respected colleague, a local leader of pediatric psychopharmacology, whether my questioning current pediatric psychopharmacology practices meant I wasn't a "good" doctor anymore. "Quite the opposite," he assured me, "Your questions mean that you are."