Should I Medicate My Child?

Sane Solutions For Troubled Kids With-and Without-psychiatric Drugs


By Lawrence Diller

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When Running on Ritalin was published in 1998 it touched off a firestorm about treating children with psychiatric drugs. Dr. Lawrence Diller established himself as the leading expert on the controversial use of stimulants for attention deficit disorder. Since then, parents, physicians, teachers and psychologists, have clamored for his expertise on psychological problems beyond ADD and on drugs beyond Ritalin. More and more parents are asking the simple question: Should I medicate my child? The answer is not as simple as some “experts” say. Children who are angry, intense, distractible, over-energetic, obsessive, shy, listless, or remote rarely benefit from an either/or strategy. Unlike those with a strong pro- or anti-drug agenda, Dr. Diller advocates a balanced approach; he shows how a wise pediatrician — one who prescribes drugs but also urges non-pharmaceutical interventions when possible — makes decisions. Should I Medicate My Child? empowers parents to ask the same questions Dr. Diller poses in diagnosis and treatment: Have all non-drug approaches been tried? Is the diagnosis accurate? What’s known (or unknown) about the recommended drug? Calmly comforting, authoritative, and illustrated with real-life examples, Should I Medicate My Child? is essential reading for parents who have been told their preschooler should be “tested” for a disorder, whose fifth-grader has been prescribed Prozac or Depakote, or whose teenager has been diagnosed with a “chemical imbalance.” Should I Medicate My Child? features a detailed, easy-to-access Appendix of Frequently Prescribed Drugs — what they do, side effects, dosages, and more. Should I Medicate My Child? answers parents’ vital questions:

* Is it fair to discipline my hyperactive child if he can’t help himself when he misbehaves? Choosing the right kind of discipline is essential. Often the time-honored “time-out” is not the best choice.
* The psychiatrist says the medication he’s prescribing is “safe.” How can I know if that’s true? Dr. Diller’s detailed Appendix includes little-known information on how (or if) a drug has actually been tested on children.
* Does it make good sense to use medication right away? Dr. Diller explains why this can sometimes be the best course of action.
* My pediatrician says there are drugs that will help my shy six year old be more outgoing. Is this true? Prescribing drugs for withdrawn children is a risky business. Dr. Diller explains why and offers alternatives to help ease their distress.


Running on Ritalin

This book is designed to help you make informed choices; it is not meant to replace treatment by a physician or other licensed health care provider in the diagnosis or treatment of emotional or behavior problems in children.
Note: Many of the cases in this book are based on composites of families I have met in my professional experience. Where cases are based on individuals I have encountered in my medical practice, I have changed the names, sex, family constellations, and occupations to protect the subjects' privacy.


Eight Questions to Ask Yourself Before Accepting or Rejecting Medication

Weighing Your Options
Brandon has just turned three and is driving his parents crazy. He has temper tantrums several times daily, beating his arms, legs, and even his head against the floor. On one frightening occasion, he cut his temple on the corner of the fireplace mantel. When his parents try to hold him in their arms for protection, he kicks, bites, and hits them, arching his back until he wriggles out of their grasp.
Tantrums are Not the only problem. Brandon picks up and tosses aside toys as if he were a human weed whacker; despite his mother's constant efforts to maintain control over her son's behavior, the house is strewn with plastic animals, toy race cars, and broken games. His parents are embarrassed to let Brandon play at anyone else's house, and they have Noted the disapproving looks of visitors. They would like to teach Brandon to pick up his toys, but all attempts so far have only yielded more of his violent tantrums—which, his exhausted parents agree, they want to avoid whenever possible.
Carrie, Brandon's mother, dislikes the idea of giving psychiatric medications to children. She would prefer alternative therapies and has already consulted a food allergist. She is considering eliminating sugar from Brandon's diet. But, she tells me, No one else she knows has a child like this. She wonders aloud: If Brandon has a disorder that makes him hyper and unhappy, wouldn't it be cruel Not to give him a drug that would help?
Eight-year-old Ruth cries every morning before she goes to school. "No one likes me," she says, adding that the teacher is mean. But the teacher has told Ruth's parents that their daughter is doing well in school, both academically and socially. When Ruth is introduced to New people, she won't talk and sometimes tries to crawl under her mother's coat.
But with her family, Ruth is a Mr. Hyde. She insists on wearing only T-shirts and blue jeans—and throws a fit if her mother insists that she wear something different, like, God forbid, a dress. In the midst of her tantrums, she's yelled, "You're horrible! I'm going to kill myself!"
Natalie, Ruth's mother, has tried techniques ranging from patience and reassurance to antianxiety medication for her daughter. But she feels it's only a matter of time before her family implodes under the pressure of the child's extreme sensitivity. "How do I know if she Needs a different drug?" Natalie asks me, her voice constricting. "Or if I've just been a lousy parent?"
Jerry, Nearly sixteen, came home with two Ds and two Fs on his latest report card. His parents recall a time when Jerry was an A student, but Now he ignores major assignments as well as his homework. He doesn't appear to have a behavior problem, but it's hard to tell: Jerry spends most of his time these days in his room with the door closed, presumably on the computer or the telephone. Nor does he seem to lack for intellectual ability, since he still pulls a B+ in history—a subject he has always liked—and is enthralled by the cerebral computer game Myst.
A relative mentioned that many of Jerry's traits fit the profile for attention deficit/hyperactivity disorder, inattentive type. His mother, Joyce, is concerned that her son Needs medical care. Rick, his father, thinks that Jerry is just plain lazy. But Joyce is quick to point out that Rick works a seven-day week, is often on the road, and doesn't have the opportunity to Notice the subtleties of their son's behavior. For his part, Jerry agrees with his father's diagnosis of laziness. However, he has volunteered that he is willing to take medication. "But it can't have any bad side effects," he declares.
Although Anna and Steven MacAteer agree that their daughter Susie is "high energy," they do Not report misbehavior from her at home. But the teacher at the private Christian school where Susie is a second grader has been calling Anna Nearly every week. Susie drifts away from her work, constantly getting out of her seat to visit the bathroom, chat with her friends, or play with the class aquarium. Punishments like missing recess or going to time-out seem to have No effect on her behavior. The teacher thinks that Susie should see a doctor for testing. The tone in her voice makes it clear the point behind the "suggestion": If Susie doesn't improve soon, she will be asked to leave the school.
Anna and Steven do Not want their daughter to receive a psychiatric label so early in her life, Nor do they like the idea of giving her a drug to improve her behavior. But they aren't sure which is worse—medicating their child for a disorder they're Not sure she has or risking expulsion from a school she enjoys.
This book is for parents of children like Brandon, Ruth, Jerry, and Susie, who, from toddlers to teens, are experiencing behavior or emotional problems. These problems range in kind and severity. The child may be angry, intense, distractible, energetic, strong-willed, obsessive, fearful, shy, listless, or remote; or she may have difficulty forming normal relationships with other people.
If you are a parent of such a child, you have probably sought out and received plenty of advice, none of it entirely successful and some of it disastrous. By the time parents arrive in my office, they have usually run through a series of approaches: time-outs, negotiation and compromise, reward systems, reassurance, and so on. The parents are worried, naturally, about their child's mental health and prospects for the future. Will she struggle with this problem throughout her life? Will it ultimately keep her from getting a good job or making a happy marriage? What will happen to her self-esteem? Often parents experience battle fatigue; it's common for them to feel guilty and confused or angry at the not-so-subtle sense of blame imposed on them by schools and other parents. They often feel tyrannized by their child's problems and long for escape. "I'd love to spend a week—no, a month—on a deserted island," one mother told me, the circles under her eyes like blue half-moons. These fantasies, which are perfectly normal, can be terribly distressing for parents, who may fear that they indicate a secret lack of commitment to their child.
Parents who have reached this point often come to me because they know that I am licensed to prescribe psychiatric drugs to children and have many years of experience doing so. On the first visit they usually ask, Does my child Need medication?
There is no easy answer to that question. If you are reading this book, the prospect of giving psychiatric drugs to your child probably leaves you with mixed feelings. You may not be sure what these drugs do or how they help. You are probably worried about side effects. If your child is already taking medication, you may be asking yourself whether you've made the right choice—even if the drug appears to be helping. Like many parents I see, you may be uneasy with the number of prescriptions written for children these days and wonder if our culture sometimes uses medication to shoehorn children into a onesize-fits-all mold of smiling compliance.
You may also worry about the repercussions of Not medicating your child. All of us involved in a child's treatment frequently worry that ongoing problems will cause the child to lose hope. "Why even try?" she might say in response to a challenging homework assignment or a situation that requires self-control. "I'm just a dumb/bad/weird kid." Like Natalie, the mother of Ruth, you may fear for the well-being of the rest of the family. Like Anna and Steven MacAteer, you may be weighing the act of medicating your child, thereby ensuring that she will stay in her current classroom, versus the threat of expulsion or placement in a special class.
Both sets of concerns are present in loving parents who want their child to be healthy and happy. I've written this book for parents who want to see how a thoughtful doctor—one who keeps these same concerns constantly in mind—thinks through the problem of psychiatric medication on a case-by-case basis. My hope is to help you make a difficult decision from a stance that is as informed and balanced as possible.

Battle of the B Movies

I am a behavioral pediatrician—a medical doctor (M.D.) with a specialty in children's behavioral and developmental problems—who has been practicing for more than twenty years in Walnut Creek, California, a suburb of San Francisco. I have evaluated and treated more than twenty-five hundred children with emotional, behavioral, and performance problems at home or at school. Trained in family therapy, I work with the parents and siblings of these children as well.
The skyrocketing rate of Ritalin use in the 1990s led me to write a book called Running on Ritalin, in which I addressed the bureaucratic, social, medical, and economic forces squeezing parents and doctors into rushing to treat kids' behavior problems with that drug. Since then, the use of other psychiatric drugs—antidepressants, antipsychotics, anticonvulsants, and so on—for children has exploded as well. I've appeared on many television and radio shows to discuss this phenomenon. When producers are screening me for these appearances, they often ask, Dr. Diller, are you for psychiatric drugs in children, or against them?
The question itself reflects the hyperbolic debate that has been waged on the airwaves for the last decade or so. Robert Fancher, reviewing Running on Ritalin for the Washington Post, likened the process to "dueling B movies," in which heroes and villains battle for the souls of children in an atmosphere of Gothic dimensions. In one of these hypothetical movies, doctors who prescribe medications are noble knights, their chargers aloft, freeing children and their families from the tyranny of a biologically based mental illness. In the other scenario, physicians—especially psychiatrists—are child-hating mad scientists who sedate and control our youth at the behest of their lazy parents and teachers. These dramatic scenarios appeal to television talk shows and tabloid journalism, but they don't do justice to people who are struggling with unhappy, difficult children.
In answer to that question—am I for or against psychiatric drugs for children—I say something like this: I'm certainly not against them. In the last year, I wrote more than four hundred prescriptions for Ritalin or its equivalent. I also prescribe, although much less frequently, antidepressants, major tranquilizers, and mood stabilizers. I'm "for" psychiatric drugs in the same way I'm "for" antibiotics. When antibiotics are used judiciously, they can save lives. But those who reach for antibiotics at every sniffle and cough, regardless of the underlying cause, endanger us all by encouraging strains of resistant bacteria. No drug, including psychiatric medication, is either good or bad. Drugs are simply tools that can be used with a greater or lesser degree of judgment.
But parents don't buy books titled "Should I Give My Child Penicillin?" Applying good judgment to an antibiotic is not as difficult: It attacks an identifiable agent of disease; its targets—bacteria—produce recognizable symptoms; and its side effects and contraindications are well-known. Not so for psychiatric drugs.
Psychiatric drugs do not target an invasive organism. Rather, they are directed toward the child's brain, the very center of personality and of the functions that define who we are. There are no clear tests, no X rays, no MRI scans, that tell us when a child should be labeled with a certain behavioral or emotional condition or receive psychoactive medication. Although we can hazard some good guesses about their efficacy, we do not know for sure if many of these drugs actually improve the problems for which they are prescribed. None of us—doctors, parents, researchers, pharmaceutical companies, law-makers—knows for certain what kinds of long-term side effects these drugs might cause when given to children, with their still developing bodies and brains. If psychiatric drugs are tools, they do not come with a clear set of instructions. The best we can do is to think thoroughly through what we know—about the side effects, the benefits, and the dangers of withholding medication from a child in trouble—while constantly reminding ourselves of all that we do not know.

Who's Minding the Scales?

I feel strongly that the decision to medicate can be made only after the benefits of a specific medication for an individual child are carefully weighed against the potential risks. I also want to be sure that appropriate nondrug interventions have been tried. I have had excellent results with behavioral strategies that help kids avoid drugs or reduce their need for them.
To my mind, this approach is neither radical nor reactionary. It's simply the way a doctor is trained to handle any potent drug, especially one whose effects are not fully understood. It's a matter of basic medical ethics.
Yet I know the pressure on parents and doctors to medicate—quickly, as a first line of action when problems arise—is so intense that ethics are sometimes pushed out of the picture. The statistics tell a disturbing story. Approximately 5 million children in America take at least one psychiatric drug; the number of kids I see on two or three simultaneous medications grows exponentially with each passing year. According to IMS Health, the pharmaceutical industry's equivalent of the Nielsen ratings service, the use of Prozac-like drugs for children was up 74 percent between 1995 and 1999. During that same period, the use of mood stabilizers, not including lithium, rose by 4,000 percent, and prescriptions for new antipsychotic medications like Risperdal have grown by nearly 300 percent. According to DEA statistics, production of Ritalin increased by over 700 percent between 1990 and 1998.
I see the real-life counterparts to these statistics walk into my office every day, kids like Doug, a five-year-old in constant motion whose developmental milestones appeared to be one to two years behind normal. His previous doctor tried several medications to calm him down but did not find the time to explore Doug's developmental problems and their impact on his parents' ability to manage him. I called the doctor to share my thoughts about Doug. "Sorry," he told me, in a resigned and apologetic voice, "but I have to see a kid every fifteen minutes. It's the only way I can make an income under managed care."
Or take Bobby, an impulsive, angry third grader who was on Dexedrine (a stimulant), Anafranil (originally used in adult depression and obsessive-compulsive disorder but here prescribed at night for its sedating effect), and Neurontin (an anticonvulsant). No one talked to his parents about how to set limits and enforce house rules effectively; the problem of his parents' brutal divorce was given barely a nod. It was assumed that Bobby's anger was rooted in a "chemical imbalance" that could be fixed by medication. When one drug didn't work, his doctors simply added yet another to the mix.
It's possible to argue that these statistics and my experience reflect an increasingly sophisticated and compassionate attitude toward mental illness in children. We finally recognize the biological nature of mental illness, this argument runs, and at last we have the appropriate treatment at our disposal. To an extent, I agree. Anyone who has seen a truly hyperactive child who is able to play with her friends thanks to Ritalin or Adderall would feel the same way.
But when I talk with families and professionals in the office, at dinner parties, and during conferences, I hear an echo of my own professional qualms. Most of us are uneasy with how quickly and how far the numbers have shot up. It doesn't take much imagination to put the statistics together with ever increasing classroom size, heavy burdens on parents at work, the relentless drumbeat of pharmaceutical advertising, and the pressure on doctors from HMOs to find treatments that require as little office time as possible. Add to that the little that is actually known about how these drugs act in children's bodies, and I think it's fair to ask: Are we forgetting to consider the risks of drugs as well as the benefits? Who is keeping an eye on the scales?
One popular reaction to the wave of prescriptions for kids is to dismiss psychoactive drugs altogether. But adherents of this philosophy ignore the fact that drugs can sometimes be very useful, especially when children are suffering so much that their schooling or safety is in jeopardy. A more sophisticated response to the statistics is to gather the information that will help you weigh all your options.
As a parent, you have the ultimate responsibility for medication. Doctors and psychiatrists can make recommendations, and your child can have some input, but in the end, you are the person who decides whether your kid takes a little yellow pill with breakfast. Given the current climate, in which psychoactive drugs seem to be dispensed as readily as Tylenol, you'll need to ask the hard questions, make the tough calls, and always keep a close watch on that scale.

Eight Questions That Can Help

In this book I detail an approach to evaluation and treatment that in my experience decreases the need for medication, even in children with severe problems. Many kids who come into my office taking one, two, or three psychoactive drugs eventually discontinue them in favor of other means of resolving their difficulties. But I do not mean this as an antidrug polemic. In my experience, families who decide to medicate after they have taken the time to examine the available information and nondrug approaches report a much higher level of satisfaction with their choice than those who don't.
One of the strategies I find most useful in weighing a child's individual situation is to ask myself a series of questions, a kind of mental checklist: Is the immediate safety of the child or family in danger? Have appropriate nondrug approaches been given a fair trial? What are the known side effects of the drug this child might receive, and how much remains unknown? And so on. These questions help me slow down and hold the problem up to several different lights before making a recommendation. They help me know each variable more intimately—its weight, its significance to a family and child—before I put it on the scale.
In contemplating this book, I came up with several questions that I felt would be useful for those on the other side of the desk—parents and families who want a firm say in the process. The first part of this book replicates this checklist for you, with each of the following eight chapters organized around one of the questions. In each chapter, I help you understand the major issues underlying the question, arming you with statistics and psychological theory whenever possible. I also show you how real parents and children have responded to these questions, along with their degree of success and satisfaction.
The questions include:
Does your child have a disorder? The word "disorder," like the term "chemical imbalance," is charged with several assumptions that often go unexamined. In this chapter, you'll learn how we arrived at the current biological model of childhood mental illness, in which behavioral or emotional problems are viewed as symptoms of a disorder. You'll also see alternative perspectives that can be useful in caring for difficult children.
Has your child received a complete and ethical evaluation? You may already know from experience that brief evaluations are the norm these days. Unfortunately, this sped-up process often leads to thoughtlessly prescribed medication or to serious problems like learning disabilities being overlooked. When you know what a complete evaluation looks like, you are in a better position to demand one from your practitioner. This chapter also includes tips for helping you find the best doctor or therapist for your child.
When time-outs don't work: Have you tried these strategies for effective discipline? One of the many ironies of parenting is that challenging kids are those who need the most order in their lives. They're also the ones who resist it most aggressively. This chapter shows how one family used methods for limit setting, structure, and—yes—time-outs to help their children, although those approaches had failed before.
Beating Mrs. Bossy and defeating Darth Vader: Can you externalize the problem? Here you'll discover a nondrug approach that helps families reframe their child's problem in a way that offers them more power and hope. It often works surprisingly well, especially for kids who are dominated by fears, obsessions, or sensitivities. It doesn't work for every child—nothing, not even medication, can claim to be 100 percent successful—but it can be a rejuvenating exercise for worn-out families, and I have seen it help many children avoid medication altogether.
How can teachers and schools help? Teachers and other school staff, surprisingly, can be surprisingly willing to offer assistance. This chapter covers the options available within the regular classroom and in special programs.
When is enough enough? In most cases, it is wise to look at all your options before coming to a decision regarding medication. But sometimes a child's mental state or unavoidable circumstances call out for the particular help that drugs can bring. This chapter helps you identify these conditions.
How will the medication affect your child? This chapter describes the classes of pharmaceuticals most likely to be prescribed for children, along with their known and potential benefits and risks. You'll learn how to decipher pharmaceutical claims, and I'll share with you my observations from twenty years of watching how children's bodies and personalities react to certain drugs.
What if your child won't swallow the pill (and other day-to-day questions when your child is on medication)? This practical chapter anticipates the daily challenges that may arise when psychiatric medications are used. What do you tell the child about the drug? How can you tell if the child no longer needs medication? How do you get a fractious child to take a pill in the first place? And so on.
The second part of the book focuses on specific behaviors. The three chapters in this section look at traits that often appear in tandem—aggression, anger, and hyperactivity; shyness, fears, and obsessions; trouble connecting to other people—and show how the strategies outlined in the first part have worked for various children I've seen.
The last chapter of this book is a bit different from the rest. Current professional and popular thinking emphasizes the effects of genetics and biochemistry on children's brains and behavior. Although I do not deny the importance of biological factors, it's critical to remind ourselves that children's brains do not operate in isolation. Our expectations of our children and responses to their actions also have major influence. And we cannot help but be affected by the social, cultural, political, and particularly economic forces that drive the world in which we live. Even if we cannot immediately change our world to the better for our children, our awareness makes such change more likely.
At the very back of the book you'll find a quick guide that lists psychoactive drugs by class and brand name. It is intended to help you locate a specific drug's benefits and known side effects, dosages, and any controversies of which you should be aware.
In the best of worlds, the decision to place a child on medication, or not to, is a matter of art, science, and good intentions. You have already contributed the most important element of the equation—the loving concern that is a child's best therapy. It is my hope that the information and the stories in this book will help you blend hard science with the delicate art of cultivating a child's individual character and temperament. This careful blending is more than just a smart way to help your child. It is a philosophy that rejects mere convenience and speed in favor of moral deliberation about the needs of your child and the world in which she lives.

Does Your Child Have a Disorder?
The voice on the other end of the line is gracious, with a slow Virginia drawl that's unusual here in northern California. But it tells the story of a family on the edge. "My daughter is only five years old, and she's already floundering," Carol Huggins tells me. "Michelle won't sit still during story time at her kindergarten, and she gets angry when it's time to stop doing art projects and move on to the next thing. Yesterday she was furious when a little boy wouldn't give up his swing for her, so she pushed him off. The teacher thinks she should have a medical evaluation." At home, Michelle runs around the table during dinner; she won't leave her videos when her parents call. They have tried time-outs and withholding treats when she misbehaves, Carol explains, but they don't want to continue punishing Michelle if she can't help what she's doing. "Can you test her for ADD—or is it ADHD? My sister's older kid is bipolar, and she thinks Michelle might have a chemical imbalance like her son . . . "


On Sale
Apr 17, 2003
Page Count
256 pages
Basic Books

Lawrence Diller

About the Author

Lawrence Diller, M.D., practices behavioral-developmental pediatrics and family therapy in Walnut Creek, California. He lives nearby with his wife and two teenage sons. He is the author of Running on Ritalin: A Physician Reflects on Children, Society, and Performance in a Pill.

Learn more about this author