Should I Medicate My Child?

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.

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.

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.

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:

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.