by Cynthia Washam
Jessica Hold never was big on playing with dolls or house or Ring Around the Rosie. Her favorite pastime at the playground was studying rocks and leaves. Parents Bryan and Patricia didn’t worry that her interests differed from other girls’. Clearly, Jessica was bright. It wasn’t until kindergarten that her behavior gave them pause.
“I thought school was terrific,” says Patricia, “but she wasn’t interacting with other kids.”
When Patricia raised the issue with Jessica’s teacher, she was told not to worry; Jessica was a good student. Through the next few years, Patricia appealed to one teacher after another. She moved her daughter to a private school. She spoke to school administrators and school psychologists.
“All they cared about was that her test scores were good,” says Patricia.
Desperate to help their daughter fit in, Patricia and Brian sought the advice of a psychiatrist, who said Jessica suffered from social anxiety. She was in second grade when he prescribed the first of a series of psychotropic drugs she would take over the next five years. The list included the antianxiety drug Clonapin and the antidepressant Prozac. Other times it was Lexapro or Xanax, both used to treat anxiety, depression and panic disorder.
None helped Jessica fit in, though they did give her something in common with her peers – several million American children and teens take mood-altering medication, and many of them may not have a serious mental disorder.
Doctors these days write youngsters more prescriptions for psychotropic drugs than for acne remedies. Drugs help failing students excel and restless ones sit still. But such success comes at a cost. All psychotropic drugs have side effects, some life-threatening. That may seem an acceptable risk for children to relieve serious mental illness, and many respected psychiatrists support use of drugs in those cases. Yet critics claim mentally ill children are a mere fraction of the millions taking mood-altering drugs. They say most are troubled youngsters who would benefit from other therapies or less potent drugs.
“We want kids to calm down and make our lives easier,” says Dr. Nadine Kaslow, a psychology professor at Emory University and president of the American Board of Clinical Psychology. “Sometimes it’s just easier to think about giving a pill than dealing with the issues.”
Most of the mood-altering drugs prescribed for children were never intended for pediatric use. Volunteers who went through the drug trials required for approval from the U.S. Food and Drug Administration (FDA) were adults. Information from manufacturers about dosage, expected effects and side effects applies to adults. When physicians write so-called “off-label” prescriptions for children, their patients become unwitting guinea pigs in a drug experiment.
Even the FDA acknowledges the risk of giving adult psychotropic drugs to children. Physicians “attempt to treat [childhood psychiatric illnesses] with medications used in treating adult psychiatric illnesses, often in the absence of good information about the safety and efficacy,” explains FDA spokeswoman Sandy Walsh.
Although the FDA encourages pharmaceutical manufacturers to test drugs in children, manufacturers have little incentive to do so.
The most widely used, studied and accepted psychotropic drugs in youngsters are stimulants. More than 2.5 million American children and teens take stimulants such as Ritalin or Adderall for attention deficit hyperactivity disorder (ADHD). Studies have proven the drugs’ effectiveness in improving inattentive children’s performance in school. Yet the drugs come with a risk. Recent research linked stimulant use to sudden cardiac death in children with heart conditions. Some symptoms of heart conditions are so subtle that nobody knows the child has a heart problem until it’s too late. Sadly, many experts say children are being needlessly endangered by parents looking for a quick and easy way to boost their child’s grades.
“I get calls all the time from parents and schools demanding kids be put on these medications for behavior,” says Dr. Evan Zimmer, a psychiatrist who at last recommended a therapy for Jessica and her parents that did not involve drugs.
Far more controversial than stimulants are antipsychotics. These potent mood stabilizers for decades were used almost exclusively for adults with schizophrenia. Their use broadened early in the 1990s with the introduction of “atypicals,” antipsychotic drugs that seemed to spare users the debilitating tremors of older medications. Only a few of the antipsychotics most often prescribed for youngsters have been FDAapproved for pediatric use. Exceptions are Seroquel, which is approved for bipolar mania and schizophrenia, and Risperdal and Abilify, both approved for manic or mixed episodes associated with bipolar disorder. Surprisingly, the most common diagnosis in pediatric antipsychotic users is neither bipolar disorder nor schizophrenia, but ADHD. Between 2001 and 2005, the number of children under 20 using antipsychotics soared 73 percent, nearly twice the increase in 20- to 44-year-olds.
Doctors attribute the trend in pediatric antipsychotic use to Harvard psychiatrist Joseph Biederman, who in 1996 claimed a quarter of his young ADHD patients also had bipolar disorder, or manic depression. Psychiatrists just a decade earlier questioned whether bipolar disorder even existed in children. Suddenly bipolar diagnoses in children and adolescents skyrocketed, in spite of psychiatrists’ admission that pediatric cases are tough to diagnose. A list of symptoms published by the National Institute of Mental Health (NIMH) includes “distractibility,” “difficulty concentrating” and “talking too much, too fast,” symptoms that are also characteristic of ADHD.
“Antipsychotics need to be used very judiciously,” warns Kaslow. “They have powerful side effects.”
The most common one is weight gain. Children taking antipsychotics typically gain twice as much weight during their first six months as nonmedicated youngsters. Most of the weight is around their waist, raising their risk of diabetes and heart disease. Between 2000 and 2004, antipsychotics caused at least 45 children’s deaths. Six were related to diabetes.
Critics worry not only about the known physical side effects, but also about the unknown effects on the developing brain.
“We don’t know a lot about the long-term effects,” says Kaslow. NIMH researcher Dr. Gonzalo Laje also admits little is known about how antipsychotics will affect young users mentally in 10, 20, 30 years.
“We don’t have those studies in children,” he says. “But leaving a major medical disorder untreated is corrosive to a child’s education. It’s very detrimental to their development.”
Yet another class of psychotropic drugs widely prescribed for pediatric patients is antidepressants. Between 1994 and 2002, antidepressant use among children and teens tripled. Prescriptions for youngsters plummeted a year later, when researchers discovered that the drugs doubled the risk of suicidal thoughts in teens and young adults. The FDA now requires a “black box” on pediatric antidepressant prescriptions warning of the suicide risk.
Psychotherapy Improves Results
For many depressed adolescents, medication simply doesn’t work. Forty percent of depressed youngsters do not respond to their first antidepressant, according to the NIMH. Nor do they respond much better when they switch to another antidepressant. They fare best, according to a recent NIMH-funded study, when they switch antidepressants and add psychotherapy.
Studies suggest psychotherapy also enhances treatment for children with ADHD. The 1999 Multimodal Treatment Study of Children With ADHD showed that patients fared better with medication than just behavioral therapy. The best results, though, came from medication along with frequent therapy sessions. Some clinicians contend that although drugs may bring quicker results, psychotherapy is more enduring.
“Medicine should be used in conjunction with psychotherapy,” says Kaslow. “Medication doesn’t give coping skills.” She recommends family counseling so parents understand their child’s illness and improve their home environment.
“Parents need to say, ‘I want combined treatment,’” says Kaslow. “Some parents want their kids on medication. It makes them feel less guilty. They can say the problem is biological.”
Psychologist William Samek contends many disruptive children respond to old-fashioned discipline. “[Drugs] are cheaper and easier than fi xing a parenting dysfunction,” he says. “Kids need structure. They need limits. They need rules. The biggest problem I see with parents is not setting limits, and when a child disobeys, they don’t punish.”
The first antianxiety drug Jessica took made her so tired she’d fall asleep at lunch. Her psychiatrist replaced it with one that made her jittery. By the time she reached middle school, she was so fed up with pills that she stopped taking them altogether. Her problems, meanwhile, grew worse. Middleschool classmates called her “Casper” because she was as quiet and pale as a ghost. She felt so isolated she ate lunch alone in front of her locker. After a while, she refused to go to school, spending her days at home in front of her computer.
“She was in her room and she wanted to die,” recalls Patricia.
Once again, she and Brian found themselves looking for someone who could help their daughter. A dozen specialists evaluated Jessica. They told the Holds their daughter had Asperger syndrome, a form of autism. They said she would never get married. She might not be able to hold down a job. But with the right medication and therapy, she could improve.
“They recommended we send her away to a special boarding school that was about $100,000 a year,” says Patricia. “I said, ‘We can’t afford that.’”
Patricia had no reason to doubt these psychiatrists, but on a whim she decided to try another psychiatrist whose name she’d recently heard. When Dr. Zimmer reviewed Jessica’s history, his heart sank.
“She was mute,” he says. “She couldn’t go to school. She was losing weight and staying in her room. I thought I would see a child who was schizophrenic. Within 10 minutes of meeting her, I was astonished. She was not only remarkably conversant, she had a sense of humor more adult than childlike.”
He hesitated to contradict the other experts. But deep down, he knew he was right.
“I said, ‘I think you’ve been grossly misled,’” recalls Zimmer. “You have a genius on your hands.”
He explained that Jessica had trouble relating to her peers because she was much smarter than they were. She was also shy. To make matters worse, any self-esteem she might have had was eroded by years of treatment for “mental illness.” She was as sure as the university psychiatrists that she was sick.
“I saw a child whose life was about to be ruined [by more treatment],” says Zimmer. “I said, ‘Why don’t you send her away to a wilderness camp and let her reboot.’”
The first time Jessica called home from her nine weeks at camp, she told her mother she “felt secure.” Physical challenges taught her how to rely on others, and herself.
Today, at 13, Jessica is in the gifted program. “She’s a popular child,” says Zimmer, adding that she likes being a big fi sh in a small pond.
Patricia admits her daughter is still a little bored with her classes. But, she continues, “She’s totally changed in self-confidence. She doesn’t need medicine.”