Psychiatric Drugs: Weighing Your Options
Brandon has just turned 3 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 racecars 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 anti-anxiety 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 or if I've just been a lousy parent?" Natalie asks me, her voice constricting. "Or if I've just been a lousy parent?"
Jerry, nearly 16, 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 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?
Does Your Child Need Medication?
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 were 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 one-size-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 vs. 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.
In the last year, I wrote more than 400 prescriptions for Ritalin or its equivalent. I also prescribe, although much less frequently, anti-depressants, 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; it targets bacteria that 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, lawmakers 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.