Medication and Children: Use Caution, not Overreaction

We’re into another one of those “hot topic” runs when the media begins tripping over itself to cover an issue of concern. The end result is often a lot of misinformation and misguided advice. The latest issue is a concern that we are over medicating children with drugs such as Ritalin and anti-depressants. The concerned cite a doubling of the use of Ritalin with toddlers, alleged high rates of prescribing Ritalin for children, and a growing use of prescribing anti-depressants for children. Parents, educators, and the health care professionals are being criticized for choosing allegedly simple but risky treatments for problems that could be dealt with in behavioral ways. Parents are being blamed for not being home enough. Overcrowded classrooms and poorly trained teachers are another source of the problem according to the concerned critics. HMO’s are also under fire for trying to save money by urging primary care physicians to prescribe solutions rather than refer to teams of specialists.

The primary concerns are that we are teaching children to solve problems with drugs, that many of the medications have not been approved for use with children, and that we don’t know the long-term effects of prescribing these medications for children. While there is reason to be concerned and to use caution, it is no different than similar concerns about the extensive use of medication at all ages and for an incredible wide range of problems. Despite marketing hype, most medications on the market have not been adequately tested in a way that answers all possible concerns about the risks involved. To some extent it is impossible. Every medication has potential negative effects on somebody. Research, even at its best, is a comparison of group averages, which means there is usually a considerable range of responses within each group.

What this really calls for is more time spent with patients in monitoring reactions to medications, which does collide with the now-heavily criticized managed care approach to treating medical and psychological problems that overemphasizes reducing time spent with patients. It also means adequately exploring non-medication solutions before prescribing. This is particularly relevant to the question about using psychotropic medications with children.

Ritalin, which is relatively well researched and has been used for decades, should only be tried after educators, parents, and mental health professionals have concluded that other strategies are not effective. Those who claim there is no such diagnosis as Attention Deficit Disorder, with or without Hyperactivity, either hasn’t spent much time working with children or refuses to acknowledge the increasing body of work showing differential brain activity for children with this disorder. Of course there are side effect concerns. Some children have negative emotional reactions. Others have sleep or eating disturbances that require discontinuing the medication. There is work being done to find non-medication treatments. So far there is some promise with neuroContact techniques but it’s early yet and these are time consuming and expensive procedures.

While there has been a dramatic rise in the use of Ritalin, it is still significantly less than the estimated 4-6% of the incidence of ADHD. However, I’m sure there are instances where it is being used inappropriately. As parents, you should expect to have your child thoroughly evaluated by health care and educational specialists that work with children with ADHD. Behavioral strategies for helping the child should be tried first at home and in school. If the child is still struggling than medication should be seriously considered. When that is done, it should include the use of behavioral checklists given to parents and teachers before and after medication is used to provide some objective measurement of change. A mental health specialist who also works closely with the parents and the prescribing physician should see the child on a regular basis. This type of careful monitoring should help to ensure that the medication is only being used when appropriate and only continues to be used if it helps the child without harming the child.

For those who believe that Ritalin should not be given to very young children, I would urge you to spend a few days in a home where there is a child who, from day one, has been wildly hyperactive. That child has literally turned his household upside down and drained his parents and siblings beyond belief. The judicious use of Ritalin, or related meds, has resulted in some striking improvements where nothing else worked. This is incredibly important because some of these children are the ones we read about years later as suicidal adolescents or hard core criminals. This is the result of these children being constantly “disobedient” and experiencing years of punishment, social rejection, and academic failure.

I have seen some dramatic positive changes and a return to reasonable normalcy in a number of such cases. This is not about creating zombies, i.e., drugged children. They are still very active and still have problems with organization, attention, and impulse control. But the problems have been reduced to a level where the other strategies at school and at home are now effective and the child is able to experience success academically and personally.

As for the use of antidepressants with children, the criticism that these medications have yet to be approved for use with children is a valid point. But we are doing an increasingly better job of identifying depression in children and adolescents. We are also beginning to recognize, though not without some debate, that children also can be diagnosed with Bipolar Disorder (Manic-Depression). While psychotherapy should be an essential part of any treatment plan, in many instances, just as with adults, medication becomes an important component of the treatment when psychotherapy isn’t effective on its own. It should be noted that these disorders commonly run in families and it is not unusual for a medication that has been effective for a blood relative to be effective with a child or teenager.

Are there risks in using these various medications with children? Yes. But there are risks giving aspirin, antibiotics, and many other medications and medical treatments to children. The issue is not to restrict or deny access to these medications, but to do your best, as parents, to be knowledgeable, to ensure that qualified professionals are seeing your child, and to have the treatment closely monitored. Don’t allow managed care to restrict the use of properly trained specialists. Don’t allow busy professionals to not meet regularly with you and your child. Don’t let alarmist magazine articles frighten you into not getting the best treatment for your child.