WALNUT CREEK, Calif. — The patient that came into Dr. Lawrence Diller's office had a drug problem. He was also just 5 years old.
“Before he came to see me, he had eight different psychiatric drugs offered to him over the previous 12 months,” Diller told the Register.
Some patients with similar histories are even younger.
“A 2 1/2-year-old [was on] on lithium — that's a drug for manic depression — and wound up on Zoloft, supposedly because the child was depressed, and also Respirol, which is a major tranquilizer,” said Diller, a physician practicing in behavioral pediatrics.
“I just talked to the doctor, I tried to understand what he was thinking — a 2 1/2 -year-old on three different kind of drugs?” Diller recently wrote a book, Running on Ritalin, to notify parents about the misuse of prescribing psychotropic drugs to young kids.
While the widespread use of powerful drugs such as Ritalin and Prozac on young children has recently caught the attention of the media and politicians, health care professionals have been dealing with the problem for some time.
Gladys Sweeney, who heads the Institute of Psychological Services in Crystal City, Va., pointed to modern lifestyles, which discourage parents from spending time with children, as a reason why adults are quick to resort to powerful medications.
“If they both work, they come home tired. They don't want to give themselves to their children. It's just easier to medicate them,” Sweeney told the Register. “The parents aren't even aware that they are putting themselves first.”
At a March 20 press conference following a meeting with teachers, psychiatrists, family doctors and drug companies, first lady Hillary Clinton observed that “some of these young people have problems that are symptoms of nothing more than childhood or adolescence.”
But in announcing the effort to curb the use of such drugs by children, she was careful to mention that the medications can help those children who really need them.
“We are not here to bash the use of medications. They have literally been a godsend for countless adults and young people with behavioral and emotional problems,” said Clinton, who is also a candidate for the U.S. Senate from New York.
A program of President Clinton's administration calls for a $5 million study by the National Institutes of Mental Health to research the impact of psychotropic medication on children under 7 and a national conference on treating children with behavioral problems in the fall.
“There are no long-term studies at this point,” Crystal Yard, a spokes-woman for the Food and Drug Administration's Office of the Center for Drug Evaluation and Research, told the Register. “We're trying to get a handle on the long-term effects of psychotropic drugs.”
The White House initiative comes in part as a reaction to the February issue of The Journal of the American Medical Association that reported a doubling in the number of children on psychotropic drugs from 1991 to 1995.
The $5 million study is needed, observers said, because almost no data or research exists on the effects of psychotropic drugs on children under 6.
“Eighty percent of all drugs that kids take have not been approved by the U.S. government, by the Food and Drug Administration,” for use on children under 6, Douglas Pasternak, senior editor of U.S. News & World Report told the Register. Pasternak recently led an exposé published in the magazine on the effects of these drugs on young children.
“Now you have a situation where lots of kids are given this medication and there's no scientific information on how the medication works,” said Pasternak.
The Food and Drug Administration has long wanted to test the effects of these drugs on children, but was impeded by ethical concerns. “The FDA raised the issue and said that they needed to look at this issue, but everyone was fearful of testing drugs on kids,” said Pasternak.
As drugs like Prozac received federal approval for adults, a demand quickly surfaced for their use on children. This occurred without research that doctors could rely on. Doctors started to dispense the medications for teen-agers, then children, and now toddlers.
“Doctors legally are allowed to … dispense the drug to a child even though it's not government-approved for use in kids,” explained Pasternak.
‘If you're considering these medications … you better be certain that the symptoms are quite severe, that they merit this kind of intervention, and that you really have exhausted alternative approaches …’
He also noted that things are changing. “To the FDA's credit, they're starting to mandate” testing, Pasternak said. “And pharmaceutical companies are starting to do clinical trials on children.”
Doctors in the Dark
Pediatrician Diller said most of the doctors writing out the prescriptions for these children are family physicians and probably don't have much background in the neurological effects of such drugs on young people.
Often, he said, doctors spend little or no time with a child before writing a prescription for powerful drugs.
“People tell me the 15-minute diagnostics of [attention deficit hyperactivity disorder] is alive and well in America.”
This is dangerous, he said, because no doctor can make a proper judgment in such short time. “So many of these diagnoses are made just by talking to the mother, and they spend almost no time with the child.”
Cost-cutting care might be responsible for some of this.
“It's a little cheaper, at least initially, to spend less time with the child and offer him or her a medication that, admittedly, on the short term may be beneficial, but may not be the most appropriate intervention for this kid,” Diller said.
Pasternak said that managed care groups are applying pressure on doctors as well.
“The HMO doesn't want to pay for children going to therapy, so they believe it's cheaper to medicate children. There's been at least subtle pressure on doctors to do that,” he told the Register.
Another problem, critics said, is a lack of training in identifying whether behavior is truly a disorder or if it's just anti-social behavior or even youthful exuberance.
“To diagnose a psychiatric disturbance, in general, there is no biological or psychological test. There is no brain scan or no blood test,” said Dr. Diller.
This leads to variations in diagnosis from region to region. Some communities have 20 times more diagnosed cases of attention deficit hyperactivity disorder than other cities.
Four million children currently receive Ritalin for treatment of disorders. Use of Ritalin has doubled in just five years. Production of the drug is up 700% since 1990, and America consumes 90% of the Ritalin manufactured worldwide.
“It's difficult to ascertain: are there more [attention deficit hyperactivity disorder] kids,” Diller wondered, “or is there more of it simply because our tolerance for temperamental diversity” has been reduced so much.
He also stressed that today's children are under more pressure: “The demands on children's performance and behavior have increased over the last 30 years while the supports relative to them, their families and their schools, have decreased.”
Another problem, he said, is an educational theory that insists that all children have to learn the same things and at the same rate.
In a March 6 Time magazine article, Dr. Ian Smith, a New York psychiatrist, told parents to watch for environmental changes that can be stressful for children.
“Has there been a disruption in the daily routine? Amove to a new house? The arrival of a new sibling? Understanding what is causing the stress is the first step to resolving the problem,” wrote Smith. Only after those factors have been examined should parents and doctors consider resorting to Ritalin.
While Dr. Diller is concerned by the overuse of Ritalin and other drugs, he said that these drugs do provide genuine help to children in need.
“I don't want to give you the impression I'm against medication,” because there are some kids who really need such drugs, he said. “So many children would otherwise look normal, but in our culture they are getting treated.
“If you're considering these medications for your children, you better be certain that the symptoms are quite severe, that they merit this kind of intervention, and that you really have exhausted alternative approaches … with the family and working with the school.”