The Drug Dilemma

SPECIAL TO THE TIMES

Teri Burley realized her 2-year-old son, Tanner, was out of control when he threw his brother, Tayler, off the jungle gym in the schoolyard playground, breaking the older child's arm.

From the time he was a baby, Tanner had been a blur of activity. "He was into everything and rarely slept," says Burley, adding that she and her husband took turns staying up throughout the night because they never knew when their overactive child would awaken. "But we figured he was just energetic."

The playground incident was a watershed, however, and preschool officials felt compelled to expel Tanner. "They said he was too much of a liability," recalls Burley. Desperate for answers, the Burleys shuttled their child from one pediatrician and psychologist to another near their home in Whittier.

But no one could determine what was wrong in a child so young. Finally the Burleys were referred to a clinic at UC Irvine, where Tanner was diagnosed with attention deficit hyperactivity disorder, or ADHD. The UC Irvine doctor prescribed Ritalin, a stimulant that has a calming effect on hyperactive kids and helps them to focus.

Burley kept the prescription in her purse for days before she filled it, and it took her several days more before she could bring herself to give her toddler the drug. "My husband and I agonized, but we felt we had no choice," recalls Burley. "It was either remove him completely from society or dope him up with drugs to make him manageable."

The Burleys are not alone in their dilemma. Parents of very young children who show signs of mental disturbance face a difficult choice. Should they do nothing, in hopes that this is merely a phase--the so-called terrible 2s and 3s--that their child will outgrow? Or should they give their toddlers psychiatric drugs--none of which have been tested on children under 6--to control what may seem to outsiders to be garden-variety problems of childhood?

Growing numbers of parents are choosing the latter option, though often reluctantly.

A study published in the Journal of the American Medical Assn. in February revealed an alarming rise in the use of powerful, mood-altering psychotropic drugs among children ages 2 to 6. The use of stimulants like Ritalin in this age group more than tripled from 1991 to 1995. Further, prescriptions for antidepressants such as Prozac doubled, and those for clonidine, an adult blood pressure medication used as a sleep aid for kids with ADHD, spiked significantly.

These troubling results prompted First Lady Hillary Rodham Clinton last month to announce plans for a $5-million research project to be conducted by the National Institute of Mental Health, or NIMH, on the use of these medications in preschoolers, and to convene a conference on the issue in the fall.

'Everyone Wants to Point Fingers'

Some blame the sharp increase on managed care, saying pediatricians who aren't trained to spot symptoms of mental illness are encouraged to dispense pills rather than refer children for costly therapy.

Others accuse harried parents of being too busy to adequately discipline rambunctious kids. Teachers and day-care workers share the blame, they say, for insisting that toddlers be docile in their overcrowded classrooms.

But some experts and parents say the increase in prescriptions for young children is a legitimate trend, driven by the increasing sophistication and diagnostic accuracy of mental health professionals.

"Everyone wants to point fingers," says Julie Magno Zito, the principal author of the JAMA study and a professor of pharmacology at the University of Maryland in Baltimore. "But it's really the result of a confluence of [these] factors."

The sharp uptick in the use of these drugs in very young kids "does seem to neatly coincide with the ascendancy of HMOs," says Joseph T. Coyle, chairman of the department of psychiatry at Harvard Medical School in Boston. But it is also true that scientists now have a much better understanding of the delicate mechanisms of brain chemistry, an advance that in turn has engendered more acceptance of the use of drugs to treat behavioral disorders.

Additionally, the diagnostic guidelines for ADHD and its milder cousin, ADD (attention deficit disorder), once considered problems that only affected boys, have broadened. Now many young girls who aren't hyperactive but do have persistent problems concentrating take Ritalin too, which may account for some of the increase.

Further, with public school resources steadily shrinking, parents complain that they are under tremendous pressure to make their kids conform.

Clearly, medication is called for to help severely impaired kids. But they're a tiny fraction of the population, say experts, certainly not the 1% to 2% of preschoolers now taking such medication.

Lack of Test Data Troubles Experts

One of the things that disturbs experts most is that these drugs have never been tested on such young children. Consequently, there's no data on their safety and efficacy, their potential side effects (Ritalin, for instance, can cause nervousness and insomnia, and clonidine used in combination with stimulants has been linked to heart problems in children) or their long-term consequences in this age group.

"Essentially, this is a vast uncontrolled experiment," says Larry D. Sasich, a pharmacist and research analyst for Public Citizen, a health-care watchdog group in Washington, D.C., "and these children are the guinea pigs."

What's equally alarming is that early childhood is the key stage of neurological maturation, with the brain undergoing 90% of its growth during the first five years of life. "The chemical messenger system that is affected by these drugs plays an important role in regulating brain development," says Coyle. "Where will these kids be in 10 or 20 years? We just don't know."

Despite the lack of scientific proof, however, desperate parents feel the benefits far outweigh whatever future risks there may be.

"Sure, we worry about the long-term effects," says Burley, whose older son, Tayler, now 10, was later diagnosed with ADD (the disorder seems to run in families). "But at age 2, Tanner was already a social outcast. No one wanted to play with him, not even his cousins, because he was too rough. It was pitiful. Now, at age 9, he's happy and in control. So we've made a conscious decision that it's better to have a shorter, enjoyable life, than [possibly] a long, miserable one."

Although there is no reason to believe that the medicines could shorten a child's life span, Shelley Dorman understands the fear of the unknown when deciding what is best for her child. She too, however, has chosen to give her child psychiatric medication.

Her 10-year-old daughter, Holly, had been a precocious child who started walking at 6 months. But by 5, Holly would throw such intense temper tantrums that she was suspended from kindergarten. "At first, I thought she was bored and people were picking on her--until she flew into a rage at home," says Shelley, who lives in Palm Springs.

Months of intensive counseling didn't help, and Holly's behavior veered wildly between violently destructive and suicidal. "When you're pulling your 6-year-old out from underneath a car because she wants to kill herself, you have to do something," says Shelley, who, like other parents in similar circumstances, was criticized by friends and family for giving her child drugs.

After several years of experimenting with different combinations, Holly, who was diagnosed with bipolar illness, was finally stabilized by two powerful psychiatric medications, neurontin and seroquel. "Now she acts like a normal child," says Shelley. "The medication has truly saved her life."

When Is Misbehavior a Clinical Disorder?

Still, some physicians worry that kids are indiscriminately being given prescriptions rather than counseled to manage their behavioral problems.

"With very young children, it's hard to distinguish hyperactivity from just being a nuisance, but everybody rushes in to fix and nobody tries to understand," says Barbara M. Korsch, a professor of pediatrics at USC and a pediatrician at Children's Hospital. "Are we now giving youngsters Prozac when they have a bad hair day or using Ritalin as a new solution for poor classroom etiquette?"

Despite the lingering question of whether we're truly over-medicating young kids, a 1999 NIMH survey revealed that 5.1% of children meet the diagnostic criteria for ADHD, yet only 12.5% of those kids were being treated with stimulants.

"I know no one believes this, but we're probably under-prescribing," says Richard L. Ferman, an Encino psychiatrist who specializes in ADD. "Of the estimated 10 million children and teenagers in the United States who suffer from mental illnesses, studies have shown that only one in five are being given medication."

The upcoming NIMH study, which will track youngsters taking Ritalin and other psychiatric drugs, may clear up some of the confusion surrounding the use and effects of these mood-altering medications. But the test results are at least five years away. In the meantime, anxious parents with toddlers exhibiting abnormal behavior will have to look elsewhere for guidance.

"They should be seen by a specialist in psychiatric disorders in children," cautions Harvard's Dr. Coyle. Teachers and pediatricians aren't trained to make these diagnoses, he adds, "and drugs should be used only as a last resort when everything else has failed."

That was the strategy Elizabeth Harris, a Los Angeles psychologist, adopted when her 5-year-old was diagnosed with ADD.

"I was adamantly opposed to using drugs," says Harris, who instituted an intensive behavioral management plan for her child. The program worked well at home, but her child continued to act up at school. So she tried neurofeedback, a form of biofeedback, to help her child concentrate. It worked for several months, but soon her child's problems came rushing back. At that point, Harris felt medication was the only alternative, and her child now takes Adderall, a stimulant similar to Ritalin.

"I was at the end of my rope," says Harris, whose 7-year-old is now doing well. "But I feel comfortable with my decision because I exhausted every other option."

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Resources

* National Alliance for the Mentally Ill, 200 North Glebe Road, Suite 1015, Arlington, VA, 22203, (800) 950-6264, http://www.nami.org.

* National Depressive and Manic-Depressive Assn., 730 N. Franklin St., Suite 501, Chicago, IL, 60610, (800) 826-3632, http://www.ndmda.org.

* Children and Adults With Attention-Deficit/Hyperactivity Disorder, 8181 Professional Place, Suite 201, Landover, MD, 20785, (800) 233-4050, http://www.chadd.org.

* Child and Adolescent Bipolar Foundation, http://www.cabf.org.

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To find the study on children's psychiatric drug use, published in the Feb. 23 issue of the Journal of the American Medical Assn., go to http://jama.ama-assn.org, click on "past issues," click on Feb. 23, then scroll down to the study.

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