Preschoolers in the Prozac Nursery
The most recent study, reported in the Feb. 12th edition of the Journal of the American Medical Association, found that the use of antidepressants such as Prozac, and Ritalin, a standard treatment for children diagnosed with attention-deficit/ hyperactivity disorder (ADHD), more than doubled between 1991 to 1995.
The report, which triggered a response by the White House, re-ignites the debate on whether psychiatric drugs are prescribed too often to children in the United States. First Lady Hillary Rodham Clinton on Monday announced a federal program to study the use of psychiatric medications, especially among children aged 2 to 4, and to require additional warning labels on the drug packages. "Most of these medications are not approved for children,'' says Daniel J. Safer, an associate professor of psychiatry at Johns Hopkins, Division of Child Psychiatry, who co-authored the JAMA study that drew the White House's attention. As is the case with just about any drug, he says, clinical drug trials typically do not involve children.
Parents Beware
David G. Fassler, a Vermont child and adolescent psychiatrist who is chairman of the American Psychiatric Association's Council on Children, Adolescents and their Families, says there are two top concerns parents should have about the use of young children and psychiatric medications:
1.Psychiatric medications have undergone little or no testing on children, and therefore raise questions about possible long-term effects.
2.These drugs should not be used as quick pharmacological fixes for emotional or behavioral problems, but rather as a part of a broader treatment that includes behavioral therapy. "Medication alone is rarely an appropriate or sufficient treatment,'' Fassler says.
Who needs these drugs?
Why are so many American children on these drugs in the first place? Most experts agree it's a combination of factors: better diagnosis of children with mental or psychiatric problems, Americans' comfort with using psychiatric medications, heavy advertising by drug companies, and better drugs for depression.
Experts say the changing face of the health care system has a role as well. More pediatricians and family practitioners are prescribing psychiatric drugs, not just psychiatrists, and some managed care companies will cover a drug but not a broader range of treatments, which may be more expensive but are more effective.
Some also argue that there is a societal component. "Kids are under significantly more stress these days,'' Fassler says, "And we do know that early life experiences and stress can increase the risk for these kinds of problems.''
Too much expected of kids
Experts say we expect children to be developmentally more mature younger and younger, and some of them aren't able to cope. Increasingly, toddlers, who typically have high activity levels, go off to daycare or preschool while their parents go to work. Leading experts say the more active, more inattentive children stand out in these more structured environments, and they worry that as a result attention-deficit disorders are diagnosed unnecessarily too often.
"I don't think that ADHD is increasing in prevalence, I just think we're diagnosing more children,'' says Maura Rossman, medical consultant for Baltimore City Health Department's school health programs. Rossman is a pediatrician trained in child development.
ADHD is the most commonly diagnosed disorder of childhood, estimated to affect 3 to 5 percent of school-age children, and occurring three times more often in boys than in girls, according to NIH figures. Ritalin, (methlphenidate), many doctors' drug of choice to treat attention-deficit disorders in children, is derisively called a "nanny drug'' by those who think it is too freely prescribed for school-age children. The drug, classified as a psychostimulant, has been shown to calm a child and increase his alertness by stimulating the central nervous system. A 1998 study by the National Institute of Mental Health showed that drugs like Ritalin work - as long as they continue taking them. But there''s no proof that in the long run the drugs help kids get better grades or do better in life.
Ritalin has relatively few side effects as far as medications go, according to Safer. Nervousness and insomnia are the most common side effects, and they can usually be controlled by reducing the dosage and omitting the drug late in the day or evening.
However, some of the most troubling news about Ritalin is that it is used in children under six even though it is not approved for them. The JAMA study, which examined prescription records of children ages 2 to4 enrolled in two Medicaid programs and a Health Maintenance Organization, showed that use of Ritalin among U.S. preschoolers increased 150 percent from 1991 to 1995.
The NIMH says long-term administration of a stimulant, such as Ritalin, might alter the way the brain reacts to a variety of environmental challenges, including stressful events, and other drugs.
As for antidepressants, some psychiatrists say while they show great promise with adolescents, they have not been studied in children as young as five and younger. "There really isn't any great evidence that kids, particularly preschoolers, benefit from antidepressants,'' says Safer. Still, many child psychiatrists contend that despite the outcry about overprescription of anti-mood drugs for children, more children who legitimately do need help don't get it. According to the U.S. Center for Mental Health Statistics, two-thirds of children with mental health problems go untreated.
When disorders go untreated
"Medications can have side effects, and we need to learn more of consequences of long-term treatment,'' Fassler says. "But it's also true that underlying psychiatric disorders have very serious side effects and consequences as well.'' Children with ADHD - the most common reason for taking Ritalin and similar stimulants - are at higher risk than their peers of dropping out, of becoming smokers, of abusing alcohol or drugs, even of spending time in prison, according to a NIH study. Children with untreated depression are more prone to self-esteem problems, drug and alcohol addiction problems, and suicide.
Still, experts emphasize that psychiatric medications can be effective for some children with emotional or behavioral problems, but certainly not for all, and that medication alone is a BAND-AID® treatment.
"These children need a comprehensive evaluation and an individualized treatment plan,'' Fassler says. "Treatment will usually include individual therapy and work with the family and or the school, and it may also include the use of medication. But medication alone is rarely appropriate.''
The National Alliance for the Mentally Ill, a self-help and family advocacy organization solely dedicated to improving the lives of people with mental illnesses, has a toll-free number (800) 950-6264 parents can call or they are invited to visit the youth section of the NAMI website (www.nami.org/youth/index.html).
