Good Behavior in a Pill
First of three parts
By Lisa Popyk, Post contributor
Originally published in The Cincinnati Post, April 15, 2000
They line up in schools across the tri-state—tots still learning to print their names—waiting for their daily dose of psychotropic drugs designed to turn them into better students.
It's a snapshot of an expanding national scene: impatient adults strapped for time, a society smitten with the magic fix of prescription medicine, and everyone determined to have perfect children.
In some Greater Cincinnati elementary schools, officials say as many as 10 to 15 percent of the student body files into nursing or administrative offices each day for pre-lunch doses of stimulants like Ritalin, amphetamines like Dexedrine and antidepressants like Paxil and Prozac.
Ten years ago, local school officials knew each medicated student by name. Today, nurses keep computer files to track who is taking what mind- or personality-altering drug.
"In 1983, I think we had one student in the building on (psychiatric) medication," said a Cincinnati Public Schools elementary teacher who asked that her name not be used. "Today, we could have three to four students in a class of about 30."
Nationally, the number of 2- to 4-year-olds on psychiatric drugs soared 50 percent between 1991 and 1995, according to a recently released study published in the American Journal of Medicine.
Doses of the antidepressant Paxil jumped 71 percent from 1994 to 1999 for children under 18, according to IMS Health, a health care information firm in Plymouth Meeting, Pa. The same period saw a 76 percent increase in prescriptions for children of the amphetamine Dexedrine.
The White House recently called for a national initiative to educate the public on the potential hazards of medicating youngsters, especially since most of these drugs never have been approved by the U.S. Food and Drug Administration for pediatric use. And little is known about the long-term effects of psychotropic drugs on young minds.
Doctors who write the prescriptions say they are a therapeutic lifeline to the real world for children who suffer from serious and significant mental illnesses.
"With (psychiatric medication) they have their lives back—they're not trying to kill themselves or suffering from deep emotional pain," said Dr. Keith Foster, associate professor of psychiatry at Children's Hospital Medical Center.
Even in less severe cases, the medication helps youngsters with attention deficit disorder compete and succeed socially and academically, said Dr. David Feiman, a psychiatrist with Braxton Cann Medical Center in Madisonville who also works with Cincinnati Public Schools.
"The medication can help them focus, literally helping these kids save the quality of their lives," said Feiman.
Still, some of the staunchest supporters of medical intervention worry about the overwriting of prescriptions for children who could be helped instead by time, attention or behavior modification therapy.
"Parents and teachers are less tolerant of a child who doesn't quite fit in with the 'ideal-student' picture," said Dr. Jennifer Margolis, a pediatrician with Wyoming Family Practice. "Everyone wants their child to get As and Bs, to follow all the rules all of the time and to fit in everywhere. But that just doesn't happen."
And when it doesn't, some parents look for what experts call the "quick-fix solution"—psychiatric medication.
"We have several students who are simply active children; they just need more time and more attention. But their parents have them on Ritalin because it makes them easier to control," said a Mason elementary school teacher who asked that her name not be used for fear of reprisal.
"One mother told me straight out that she and her husband are both on career tracks and when they get home at 7 at night, they don't have the time or the patience to deal with Johnny. And so they put him on medication that literally zones him out," she said. "It makes him a little robot. It breaks your heart. To me, it's like putting your dog in a tiny fenced area and leaving him in there all day."
Sadder still, the veteran teacher said, is that the children who don't need medication know they're just being controlled.
"They're little, they're not stupid," she said. "You see them trying to pretend they're taking the pills, then trying to throw them away."
Many students would likely improve with more parental support, patience and input, said Jenny Mitchell, psychologist for Cincinnati Country Day private school in Indian Hill. She sees an increased number of students—starting in first and second grade—on Ritalin, and a growing number of middle school students on anti-depressants and anti-anxiety medications.
"Kids today lead a very stressful life. They go from school to soccer to piano lessons to church. There's very little free time to choose what they want to do. And it's very rare for middle class families to not have both parents working. That all creates problems."
Dr. Terrance Wade, an assistant professor in the University of Cincinnati's Department of Psychiatry and head of the Institute for Health Policy and Health Service Research, says it's a matter of what we will tolerate.
"It's a shift in acceptable societal control," he said. "Twenty years ago, parents controlled their kids with physical discipline. Today, that's not as acceptable. So now, we turn to chemical control."
The most common psychiatric prescriptions for children are Ritalin, Adderall and Dexedrine—stimulants aimed at increasing the levels of dopamine in the brain and thus theoretically inhibiting impulse behaviors, particularly in patients diagnosed with attention deficit hyperactivity disorder.
Adderall and Dexedrine both come with warnings that as amphetamines, they can lead to "extreme psychological dependence and abuse."
Still, doctors last year penned nearly 6.4 million prescriptions for children under 18 for these top three stimulants alone, up from 3.85 million prescriptions in 1994, according to IMS. That's a 40 percent increase.
Also on the rise is the use of personality-altering antidepressants such as Prozac, Zoloft, Paxil and Luvox. Pediatric prescriptions for these four medications reached 1.7 million in 1999, up 42 percent from the 988,000 prescriptions written in 1994.
"When we drug millions of children to make them more compliant and easier to manage at home and in school, it says much more about our society's distorted values than about our children," said Dr. Peter R. Breggin, the nation's leading critic of psychiatric drugs for children and director of the Center for the Study of Psychiatry and Psychology in Bethesda, Md.
"Instead of impairing the brains of children with drugs, we should be identifying what's causing their problems—their individual psychological, social and educational needs. And then making the necessary reforms in our families, schools, and communities."
It's an increasingly volatile, controversial struggle. Parents are overworked. Classrooms are understaffed. Doctors are rushed. Insurance companies push for the cheaper route of medication rather than costly therapy.
Psychologist Dr. Leslie Swift of the Cincinnati Psychological Center in Kenwood said he sees it all every week.
"We've become overly enamored with what are more effective medications, that are more helpful than the older ones and have less serious side effects," said Swift. "But the pendulum has swung too far. We're putting kids on medication too quickly."
Swift, an expert in child psychology, said he sees an increasing number of parents demanding medication rather than counseling.
Giving their child three pills a day takes minutes; bringing him in for therapy sessions means working out their schedules, taking time off from work and committing to a potentially long-term course of action.
"They want the quick fix," and ask for popular medications, Swift said. "But often, they're covering the problem over rather than addressing the cause."
Other parents request medication because their child's teachers are demanding it. Doctors said they frequently see patients whose teachers have sent word home than Bobby can't come back to class until he is put on medication. He's being disruptive, uncooperative and unruly.
"At times that makes very good sense," Dr. Margolis said. But it could be that the child is just immature or that the teacher is dealing with too many children and doesn't have the time for one running outside of the pack.
Dr. Margolis said before she writes a prescription, she tries to talk with the teacher. But because of classroom schedules, it could take several days before teacher and doctor hook up. Working with more than 100 patients a week, with at least five to 10 of them on psychiatric medications, she said such cases become more than frustrating.
"Most doctors don't have the time for that," she said. "They take the easy way out and just write the prescription."
Complicating matters: There is no biological test for most psychiatric illnesses. It is a subjective diagnosis based on the observations of a teacher, parent or physician.
The goal is for all parties to work together to reach a solid conclusion. And, Dr. Wade said, for a thorough psychological evaluation to precede any psychotropic prescription.
But too often the careful evaluation is replaced by hurried judgments, he said.
Pushing the number of prescriptions still higher are managed care providers, which would rather pay for a bottle of pills than thousands of dollars in on-going therapy. Doctors said the providers put "inappropriate pressure" on them to medicate rather than counsel youngsters.
"It's becoming a very problematic situation," Swift said.
He said he has a youngster now whose treatment hangs in the balance of an insurance debate. The provider is demanding that medication replace costly counseling. Both mother and doctor disagree, saying the 6-year-old is making progress and that personality-altering drugs are not needed.
But the insurance company is refusing to cover any additional therapy sessions.
"The parents are faced with either paying out-of-pocket, going along with a treatment that neither they nor the doctor advocate, or discontinuing treatment," Swift said.
What's best for the child, he said, is lost in the shuffle.
