Use of Drugs to Control Kids Worries Specialists
Florida doctors raising questions
By Carol Marbin Miller
Originally published in The Miami Herald, July 2, 2001
Troubled youngsters across the nation are being prescribed mood-altering drugs with increasing frequency, raising questions among psychiatrists and researchers specializing in the mental health needs of children.
Supporters of the current trends in child psychiatry see the burgeoning use of often expensive new drugs as a sign that needy children are gaining access to a mental healthcare system that once often excluded them.
Critics disparage the statistics as evidence that healthy but unruly children are being given drugs for the convenience of their caretakers, not because they need them.
"This trend has been a source of concern among parents, practitioners and public policy makers,'' said a recent report of the Yale Child Study Center and other researchers.
The debate is particularly poignant in Florida, where child advocates recently have complained about the use of such drugs to control the behavior of children in state care.
In April, Broward lawyer and child advocate Andrea Moore told Department of Children & Families administrators that a large number of children in foster care were being given Risperdal—an antipsychotic drug a UCLA child psychiatrist describes as among the "big guns'' of psychiatric medications.
State officials have confirmed that thousands of children, including toddlers, are being prescribed psychiatric drugs, from Ritalin to more powerful drugs like Risperdal and Haldol. At least two advocacy groups have announced plans to investigate the widespread use of such drugs.
The use of psychiatric drugs among children, including very young children, has increased dramatically over the last decade.
A study published in February 2000 in the Journal of the American Medical Association reported a threefold increase between 1991 and 1995 in the prescription of Ritalin among preschoolers.
Ritalin, a stimulant that helps to improve concentration and behavior, has been on the market about 40 years. Unlike many other psychiatric drugs, it has been specifically approved for use with children.
The study looked at children in two undisclosed states and a northwestern U.S. managed care organization. In each area, "psychotropic medications prescribed for preschoolers increased dramatically between 1991 and 1995,'' the journal reported, referring to all types of psychotropic drugs—not just the medications for attention deficit/hyperactivity disorder (ADHD), such as Ritalin.
In a study of prescribing practices in North Carolina's Medicaid program, the Archives of Pediatrics and Adolescent Medicine reported in May that the use of drugs such as Ritalin and Adderal, another psychostimulant, increased by nearly 550 percent from 1992 to 1998. In 1992, 24,584 such prescriptions were signed, compared with 135,057 prescriptions in 1998.
Use of newer antidepressant drugs, such as Prozac and Paxil, increased by nearly 1,200 percent during the same period, the article said. In 1992, North Carolina's Medicaid program processed 1,326 claims for such drugs; by 1998 the number of claims soared to 25,392.
The article's authors would not speculate on what is behind the surge in prescriptions.
"While we must be judicious in the application of these psychotropic medications, we cannot present an alarmist view that equates all increases in prescriptions with negative consequences,'' they wrote.
Ross W. Greene, director of cognitive and behavioral psychology at Massachusetts General Hospital and a professor of psychology at Harvard Medical School, suggests psychotropic drugs improve the lives of many children.
Greene, the author of the 1998 book The Explosive Child, largely attributes the increase in psychotropic drug use among children to a greater understanding by doctors of youngsters suffering from conditions like bipolar disorder, formerly called manic-depression.
"Some of the newer [drugs] out there are really life savers for some kids, but only under the right conditions,'' Greene said. "They should only be prescribed by someone who knows what they are doing, after a comprehensive evaluation, and conservatively.
"It's not a black-and-white issue.''
A recent study of Connecticut children being administered psychotropic drugs found that close to 5 percent of children on Medicaid had been prescribed a mood-altering drug.
The study didn't conclude how many of the prescriptions were necessary.
"Our guess is that some kids are getting appropriate care, some are not getting the medications they ought to, and some are getting drugs they don't need,'' said Judith Meyers, executive director of the Child Health and Development Institute of Connecticut, and co-author of the May study jointly published with the Yale Child Study Center.
Janet S. Shapiro-Weiss, a former fellow at Yale University's Medical School who publishes the monthly Psychiatric Guide, worries that the emergence of managed care as a powerful gatekeeper in child psychiatry has contributed to an over-reliance on drugs in treating troubled youngsters.
In every issue of the Psychiatric Guide, Shapiro-Weiss and her husband, George D. Shapiro-Weiss, who helps publish the newsletter, remind readers that "Drugs are for symptoms.'' Finding "the child behind the symptoms'' requires detective work, the couple say.
"Each child has a story,'' said Shapiro-Weiss. "Everyone has a threshold, and these kids reach that threshold really quickly because of what has happened in their lives.''
Some children become so disturbed that they can barely function, Shapiro-Weiss said.
"They can't have a conversation, they can't sit still,'' Shapiro-Weiss said. "They are feeling really unsafe, and sick and anguished and frightened . . . they need to feel settled in order to speak,'' she said. For such kids, medications can mean the difference between success and failure in school.
But, like most doctors, Shapiro-Weiss does not favor the use of such drugs without other therapeutic services, such as counseling or behavior analysis for which managed care companies often refuse to pay.
Under some plans, insurance will pay for monthly 15-minute medication-management visits but nothing more.
For children who are dealing with extremely traumatic issues, such as grief, divorce or separation, five or six visits with a psychiatrist or therapist might not be enough, Shapiro-Weiss said.
In many cases, she added, doctors will write prescriptions because there's nothing else that can be done.
"Do you do nothing? The parents are begging you to [prescribe a drug], and the school says they will kick the kid out.''
David Feinberg, a child and adolescent psychiatrist at UCLA who treats a large number of foster children, said doctors often relent and write a prescription when caretakers at foster homes or institutions plead with them to help quiet a particularly troubled child.
"The staff keeps calling you. The kid is out of control, they say, he's on the roof, he's out the window. He's out of control, and they've got to get some medication,'' Feinberg said.
"There isn't anyone stopping and saying, 'Is this what's best for the kid?'''
