Medication and Your Child: Dealing With
Behavioral Disorders
Children will be children, says the popular
wisdom; occasional bouts of unpredictable, and even difficult,
behavior are simply part of
the adorable package. However, for some parents, there are times
when “adorably difficult” behavior isn’t so adorable.
When a child’s actions cause serious problems at home or at
school, a behavioral disorder—a malfunction in the chemistry
of the brain that can drastically affect behavior—may be the
cause. Unfortunately, because erratic behavior is common among children,
it can be challenging to determine whether your child’s behavior
is caused by a behavioral disorder; even more difficult is the decision
of when and how to treat a behavioral disorder once a diagnosis has
been made. Most parents want their children treated for the medical
conditions that affect them; few parents want to medicate their children
simply for being children.
Accordingly, many parents seek out as much information
as possible regarding “problem” behavior.
Their sources will vary: parents may be consulted, along with the child’s
physician, parenting books and magazines, and the like. The Internet can also
serve as a valuable tool for parents in this situation, allowing them to research
the signs and symptoms of a host of behavioral disorders, share experiences
with other parents, seek advice from experts around the world, and more. Unfortunately,
parents will also encounter online a considerable amount of false and/or misleading
information on the subject of behavioral disorders and mental illness, particularly
when the subject of drug therapy is introduced.
If you suspect your child might be suffering from a behavioral
disorder, the first thing you need to know is that you are not
alone. The National Institutes
of Health (www.nih.gov) estimates that nearly one in five US children between
the ages of 9 and 17 suffers from a behavioral disorder, more than 10% of
whom experience symptoms severe enough to cause significant impairment
in functioning.
Unfortunately, only about one in five of these children will ever receive
treatment. There are many conditions that can affect the behavior
of your child; the culprit
might be any of the disorders listed below.
The most important form of depressive disorder is major depressive
disorder (MDD), which may affect up to 5% of children. Although
every child experiences “the blues” from time to time,
MDD is a much more significant problem that can endure for great
lengths of time, affect functioning, and can be associated with
elevated risk of later problems (including suicide). According
to the National
Institute of Mental Health (NIMH),
MDD may result in any of the following symptoms:
- Persistent sadness or irritability
- Loss of interest in favorite
activities
- Significant change in weight or appetite
- Sleep disturbance, including
insomnia or chronic “oversleeping”
- Lack of energy
- Feelings of worthlessness or guilt
- Difficulty concentrating
- Thoughts of death or suicide
Obviously, none of these characteristics alone
is sufficient to justify a suspicion of MDD. Generally, a person
with MDD will experience
five or more of the symptoms listed above, although every case
is unique.
Unfortunately, identifying MDD among
children can be difficult, in part because “children
may not express symptoms as articulately as an adult,” says Carol
E. Watkins, MD, a Baltimore-based psychiatrist with significant experience
in this area). Accordingly, Dr. Watkins recommends
looking for general patterns of behavior. Younger children “might
look vaguely sick, less bouncy, or spontaneous,” she writes. “He
may say negative things about himself and may be self-destructive.” Parents
of older children with MDD may notice “academic decline, disruptive
behavior, and problems with friends. Sometimes one can also see aggressive
behavior, irritability,
and suicidal talk.”
Another form of depressive disorder is bipolar
disorder, once known more widely as “manic-depression” or “manic-depressive disease.” Bipolar
disorder is somewhat less common than MDD, affecting only about 1% of adolescents
age 14-18. Generally, bipolar disorder consists of rapidly or suddenly alternating
depressive moods (similar to those encountered in MDD) and manic moods (characterized
by high energy, excessive cheerfulness, etc). Depressive disorders may be treated
with medication or with cognitive-behavioral therapy.
Anxiety disorders (AD) are even more common than depressive disorders,
affecting nearly 13% of all children. Like depressive disorders,
anxiety disorders may be treated with medication or with cognitive-behavioral
therapy. They may include:
- Generalized Anxiety Disorder (GAD):
Children with GAD experience constant, exaggerated feelings of
worry over minor matters.
- Obsessive-Compulsive Disorder (OCD):
Children with this form of AD engage in recurring, unwanted behaviors—repeated
hand washing or constant ordering and arranging of objects, for
example.
- Panic Disorder: Panic disorder is characterized by overwhelming
fear that strikes suddenly and is out of proportion to the situation.
- Phobias:
A phobia is an intense and inexplicable fear of an object or
situation. Social phobia is a special type of phobia in which
the patient is afraid of interaction with other people; this
phobia can lead to isolation and often, depression.
- Post-Traumatic
Stress Disorder (PTSD): Generally caused by a traumatic event
(for children, this can include abuse or witnessing
the death
of a loved one), this condition is characterized by periodic “re-experiencing” of
the trigger event, deadening of normal emotions, and a state
of “hyper-vigilance” resembling
GAD.
Considerably more common among girls than among boys, eating disorders
are often accompanied by other behavioral disturbances, and are
usually treated with an extremely complex therapeutic plan incorporating
counseling, behavioral modification (see below), and medication.
Two of the more common types of eating disorder are Anorexia nervosa,
which is characterized by unhealthily sparse eating, and Bulima
nervosa, a form of illness in which affected patients “binge” on
large amounts of food and then “purge” by forcing themselves
to vomit shortly thereafter.
Considered the most serious of the conditions affecting behavior,
this group includes autism, Asperger’s disorder, and Rett’s
disorder. Pervasive developmental disorders, present in an estimated
two to six out of every one thousand American children, affect
the ability to communicate, respond to stimulus, and form relationships
with others.
The final behavioral disorder on our list is ADD/ADHD, more commonly
referred to as ADHD. Best current estimates suggest that nearly
4% of adolescents and schoolchildren suffer from this disorder.
According to the NIMH’s outstanding site devoted to ADHD, the condition
is characterized by three major symptoms: inattention, hyperactivity,
and impulsivity. The NIMH acknowledges
how difficult it is to accurately identify ADHD, stating that “because
many normal children may have these symptoms, but at a low level,
or the symptoms may be caused by another disorder, it is important
that the child receive a thorough examination and appropriate diagnosis
by a well-qualified professional.” The NIMH also notes that
the condition has “adverse effects on academic performance,
vocation success, and social-emotional development” and is
associated with another behavioral disorder in 69% of cases. Prompt
and effective treatment is critical to reduce the long-term impact
of ADHD.
An essential part of treatment for any serious behavioral condition
is the use of medication. While most prescription medications have
been tested for safety, no drug is without risks and drawbacks; for
this reason, many parents are reluctant to give them to their children
for any illness if the symptoms are less than severe. This is particularly
the case if the condition in question is behavioral in nature. Unlike
physical disease, such as leukemia or heart attack, in which physical
symptoms are obvious and clearly harmful, behavioral disorders manifest
in ways that are difficult to separate from normal childhood behavior;
parents may feel that using medication in such a case amounts to “drugging
kids for acting like kids.” This has led to a spirited—sometimes
even strident—debate, with one side advocating the value of
appropriately applied medication therapy, and those on the other
side calling for a reduction in or elimination of the use of drugs
for behavioral disorders. The Internet has allowed this controversy
to reach epic proportions, with every interested party able to register
his or her opinion with millions of others.
The most striking example of this sort of argument
concerns ADHD, and the medication most commonly used to treat it,
Novartis’ stimulant Ritalin. At present,
the United States consumes roughly 90% of the world’s supply of Ritalin.
Some advocates believe that the drug is overused among American children,
or that ADHD is overdiagnosed in this population. Some even doubt that ADHD
exists
at all. The facts about Ritalin and the development of the controversy around
it help illuminate important points about the medication of children in general.
In 1999, Priorities, the journal of the American
Council on Science and Health, published an article entitled “The
Debate of Ritalin: Point/Counterpoint,” in
which physicians Richard Bromfield and Jerry Wiener debated whether Ritalin
prescriptions—which had risen by a factor of six in the preceding
decade—were
too common.
Dr. Bromfield argued that they were, stating that “Ritalin is being
dispensed with a speed and nonchalance comparable with our drive-through
culture.”
The debate received national attention in the
following year, when then First Lady Hillary Rodham Clinton delivered
a speech calling for curbs
on prescriptions
among children. “Mind alternating drugs meant to treat attention
deficit disorder...are being given more and more to kids who have problems
that are
symptoms of nothing more than childhood or adolescence,” Clinton
told her audience. In November of the same year, researchers at the Children
and
Adults With Attention-Deficit/Hyperactivity Disorder (CHADD)
conference concluded that ADHD is “both over- and underdiagnosed.” Speaking
about the conference, David Kessler, MD, maintained that “there’s
no way to make an adequate assessment [for ADHD] in a seven-minute visit,
so what we have is a situation where teachers complain [about a child’s
behavior] and parents write a prescription.” Dr. Kessler and other
experts at the CHADD conference called for more thorough assessments
of children with
suspected ADHD.
Also in 2001, CHADD published an article entitled “Access
to Medication as a Component of Multi-Modal Therapy,” which
remains required reading for those who think their child might have ADHD).
The paper was developed in response to proposed legislation designed
to restrict
the use of psychiatric medication in children; it expressed concern that “all
families should have access to the best, evidence-based, science of diagnosis
and treatment.”
The anti-medication movement gained momentum in
September of 2002, when the House of Representatives’ Committee
of Government Reform (CGR) held a hearing entitled “Overmedication
of Hyperactive Children.” At
this hearing, a collection of celebrities and self-appointed experts
decried what they saw as overmedication in kids. Some even denied the
existence of
ADHD as a diagnosis in the first place.
Just before the hearing, the National
Alliance for the Mentally Ill (NAMI) blasted the CGR for scheduling
a meeting with a witness
list “heavily
unbalanced with opponents of medication as a treatment for AD/HD.” According
to NAMI’s National Executive Director at the time, this hearing
recycled “bad
science and trivialize[d] the need for early identification and treatment
of mental illnesses in children and adolescents.”
The Internet has helped confuse matters further
by giving a platform to those often well-intentioned folks who present
their baseless or
incomplete theories
as solid fact, confusing parents in search of useful information.
A good example is Death
from Ritalin, a site
created
by
the
parents of
a child who died as a consequence of long-term Ritalin use. Their
admittedly horrible experience has led them to launch an aggressive
campaign against
virtually all medication of children for psychiatric illness; in
the service of this
goal, the site’s authors dismiss all of the potential benefits
of medication use, considering only the risks.
Opponents of ADHD are fond of noting that “ADHD
has never actually been validated as a biological entity,” says
Susan L. Montauk, MD, Professor of Clinical Family Medicine at the
University of Cincinnati College of Medicine.
Dr. Montauk reminds that “the
same argument, however, can be made for headache or low-back pain.” Few
parents would dispute the validity of headache as a diagnosis,
or the value of appropriately
used medication
in its relief. Furthermore, says Dr. Montauk, imaging studies have
demonstrated differences in the brain of people with clinically
diagnosed
ADHD compared
to healthy subjects. There is widespread agreement among experts
today that ADHD is, in fact, a valid diagnosis. However, because
there is
no definitive
test for the disease, there is disagreement about what constitutes
ADHD. Concerns
about overdiagnosis, and consequent overtreatment, of the disease
may therefore be well founded.
Certainly, if physiological ADHD is present, the
use of medication can be extremely helpful. There are alternatives,
however; specifically,
cognitive-behavioral therapy (CBT), which has proven useful in
treating symptoms of the condition
without medication. With CBT, a therapist talks to the affected
child, helping
to guide the patient toward realistic and practical ways that behavior
can be changed for the better. In a recent NIMH
study, researchers
found
that
medication “has
a substantial positive impact on symptoms and behavior at home
and at school,” and
that CBT may play a useful role, as well.
The debate rages with equal furor over many other childhood behavioral
therapies. Earlier this year, the NIMH issued a detailed
paper clarifying its position
on the increasingly controversial use of antidepressants in children.
As a parent, the first step in providing your child with the
best care while avoiding
unnecessary medication
use
is to allow
your child’s doctor—not his or her teacher or principal—to
advise you on the matter. In virtually all cases, a teacher should
never suggest medication
for your child; it is sometimes against the law for them to do
so (Connecticut was the first state to pass a law of this kind;
it now sees far fewer Ritalin
prescriptions than neighboring Massachusetts,
which has no such law.
If your child’s teacher does suggest that
there may be a problem with your child’s behavior, you can
assess that behavior yourself with resources such as the Young
Mania Rating Scale,
Depression-Screening.org,
and the ADHD
Screening Tool.
These and other tools can help parents to determine whether their
child needs to see a physician. If you do receive a diagnosis
of a behavioral
disorder,
use the power of the Internet to learn everything you possibly
can about the condition and its treatment, by visiting the sites
profiled
here
and elsewhere
in Family Medicine Net Guide. Be sure to discuss what you find
with your doctor; he or she can help you determine what information
is
reliable and how it applies
to your child. All of these steps can help you to make an intelligent,
informed decision regarding your child’s treatment.
| Depressive and Anxiety Disorders |
| Check out the resources below for more information
on the nature and treatment of these conditions. |
| Depressive Disorders |
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| Anxiety Disorders |
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