Photo by Rory Mcnamara
Child Welfare: Dr. John Leipsic, who specializes in pediatric psychopharmacology,uses medication in conjunction with psychotherapy and behavioral therapy.
Can troubled kids find mental health at the local pharmacy?
By Patrick Sullivan
Once upon a time, Morgan was a boy in a box. Back in fourth grade, this gregarious child became so talkative and disruptive at school that his teacher finally took a desperate measure. "I didn't know anything about it at the time," explains Zoe, Morgan's mom, who lives in a small town in Marin County. "But the teacher told me later that he had arranged a three-sided cardboard box around [Morgan's] desk so he wouldn't turn around and talk to the kids behind him."
That wasn't Morgan's only problem. He couldn't finish his homework, and he was getting into big arguments on the playground. "His thought process was odd," recalls Zoe, who prefers not to give her last name. "He saw everything in black and white. There was no gray. He knew all the rules to baseball, and if someone wasn't playing exactly right, he'd want to kick him out of the game. So he'd get into trouble."
Morgan, now 13, is out of the box. The family's pediatrician believed the boy had attention deficit hyperactivity disorder, a mental health condition usually marked by hyperactivity, impulsiveness, and an inability to focus. A specialist agreed, and Morgan began taking Ritalin, an amphetamine-derived stimulant widely used to treat ADHD. Later, Morgan was switched to a new ADHD drug called Adderall.
His mother says the medication has reduced Morgan's discipline problems at school, improved his social life, and helped him get his homework done.
But Zoe says the medication created new challenges for her son. He has trouble sleeping. His appetite is poor. He has experienced uncomfortable tics such as constant eye blinking.
Is the cure worse than the disease? Zoe doesn't think so, but she worries about side effects, struggles with guilt about her parenting, and tries to find time to help her son manage his condition and his medication.
Her dilemma is faced by a growing number of parents across the country as modern medicine increasingly turns to drugs to treat childhood mental disorders and behavioral problems. A flood of recent studies has demonstrated that children's use of stimulants like Ritalin, antidepressants like Prozac, and other psychiatric drugs has soared over the past two decades.
Among the most dramatic findings shows that about 6 percent of American kids 19 and younger are now taking some form of psychiatric medication, according to a high-profile study published in a recent issue of Archives of Pediatric & Adolescent Medicine. Another widely reported study found that the use of psychiatric drugs in kids two to four years old has increased sharply. And regulators don't seem to be hitting the brakes. In January, the Food and Drug Administration formally approved the use of Prozac for children eight and older, though doctors have long prescribed it off-label for young patients.
California, curiously, appears to be at the back end of this trend. The state that so enthusiastically embraced medical marijuana has one of the lowest per capita rates of prescriptions for psychostimulants like Ritalin, according to the Drug Enforcement Administration.
Still, some mental health professionals in Northern California say they've seen a steep increase in the use of psychiatric drugs in kids over the past decade. And there's no question that the North Bay is prime Ritalin country: The white, middle-class suburbs of Marin, Sonoma, and Napa counties are chock-full of the demographic that in other communities across the country has leapt into the comforting arms of the drug.
What this trend means is a matter of deep dispute. Nationally, the discussion about kids and psychiatric drugs has been a tangled mess. One side points an accusing finger at profiteering drug companies and irresponsible parents. The other complains of media sensationalism and discrimination against the mentally ill.
In the North Bay, the debate seems more polite, more focused on discovering the best way to help children in trouble. But there are still sharp disagreements and strong emotions on both sides of the issue.
Meeting in the Middle
It's a rainy February night in Corte Madera, and some 35 adults have gathered in a windowless conference room. A more typical Marin County crowd would be hard to imagine. Nearly everyone is white, and the average age is about 40. Clothing ranges from slacks and sports jackets to an animal-rights T-shirt and tinted glasses. Somebody forgets to turn off her cell phone and has to leave the room when it starts to warble.
They're here for a meeting of Children and Adults with Attention Deficit Hyperactivity Disorder, a national support group with hundreds of chapters around the country. The main attraction at tonight's meeting is a speech by Dr. Michael Freeman, a Marin County psychiatrist. Freeman offers a broad overview of ADD, ADHD, and bipolar disorder, and then takes questions from the audience.
At the national level, CHADD suffered a major blow to its reputation back in 1995 when a television documentary revealed that the pharmaceutical company that makes Ritalin had donated nearly $900,000 to the organization--and that CHADD had not come clean about that funding to most of its members.
But no drug-company-financed campaign to push Ritalin seems evident at this Marin County meeting, which features a frank discussion of both nondrug alternatives and the side effects of psychostimulants. "Medication is just a piece of the answer," Dr. Freeman tells the crowd. "A lot of it is acquiring life-management skills."
In the audience is Randy, a middle-aged man with a slightly manic manner who hails from nearby Larkspur. Randy, who has ADHD himself, has a son who was diagnosed with the same condition at age eight.
"The kid was really suffering," Randy says. "He couldn't sit still. He couldn't do his homework. He was going nuts. Then he knocked a little girl down at school and the teachers freaked."
Now 11, Jeremy is taking both Adderall and the antianxiety drug Paxil. Randy says he and his now ex-wife thought long and hard before deciding to go with medication. They tried nondrug treatments like counseling first but didn't see many results. These days Randy calls medication a magic bullet. "It has made a huge difference," he says.
Randy isn't the only firm believer in medication in the audience. Connie De Propris, 50, is an Oakland resident who attends Marin CHADD meetings and works as a career coach in the county. She says she has suffered from ADHD since childhood but only began taking medication two and a half years ago. It changed her life. "The barriers were gone," she says. "I was, like, wow, I can do the dishes, I can do my homework, I can do all these tedious tasks around the house."
Growing up as an untreated ADHD child, says De Propris, is extraordinarily painful. When she was in high school, De Propris had poor social skills, few friends, often couldn't do her homework, and accumulated a stack of failing grades. She felt lonely and incompetent.
Leaving such psychiatric conditions untreated is profoundly dangerous, De Propris argues. "If we trained psychiatrists to recognize mental problems and weren't afraid to medicate, we probably wouldn't have half the drug problems that we have in this country," she says. "I'm sure there are a lot of people in prison who wouldn't be there if they had been diagnosed correctly and medicated correctly."
Untreated psychiatric conditions do have a social cost--and, in their cruelest manifestations, even a body count. Depression, for instance, is a cold-blooded killer. Suicide claims the lives of approximately 3,000 people a year in California, and kids are not immune. Nationwide, suicide is the third leading cause of death for young people aged 15 to 24, according to the Centers for Disease Control.
In the United States, one in five children and adolescents suffers from mental health problems at any given time, according to the American Psychiatric Association. The APA says that psychiatric disorders in children remain underrecognized, underdiagnosed, and undertreated--and the results are often tragic.
Even young children can suffer dangerous despair, as Dr. John Leipsic can attest. A child and adolescent psychiatrist who practices in Santa Rosa, Leipsic specializes in pediatric psychopharmacology. In an e-mail, he recalls one eight-year-old girl named Sarah who became so upset after the death of the family dog that she missed a week of school because she couldn't stop crying.
"Her mother found writings in her diary about not wanting to be alive anymore," Leipsic explains. Sarah was diagnosed with depression, began taking a low dose of antidepressants, and, Leipsic says, "three months later, she was well on the road
But if untreated mental illness can wreak havoc, so can medicating an illness that isn't there. Leipsic puts it this way: "Take ADHD for example," he says. "Estimates are that it occurs in 6 to 8 percent of kids. Thus, if 6 to 8 percent of kids are on medication treatment for ADHD, it is an appropriate rate. The key is getting the right 6 to 8 percent."
Leipsic sees medication as a valuable tool, but he uses it in conjunction with psychotherapy and behavioral therapy. And he sees some disturbing trends in diagnosis and prescription writing for children.
Other psychiatrists take their criticism a few steps further. For Dr. Lawrence Diller, the rising pediatric use of psychiatric drugs reveals painful problems in the way contemporary society looks at kids. "It raises a big question," says Diller, speaking by phone from his office in Walnut Creek. "Is children's behavior becoming worse, or has our view of children's behavior changed? Do we simply have less tolerance for personality diversity?"
Diller is a behavioral pediatrician and author who has become one of the country's best-known critics of society's move to medication. In his most famous book, Running on Ritalin, Diller explained why he's concerned: "Valium, Prozac, Ritalin--all these are drugs that smooth the edges off human diversity, making our culture less rich and interesting, and perhaps affecting, in ways we cannot predict, the time-honored eco-evolution of personality and society."
Diller acknowledges that some kids do need pharmacological help; he writes prescriptions for psychiatric drugs in his own practice. But he argues that only about 10 percent of the children who are given drugs like Ritalin really need them.
"We have a much larger group of Huck Finns and Pippi Longstockings and Tom Sawyers out there who for a variety of personality and talent reasons have difficulty in school or at home," Dr. Diller says. "These children do not have mental disorder in the sense that I think of mental disorders. We have drugs that take these round kids and make them fit into square holes."
Diller, who has two sons of his own, is especially well-known for making the case against the boom in Ritalin and other psychostimulants. One major reason he believes that the drug is overprescribed is the tremendous regional variation in its rate of use around the country and across the world. Above all, a child is most likely to be on Ritalin if he or she is American; the United States consumes around 80 percent of the world's supply of the drug.
But it's not just Ritalin that's getting the hard sell. For proof of that, Diller points to a survey of child psychiatry practices by the Yale Child Study Center, published in the Journal of the American Academy of Child and Adolescent Psychiatry. According to the survey, only one in 10 children who visit a child psychiatrist's office leaves without some kind of psychiatric drug prescription.
What are the long-term physical and psychological effects of such medications on children? The answer to that question, says Diller, is that no one really knows. That's because most of these drugs have not been tested in large groups of children for more than a few months. Even Ritalin, which has been in use for decades, has been studied no more than 18 months for safety. As more and more kids use psychiatric drugs, Diller says there's a corresponding expansion in the potential for dramatic disaster or subtle but damaging side effects.
Diller offers many reasons behind this booming new trade in psychiatric medications for kids. He cites poor parenting skills, increasingly rigid school curriculums, aggressive marketing by drug companies, and the strong preference of HMOs to pay for a quick pharmacological fix instead of months of family therapy.
"This is a money-driven phenomenon," Diller says. "It's not that I believe that Ritalin doesn't work. The problem is that it works too well. It becomes a substitute for helping parents parent better or teachers teach better."
That kind of talk frustrates a parent like Zoe. "People tell me that I should not be giving my son medication, that it's just a parenting issue, that he just needs more structure, that he needs more hugs."
But the drugs have improved her son's life, Zoe says. And though she wonders whether Morgan will ever outgrow ADHD and be able to stop taking his pills, she's not holding her breath.
"I don't see it happening anytime real soon."
"The high was incredible, better than anything you can get on the street," says Amber with a sigh. Now in her 30s, Amber (not her real name), is a recovering Ritalin addict. In her teens and 20s, this Santa Rosa resident got her kicks close to home: She stole medication that was prescribed to her little brother, who had been diagnosed with attention deficit disorder. Ritalin wasn't the only drug Amber abused, but it's the one she seems to have the fondest memories of.
She has plenty of company. The federal government classifies Ritalin and other trademarked versions of methylphenidate as a Class II controlled substance. That puts these drugs in the same category as cocaine and opium, and the Drug Enforcement Administration emphasizes that the potential for abuse is serious.
The DEA's website says that Ritalin abuse is limited but has increased along with the availability of the drug. Some areas of the country where Ritalin and other psychostimulants are widely prescribed also display disturbing levels of recreational abuse of the drugs. Among the related studies the DEA lists on its website is a 1998 Indiana University survey of 44,232 high school students in which nearly 7 percent reported using Ritalin illicitly at least once, and 2.5 percent reported using it monthly or more often.
Zoe and her son Morgan know about the problem firsthand. When a boy approached Morgan in his Marin County school about buying some Ritalin, Morgan told him no. Then he told his mother what had happened. "I said that he could get into a huge amount of trouble, and so could the other child," Zoe recalls. "He assured me that he would never do that. But I was a little concerned because he does like money."
On the hand, some recent research may relieve another of Zoe's concerns about Ritalin. She worries that the drug might predispose her son to addiction, but new studies appear to show that kids with ADHD who are medicated with psychostimulants are actually less likely to become addicted to illegal drugs later in life.
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From the March 6-12, 2003 issue of the North Bay Bohemian.