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Kids on drugs
A behavioral pediatrician questions the wisdom of medicating our children.
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By Lawrence H. Diller, M.D.

March 10, 2000 | The opposing voices in the "debate" over the use of psychotropic medications in children veer toward hyperbole. One reviewer likened the process to "dueling grade-B movies," where supporters of drug therapy view doctors as noble knights freeing children and their families from the tyranny of a biologically based mental illness, and the other side has physicians, especially psychiatrists, as evildoers who sedate and control children's behavior by drugging them at the behest of their parents and teachers.

This dichotomy, while appealing to TV talk shows and tabloid journalism, doesn't do justice to the motives of nearly everyone involved. Nor does it describe the economic, bureaucratic and social realities that can lead to an 8-year-old boy taking three psychiatric drugs simultaneously.

The discussion is complicated by the fact that children are dependent on their caregivers and are not allowed to make the final decision about their own care. At best, children are offered informed choice but not consent. Also, because children are in a developmental stage, the stakes are higher when they take medication. Parents and doctors are concerned that the medications may affect normal physical and developmental growth, leaving, in essence, permanent side effects.

Doctors genuinely desire to ease suffering. But they are also strongly influenced by economic factors. The profit motive affects whether and in what manner doctors offer treatment. The traditional fee-for-service arrangement encourages interventions. A capitated system of payments to doctors common in health maintenance organizations (HMOs), which sets a limit on how much money physicians receive regardless of what services are offered, discourages interventions that are deemed costly or result in only marginal benefits to the patient.

Our current systems of care and payment for children's emotional problems, in tandem with often desperate parental expectations that the doctor will supply the "answer" to the problem, place inexorable pressure on the doctor to do something quickly.

Typically today under managed care the doctor must make a judgment about the diagnosis and a decision whether to medicate in a 50-minute meeting with the child and parents (usually just the mother). The doctor is then allowed two follow-up meetings of about 20 minutes each to review the child's behavior on the medication.

Such was the case with Peter, a 5-year-old I was asked to evaluate. Peter's developmental milestones were those of a 3-and-a-half-year-old. His language development was that of a 2-year-old. However, no one could be really sure about Peter's intelligence because he was in constant motion and ignored his parents' commands.

Peter lived too far away to receive ongoing treatment from me so I called Dr. Murrow, a child psychiatrist who had previously worked with Peter and his family in their community. Murrow had already tried a number of medications with Peter. I thought to offer a couple of ideas on Peter's medications but also wanted to address his parents' ineffective approach to limits with Peter.

I asked the doctor if he was doing anything else these days besides prescribing drugs. He sounded resigned and apologetic: "Nope. I see a kid every 15 minutes. It's the only way I can make an income under managed care." But he promised that, for Peter, he would try to include some of my ideas about the family the next time he saw the child and his mother.

Parents and schools complete the chain that squeezes the system toward a rapid medication intervention. I've never met a parent who, at least initially, wasn't ambivalent about giving their kid a medication. However, parents today, when pondering their children's problem behavior, begin to consider medication much sooner than parents did just 10 years ago. These days, after only several weeks of feeling like "We've tried everything," moms and dads think, "Maybe Johnny can't help what he's doing. Maybe he does have a 'chemical imbalance.'"

Imperceptibly at first, people go from believing that a child or parent has influence over a behavior problem to believing that the behavior is involuntary and that something biological is the cause. Medication becomes the reluctantly arrived-at solution. This kind of thinking is powerfully reinforced by much of American psychiatry and the media. Now when I meet parents who strongly believe that their child has "a disorder," I find that they aren't interested in considering other interventions unless I also write a prescription for their kid.

Teachers and schools are the final pressure point. Teachers are faced with a broad curriculum that today includes much more than the three Rs. Poorly educated students and social passing have led to increasing use of standardized tests. Not only are students more scrutinized, but so are their teachers. The demands on a teacher's time and attention in a crowded classroom make managing behaviorally difficult children harder.

Teachers, like parents, consider a medication option much sooner these days. Few teachers come right out and make that suggestion, but the message is unmistakably clear to parents, and to the doctor, when a teacher suggests that the child get a medical evaluation to address problems of behavior and performance at school.

In fact, the Colorado State Board of Education recently passed a resolution urging teachers to first use discipline and educational resources before referring a child for a medical evaluation. They believed that teachers in Colorado were too quick to move to a "medication fix."

Parents and doctors sometimes have to choose between giving a child medication and having the child attend a more restrictive classroom environment. Steven, 9, still couldn't write a coherent sentence and instead hid under his desk. Would adding another medication allow him to remain in the regular class? Or should he be sent to "Special Day Class," where there are fewer children but where they all have similar or more severe problems?

The costs and benefits of such choices are often clouded by an inefficient, overworked public education system that pushes parents toward choosing medication over special education. One can't medicate a school system.

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