It's Nobody's Fault

by Harold Koplewicz

  I’ve met a lot of parents who don’t like the idea of medicating a child for a brain disorder—or anything else, for that matter—but that was the first time I had ever encountered parents who preferred 750 sessions of psychotherapy that didn’t work to a daily dose of medication that does work. After two weeks of a moderate dose of Ritalin Adam was a lot better. His parents, his teacher, and his peers noticed the change right away.

  FOOLING MOTHER NATURE

  Adam’s parents are not alone, of course. Many fathers and mothers are adamantly opposed to the idea of psychopharmacology for their children. “My kid on drugs? Never!” is something I’ve heard more than a few times. Parents who wouldn’t think twice about giving their children insulin to treat diabetes or an inhaler to ease the symptoms of asthma balk at the prospect of giving their child medication for a mental disorder, for any number of reasons. They worry that the child will become addicted to the medication or will be encouraged to abuse other drugs. They fear that the child will be stigmatized by taking medication. They’re concerned about the negative side effects. Some parents regard giving a child medication as taking the easy way out. They think that a more “natural” approach—for example, withholding sugar and caffeine, or using discipline, or trying to get to the root cause of every problem—is the more desirable, even the morally superior, course of treatment.

  “Isn’t it a crutch?” some concerned parents ask, and I have to say yes, I suppose medication is a kind of crutch. But if a child’s leg is broken, what’s wrong with a crutch? If a youngster has a broken limb, he can’t be expected to get around without some help. If a child has an infection, doesn’t he take antibiotics? If a child’s brain isn’t functioning the way it’s supposed to, shouldn’t he be given whatever assistance is available to make it easier for him to lead a normal life, free of distress and dysfunction? Parents have to understand that brain disorders must be taken as seriously as asthma, diabetes, or any other organic problem. A child with a brain disorder is suffering, and there is nothing wrong with using medication to relieve a child’s suffering.

  Many parents who come to see me don’t need to be persuaded about the virtues of medication. This is especially true of parents who have been helped by some of these medications themselves. When I recently prescribed a low dosage of Zoloft, an antidepressant, for a little girl with selective mutism, her parents didn’t hesitate for a moment to follow my advice. “You know, a year ago I started taking Zoloft for depression, and it completely changed my life,” the little girl’s mother said. “There was a time I would never have dreamed of giving my child psychiatric medicine, but I don’t feel that way anymore.”

  The father of a little boy with severe obsessive compulsive disorder put his feelings about medication even more succinctly: “Our son’s life began the day he started taking his medicine.”

  THE STIGMA OF MEDICINE

  It’s all very well for my colleagues and me to equate brain disorders with diabetes and to say that giving a child Ritalin shouldn’t be any different from making sure he takes his insulin. We know that there is a difference. A pediatrician looks in a child’s ears, detects an infection, and prescribes ampicillin. Parents give the child his medicine without missing a beat. Do they ask the pediatrician about its long-term side effects or question him closely about what caused the infection? Probably not, or at least not at any length. They might even tell their friends about it. There’s no stigma attached to having an ear infection. Most parents won’t keep a child’s diabetes a secret. There is, unfortunately, a stigma attached to having a brain disorder, and as a result many parents are secretive about their children’s problems and the fact that they’re taking medication.

  When I hear stories of how some people react, I can’t really blame parents for keeping the news to themselves. One worried mother called me because the principal at her child’s school said her son shouldn’t be taking the Ritalin I had prescribed (and to which he was responding wonderfully well). The Ritalin is a crutch, the principal said; what the child really needed was a lighter school schedule and a different teacher. I was shocked by the principal’s ignorance, not to mention his colossal nerve. If I had prescribed two puffs of an inhaler to keep a child with asthma from wheezing during gym class, I doubt that the principal would have suggested that the child forget the medicine and be excused from gym instead.

  Another mother showed up at my office in tears. Her daughter’s teacher had told her that medicine—in this case an antidepressant for separation anxiety disorder—is the worst possible thing for a growing child. “I can’t believe you’re giving her drugs,” the teacher said to the mother. (This was the same teacher who, only a few months earlier, had told the mother that her six-year-old daughter Ellen had some real problems, that all she did all day in class was stare down at her desk, cry, and ask to go home to her mommy.) Ellen’s mother sputtered a response to the teacher: “But you told me there was a problem. I’m trying to fix it.” The teacher’s response: “I told you to do something, but I didn’t mean this.” The fact that with the medication Ellen was able to attend class all day without chronic worries and fears didn’t affect the teacher’s attitude.

  Teachers aren’t the only people who routinely second-guess child and adolescent psychiatrists who prescribe medication. Most relatives aren’t shy about giving their medical opinions either. We’re always being told that Aunt Judy heard that Zoloft is better than Prozac or Grandpa read somewhere that Lithium doesn’t really work. And then there are the well-meaning family members who just blame the parents.

  “When we told my family that Josh is taking medication, they completely flipped out,” said the mother of a four-year-old. “They think that we should be able to handle Josh ourselves. My sister gave me a long lecture about how I spoil my son and how he would be perfectly fine if I would just stop paying so much attention to him.” The attention that she’d been lavishing on her son involved preventing Josh from overturning tables and pulling down drapes at family gatherings. Before the medication she couldn’t turn her back on Josh for a minute. He would literally climb the walls.

  When children are on medication, it’s not just the parents who are judged. Teachers and others sometimes look askance at the children themselves. That’s why one mother waited until halfway through the school year to tell the school that her eight-year-old daughter was taking Prozac. “I wanted them to get to know Maria first, without hearing about the Prozac. If they knew about the medicine from the beginning, they’d have all these preconceived notions about her. That’s all they would think about. Once they know she’s a great kid, they won’t think about her as the little girl who takes the medicine. When I finally got around to telling them she was taking Prozac, their reaction was, ‘Why? She seems fine to us.’”

  Other parents flatly refuse to tell the school about a child’s medication. The father of a 13-year-old girl who has been taking Cylert for many years says that he has been burned so often by unsupportive, uncooperative school officials that he has decided not to tell them about it anymore. “We lied on the health form, and we’ve encouraged our daughter not to say anything about her treatment,” the man, himself a doctor, said to me. “This isn’t how we want it to be, but we’re tired of hearing lectures from people who don’t know what they’re talking about. I don’t want my daughter to suffer because people are ignorant and prejudiced.”

  Naturally no one can force parents to confide in teachers or other school officials, but schools do usually require full disclosure, and I recommend it too, in theory at least. A collaborative approach should be the goal. I advise the parents of my patients to let me work with the school psychologist and the school nurse to coordinate the child’s treatment. I believe that teachers should be involved in the treatment whenever possible, especially if a child’s symptoms affect his behavior in the classroom. It is a teacher’s job to help all the kids in class, but before teachers can help, they have to know what the problem is.

  I’v
e known many teachers who are immensely helpful to these troubled kids; it’s not unusual, in fact, for a teacher to be instrumental in identifying problems or persuading parents to seek help. One school principal I know, a seasoned professional, arranged to meet two parents near the end of their eight-year-old son’s academic year. The principal suggested gently to the parents that their child’s behavior was out of the normal range and that he should be evaluated by a child and adolescent psychiatrist. The principal went on to say that the child might need medication.

  “Oh, we’ve had him looked at,” the mother said.

  “Yes, the psychiatrist said he needed drugs, but we don’t believe in them for kids,” the father added.

  “I believe you should reconsider,” countered the principal. “If your son had a vision problem, you’d get glasses, wouldn’t you? You wouldn’t just expect him to squint.” The parents showed up in my office the following week.

  Most very young children in treatment for a brain disorder hardly give a thought to the fact that they have to take medication on a regular basis, except perhaps to regard it as a minor inconvenience. However, as kids get a little older, they may become embarrassed or even ashamed about needing medicine. Many children don’t want their friends to find out. They’re fearful that what happened to a 14-year-old boy I treated will happen to them: when he told his friends he was taking medicine, they laughed at him and called him “Psycho.” No one ever said that children are overly sensitive to the vulnerabilities and shortcomings of their peers. Kids can be brutal sometimes. They can also be remarkably supportive, especially if a good example is set for them. Children follow the lead of the significant adults in their lives—Mom, Dad, teacher. If the adults treat taking medication as perfectly normal, children will usually follow suit.

  Each child is different, of course, but in general I find nothing wrong with a child’s desire to keep his illness and medication private, provided that the child truly understands and appreciates that there’s nothing wrong with taking a medicine that fixes the brain. The way I explain it is that people, grown-ups as well as children, aren’t always educated about these kinds of disorders. They don’t understand what makes people sick and why they need medicine to get well. That’s why they call people names and say silly things that hurt other people’s feelings. Perhaps it is better not even to tell them about it. Besides, it’s none of their business. A visit to any doctor is a private matter. Many of the kids I treat with medication never even mention it to their friends and classmates. Others are very open about it. The decision about how to handle this should be made by the parents, the child, and the psychiatrist.

  Children, even very young ones, usually find it easier to accept the fact that they take medication if they understand their disorder and accept some responsibility for taking the medicine. One of my colleagues says that when he prescribes medication, he makes a speech to his young patients that goes something like this: “This is your medicine. It is not your mom’s medicine. It’s not your dad’s medicine. It is not your teacher’s medicine. It is your medicine, and it’s going to make you feel better. It will help you stop worrying all the time. Even if you don’t always want to, you have to take it every day, so I want you to know the name of the medicine. It’s called Zoloft. I don’t want you coming in here next time and telling me that you take little blue pills. I want you to tell me you take Zoloft. And I want you to know how much you are taking, when you take it, and what it’s doing for you.” Involving a child in his own treatment in this way helps to remove the stigma.

  THE MEDICATION Q AND A

  Not all mental disorders should be treated with medication, of course. Sometimes the recommended treatment is psychotherapy, and most often a combination of medication and psychotherapy is the solution. The psychotherapy I recommend most strongly for children and adolescents is behavioral therapy, which is characterized by its direct, supportive quality. In this kind of therapy we target specific symptoms and goals, and every aspect of the treatment is geared toward minimizing symptoms and achieving those goals. This is not psychoanalysis. We don’t try to unearth trauma and repair it. We don’t “regrow” the child. We focus on getting rid of a child’s symptoms and improving his ability to function. This kind of therapy may involve relaxation techniques (which include deep breathing and visual imagery), behavior modification, parent counseling, and family therapy. A child’s problems aren’t just a child’s problems. They affect the entire family.

  Medication should be prescribed only after careful diagnostic evaluation. Just as antibiotics are prescribed for bacterial infections but not for viruses, the medicines I prescribe are effective only for specific disorders. Diagnosis drives treatment is one of the most important maxims of any physician. Before any treatment begins, a physician must make a diagnosis.

  Parents have to make it their business to understand their child’s disorder and the recommended treatment by asking questions. Here are a handful of drug-related questions that any child and adolescent psychiatrist should be prepared to answer when prescribing medication:

  What is the diagnosis?

  What is the medicine, and how does it work?

  Have studies been done on the medication?

  Which tests need to be done before my child starts the medication?

  How soon will I see an improvement?

  How often will his progress be monitored, and by whom?

  How long will he have to take the medicine?

  How will the decision be made to stop it?

  What are the negative side effects of the medicine?

  What will happen if my child doesn’t take it?

  Doctors won’t be able to answer all of the questions with precision, of course. “How long will he have to take the medicine?” is an especially hard one. Adults who take medication for high blood pressure can never be sure how long they’ll have to keep taking it. With diet and exercise and a lot of luck perhaps they can discontinue the medication after six months or a year, but it’s also possible they’ll have to take it for the rest of their lives. Regular checkups with the doctor tell the tale. The same goes for children’s brain disorders. Many kids need medication for an extended period of time; others thrive without it after a short “trial.” Regular evaluation and monitoring of a child’s progress will tell the physician and the parents what they need to know.

  Careful, individual titration is also vital to the treatment; the prescribed dose of any psychiatric medication given to a child may have to be adjusted, perhaps many times, before we get the results we’re looking for. Too often a child is given a dose of a medicine that is not sufficient. When the behavior doesn’t change and the child doesn’t get better, it shouldn’t be assumed that the drug isn’t working. The child may simply need a little more of it.

  The answer to another question, “Have studies been done on the medication?” may not be what parents want to hear. We have several ways of gauging the effectiveness of a medicine. The simplest is the case study method, in which we follow the progress of one case. We give a child medicine, see what effect it has on certain symptoms, stop the medicine, see what happens, and then start it again. Open clinical trials are more sophisticated. We take a group of kids with the same disorder, give them all the same medicine, and measure their progress after six weeks. The gold standard of tests is the placebo-controlled double-blind trial We choose a fairly large group of children with the same disorder—96 children from ages 8 to 18 who have major depressive disorder, for instance—and give half of them medication and half of them a placebo. Neither doctor nor patient knows who is getting what. That’s why the study is called double-blind. After eight weeks we measure and compare the progress of both groups.

  Unfortunately we do not have placebo-controlled double-blind trials for many of the drugs we routinely prescribe for children’s brain disorders, but this doesn’t mean that a child or adolescent shouldn’t take them. It does mean that both parents and physicians should be careful t
o examine all options before starting a child on any medication.

  DRUGS AND PERSONALITY

  Here’s how one mother reacted to the changes in her son that were brought about by medication: “When Allen takes his medicine, he’s so much quieter than he was before. He seems to listen to me a lot more carefully, and our conversations are much deeper and more enjoyable. He’s practically a different person. I hate to admit it, but I like him better when he’s on the medicine. He’s more in tune, more attentive, more interesting. What worries me is, Is this really my child?”

  The answer is yes, the new Allen is really her child. The medications that we prescribe don’t change children’s personalities; they simply free kids up so that they can be themselves. A brain disorder disguises a child’s true nature and hampers his abilities. Medicine lets him use his assets.

  Children with brains that don’t work quite right are like kids whose thermostats are out of whack. They’re always a little colder than everyone else. The other kids are running around in the sunshine in shorts and T-shirts, but the child with the disorder always has on a bulky sweater, mittens, a scarf, perhaps even a coat. Because he’s weighed down by all the extra clothing, the child with the disorder finds it difficult to run and play with the other kids. He looks different. He tends to stand on the outskirts of the activity, away from the others. He knows how to run and play, of course, but it’s a lot harder for him to manage than it is for his peers. When this child takes the medication that repairs his thermostat, he’s finally able to take off the coat, the mittens, and the extra layers. Unencumbered, he can run faster and play more vigorously, more happily, than he did before. He seems different, and in some ways he is different.