Middle ground on medicating kids

March 15, 2000|By Mark A. Riddle

A FLURRY OF media coverage in recent months has been fueling an old debate: Are we over-medicating children?

A recent study in the Journal of the American Medical Association (JAMA) reported that increasing numbers of preschoolers are being prescribed anti-depressants and stimulants, untested in children this age, to treat behavioral problems. Pundits and reporters cited the findings as further evidence that prescription practices have run amok. Can the press be faulted for sharing concerns published in a major scientific journal? Who could blame parents for wondering whether to administer the psychiatric medications prescribed for their own children?

Parents and children need balanced presentation of the most current research and clinical wisdom in this regard. Sadly, in the wake of such reports, we see young patients in Hopkins' pediatric emergency department whose anxious parents have confiscated their child's anti-depressants.

No one would argue the wisdom of protecting children from improper treatment. Some children with psychiatric disorders are misdiagnosed and over-medicated, just as some practitioners are more thorough and skilled in their diagnosis. More training for clinicians and medical students in behavioral and developmental disorders, as well as a higher quality of clinical services, would reduce abuses and miscalculations.

To trivialize psychiatric illness, however, or the suffering it inflicts, perpetuates the stigma felt by parents and children who would seek expert treatment, or have benefited from expert treatment. The goal in pediatric psychiatry is to do what is best for the child.

Psychiatric disorders are common in children and adolescents; are distressing to children and families; and are often severe enough to disrupt school, family life and social development. Autism, depression, panic attacks, obsessive compulsive and anxiety disorders, and even attention deficit and hyperactivity disorder (ADHD) are not normal variants of childhood, nor are they problems with temperament, morality or parental involvement.

These disorders are generally not eased or understood with affection, discipline, and instruction alone. They are legitimate chronic illnesses, like diabetes or asthma, and as such deserve expert medical care. Proper follow-up demands a comprehensive psychiatric/psychological evaluation, conducted by a clinician with adequate training and experience in the diagnosis and treatment of developmental and psychiatric disorders in children.

Ironically, for all the publicity surrounding the relatively small number of cases of questionable prescriptions of psychotropics (medications used to treat brain disorders), little attention has been given to the significantly larger problem of children whose disabling psychiatric issues are undiagnosed and untreated. Worsening social and cultural conditions for children are exacerbating pre-existing problems.

In the end, lingering questions of how best to treat legitimate, childhood psychiatric disorders will only be answered through long-term research. Critics of pediatric psychopharmacology often cite the lack of clinical studies on the long-term effect of medications on children as the best reason not to treat children pharmacologically.

At Johns Hopkins, we are rigorously examining psychotropics -- many of which have, to date, been approved only for adults -- to advise clinicians on the best medications and therapeutic approaches available. Our research unit at the Hopkins Children's Center is one of several funded nationally by the National Institute of Mental Health (NIMH) to evaluate the safety and effectiveness of psychotropics used in children. This summer, we will begin studying the long-term effects of psychotropics on children ages 3 to 17. Some significant mental disorders, including manic-depression, begin to incapacitate children as young as 3, so the attempt to treat them safely, as mentioned in the JAMA study, is understandable. With still a disproportionately small number of psychotropics yet tested for children, clinicians are often faced with the choice of estimating pediatric doses or withholding treatment altogether.

In our experience, children and parents have been grateful for the clinical treatment opportunities and successes provided by new neuroscience research. Psychiatric interventions, whether in the form or psychotherapy, drugs or a combination of both, are saving children, like adults, from needless, debilitating suffering.

Dr. Mark A. Riddle is director of the Division of Child and Adolescent Psychiatry at Johns Hopkins University School of Medicine.

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