Jessica Holland watches as her 4-year-old son, Avery, throws himself uncontrollably onto the kitchen table several times before she stops him. His pediatrician recommended medication for Avery's attention-deficit hyperactivity disorder and "oppositional" behaviors, but Holland resisted. Sacramento Bee/Lezlie Sterling

Pills or patience

More children are being given drugs for behavioral and emotional problems

By Dorsey Griffith -- Bee Medical Writer
Published 2:15 a.m. PDT Sunday, June 23, 2002

First of three parts.

From fidgety preschoolers to anxious teenagers, American children are being prescribed mood-altering drugs more often, at younger ages and in increasingly complex combinations, a three-month Bee analysis has found.

In just five years, the number of prescriptions or refills doubled for stimulants such as Ritalin for attention-deficit hyperactivity disorder (ADHD) in patients younger than 18.

The same is true for antidepressants, according to data evaluated for The Bee by the federal government, which collected it from doctors' offices and hospitals in 1995 and 2000.

Yet most psychiatric drugs -- developed for adults -- do not carry the U.S. Food and Drug Administration seal of approval for all children, whose brains, bodies and coping skills are still developing. Even with new government-created financial incentives to test drugs for children, research is outpaced by the medicine marketplace, which churns out and aggressively advertises new psychiatric drugs.

A backlash is building, from suburban dining rooms to statehouse hearing rooms. One bill making its way through the California Legislature would require a parent's signed consent before stimulants could be prescribed for children with ADHD. Several states have passed laws limiting the role schools play in recommending medication.

Caught in the middle are parents of troubled kids. Eager to address their children's problems, they face wildly differing views on the role of medication and confront a dearth of scientific information on its safety and effectiveness.

Some parents feel they have no choice but to medicate their children; others will try anything else.

Jessica Holland of Sacramento was told by her son's pediatrician that 4-year-old Avery might benefit from medication for his attention-deficit hyperactivity disorder and what his psychologist labeled "oppositional" behaviors.

ADHD, Holland knew, is a disorder where kids act impulsively and have trouble focusing. Kids with oppositional behavior, the psychologist told her, are unwilling to conform to others' demands.

True, Avery has been booted out of seven preschools, kicked holes in the walls at home and once urinated on another child. But Holland does not believe her son has mental problems.

"I am adamant about not putting him on medication," she said in March. "I don't believe in drugging kids. I think I just need parenting instruction."

The range of opinions about the role of psychiatric drugs is as broad as the array of available medications. At one extreme are groups such as the Citizens Commission on Human Rights, founded by the Church of Scientology. It distributes bumper stickers that read "Psychiatry Kills," characterizes psychiatrists as "pushers" in its literature and promotes legislation curtailing the role of schools in psychiatric evaluation of children.

At the other end of the spectrum are people such as Russell Barkley of the University of Massachusetts. An ADHD expert, Barkley has responded to the backlash with an "international consensus statement" signed by more than 75 scientists that blasts critics of the disorder. The statement argues that ADHD is real and that medicine works.

And then there are other mental health experts, who agree that drugs help many children with behavior and emotional problems, but acknowledge major gaps in knowledge about how the drugs work and whether they circumvent children's ability to learn to cope without them.

None of that appears to be slowing the use of psychiatric medications in young people.

Even the experts don't know precisely how many children are taking psychiatric drugs, although one study in Virginia found 12 percent of elementary students were receiving medication to treat ADHD alone.

The National Center for Health Statistics tracks "drug mentions" that occur during a hospital or office visit when a doctor provides or prescribes a medication, or orders it refilled.

According to data the national center tallied for The Bee, between 1995 and 2000 mentions of antipsychotics and antianxiety drugs surged the most, more than tripling for patients under 18.

Mentions of antidepressants such as Prozac and Paxil more than doubled in the five-year span. That doubles an already record high: Prescribing of antidepressants jumped four-fold between 1990 and 1995.

Stimulants, the psychiatric drugs most often prescribed, were mentioned 5.3 million times in 2000, nearly twice as often as they were in 1995. Part of the growth in stimulant prescriptions stems from the popularity of Adderall, an amphetamine approved in 1996 for ADHD and aggressively marketed ever since.

Although stimulants would seem to be the last thing parents would give hyperactive children, the drugs actually stimulate the part of the brain that allows them to be more attentive, while putting the brakes on impulsiveness.

As another measure of the growing emphasis on medication, California spent $24.6 million last year on psychiatric drugs for kids covered by Medi-Cal, the state's insurance program for the poor -- a 32 percent jump over 2000.

In Sacramento County, doctors wrote nearly 5,000 stimulant prescriptions for children ages 5 and under in 2000, according to state Department of Justice records. That included 458 prescriptions for 2-year-olds.

Even the director of Sacramento County's Child and Family Services, Dr. Joseph Sison, was floored when he learned of the numbers last week.

"I am concerned about these 2-year-olds," said Sison, a child psychiatrist. "I wonder if everything has been tried before using medication."

The phenomenal increases only began to be noticed two years ago, with the wide publicity of a study highlighting a surge in use of psychiatric drugs in preschoolers. Around the same time, women's magazines began to feature advertisements for stimulants with pictures of young boys and messages such as "One dose covers his ADHD for the whole school day."

Pamphlets about the latest antipsychotic and antidepressant medications line the walls of child psychiatry offices. Doctors find they can prescribe from a dizzying selection of new medications for very specific symptoms, from fear of social situations, to an especially hot temper.

Herb Kutchins, author of "Making Us Crazy," a book that criticizes the criteria used to reach a psychiatric diagnosis, says that what passes today for a mental disorder used to be fairly routine childhood and adolescent behavior.

To be diagnosed with oppositional defiant disorder, for example, four or more of the following must happen frequently for at least six months: loses temper, argues with adults, actively defies or refuses to comply with adults' requests or rules, deliberately annoys people, often blames others for his or her own mistakes or misbehavior, is touchy or easily annoyed by others, is angry and resentful, is spiteful or vindictive.

"This behavior is a teenager," said Kutchins, a social work professor at California State University, Sacramento. "It's the monster everybody has to raise. If the kid is going to amount to anything, this is the least you can expect."

The disorder often is treated with clonidine, a blood pressure medication, as well as antipsychotics such as Zyprexa and Seroquel.

Kutchins is among those who believe the pharmaceutical industry is driving the treatment of such behaviors.

"As a drug becomes useful and popular, the disorder for which it is useful and popular gains currency," he said.

Barkley, the ADHD expert, argues that drugs are being used more because more is known about the nature of psychiatric illnesses and their treatment. For instance, scientists already have identified one gene associated with ADHD and are searching for more.

Sison, the child psychiatrist, said criticism of child psychiatric treatment is discrimination that would not occur if the child had a disease such as diabetes.

"The brain is like any other organ in the body," he said. "Something can go wrong with it."

Jessica Holland has her doubts. She believes that her son, Avery, acts the way he does because of her own chaotic lifestyle and shortcomings as a parent.

A 26-year-old single mother, Holland has bounced from apartment to apartment, leaving failed relationships and staying with friends while trying to save up for a permanent place. In the midst of the frequent moves, she has maintained her full-time job as a credit union debt collector, but Avery has tried and failed in preschool after preschool.

Holland and Avery's father, who cares for him part time, do not agree on how to handle their son's aggression. Holland tries to keep him on a strict sugar-free diet, but she said Avery's father will buy him bubble gum. Holland's own family criticizes her for "raising a monster."

Holland's response to Avery's diagnosis was to build her own kit to cure him. She bought two books: "Back in Control: How to Get Your Children to Behave" and "Unraveling the ADD/ADHD Fiasco." She picked up soothing lavender oil for Avery's bath, lavender lotion and a bottle of herbal supplements that claim to enhance mental concentration.

But she worries that her home remedies won't make up for the deficits in their home life. "Your environment has a lot to do with your behavior," she said.

One theory about the increase in use of behavioral drugs is that kids and their parents can't cope with the mounting stresses of modern life.

Los Angeles psychologist Jack Wetter, former director of pediatric psychology at UCLA Medical Center, said kids are "over-programmed" with too many activities and too much homework. "These kids burn out very quickly and then they turn off, tune out or go into illicit drugs," he said.

At the same time, schools are adopting zero-tolerance policies for unconventional behaviors, said Pam Wright, a psychotherapist who edits an online newsletter for parents of children with special needs.

"No one sits down and talks with the kid and uses (these behaviors) as a learning experience," she said. "I think we are at risk for trying to come up with a simplistic answer."

Lew Mills, a Bay Area family therapist who specializes in ADHD, said psychiatric diagnoses and treatment may be appropriate now for problems that were not disabling in the past.

"Five thousand years ago dyslexia wasn't a problem because there wasn't reading," he said. "Being in a society where people are expected to organize tasks and get things done ... makes ADHD an impairment in a way that it would not be an impairment in a tribal or hunter-gatherer civilization."

Mills backs his conclusions with personal experience: He himself takes medication for attention-deficit disorder, as do his two children, ages 9 and 16.

Some parents welcome a psychiatric diagnosis. When Michael Nalewaja was struggling in school, his mother found a label reassuring.

Michael was very withdrawn. He didn't make eye contact, rarely raised his hand to respond to a question and lacked reading comprehension and spelling skills. He was not a candidate for the prestigious gifted and talented classes at his Carmichael school.

When the boy reached third grade, his pediatrician diagnosed him with anxiety and attention deficit disorder -- or ADHD without the hyperactivity. At first, the family "welcomed it as 'Thank God, there is a reason my child is not GATE,' " said Kelley Nalewaja. But the third day Michael was on Ritalin he became wild, throwing things, threatening to kill his sisters.

A psychologist later determined that Michael had been misdiagnosed -- he did not have ADD after all. He was, nevertheless, put in special education with a modified program which, his mother said, "made him appear very successful. In reality, I have a 12-year-old son with a fourth-grade education."

Today, Michael takes no medication and is home-schooled with the help of a teacher and regular curriculum, including eighth-grade math. Next fall he'll go to a Catholic school. His mother has joined the chorus critical of psychiatric drug therapy for most children.

Resisting the pressures to medicate a child diagnosed with any psychological disorder can be difficult, as Jessica Holland found out during her first parenting class at Kaiser Permanente's psychiatric facility in Sacramento.

She listened as parents of children with ADHD and other disorders shared the latest war stories from home: The boy who can't sleep alone at night, the girl who pulls people's pants down, the girl who pees on the floor.

Holland could not hold back. Tears streaking her cheeks, she blurted out, "My son kicks holes in walls. He stomps on toys. He's on me, and he weighs 70 pounds. ... I don't like to be around him."

All eyes turned toward her. Kaiser psychologist Joe Riddle suggested she pick winnable fights with Avery, then use timeouts to enforce simple rules. Other parents chimed in with examples.

Gradually, the discussion turned to medication. Holland remained opposed, saying her son is not sick. "Are we giving medication because it is going to make our lives easier, or because it is making his life easier?" she asked the group.

Parents peppered her with responses:

"It helps them with friends."

"It helps him focus."

"I did it when my daughter was 6. I wish I had put her on it at 3."

Added Riddle: "I think about medication if they are having a lot of failures. Medication gives them the control to think ahead a little."

But even Riddle and others who regularly refer children to physicians for prescriptions acknowledge that the information used to diagnose the disorders is not always thorough, consistent or accurate.

Relatively few children have access to comprehensive psychological or psychiatric examinations and follow-up treatment, which can be costly and often are not covered by health insurance.

Part of the problem is a lack of child psychiatry services, particularly in California, said Dr. Mark Edelstein, president of the California Academy of Child and Adolescent Psychiatry.

"When people call me and say, 'Can you recommend a child psychiatrist ... for a behavior or mood problem,' I have trouble coming up with somebody," Edelstein said. "The child psychiatrists that I know and respect the most often have long waiting lists."

The result: Most children with mental health problems are seen and treated by pediatricians or family-practice physicians, who often have scant psychiatric training and too little time to assess and treat the disorders, said Edelstein.

Cathy Hollister considers herself one of the lucky ones. Her son, Clint, was referred to a pediatric neurologist when he was 6. He had been jerking his head and rocking back and forth, signs of a tic disorder known as Tourette's syndrome.

Clint was later diagnosed with associated ADHD and obsessive-compulsive behaviors. He rarely stopped to think, for example, about the consequences of throwing a ball at his sister, or using profanity.

One by one, the drugs were prescribed. Today, Clint, a wiry fifth-grader with bleached blond hair and a fascination with comic books, takes pills three times a day. He takes Metadate CD, an extended release stimulant for the ADHD; Neurontin, an antiseizure drug, to stabilize his mood; Risperdal, an antipsychotic, for the tics; and benztropine, usually a Parkinson's drug, to counteract the potential side effects of the Risperdal, including tremors.

By conducting research on the Internet, Hollister learned that three of the four drugs never have been approved for use in children, and that they were being prescribed for problems other than those for which they originally were developed.

But Hollister has concluded that medications reduce a child's chances of school failure and help prevent the scariest consequence of untreated mental problems in kids: suicide.

"No parent wants to put their kids on medication if they can help it," she said. "If he didn't take medication, he wouldn't be able to be in a regular classroom. ... The medication makes it easier for him to live with himself, to form friendships and not drive other people away."

Like Cathy Hollister, many parents are forced to choose between two unknowns: What will happen to the child who does not get medical treatment, and what might happen to the child who relies on the drugs, especially over the long term.

A review in the Journal of Child and Adolescent Psychiatry in 1999 found long-term safety had been established in only one of eight categories of psychiatric drugs used in children and adolescents: stimulants.

Even then, "long-term" usually means about 12 months, rarely the extent of time a child is treated with stimulants.

"This thing has shifted from being a childhood disorder to a lifetime disorder," said Andrew S. Rowland, a former NIH official who studies ADHD. "Some may be on these drugs their whole lives."

Scientists at the University at Buffalo in May reported that in tests in rats, methylphenidate -- the generic form of Ritalin -- appeared to spark lasting changes in brain function.

In addition, many children are being diagnosed with more than one disorder and prescribed a multitude of drugs to treat their various symptoms. One recent study at the University of South Dakota indicated a five-fold increase in the combined prescription of stimulants and another psychotropic medication between 1993 and 1998.

Safety studies on use of more than one drug at a time are rare and difficult to do.

UCLA researcher Dr. James McGough is in the midst of conducting one on the combination of stimulants for ADHD and Luvox -- one of a newer class of antidepressants noted for having relatively few side effects -- for anxiety in children over age 7.

Yet, McGough asks, "How do you assess what one drug is doing versus the other?"

Similarly, parents have no way of assessing whether drugs are the best -- or only -- answer for their child's problems.

"Right now, we have information on medication, on behavior therapy or other psychotherapy, but we don't have direct comparison between the two, so it's not clear which one should be selected first," said Dr. Benedetto Vitiello, chief of the Child and Adolescent Treatment and Preventive Interventions Research Branch of the National Institute of Mental Health.

Results from a study that compared treatments for ADHD are ambiguous. While it found that medication alone worked better than non-drug therapy alone, it also found that drug doses could be lowered if combined with non-drug therapy.

Deborah Beidel, a University of Maryland psychology professor, is studying two approaches to social phobia, an anxiety disorder increasingly being treated with antidepressants such as Prozac.

Beidel is comparing Prozac with her own behavioral treatment program, proven to help children overcome social anxiety. From a practical perspective, she said, if Prozac turns out to be effective, "that would be great, because it could help children who don't have access to behavioral interventions."

As a countervailing force, some legislators are trying to slow down the prescribing. A Minnesota law clarifies that a school cannot penalize parents for ignoring recommendations that they give their child psychiatric drugs. A Connecticut law bans school officials from even suggesting psychiatric medication for children.

In California, Sen. Ray Haynes, R-Riverside, has two such bills. SB 1290 would require a doctor to get written consent from a parent before prescribing a psychotropic medication for ADHD.

The other, SB 1289, originally would have barred school employees from recommending the use of psychotropic drugs for students. That bill recently was watered down; it now would require the state merely to study how often schools are recommending drugs and what results teachers are noticing.

Yet in some cases, overwhelmed parents conclude that the best way to get help from schools is to get a diagnosis, which often leads to medication.

Jessica Holland was nearing that breaking point. She had rented her own apartment, but because of that expense could not afford full-time child care for Avery, who was spending his days with a family friend.

"He's getting so out of control," Holland said. "Nobody wants to be around him."

By late spring, she found herself thinking the previously unthinkable: Would putting a name to his problems and starting treatment help qualify Avery for special public schooling?

So, Holland did what she had vowed never to do: She called Riddle and asked him for a diagnosis, the first step toward medication. He mailed her a letter with the diagnosis of ADHD and contacted Avery's pediatrician, who a day later called Holland to discuss treatment.

Adamant that Avery not take Ritalin, Holland agreed instead to try Dexedrine, an amphetamine.

"I need to get him to be more willing to work with me," she said. "I don't know that this is going to be the answer either."

Holland watched the pharmacist remove the bottle of pills from a locked cabinet of controlled substances. She felt guilty about the prospect of giving her son "speed."

For four days, the medication stayed sealed in its bottle. "I was afraid," Holland said.

When Avery awoke on Saturday, Holland put the capsule on his tongue and held a glass of juice to his lips. She told him it was a vitamin. Then she cried.