Children and Antipsychotics: Medicate or not?

by Karoli on June 14, 2006 · 10 comments

[Comments are now closed - 8/18/2006]

The controversy continues, and goes on… Although I have not been faced with the prospect of medicating Sticks with any sort of antipsychotic medication, the dilemma for parents of ADHDers and whether to take stimulant medications is the same, and as usual, there is much more heat than light being cast on the debate.

This week’s burst of hot light is a bloggy battle of sorts between WebMD’s Dr. Parker and Dr. Flea, another pediatrician blogger that I read.

Dr. Parker

Because of his extreme symptoms and a positive family history, I had always been suspicious that Billy was manifesting, at an unusually young age, symptoms of Childhood Bipolar Disorder. So, reluctantly, I started Risperdal (one of the newer antipsychotic medications).

His mom described the difference as ‘miraculous’. Billy’s hyperactivity, aggressiveness, and disruptive behaviors became quite manageable.

and asks:

Frankly, I struggle with these questions every time the issue of using psychiatric medications comes up (which is more and more often!). I don’t see any easy, pat answer to the good news/bad news question. For better or for worse, I take it case by case and weigh the pros and cons as best I can.

Anyway, I hope I’ve at least highlighted for you the complexity and importance of what is at stake. This is an issue and a debate only likely to grow in intensity and importance over the next years. Your thoughts?

Dr. Flea

Finally, Parker pays lip service only to the concern that there may be something wrong with medicalizing complex psychiatric and psycho-social problems:

Are we too quick to default to medications as the first line of treatment? Could this trend reflect an easy way out for a society facing a critical shortage of mental health professionals for children?

For Parker the question is rhetorical and his answer, clearly, is ‘no’. Now that the famous Dr. Parker, the Spock protege, has drunk the Kool-Aid, what hope is there for the rest of us?

Dr. Flea’s comment
on Dr. Parker’s entry was also interesting and actually provoked ME much more than his blog entry did:

You chemically tamed this boy, and you made him fat. And you’re pleased with this outcome?

My Response

First, to Dr. Flea:

Before I framed this reply, I searched Dr. Flea’s blog to see if I could discover what his position was on medicating children for ADHD and bipolar disorder. I found no posts on bipolar disorder; 10 on ADHD. Each and every ADHD post that I read revealed a clear anti-medication standpoint, but I saw no constructive ideas for alternatives. Evidently Dr. Flea believes that stimulant medications for ADHD are evil, but hasn’t really presented other options for managing it.

Here’s the problem with that approach: As a parent, we are given the responsibility to feed, clothe, and educate our children. But those are just the basics. Most parents that I know want their kids to grow into successful, happy, productive adults who contribute some small good thing to the world.

When our child is born, we don’t gaze upon them and say to ourselves, “This one is hyper and should be medicated”. We just love them with all our hearts. As time goes by, there are behaviors and patterns that emerge that give us pause and more to the point, begin to gnaw at the child himself. When other children won’t play because he’s too rough, when other parents exclude him from the play dates because he’s loud and won’t stop running around the house hassling everyone, when babysitters and daycare employees ask you politely not to bring him back, there are cues and clues. In our case, Sticks was a very happy, yet very, very hyper child who was confused by the rejection he was experiencing.

The realization that something is wrong dawns over time. I could launch into a litany of all the reasons that ADHD began to hit our radar screen at about age three, but what I’d really like for Dr. Flea to consider is that we brought the problem to our doctor, not the other way around. We went looking for answers to questions that we couldn’t find answers for, and brought concerns that were weighing heavily on us, because it was not just a behavior issue at that point — it was a family issue that threatened Sticks’ self-esteem and mental health as well as our own.

Had we been dismissed out of hand with our concerns, told that he was just being three, told that he would “outgrow” it, we would have had to become hermits, because we were at a point where our entire family was not welcomed — even at some family gatherings.

Honestly, if our pediatrician were as dogmatic as Dr. Flea seems to be, I’d be shopping for a new doctor.

Turning now to Dr. Parker, I see that his patient also brought the problem to him. And rightly so — any child staying awake for 72 hours as a toddler would be a cause for concern! I’m amazed that the single mom had even a shred of sanity left. It seems to me that there was an atmosphere of concern about doing what was right for the child, even if it meant the risky business of trying rather strong medications for him at a very early age.

As a parent, I would be very apprehensive about my child taking antipsychotic medications (as we were when faced with stimulant meds). I think that it also weighs on any doctor who prescribes them.

Dr. Parker asked for thoughts on this issue. I’ve blogged this before, but will reiterate again here. I think it’s important that before these medications are prescribed, the parents know what all of the alternatives are, why they’re being prescribed, what they can expect, and why the doctor feels this is the best option available. I think that they should be prescribed only after the doctor is thoroughly familiar with the child and that the doctor should have experience making such diagnoses. The single mom in Dr. Parker’s case study is fortunate that Dr. Parker has experience with kids who have psychiatric as well as physical problems.

The only thing I would have done differently as a parent would have been to have the diagnosis confirmed by a pediatric psychologist familiar with symptoms of childhood bipolar disorder and/or ADHD. That may not have been an option available to her.

Doctors, as a concerned parent I am asking you to please keep your minds open and all options available. Parents depend on their doctors to understand what steps they need to take medically for their children’s health. Don’t be dogmatic — be open to the possibility that our kids might need these medications.

By the same token, let your decision be guided by your expertise and understanding of the patient, and not what the latest, greatest medication is or an off-the-cuff diagnosis. Much of the backlash that I see toward medicating kids for ADHD comes from the fact that the diagnosis is often made too quickly.

And one final question to anyone reading this — If doctors cannot be supportive of other doctors’ decisions in this regard, how can parents possibly understand what the right thing is?

(ps to Dr. Flea: I highly resent the term “chemically tamed”. My child wasn’t a beast to be tamed and neither is this one)

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  • Dr. Deb

    There is a larger issue here. A psychiatric or psychological concern in a young child should *always* result in a referral to a specialist. The problem with healthcare in the US is that there no longer is a community minded approach in treating patients. A thorough evaluation would take the guess work out of this case. Medication is a wonderful treament option, and one that I endorse wholeheartedly. For anyone to prescribe “despite being unsure of his diagnosis” is reckless. Doesn’t the saying go “First Do No Harm?”

  • drumsnwhistles

    Dr. Deb –

    I agree with you in principle, but reality is entirely different. As I said in my entry, that would be the one thing I as a parent would want to do. However, I speak from personal experience when I say that it works better in theory than it does in practice.

    For starters, it’s difficult to find pediatric psychiatrists. If you are a single parent with no money, you might as well get in line and hope for the year 2021. I was fortunate – I had the money to pay out of pocket for the psychiatrist, because my insurance company wasn’t going to honor my primary provider’s referral.

    Dr. Parker’s bio indicates that he is the director of behavioral and developmental pediatrics, so that would indicate that he must have a pretty solid background in psychiatry as well as medicine.

    The psychiatrist that evaluated Sticks came right out of the box with the statement that diagnosing ADHD and/or bipolar disorder was, at best, guesswork, based on input from a number of sources. Unfortunately, there’s not a blood test that will tell us for sure…

    As for the lack of community-mindedness with regard to treating patients, lay that one right at the feet of the insurance companies, who much prefer to underpay primary physicians at the expense of specialties and encourage their insureds NOT to seek specialists.

  • Donna

    Beautifully written post, DnW.

  • Dr. Deb

    If you visited my blog, I think you’d see that I take meds myself, and a very pro medication. Dr. P being a chief of “developmental pediatrics” is in no way the same as being a psychiatrist. I agree that healthcare in the US is terrible in many respects – but local universities, local clinics and even specialists like myself will see individuals and families at no cost (pro bono) or at low cost. It is important for health care professionals to work together in a community. I endore that seriously and I practice in that way too. What my concern was that by Dr. P’s own admission, he was unsure of a diagnosis. A specialist should have been called in – that would have been in the patient’s best interest, it would have been ethically and morally correct. As a parent of an ADHD child as well, I know that meds work. As a professional who treats ADHD and Bipolar issues, I know how life changing meds can be. But never, ever should meds prescribed without a diagnosis.

    Thanks for the opportunity to express my thoughts here.


  • Dr. Deb

    Oh, one more thing…..diagnosis of ADHD or Bipolar disorder in children is not guesswork. There are psychological tests and scales that are used to secure the diagnosis.

    Thanks again for letting me express this info.

  • drumsnwhistles

    Dr. Deb –

    I appreciate your comments and they’re welcome any time. I hadn’t read your blog till you posted last night, then I went and read through your entries for the last couple of months, so I am now more familiar with you than I was when I responded to your first comment.

    I agree with everything you said with regard to community. Perhaps Dr. Parker did consult with someone, though it is not clear in his post. It seems to me that his primary point in blogging this topic at all was to highlight the dilemmas faced by doctors when working with a very young child with serious behavioral problems. Yet instead of really looking at those issues, many simply smacked at him for prescribing without a consultation by a pediatric psychiatrist (or psychologist, for that matter).

    Should the practice of medicine be more communal? As a patient, I heartily answer with a resounding “YES”. I can’t speak for the medical profession, but there are areas of specialty within my own field where I would much prefer to refer clients out to the specialists than try to handle it myself, and I do refer as a matter of routine.

    Why isn’t community more routine within the practice of medicine? That’s probably a topic for another blog post by someone more qualified than I to answer. From my vantage point, practices are so tightly controlled by what insurance will and will not pay, what specialists are and are not approved, and what conditions will be covered, that it’s almost a science unto itself.

    Sticks and I were referred by our primary care doctor to one of the best area specialists in childhood ADHD. As I mentioned, the referral was not honored by the insurance company despite the fact that this doctor was on their approved list. Ultimately, they DID approve it, but only after the suspected diagnosis was changed from ADHD to depression. Why the bias?

    I write this to share some of the problems we have in the diagnostic process. What if I were a parent who had no discretionary funds to pay out of pocket for such an evaluation, yet had too much to qualify for free services (the wonderful middle class…)? There are times where our pediatrician is a lifeline and parents would simply be hung out on a line without any help if it weren’t for them.

    I guess what I’m trying to say in an awkward way is that this is an imperfect system inside of an imperfect world, and as parents, we’re doing our best to do our best for our kids. Sometimes we need help, and we take what’s available. I’m grateful for pediatricians who listen and take me seriously.

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  • liz

    Here I’m wondering about differences in differing areas. Example: I have a dear friend who lives in a western state. Her child has neurological challenges (don’t want to go into details) very similar to those of a friend’s child who lives in my town. The children have faced *very very* different treatment options. The Western State friend has had virtually zero support for her child’s education and behavior management. As a result, the child, although quite bright, has had nearly no education. The Neighbor friend’s child is enrolled in community college.

    Dr. Flea is in the Northeast — in Mass, I suspect. He is resisting the “medication will solve all problems” mindset. There are school districts with huge numbers of kids referred for medication, when the real issue is weak parenting skills and weak classroom management.

  • David Harmon

    My own experience shows both sides of the issue. I got Ritalin for what’s now called ADHD through elementary and middle school, and it did indeed help a lot. But when it stopped working around 12-13, then they put me on Thorazine, — telling both Mom and me that it was an “anti-emetic”! I then spent much of my adolescence in a tranquilized haze….

  • drumsnwhistles

    Hi David,

    Thanks for coming and commenting! Your story is awful…I cannot imagine what possessed any doctor to move from Ritalin to Thorazine. I did a brief stint while in college at the local VA hospital with vets medicated on Thorazine, and it’s powerful stuff.

    I’m glad you stopped by — your story deserves to be heard!

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