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Parents of children with emotional or behavioral problems sometimes have opposite reactions when their doctor recommends a mood-altering medication for their child. Some refuse to consider it, while others have reached the point where they'll try anything.
The use of psychotropic medications in children has indeed become more commonplace but no less controversial. Hundreds of thousands of teens and children as young as preschoolers take Prozac® or some other type of antidepressant. Also, as many as 1 million American children every day take Ritalin®, a little yellow pill that has become one of the most popular drugs to treat attention-deficit/hyperactivity disorder (ADHD).
While these medications help treat children with psychiatric problems, many parents have concerns, including whether the medications are right for their child, if the drugs will work, and what the side effects and long-term effects are.
"Research indicates medication can be quite effective for some children but certainly not for all children," says David G. Fassler, a Vermont child and adolescent psychiatrist and former chairman of the American Psychiatric Association's Council on Children, Adolescents and their Families.
Fassler and many other child psychiatrists caution that medication should not be used as a quick fix of problems. Psychotropic drugs can help certain children if combined with other types of therapy, such as individual or family counseling, according to experts.
Also, a child's age can be important in determining if medication is right. Most medications are not approved for very young children, even though some doctors still prescribe them for children younger than 5.
Parents need to be advocates
How do parents know whether a psychotropic medication might be right for their child? If their toddler is like a perpetual motion machine and unable to sit through a "Barney" episode, is he or she a candidate for Ritalin? Similarly, if a 14-year-old turns moody, spends a lot of time in his or her room and loses interest in hobbies or sports, is an antidepressant the right treatment?
The key is getting a good diagnosis. The National Institute of Mental Health (NIMH) urges parents to watch for behavior changes and to learn to differentiate them from signs of more serious problems. All children act out at times and moodiness in a teenager isn't uncommon.
Diagnosing ADHD and depression isn't as simple as taking a throat culture to see if a child has strep throat. And treating these mental conditions isn't as easy as dispensing an antibiotic for an ear infection. Furthermore, the medications available to treat emotional and behavioral problems are not cures. They control symptoms and often help people cope better, experts say.
The NIMH says parents should seek help if the problems are severe, persistent and impact daily activities. Some examples include changes in eating and sleeping habits, social withdrawal, increased irritability or agitation, erratic and aggressive behavior, missed school or poor school performance, a tendency to be easily distracted or forgetful, an inability to sustain attention, or self-destructive behavior such as drug and/or alcohol abuse.
A child's age is an important consideration in diagnosing ADHD. For example, it is normal for a 2-year-old to behave hyperactively, to constantly explore the environment and to be incapable of sitting through a meal. However, a 5-year-old who can't sit still long enough to get her teeth cleaned at the dentist's office may be abnormally hyperactive.
Treating ADHD
The primary symptoms of ADHD include:
- Inattention: Children who are inattentive have trouble concentrating or completing routine tasks that may be difficult.
- Hyperactivity: Children who are hyperactive have trouble sitting still. They always seem to be in motion.
- Impulsivity: Children who are impulsive seem unable to curb their immediate reactions or think before they act. They may have a hard time waiting their turn, grab a toy from another child or hit others when they are upset.
Four psychostimulant medications, including methylphenidate (Ritalin®, Concerta® and Metadate®) and amphetamines (Dexedrine®, Dextrostat® and Adderall®), are commonly used to treat ADHD. A newer medication, atomoxetine (Strattera®), is available to treat ADHD and may be as effective as stimulant medications. This medication is not a stimulant. Daniel J. Safer, an associate professor of psychiatry at the Johns Hopkins University School of Medicine and co-author of a study that found a rise in the use of antidepressants and Ritalin in preschoolers, says about 75 percent of children on medication for ADHD respond well. However, he and other experts agree the drugs are most effective when combined with intensive behavioral therapy, such as counseling, family therapy or support groups.
Safer and other experts caution results of long-term studies aren't available on the safety of Ritalin and other ADHD medications. "There is concern about the effect on the developing nervous system," he says. And in February 2007, the Food and Drug Administration (FDA) directed all manufacturers of approved ADHD medications to create patient Medication Guides to alert patients to possible cardiovascular risks and risks of adverse psychiatric symptoms associated with the medicines.
 Strattera may cause severe liver injury, according to a warning from the Food and Drug Administration (FDA). This warning is based on two reports of liver damage in a teenager and an adult who had been treated with the medication for several months, both of whom recovered.
The FDA is also alerting doctors and patients about reports of suicidal thinking in children and teens taking Strattera. Children and teens taking this medication should closely monitored for worsening of their ADHD, agitation, irritability, suicidal thinking or behaviors and unusual changes in behavior, especially during the first few months of therapy or when the dose is changed (either increased or decreased).
When is it depression?
Clinical depression is more than having a bad day or coping with a major loss such as the death of a parent or grandparent or favorite pet. Children suffering from depression can't just "snap out of it."
Persistent sadness and hopelessness, withdrawal from friends and activities once enjoyed, increased irritability, lack of enthusiasm or low energy, drug and/or alcohol abuse, and thoughts of death or suicide are all red flags of depression.
Most newer antidepressants are not labeled for pediatric use. For the treatment of depression, sertraline (Zoloft®) is approved for children 6 years and older, and fluoxetine (Prozac®) is approved for children 8 years and older.
These drugs raise brain levels of the mood-regulating chemical serotonin. Experts say they are safe and help many depressed teens, but no one is sure if using the drugs early in life may affect the development of the central nervous system.
There has been considerable debate about whether antidepressants increase the risk of suicidal thinking in children and teens. Due to these concerns, in 2004 the Food and Drug Administration issued warnings that recommended close watch for mood and behavior change that might be indicative of suicidal thoughts in young people taking antidepressants. In 2007, those warnings were expanded to include people ages 18 to 24. Talk to your doctor immediately if you are concerned.
"These newer antidepressants have substantially fewer side effects than the older ones, but I don't think they are benign," says Graham Emslie, M.D., a psychiatry professor at the University of Texas Southwestern Medical Center in Dallas, who tested the effectiveness of Prozac and Paxil in two studies, one in children ages 8 to 18 and another in teens ages 12 to 18. "If they were benign - that is, completely free of side effects - then why would it matter if people took them or not?"
Emslie says one concern he has is that more pediatricians and family physicians are dispensing antidepressants for children who are depressed. A misdiagnosis can have serious results. For example, a child who has an underlying bipolar illness and not just depression is at greater risk of developing mania on an antidepressant.
As with any behavioral or emotional problem, Emslie and other experts say depression is best diagnosed by a specialist and treated with a comprehensive plan that may include psychotherapy, ongoing evaluations and monitoring or psychiatric medication.
"Medication alone is rarely an appropriate or sufficient treatment," Fassler says. He and other child psychiatrists offer this advice for how parents can help their troubled child:
- Get professional help. Seek out the most appropriate clinician who has training and experience in evaluating and treatment for the kinds of problems your child has.
- Educate yourself so you can understand a clinician's diagnosis and the treatment options.
- Beware of therapists who either push drugs immediately or dismiss them completely.
- If you are uncomfortable with a particular recommendation, get a second opinion.
The National Alliance on Mental Illness, a self-help and family advocacy organization solely dedicated to improving the lives of people with mental illnesses, has a toll-free number that parents can call: 800-950-6264.
This article was reviewed and updated June 2007.
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