It's Nobody's Fault (10 page)

In a perfect world we would be able to zero in on a specific chemical in a particular synapse and make the change that’s needed, but the drugs available to us aren’t advanced enough at this point to treat a specific disorder. The brain is complex, and very few medications are “clean”; that is, when a patient takes a drug, it is rare that the level of only one brain chemical is affected in only one part of the brain. If a drug we prescribe affects serotonin, it will affect the serotonin everywhere in the brain, not just in the areas of the brain that are responsible for a child’s compulsions or his depression. A drug that affects dopamine levels won’t work its magic just on the area of the brain that is responsible for schizophrenia; it affects all the parts of the brain that use dopamine.

Brain disorders aren’t “clean” either. We often encounter
comorbidity
,
a situation in which children have two or even more brain disorders at the same time. For example, attention deficit hyperactivity disorder may be
co-morbid with
conduct disorder; separation anxiety disorder is often
co-morbid
with major depressive disorder; and obsessive compulsive disorder is sometimes linked with Tourette syndrome. To complicate matters even further, brain disorders often involve more than one neurotransmitter, and there is interaction among the neurotransmitters; when we change the level of one, it may have an impact on the others. These neurotransmitters don’t react in a vacuum. Increasing the brain’s level of serotonin may, as a side effect, decrease the level of dopamine.

Unfortunately, much of what we know about brain chemistry can’t be diagnosed with blood tests, X rays, or other tools. If there’s something wrong with a child’s liver, we can give him a local anesthetic, use a long needle, do a biopsy, and find out exactly what the problem is. There’s no such thing as a routine brain biopsy; that procedure would be far too drastic for these purposes. Still, there has been some progress in the field, largely in the
neuroimaging techniques
, which give us new insights by allowing us to examine certain physiological and chemical processes that take place in the brain basically by producing three-dimensional images of the brain.

Neuroimaging techniques have helped us reach an important conclusion: there are brain abnormalities in adults who have brain disorders. Although studies of children and adolescents are in the very early stages, there is already reason to think that they have brain differences too. These techniques can also be very useful in helping us understand how the brain works and especially how various medicines affect the brain’s function. For all of their value, however, neuroimaging techniques are not used for diagnosis. For diagnosis the best tool always has been and probably always will be behavioral observation. No matter how many tests a child undergoes, we base our diagnosis on a child’s history and his behavioral symptoms. These tools allow us to diagnose a brain disorder as precisely and as reliably as physicians diagnose diabetes and hypertension.

The fact is, there is a lot of information about the brain that we don’t yet have. We know that children with psychiatric disorders have a chemical imbalance in the brain that is caused by a genetic abnormality, but we don’t know what the specific abnormality is. And we don’t know
precisely
why
these medicines work. We just know that they
do
work. That’s nothing new to medicine, of course. Digitalis has been around for hundreds of years. We’ve been using it for heart attacks for decades, but until relatively recently we had no idea why it works. We just knew that it did.

A
ccording to his mother, 10-year-old Adam had always been a “difficult child.” When Adam and his parents came to my office for the first time, I learned that the little boy had been seeing a psychologist three times a week for five years. That’s roughly
750 sessions.
Adam was still having serious trouble with his behavior. He wasn’t doing well in school, and he didn’t have any friends to speak of. I asked the parents what had taken them so long to bring their child to a psychiatrist.

“Well, Adam’s psychologist has been telling us for several years that he probably needs medication for his attention deficit hyperactivity disorder, but we were afraid to do it,” the mother replied. “We thought that it would change his personality,” added the father. “And besides, we don’t like the idea of medicating a child.”

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.

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.”

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’ve 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.