It's Nobody's Fault (11 page)

“Oh, we’ve had him looked at,” the mother said.

“Yes, the psychiatrist said he needed drugs, but we don’t believe in them for kids,” the father added.

“I believe you should reconsider,” countered the principal. “If your son had a vision problem, you’d get glasses, wouldn’t you? You wouldn’t just expect him to
squint.”
The parents showed up in my office the following week.

Most very young children in treatment for a brain disorder hardly give a thought to the fact that they have to take medication on a regular basis, except perhaps to regard it as a minor inconvenience. However, as kids get a little older, they may become embarrassed or even ashamed about needing medicine. Many children don’t want their friends to find out. They’re fearful that what happened to a 14-year-old boy I treated will happen to them: when he told his friends he was taking medicine, they laughed at him and called him “Psycho.” No one ever said that children are overly sensitive to the vulnerabilities and shortcomings of their peers. Kids can be brutal sometimes. They can also be remarkably supportive, especially if a good example is set for them. Children follow the lead of the significant adults in their lives—Mom, Dad, teacher. If the adults treat taking medication as perfectly normal, children will usually follow suit.

Each child is different, of course, but in general I find nothing wrong with a child’s desire to keep his illness and medication private, provided that the child truly understands and appreciates that there’s nothing wrong with taking a medicine that fixes the brain. The way I explain it is that people, grown-ups as well as children, aren’t always educated about these kinds of disorders. They don’t understand what makes people sick and why they need medicine to get well. That’s why they call people names and say silly things that hurt other people’s feelings. Perhaps it
is
better not even to tell them about it. Besides, it’s none of their
business. A visit to any doctor is a private matter. Many of the kids I treat with medication never even mention it to their friends and classmates. Others are very open about it. The decision about how to handle this should be made by the parents, the child, and the psychiatrist.

Children, even very young ones, usually find it easier to accept the fact that they take medication if they understand their disorder and accept some responsibility for taking the medicine. One of my colleagues says that when he prescribes medication, he makes a speech to his young patients that goes something like this: “This is
your
medicine. It is not your mom’s medicine. It’s not your dad’s medicine. It is not your teacher’s medicine. It is your medicine, and it’s going to make you feel better. It will help you stop worrying all the time. Even if you don’t always want to, you have to take it every day, so I want you to know the name of the medicine. It’s called
Zoloft.
I don’t want you coming in here next time and telling me that you take little blue pills. I want you to tell me you take Zoloft. And I want you to know how much you are taking, when you take it, and what it’s doing for you.” Involving a child in his own treatment in this way helps to remove the stigma.

Not all mental disorders should be treated with medication, of course. Sometimes the recommended treatment is psychotherapy, and most often a combination of medication and psychotherapy is the solution. The psychotherapy I recommend most strongly for children and adolescents is behavioral therapy, which is characterized by its direct, supportive quality. In this kind of therapy we target specific symptoms and goals, and every aspect of the treatment is geared toward minimizing symptoms and achieving those goals. This is not psychoanalysis. We don’t try to unearth trauma and repair it. We don’t “regrow” the child. We focus on getting rid of a child’s symptoms and improving his ability to function. This kind of therapy may involve relaxation techniques (which include deep breathing and visual imagery), behavior modification, parent counseling, and family therapy. A child’s problems aren’t just a child’s problems. They affect the entire family.

Medication should be prescribed only after careful diagnostic evaluation. Just as antibiotics are prescribed for bacterial infections but not
for viruses, the medicines I prescribe are effective only for specific disorders.
Diagnosis drives treatment
is one of the most important maxims of any physician. Before any treatment begins, a physician must make a diagnosis.

Parents have to make it their business to understand their child’s disorder and the recommended treatment by asking questions. Here are a handful of drug-related questions that any child and adolescent psychiatrist should be prepared to answer when prescribing medication:

• What is the diagnosis?
  

• What is the medicine, and how does it work?
  

• Have studies been done on the medication?
  

• Which tests need to be done before my child starts the medication?
  

• How soon will I see an improvement?
  

• How often will his progress be monitored, and by whom?
  

• How long will he have to take the medicine?
  

• How will the decision be made to stop it?
  

• What are the negative side effects of the medicine?
  

• What will happen if my child doesn’t take it?
  

Doctors won’t be able to answer all of the questions with precision, of course. “How long will he have to take the medicine?” is an especially hard one. Adults who take medication for high blood pressure can never be sure how long they’ll have to keep taking it. With diet and exercise and a lot of luck perhaps they can discontinue the medication after six months or a year, but it’s also possible they’ll have to take it for the rest of their lives. Regular checkups with the doctor tell the tale. The same goes for children’s brain disorders. Many kids need medication for an extended period of time; others thrive without it after a short “trial.” Regular evaluation and monitoring of a child’s progress will tell the physician and the parents what they need to know.

Careful, individual
titration
is also vital to the treatment; the prescribed dose of any psychiatric medication given to a child may have to be adjusted, perhaps many times, before we get the results we’re looking for. Too often a child is given a dose of a medicine that is not sufficient. When the behavior doesn’t change and the child doesn’t get better, it shouldn’t be assumed that the drug isn’t working. The child may simply need a little more of it.

The answer to another question, “Have studies been done on the medication?” may not be what parents want to hear. We have several ways of gauging the effectiveness of a medicine. The simplest is the
case study
method, in which we follow the progress of one case. We give a child medicine, see what effect it has on certain symptoms, stop the medicine, see what happens, and then start it again.
Open clinical trials
are more sophisticated. We take a group of kids with the same disorder, give them all the same medicine, and measure their progress after six weeks. The gold standard of tests is the
placebo-controlled double-blind trial
We choose a fairly large group of children with the same disorder—96 children from ages 8 to 18 who have major depressive disorder, for instance—and give half of them medication and half of them a placebo. Neither doctor nor patient knows who is getting what. That’s why the study is called
double-blind.
After eight weeks we measure and compare the progress of both groups.

Unfortunately we do not have placebo-controlled double-blind trials for many of the drugs we routinely prescribe for children’s brain disorders, but this doesn’t mean that a child or adolescent shouldn’t take them. It does mean that both parents and physicians should be careful to examine all options before starting a child on any medication.

Here’s how one mother reacted to the changes in her son that were brought about by medication: “When Allen takes his medicine, he’s so much quieter than he was before. He seems to listen to me a lot more carefully, and our conversations are much deeper and more enjoyable. He’s practically a different person. I hate to admit it, but I like him better when he’s on the medicine. He’s more in tune, more attentive, more interesting. What worries me is,
Is this really my child?”

The answer is yes, the new Allen is really her child. The medications that we prescribe don’t change children’s personalities; they simply free kids up so that they can be themselves. A brain disorder disguises a child’s true nature and hampers his abilities. Medicine lets him use his assets.

Children with brains that don’t work quite right are like kids whose thermostats are out of whack. They’re always a little colder than everyone
else. The other kids are running around in the sunshine in shorts and T-shirts, but the child with the disorder always has on a bulky sweater, mittens, a scarf, perhaps even a coat. Because he’s weighed down by all the extra clothing, the child with the disorder finds it difficult to run and play with the other kids. He looks different. He tends to stand on the outskirts of the activity, away from the others. He knows how to run and play, of course, but it’s a lot harder for him to manage than it is for his peers. When this child takes the medication that repairs his thermostat, he’s finally able to take off the coat, the mittens, and the extra layers. Unencumbered, he can run faster and play more vigorously, more happily, than he did before. He seems different, and in some ways he is different.

The real question is: Who’s the
real
child—the unhappy, sluggish one swathed in sweaters or the carefree, gleeful one running around in his shirtsleeves? As far as I’m concerned, there’s no contest; the one without the sweater is the child as he is meant to be. He’s the one who’s functioning properly. He pays attention in school, interacts well with his friends, and, like the new Allen, has a fruitful, fulfilling, loving relationship with his parents. He’s the one with a real chance for a happy, healthy life.

Once in a while parents give undue credit to their child’s medicine. That was certainly the case with the mother and father of 12-year-old Libby. “I remember the first year we sent Libby to camp after she started taking her medication,” her father told me. “When we went to see her for Parents Day, she seemed very subdued. All the other kids were running around, but she was quiet. I said to my wife, ‘It’s the medicine that’s making her like this. What are we doing to our child?’ My wife looked at me with a funny expression on her face and said, ‘She didn’t take the medicine today. She knew we were coming, so she didn’t take it.’”

“What will this medicine do to my kid?” is almost always the first question that passes any parent’s lips, and it’s a good one. If a child with a fever takes too much Tylenol, it may cause inflammation of the kidneys. The ampicillin that cures a child’s ear infection often causes diarrhea. All medicines, including those prescribed for children’s brain
disorders, have side effects, and parents should know in advance what to expect. (Specific medications and specific side effects are described in Part Three, which covers individual disorders, and summarized in
Appendix 3
, Psychopharmacology at a Glance.)

However, parents should also be mindful that the adverse effects of
not
taking a drug are often far more unpleasant than the possible side effects of taking it. The long-term effects of an
untreated
brain disorder—distress, low self-esteem, dropping out of school, unsatisfying interpersonal relationships, and many others—can be truly devastating.

Little Billy, a seven-year-old child with a brain disorder—attention deficit hyperactivity disorder—comes to me in severe distress and obvious dysfunction. He’s inattentive, hyperactive, agitated. He can’t focus on anything in school, and he drives everyone crazy with his obnoxious behavior. His teacher doesn’t like him; the other kids don’t want to play with him; even his parents find his behavior intolerable. He’s the only one in the class who doesn’t get invited to the birthday parties. He’s not learning anything, and he’s not having any fun. With the correct dose of a stimulant he can focus in school and follow the lessons. He can play with his friends and go places with his parents.

To be sure, the stimulant may cause a decrease in little Billy’s appetite, alter his sleep patterns slightly, or cause an occasional headache. But without the stimulant this child is heading for trouble that’s a lot more serious than a headache. To me the choice seems clear: the child needs the medication.

A colleague of mine says that the most important task that children have is to choose the right parents. Carefully chosen parents not only accept their children’s assets and deficits; they also do whatever is necessary to make sure that their kids have plenty of opportunities to use their assets and are given whatever help they need to compensate for those deficits. That’s what parenting is all about.

A child’s brain disorder is not a parent’s fault, but finding the right treatment for the disorder is a parent’s responsibility. If a son is diagnosed with diabetes, it is a parent’s job to give the child his medication, work out a proper diet, and give him the moral support he needs to keep
himself well. If a daughter has an allergy, a parent should make sure she takes her shots, keep the house allergen-free, and offer moral support. The same rules apply to a brain disorder. A parent’s job is to find the right treatment, work with the doctor and the child to implement it, build the child’s self-confidence, and make the child’s life easier along the way. Often the right treatment will include medication.

There are hundreds of thousands of success stories associated with pediatric psychopharmacology. “We got our life back” and “We finally could think about having another child” and “It was a miracle” are the kinds of comments heard every day from parents whose children’s lives have been turned around by medication. Like Adam’s parents, who took their child to a therapist 750 times before deciding to give medicine a try, they probably don’t
like
the idea of giving a child medicine, but they like it a lot more than the alternative. The story that Margaret’s parents tell, which describes a journey from despair to optimism, sums it all up.