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Medication Nation

By Judy Lin

Published Oct 1, 2007 8:00 AM

An estimated 5 million American children and adolescents take drugs such as Ritalin, Prozac and a host of other medications to treat behavioral, mental and learning disorders. Some say the drugs don't help and can even make things worse. Others claim the medicines are life-savers. Still others worry that their children are being used as guinea pigs. One thing is for sure: parents have a tough call to make, with no easy answers.

Kate and Joe Miller want their 7-year-old son, Sam, to have friends, to enjoy school. But the other kids make fun of him. He thinks he's not smart. He hates school. He draws pictures of his school blowing up.

Sam can't pay attention. He barely made it through first grade, and he's still struggling in second. He can't keep up with his schoolwork. In class he talks and fidgets, gets up and wanders around the room.

His parents (whose names, along with their son's, have been changed for confidentiality) had Sam tested for a learning disability. None was found. So they hired a tutor. It didn't help. Finally, they took their son to a psychiatrist who concluded that Sam is "highly distractable" and needs medication.

The Millers were shocked. The last thing they want to do is give their little boy drugs. Joe is adamantly opposed — and angry — at the very idea of medicating Sam. Kate is starting to wonder if it might help.

"Sure I worry about the side effects [of psychiatric drugs]," she says, "but I'm fearful about his future. I want him to have confidence. I just want him to be happy."

The Millers' hopes for their child are universal, of course, but unfortunately, so is their plight. An estimated 5 million American children in the U.S. today are on psychiatric — also called psychotropic — drugs. The brand names, by now, are household names: Ritalin, Adderall and Concerta for attention-deficit/hyperactivity disorder (ADHD). Prozac, Zoloft, Paxil and Wellbutrin for depression. Plus an assortment of other brand and generic medications to treat a wide range of behavioral, mental and learning disorders in children and adolescents.

And it seems that for every prescription, every worried parent and every little pill, there is an emotional and often heated opinion.

Some concerned parents, support groups and other critics are convinced that psychiatric drugs don't help and can actually hurt kids, arguing that children are being misdiagnosed and even experimented on by doctors and drug companies. Other parents and medical professionals are equally passionate in their belief that psychiatric medications are effective, even essential, in relieving debilitating conditions. In fact, proponents of this point of view say, too few kids are getting the medications they desperately need, due to fear and inadequate medical care.

Then there's the "drugs need scientific study" stance, which says psychotropic drugs have their place but need strict scientific testing. And there's the "something's got to be better than drugs" appeal that psychotherapy or even herbal remedies are the real answer to kids' psychological problems.

One thing is for certain: There are no easy answers, and the issue may be as painful for parents like the Millers as it is for the kids themselves. At UCLA, researchers and clinicians who work with troubled kids and their parents face the consequences and moral quandaries of a medicated nation every day. And they are committed to finding answers, because it's personal for them, too.

"Certainly among scientists that work in ADHD, there's clear evidence that medication is effective," says Susan Smalley M.A. '81, Ph.D. '85, a UCLA research geneticist whose lab is a world leader in using gene mapping to isolate the genetic origins of ADHD. But Smalley is a parent of three kids as well as a scientist, and even she admits, "I don't like to give my kids any kind of medication."

The Cons

America's apparent love affair with prescription drugs — per-person prescriptions rose from an average of seven in 1993 to a dozen by 2004 — has a lot to do with all the dosing we do to our kids, and it's far from a healthy trend, claims Greg Critser M.A. '83, author of the book Generation Rx: How Prescription Drugs are Altering American Lives, Minds, and Bodies.

"Today the expectation is that pills can and will do everything," he writes, "from guarding us against our excesses to increasing our children's performance at school." What's more, he says, "young people who've been on medication for years may begin to discount their own ability to begin to modulate the rhythms of their lives."

Indeed, psychiatric prescriptions for children and adolescents nearly tripled from 1987 to 1996 — from 1.4 to 3.9 prescriptions per 100 persons, according to the Journal of the American Academy of Child & Adolescent Psychiatry. Groups such as the Alliance for Human Research Protection accuse doctors of "abusive, haphazard" prescribing of drugs for children. They point to a rapid rise in the diagnosis of ADHD as evidence that the disorder is no more than an invention of doctors and drug companies.

Whether or not that's true, the drug-prescription trend certainly is fueled by advertising aimed directly to consumers, says Dominick L. Frosch, assistant professor at UCLA's David Geffen School of Medicine. A decade ago, the Food and Drug Administration (FDA) changed the guidelines regulating advertising by pharmaceutical companies directly to consumers. That unleashed a tidal wave of drug messaging, mostly on television, which is so ubiquitous it has become part of popular culture. Frosch did a study on these ads and concluded they are "persuading Americans that they are sicker than they really are and in greater need of medication."

The Pros

"The major risk that we face with patients with depression is untreated illness," says psychiatrist Andrew Leuchter, director of the Division of Adult Psychiatry in the Semel Institute for Neuroscience and Human Behavior at UCLA. "By far and away, the biggest risk of suicide comes from untreated depression — not from the use of medications."

Evidence of the effectiveness of psychiatric medication is well documented, experts say. Take Ritalin, for instance, a psychostimulant that's been used for nearly four decades to treat many of the estimated 5 to 10 percent of kids who suffer from attention-deficit/hyperactivity disorder (ADHD).

James McCracken, director of the Division of Child & Adolescent Psychiatry at UCLA, points to a decade of research supporting the efficacy of medication. "I think the important news that has come through," he says, "is that a number of treatments are highly effective for a range of both common and severe mental disorders in children," including ADHD, depression, anxiety, autism and related disorders.

The confidence that physicians have in psychotropic meds can be seen among students seeking treatment at UCLA's Student Psychological Services. Many students arrive on campus with a history of taking these drugs, says Director Elizabeth Gong-Guy M.A. '79, Ph.D. '85.

"For primary care providers and pediatricians diagnosing psychiatric disorders," she says, "the first line of defense often is medication. That's what their training dictates and what insurance more easily covers." (She notes, however, that the counseling center opts for non-drug therapy before meds.)

Yet some students, upon first arriving on campus, abruptly stop their meds, Gong-Guy says. "Suddenly they don't have their parents putting their pill next to their juice in the morning. They want to try without it."

The consequences of this may play out in the classroom where, she says, faculty members are often the first to see students "who are not only in distress, but who are distressing." Students nodding off in class or behaving in strange ways may signal a problem with skipped meds, for example.

Psychologist John Piacentini, director of UCLA's Child & Adolescent OCD, Anxiety and Tic Disorders Program, empathizes with parents' fears about medications yet urges an open mind.

"The many parents of kids with OCD and other conditions are very concerned about medications but these conditions can be very impairing," he says. "Some of the stories we hear on the phone from families contacting us for the first time — it's just horrible. They're desperate."

"I think it's a disservice not to use medication when we know a kid is really suffering," says Smalley. "And I think it's really problematic that our culture has a bias that it's bad to use medication in kids, because I've seen the flip side, the tremendous effect medication can have on reducing a child's suffering. Yet we all need to recognize that even if a medication is used, it is not a panacea."

The Undecided

And then there are those who claim that our rush to medicate is premature. They point to the fact that some meds have been red-flagged by the FDA. Earlier this year, the FDA warned of a potential link between ADHD meds and the risk of sudden death among users 18 and younger with a history of heart defects.

Drugs for depression have also raised concerns. In 2004, the FDA required "black box" labeling on antidepressants, warning consumers of an increased risk of suicidal thinking among school-age users. A second warning was issued this year for young adults 18 to 24.

In fact, researchers found that while antidepressant sales dropped following the FDA's 2004 warning, youth suicides actually increased. Gail Griffith, who had served as patient representative to the FDA advisory committee that recommended the labeling, was quoted in a statement by the American Psychiatric Association, "I hoped the FDA could help to inform patients, but it seems many parents have simply become fearful of antidepressants, which so often are the life jacket preventing us from being sucked under by depression's powerful undertow."

Yet the truth is that few scientific studies have been conducted on drugs prescribed to children. Most of the drugs prescribed to kids are done so by doctors extrapolating from information about drugs approved for use in adults.

"Children aren't small adults," says Edward McCabe, physician-in-chief at Mattel Children's Hospital. "Their metabolism is different and they react differently to drugs than adults do."


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Hence, he adds, "We don't [prescribe medication] lightly. There's a tension between applying the therapeutic technology that's available versus being sure that one is practicing safe pediatrics."

McCabe played a role in advocating for the Best Pharmaceuticals for Children Act, passed by Congress in 2002, which aims to enlist the pharmaceutical industry in testing whether drugs already approved for use in adults also work in children. It also mandates that all new drugs for kids be directly tested on kids, which, not too surprisingly, has drawn some fire. But McCabe poses the question, "Is it better to place [children] at risk in a controlled setting than in an uncontrolled environment?" He opts for the former, so much so that he has established a clinical trials program in his pediatrics department to expand research.

"The last 10 or 15 years have been nothing short of a revolution," says psychiatric researcher McCracken. "We've taken the scientific method and applied it to research on what treatments work and are safe for children with serious psychiatric disorders. We're at an exciting time where we're beginning to think about what a truly comprehensive treatment approach can and should be."

One promising piece of research is being led by depression expert Leuchter, addressing a problem common with antidepressants: For two-thirds of patients, the first drug prescribed doesn't work, and it can take months or even a year or more of trial and error to determine the most effective antidepressant for a particular patient. Leuchter's multi-university study, Biomarkers for Rapid Identification of Treatment Effectiveness in Major Depression (BRITE-MD), is aimed a developing a simple test: applying five electroencephalogram (EEG) sensors on a patient's forehead to measure brain patterns that might predict whether or not a particular medication is working. Initial findings suggest that this biomarker is highly predictive of antidepressant success.

The Drug-Free Promise

Even if the drugs do work, there are many who feel that approaches like therapy and changes in discipline at school and at home can do the job just as well. UCLA researchers couldn't agree more.

"We are very interested in developing educational or cognitive therapies — non-medical therapies — that could augment medication," says McCracken, who notes that ADHD medication fails to materially improve the lives of about four in 10 kids who take it. Similarly, psychotherapy used in tandem with medication has been clearly established as the best treatment for depression, says psychiatrist Leuchter.

McCracken and Piacentini are conducting multifaceted studies comparing medication, cognitive behavior therapy and other non-drug treatments, alone and in combination.

To learn how to best treat the social, generalized and separation anxiety disorders common among children and adolescents, these researchers are teaming up with their peers at other universities in the Child/Adolescent Anxiety Multimodal Treatment Study of 490 children. Their research will try to isolate which kind of child benefits most from which kind of treatment.

Another promising new approach is Mindful Awareness Practices. UCLA psychiatrist Lidia Zylowska, with Smalley's lab, is researching the use of this meditation-like training to help children and teens with ADHD. In a pilot study, teens reported improved ADHD symptoms, decreased anxiety and depression and improved ability to pay attention. Mindfulness also helps ADHD individuals better accept themselves and their struggles, Zylowska adds.

These forms of treatment may even help strengthen brain functioning, thanks to the brain's "neuroplasticity." Research on meditation, for instance, shows evidence of changes in EEG patterns and in the cerebral cortex, including areas involved in attention.

"There may be very powerful results when you learn self-regulatory tools like meditation or exercises like attention and memory training," says Smalley. "They may really change normal growth and gene expression. I think that we are at the tip of the iceberg, that what we learn for the next 50 years is going to radically alter what we know about how to 'self-regulate' our biology, including gene expression." But she cautions that, right now, "we tend to put more research into medication and fine-tuning medication and not as much in the psychosocial and alternative approach, including examining the culture in which we raise our children. For the 21st century, what we really need to be working on is prevention."

And as the science develops, the Millers, and millions of other parents, hope for more clarity, more reassurance and more reliable help for their kids. Kate has talked to other moms about their experiences and continues to search for more information.

"We're now looking for a new psychiatrist to do additional testing," she says. "We haven't committed to a drug plan. The therapist agrees. The pediatrician says yes, I'm willing to prescribe, but I want to look at all the information. One psychiatrist said, 'Oh, it's the common cold of kids these days. Your pediatrician is used to prescribing them.' That was not a good thing to hear, not really."