Tamera Ellis rattles off the names with the ease of a pharmacist: Prozac, Imipramine, Tegretol, Ritalin, Dexedrine. Each is a powerful medication that can have broad effects on the brain.
By age 6, her son had tried them all.A decade ago, psychiatrists rarely prescribed anti-depressants and other psychiatric medications for young children. But in recent years, the ground has quietly shifted. Now some elementary-age children take anti-depressants and anti-anxiety medications.
Occasionally, medicines such as Prozac are prescribed to children as young as 4.
Some of these children are seriously ill, psychiatrists and neurologists say. At the extremes are children so destructive they cannot be left alone - children who clearly need whatever help therapy and drugs can provide.
But the same experts say that some of the children holding out their hand for a morning pill have been misdiagnosed. These children might benefit equally from therapy, or might with time simply outgrow their behavior problems.
Doctors say managed care is encouraging the rush to medicate by pressuring them to choose drugs over more time-consuming alternatives such as talk therapy. Even some who strongly support the use of these medications worry that things may have gone too far.
"We've gone from one extreme to another," said Jarrett Barnhill, director of a developmental neuropharmacology clinic at the University of North Carolina-Chapel Hill. "Before, it was all therapy and no medication. Now there's a risk that it will be all medication and no therapy. It's almost as if the pendulum is swinging out of control."
While doctors sort out this rapid shift in practice, parents considering psychotropic medication for their children are left to negotiate an often bewildering world of difficult, scary choices.
When Tamera Ellis first sought medical help for her son three years ago, she was desperate. She and her husband had endured years of stress after their baby girl was born with handicaps requiring 13 surgical operations. On the heels of that trauma, her son began suffering fits of rage almost daily.
The first-grader would come home from school, fling his book bag across the room and start screaming, his mother says. Shaking and crying with rage, he smashed windows, broke toys, ripped down curtains and blinds, and threw things at his mother. His fits would sometimes last hours, and when Ellis asked him why he was so angry, he couldn't say why.
Nightmares and night terrors tortured his sleep.
"He'd tear up stuff, fight you," said Ellis, 28, who lives in Durham, N.C. "He was bouncing off the walls."
A doctor diagnosed attention deficit disorder with hyperactivity and prescribed Ritalin. But the stimulant medication, commonly used for children with attention problems, backfired. It made the child irritable. Dexedrine, another stimulant, made the child moody.
Next, the doctor tried Prozac, an anti-depressant. Suddenly, as if he had fallen down the rabbit hole with Alice, the boy began hallucinating. He saw bears in the trees, snakes and rabbits on the floor, shoes on his head.
Finally the boy was switched to another anti-depressant, Imipramine. That plunged him into a deep depression.
"Nothing was working," Ellis said. "It seemed like the more we tried, the worse he was getting."
Eventually, Ellis sought a second opinion. The new doctor, Duke University pediatric neurologist Robert DeLong, had a new diagnosis. The child was suffering not only from attention deficit disorder, but also from seizure equivalent syndrome, he said. He prescribed an anti-seizure medication, Tegretol. Later he also suggested a stimulant, Cylert, to help combat the attention deficit problems.
Finally, something worked. The boy is often tired now. But there are no more hallucinations and fewer tantrums. Ellis is so convinced the new medicine helps that even though she has no insurance, she scrapes together enough money each week to buy more.
For Ellis, there was a clear lesson in her son's ordeal: If you question the effect a medication is having on your child, get a second opinion, she says.
Psychiatrists say it's not unusual to see children who are taking the wrong medicine or who who should not be taking any at all.
These diagnoses are not happening in a vacuum, though. Many physicians say managed-care companies, with their emphasis on cost-effective treatment, are often pushing doctors to medicate.
Don Rosenblitt, a psychiatrist and medical director at the Lucy Daniels Preschool in Cary, N.C., recently saw a 4-year-old who was having violent temper tantrums. He thought the child's behavior was probably rooted in family problems. But when he described the situation over the phone, the managed-care case reviewer disagreed.
"They suggested using lithium, on the rationale that this child might have manic depressive illness," Rosenblitt said. "They strongly urged me to try the drug."
The reviewer, a child psychiatrist (Rosenblitt declines to name the doctor or the managed care company), had seen Rosenblitt's written reports about the case but had never seen the child. To him, the severe temper tantrums suggested early manic depression.
But Rosenblitt had spent months observing the child in his school's therapeutic day treatment program. He saw little evidence of manic depression. This child, he thought, did not need drugs. He refused the recommendation of the managed care consultant and continued to counsel the family. At that point, he says, the managed-care reviewer relented.
Doctors often face such pressure, according to Rosenblitt. He said he believes some children can benefit from psychiatric medication. Still, he expresses concern about an environment in which a managed-care representative who has never laid eyes on a patient feels free to question a doctor who has worked closely with a child.
Keith Conners, director of Duke University's attention deficit program, thinks medication could be valuable for some children. But he also thinks managed-care companies encourage the use of medication over other treatments.
"When your insurance will pay for four visits total to treat a complex problem like attention deficit hyperactivity disorder, giving medication is the only choice," Conners said. "Children are the big losers in the managed-care phenomenon. They are having their services unconscionably mangled."
Mike Lancaster, a child psychiatrist and regional medical director of Value Behavioral Health, acknowledged that many health care plans limit benefits for long-term psychotherapy unless shorter-term treatments have failed.
And yes, Lancaster said, he sometimes suggests medications when discussing cases with doctors. But the ultimate decision remains in the doctor's hands, he said.
Other forces also are driving the trend. Among them are the new drugs themselves, and fundamental changes in how mental illness is viewed.
When Raleigh psychiatrist Jeff Snow was in residency only five years ago, a taboo prevailed against prescribing psychotropic drugs to preschoolers. Now, like many child psychiatrists, Snow sometimes prescribes such medications for preschoolers, most often Ritalin. For older children, he sometimes prescribes anti-depressants such as Trazodone.
Two major shifts have reshaped child psychiatry since Snow was trained: changing views of childhood mental illness, and the availability of better psychiatric drugs.
"The view used to be that everything was caused by poor environments, bad mothers," said Conners, a professor of medical psychology at Duke. "Now it's swung back into more of a biological mode, and it's going too far."
For Tamera Ellis, things are better these days. Her son's medications seem to help, she says. Now 9, he has fewer outbursts, and the nightmares have calmed down. He no longer suffers terrible side effects.
But medication has not solved all the problems. Ellis has been helped by a parent counselor at a Durham group called Educare. She plans to seek counseling for her child as well.
Says Barnhill, "With a lot of kids, you can treat their depression, then they have to go back home and Mom and Dad are fighting every night. The drug can alter the child's reactive style. But it doesn't change the child's life.
(Distributed by Scripps Howard News Service.)