The Question of Medicating Children Is Only the Tip of the Iceberg
A recent Washington Post story (Sunday, April 18, 2004) indicated that the use of antidepressants for children increased as much as tenfold from 1987 to 1996, with a further 50% rise between 1998 and 2002. This increase occurred even though “the vast majority of clinical trials have failed to prove that the medicines help depressed children.” The article also pointed out that the increase has been especially dramatic in children under age 6 and that there are no clinical trial data for children in this age range.
To find an explanation for this phenomenon, we need to look at its broader context. While most professionals advocate a comprehensive approach, we’re seeing a tendency to lead with medications as a solution for a child’s behavioral or emotional challenges. Many children I see for a second or third opinion have been put on medications without a thorough evaluation of family, school, and intrapersonal functioning, and are not receiving other, often-needed, therapeutic work, for example, to improve coping skills, family relationships, peer interactions, and/or schoolwork and learning. Some children clearly require medication as part of a comprehensive program and have benefited from the enormous progress in our understanding of the biology of various types of emotional challenges. Almost all children with challenges, however, require systematic attention to personal, family, peer relationship, and educational domains.
What’s behind the tendency of at least some parents and professionals to lead with medication, rather than a broader approach within which medication may have a limited role for some children? To answer this question, we need to look at the shift that occurred over the last 30-40 years in the way society thinks about children. Gradually, as a result of the important discoveries that have been made about the biology of the brain, a growingly hurried and complex lifestyle, and an increasing tendency to rely on non-family members to care for our children, especially in the early years (e.g., daycare), the very way we characterize children has changed. More and more, as much as we may protest to the contrary, we treat children impersonally.
For example, the tendency to lead with medication, rather than a more comprehensive approach, is in part the product of seeing children’s behaviors and emotions as similar to the programs on a computer. The “person” gets left out as we try to tamper with the programs to change this or that symptom, problematic emotion, or set of behaviors. The breakthroughs in the understanding of the genetics of mental illness have been misinterpreted to mean that genetics and biology alone can account for complex human emotional functioning and that, with the right medication, we can correct specific problems without having to work with the whole person.
This perspective has become more and more extreme with changes in research and training. For example, since the 1990s, the National Institute of Mental Health has focused much more on the biology of mental illness than on psychological, social, and developmental factors. Training programs in child and adult psychiatry have also shifted from a balance of biology and psychology to an over-focus on biology.
Prior to this shift in our picture of children (and adults) and mental health, research and training programs had a more humanistic view, one that now has nowhere near the influence it should. In this view, humans are seen as complex beings who perceive and attend to a wide range of experiences, engage in ever-growing and ever-deepening intimate relationships, and experience, comprehend, and express a range of deep feelings -- from love and dependency, to assertiveness and curiosity, to anger and rage. This view sees humans as capable of engaging intuitively in complex social interactions; forming a rich, symbolic internal world of feelings, thoughts, beliefs, and values; and learning to think logically, make sense of the world, interpret and evaluate their own feelings, and progress to very high levels of compassion, empathy, and reflection.
Obviously, a picture of children that includes their deepest feelings and coping capacities, as well as their creative and reflective thinking and empathetic abilities, would necessitate a comprehensive approach to childhood emotional problems. Such an approach might include medication in selected instances, as part of an overall program, but would not lead with medication to “fix” the child.
The impersonal view of children and ourselves that guides current mental health treatments can also be seen in educational and parenting approaches. For example, the current debate regarding the “No Child Left Behind” Act is not really about evaluating children or holding educators accountable (both of which can be very valuable), but about what, in children’s learning, should be evaluated, and what it is that educators should be accountable for. The view that we should focus tests on reading, and hold teachers accountable for progress only in a narrow area of learning gives, in my view, insufficient attention to thinking-based comprehension, reflective thinking, and social problem-solving skills. What’s most important to children’s education and most predictive of their future success is their ability to reflect on and understand what they experience and what they read and learn about. We can evaluate both reading and thinking, and hold educators accountable for both. We will only approach this more ambitious, but more meaningful, goal if we broaden our definition of what constitutes a healthy and well-educated child.
For children with learning disabilities and special needs, the narrow view of human development and learning results in testing the children on specific applied skills without evaluating the developmental steps that lead to this applied skill. In the case of some children, this has meant trying to get them to memorize the words they see without developing the underlying ability to understand what these words mean.
This preoccupation with the child’s appearance (i.e., the appearance of learning) also plays out in many approaches to changing children’s behavior, including the behavior of those with the most severe challenges. For example, frequently a child is conditioned to “look” at someone else, with no attention to whether the child wants to look -- and gain knowledge and information from looking and engaging with others -- or feels coerced to look and looks without interest, curiosity, or learning. The rote “looking” is hardly what we have in mind. Yet the majority of children with special needs in this country are still taught “basic compliant looking.” There is insufficient attention to the “person” who needs to learn to engage with others and become fascinated with the knowledge he or she can gain from interactions.
The controversy over medicating children, therefore, raises fundamental assumptions about what is a human being. Are we and our children like computers? Should we “change programs” through medication or narrow, surface-based educational and parenting approaches? Or should we re-engage with our heritage and continue to develop a deeper picture of what it means to be a person?
To find an explanation for this phenomenon, we need to look at its broader context. While most professionals advocate a comprehensive approach, we’re seeing a tendency to lead with medications as a solution for a child’s behavioral or emotional challenges. Many children I see for a second or third opinion have been put on medications without a thorough evaluation of family, school, and intrapersonal functioning, and are not receiving other, often-needed, therapeutic work, for example, to improve coping skills, family relationships, peer interactions, and/or schoolwork and learning. Some children clearly require medication as part of a comprehensive program and have benefited from the enormous progress in our understanding of the biology of various types of emotional challenges. Almost all children with challenges, however, require systematic attention to personal, family, peer relationship, and educational domains.
What’s behind the tendency of at least some parents and professionals to lead with medication, rather than a broader approach within which medication may have a limited role for some children? To answer this question, we need to look at the shift that occurred over the last 30-40 years in the way society thinks about children. Gradually, as a result of the important discoveries that have been made about the biology of the brain, a growingly hurried and complex lifestyle, and an increasing tendency to rely on non-family members to care for our children, especially in the early years (e.g., daycare), the very way we characterize children has changed. More and more, as much as we may protest to the contrary, we treat children impersonally.
For example, the tendency to lead with medication, rather than a more comprehensive approach, is in part the product of seeing children’s behaviors and emotions as similar to the programs on a computer. The “person” gets left out as we try to tamper with the programs to change this or that symptom, problematic emotion, or set of behaviors. The breakthroughs in the understanding of the genetics of mental illness have been misinterpreted to mean that genetics and biology alone can account for complex human emotional functioning and that, with the right medication, we can correct specific problems without having to work with the whole person.
This perspective has become more and more extreme with changes in research and training. For example, since the 1990s, the National Institute of Mental Health has focused much more on the biology of mental illness than on psychological, social, and developmental factors. Training programs in child and adult psychiatry have also shifted from a balance of biology and psychology to an over-focus on biology.
Prior to this shift in our picture of children (and adults) and mental health, research and training programs had a more humanistic view, one that now has nowhere near the influence it should. In this view, humans are seen as complex beings who perceive and attend to a wide range of experiences, engage in ever-growing and ever-deepening intimate relationships, and experience, comprehend, and express a range of deep feelings -- from love and dependency, to assertiveness and curiosity, to anger and rage. This view sees humans as capable of engaging intuitively in complex social interactions; forming a rich, symbolic internal world of feelings, thoughts, beliefs, and values; and learning to think logically, make sense of the world, interpret and evaluate their own feelings, and progress to very high levels of compassion, empathy, and reflection.
Obviously, a picture of children that includes their deepest feelings and coping capacities, as well as their creative and reflective thinking and empathetic abilities, would necessitate a comprehensive approach to childhood emotional problems. Such an approach might include medication in selected instances, as part of an overall program, but would not lead with medication to “fix” the child.
The impersonal view of children and ourselves that guides current mental health treatments can also be seen in educational and parenting approaches. For example, the current debate regarding the “No Child Left Behind” Act is not really about evaluating children or holding educators accountable (both of which can be very valuable), but about what, in children’s learning, should be evaluated, and what it is that educators should be accountable for. The view that we should focus tests on reading, and hold teachers accountable for progress only in a narrow area of learning gives, in my view, insufficient attention to thinking-based comprehension, reflective thinking, and social problem-solving skills. What’s most important to children’s education and most predictive of their future success is their ability to reflect on and understand what they experience and what they read and learn about. We can evaluate both reading and thinking, and hold educators accountable for both. We will only approach this more ambitious, but more meaningful, goal if we broaden our definition of what constitutes a healthy and well-educated child.
For children with learning disabilities and special needs, the narrow view of human development and learning results in testing the children on specific applied skills without evaluating the developmental steps that lead to this applied skill. In the case of some children, this has meant trying to get them to memorize the words they see without developing the underlying ability to understand what these words mean.
This preoccupation with the child’s appearance (i.e., the appearance of learning) also plays out in many approaches to changing children’s behavior, including the behavior of those with the most severe challenges. For example, frequently a child is conditioned to “look” at someone else, with no attention to whether the child wants to look -- and gain knowledge and information from looking and engaging with others -- or feels coerced to look and looks without interest, curiosity, or learning. The rote “looking” is hardly what we have in mind. Yet the majority of children with special needs in this country are still taught “basic compliant looking.” There is insufficient attention to the “person” who needs to learn to engage with others and become fascinated with the knowledge he or she can gain from interactions.
The controversy over medicating children, therefore, raises fundamental assumptions about what is a human being. Are we and our children like computers? Should we “change programs” through medication or narrow, surface-based educational and parenting approaches? Or should we re-engage with our heritage and continue to develop a deeper picture of what it means to be a person?
posted by Stanley I. Greenspan, M.D. at 3:29 PM
18 Comments:
My son (age 11, FAE) does really well with behavior management plans that control his environment and give him lots of structure and no stress. His emotional development is very delayed, but has been coming along steadily. His teachers have never strongly recommended medication, and his father and I have always found that he responded so well to the right behavioral techniques that meds weren't needed. But I've never met a professional who didn't want to dose him up, pronto. We went to a psychologist once who supposedly specialized in behavior, hoping to get some tips, and his advice was: If you'd just medicate him, you wouldn't have to deal with all this other stuff. And you know, I kind of want to deal with it.
If any other parents reading this are trying to do the hard work needed to raise kids without meds, I'd like to invite you to join an e-mail group I started, "Just Managing," at http://groups.yahoo.com/group/justmanaging/ . Meds may be the only solution for some kids, but with so many I think it just gets in the way of the work that really needs to be done. Join us and discuss.
I too have a son that I have been told needs medication by school officials and doctors. My son is 9 and has a diagnosis of Asperger's Syndrome. I am reluctant to medicate a child that at home is engaging, pleasant, witty, and intelligent. Why would I want to change that? I rather like him the way he is quirks and all!
At school he is a different child than the one I see at home. I try and tell the school that he has sensory issues that need to be addressed at school and they look at me as if his problems are all my fault and if I'd medicate him he wouldn't behave the way he does. It's all so frustrating. Does anyone have any good idea's on what to do with a child that freezes up at school but is fine at home? He has so many sensory issues such as sounds that bother him, other kids irritate him, food aversions, his need to constantly turn cartwheels, the list goes on forever... The fact that he scores in the 95th percentile on state testing and claims that school is boring doesn't even factor into the schools decisions on what to do with him. Their answer was to put him in a special education class for kids with behavior problems. I refused to allow this. Any suggestions would be appreciated. You can e-mail me at emanley@comporium.net
I am concerned about the trend of teachers and other school officials recommending psychiatric medications for children. I am a counselor working primarily with young children and I've seen dozens of cases where parents seek mental health treatment (especially medication) solely in response to teachers' concerns. Many parents seem to feel coerced into putting their children on psychiatric meds by teachers. Parents often come in with a particular "diagnosis" as well as requests for specific medications as a result of pressure from teachers. I think this is tantamount to teachers' practicing medicine without a license. Although I do value the work and wisdom of many teachers, I hope that they will--as a profession--hold themselves accountable to ethical standards which would preclude their giving advice that is outside the realm of their expertise. JFindling@Yahoo.com
To JFindling--I agree. As a teacher trainer, I emphasize that teachers must NEVER tell a parent that a child needs medication. They can share behaviors observed at school, ask the parents if they have seen the behaviors at home, ask the parents if they have tried anything that seems to work (sometimes parents have answers; after all, they know the kid best, right, Anonymous?), and then suggest that an evaluation might yield information that could be useful in providing an appropriate education for their child. The teacher's job is also to document the behaviors observed and the settings in which they occur. Many teachers neglect to provide adequate information to the evaluation team. Also, if a child is prescribed medication, it's important for the teacher to document noticeable improvements as well as behavioral and academic concerns. I've heard teachers say that medication turned a kid "into a zombie," yet they don't report that information to the parents and (with parental consent) the physician. How is a medical professional supposed to know if a kid is on the wrong medication or the wrong dosage without this feedback from the teacher? The child might be very different by the time she gets home from school than she is in the morning after she's just taken her medication. The parents might not see the problem.
Also, a quick note to parents: As an adult with ADD on medication, I used to think that everyone felt the way I did and just had better coping skills. I always felt I had a cloud in the front of my head. I know that sounds strange, but the cloud went away when I started taking medication. It's not a cure. I still deal with numerous ADD-related issues, but I feel much better physically on the medication and can think much more clearly. It's frustrating that it often takes a long time to find the right medication and dosage. I went through it. However, IF a neurological deficit is truly the cause, the world might seem like a much better place to be to your child if he or she has the appropriate medication. I know it's a challenging issue for parents. The media frenzy has made it worse, as have the inappropriate diagnoses that occur because of haphazard or nonexistent psychological evaluations by physicians. Well, I guess this didn't turn out to be such a quick note, but I did say I have ADD!
To Dr. Greenspan: Your comments about the sometimes meaningless learning we do with kids with special needs is fascinating. I give my college students (obviously not special needs, for the most part) some manipulatives and ask them how they would demonstrate adding 22 + 13. Very rarely will I have students who will do anything but make a group of 22 objects and a group of 13 objects and shove them together. After working with manipulatives for a while, some of them seem to "get" place value, regrouping, distributive property, etc., for the first time. They knew how to get the right answer but not why. They simply memorized a pattern. Because most of these millennial students were subjected to a whole language approach, when I ask them how many sounds they hear in "cat," many will say "one." Can you imagine the work that has to be done to get them ready to teach kids how to think about learning? And then we could talk about standardized testing--teachers feel compelled to teach the test because of the way NCLB is designed. Bravo to you for your efforts!
I worked in the mental health field for the last two years. I learned so much, especially how most parents abuse the system. Meaning some of the fanilies I worked with, were so quick to diagnose, without understanding the child as a whole. Parents called me hysterically saying, "my kid needs to be on medication." I would then go to the home, observe and write a biopsychosocial assessment of the family including the child. This was required by Department of Community Health. I worked with children primarily with developmental delays. The range was from mild attention deficit disorder to severe cerebral palsy. In conclusion, I worked with this amazing young boy age eleven. He was on about ten different meds. His parents opted for him to be on these meds because of his "dangerous personality disorder". The psychiatrist gave him a conduct disorder diagnosis. The case was handed over to me because other departments did not want it. The team leader and I went to the home. I was envisioning to see a dangerous kid. I walked in to the home and saw a sweet and calm kid.The father reported his son is too dangerous to be around the other siblings. We recommended another family temporary home. I kept observing this kid at school.. and at his grandmother's home. School reported he is a leader in the class and a gentleman. Grandmother reported no problems so far. I went back to my boss and said,"Why does this kid need to be on meds?" Yes, he has several deficits. Receptive and expressive, so he is limited in this way. So, then child protective services became involved.The psychiatrist would not answer any of my phone calls. I beleived if we all worked together, this kid would have some hope.Finally, with the support from the school, and me not giving up, the boy was gradually taken of his meds because he was no threat to his siblings or anyone.I do not have answers as to why this child were on these meds or where the fabrication came from, but most important, the boy is doing wonderful.
Dear Dr.Greenspan, some months ago I had a conversation with a senior psychiatrist who was taking a course in biomelecular medicine. She proudly explained to me how is the biomulecular explanation of attention deficits in children with ADD, so she said all of them should be on medication. She knew that I have been working with special need children and I very seldom use medication before thouroughly evaluate the child developmental and medical history, family back ground, also perform special neurological examinations including observation of sensory profiles and motor planning, then try to deal with factors that may interfere with the chid's ability to focus his attention and to behave at his age. Most of my clients have been doing well with this type of intervention, so I rarely need medication. Since in my country, Indonesia, it is regarded as impolite to argue against a senior, I just noded politely. However I wonder how come those doctors who learn about the brain at the molecular level could forget that human brains work in very complicated ways. Each parts of the brain connected both anatomically and functionally with other parts, each parts may react differently to the same neurotransmitters, also human knowledge has not found all of the neurotransmitters. In my opinion a finding of mechanism at molecular level should not be the only answer to a set of child behavior. By the way, I have read your books and practice a lot of your advices on working with my clients. I am looking forward to hearing your talk at the ICDL coference this coming November. I am a pediatrician, since I could not find satisfying answer nor good advice for my son who has mild motor control and perception problems, I took a summer course at the OT department of USC in 1995. Since then I have been working for children with developmental challenges and their family. d_komala_utama@yahoo.com
I am the mother of a seven-year-old active little boy. After my son started Kindergarten I began to feel pressure from the school counselor to put my son on Ritalin. I felt upset, I didn’t want my son to be on medication, nor did I want him to be labeled as a problem child. I went back and forth with the idea of medicating my son until I finally caved in. I decided to try the medication over the Christmas break so that I could see first hand if the medication could help him. He did horrible. Instead of the medication calming him it made him more hyper, and he was unable to go to sleep at a reasonable hour. After three weeks of this I decided to stop giving him the medication. It took about three days to clear out of his system, but after that he was back to normal. He was even able to go to sleep at his usual bedtime again.
After this experience the school counselor continued to try and convince me that my son needed to be medicated. The counselor said that it was impossible for my son to have been more hyperactive while on the medicine. I almost succumbed to the pressure of the counselor again. I am proud to say that I didn’t give in a second time. I am going to continue working with my son and teaching him rather than drugging him. Never again will I let someone convince me to do something that I don’t feel is right.
Dr. Greenspan,
You are one of the few psychiatrists who I have run across who take such a reasonable, conservative view to medication managment. As a psychologist who evaluates young children for mental health issues, I am distress at how often children are apparently arbitrarily diagnosed with very serious conditions, such as Bipolar Disorder (very young, even as young as 5 or 6), and then given very strong medications, without having been given a thorough assessment. Many of the parents I run across, who are often fairly dysfunctional or low-functioning, buy into this approach. I'm very conscientious regarding the need to be respectful of my psychiatric colleagues, but I must admit that it is difficult, sometimes, seeing this abuse of the medical model. It is so refreshing to read your comments, and see that there are psychiatrists that understand the role medication should play in treatment. Thanks so much!
Hi,
I was just looking around the net for web sites related to customer relationship and came across your blog. I was going to add a blog to my site, for customer relationship and of course other related material, but I'm not sure if it would work.
I'm a bit worried about getting un-wanted 'rude' posts rather than ones related to customer relationship on my site...... perhaps I just try it out - then you can come and post on it :)
Take care
Stewart
Many of our modern drugs have harsh side-affects and cost the “earth”, so the next time you come down with a cold or the flu or anxiety self help, why not try a gentle alternative that costs next to nothing?
Instead of immediately forking over large amounts of money for over-the-counter drugs, go to the kitchen cupboard and see what you can find to relieve your symptoms including anxiety self help.
Here are some helpful hints for anxiety self help …
A simple hot compress applied to the face is very soothing to those throbbing aches and pains of a blocked sinus, while a few drops of eucalyptus oil on a handkerchief can provide welcome relief for similar conditions. While supplements of vitamin C, D and zinc will shorten the lifespan of a common cold, a hot lemon drink is also extremely good. And be sure to cuddle-up in bed when you have a cold, as it will make the body sweat out the germs.
Cool lemon juice and honey are a great soother for a sore throat and gives the body much-needed vitamin C at the same time The juice of one lemon in a glass of water is sufficient. Melt the honey in a little hot water for ease of mixing.
A smear of Vaseline or petroleum jelly will do wonders for those sore lips and nose that often accompany a cold.
A 'streaming cold' where the nose and eyes water profusely, can respond to drinking onion water. Simply dip a slice of onion into a glass of hot water for two seconds, then sip the cooled water throughout the day. Half an onion on the bedside table also alleviates cold symptoms because its odor is inhaled while you sleep.
People prone to catarrh may find that chewing the buds from a pine or larch throughout the day will clear up their condition in just a few days.
Do you suffer from sore eyes? If your eyes are sore from lengthy exposure to the sun, try beating the white of an egg and then spread it over a cloth and bandage the eyes with it. Leave the preparation on overnight. Soft cheese (quark) is also a good remedy for this condition.
For those unpleasant times when you suffer from diarrhea, two tablespoons of brown vinegar will usually fix the problem. Vinegar can be rather horrible to take, but who cares! The problem is more horrible. Vinegar can usually be found in most people's cupboards, so you don't need to worry about finding someone to run to the shop for you in an emergency.
Sleepless? Instead of reaching for sleeping pills, which can quickly become addictive, try this: Drink only caffeine free tea or coffee starting late in the afternoon.. Go to bed earlier rather than later, as being overtired tends to keep people awake. Make sure the bedroom is dark and quiet. Use only pure wool or cotton sheets and blankets. Polyester materials can cause sweat and make you thirsty (if your child constantly asks for water throughout the night, this could be the reason).
And don't watch those scary movies just before retiring! If you still can't sleep, make a tea of lemongrass or drink a nightcap of herbal tea containing chamomile. It's easy to grow lemongrass in your garden or start a flower pot on the balcony for ease of picking. Simply steep a handful in boiling water for five minutes. Honey may be added for a sweetener.
Of course there will be times when you do need modern drugs, so if these simple remedies don't have the required affect, be sure to see a health care professional.
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Dear Blog Owner,
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Regards
Barbara
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