Growing Up on a Ritalin-Prozac Cocktail |
Posted by FoM on April 18, 2000 at 15:22:29 PT Is This What Ricky Needs? By Howard Markel, M.D. Source: New York Times Ricky is one of the most appealing teenagers in my practice. Bright, funny and a genuinely cool kid, Ricky suffers from the worst case of attention deficit disorder with hyperactivity that I have seen in 14 years as a pediatrician. He is also prone to serious bouts of depression, poor self-esteem, forays into alcohol and marijuana abuse, and, at unpredictable junctures, violent outbursts. A broken hand from punching out a brick wall, physical attacks on family members, frequent run-ins with the police, and even suicide attempts have all brought Ricky into my clinic for medical care and counseling. Yet in the six years that I have been Ricky's pediatrician, I have never seen him when he was not medicated with a staggering combination of Ritalin, Prozac and, at different times, far stronger psychotropic drugs under the supervision of a child psychiatrist. In Ricky's case, the medications for attention deficit disorder and depression have, at best, only partly ameliorated his problems. But at this point, it is impossible to be certain of the exact effects of this combination of drugs on his behavior. Ritalin, an amphetamine, has a paradoxical effect on children with the disorder. Instead of speeding these children up, it enables them to focus on learning tasks and even calms their hyperactivity. But the drug is not uniformly predictable and may cause several unwanted results ranging from insomnia and appetite suppression to behavioral outbursts. Prozac is thought to help alleviate depression by allowing serotonin, a neurochemical that modulates mood, to be absorbed from the synaptic spaces of neurons more slowly. But this drug, too, can have multiple untoward effects including insomnia, jumpiness, fatigue and irritability. When taken together, Ritalin and Prozac are usually well tolerated. But for some children, the combination creates mixed results. Ricky came to my practice as a 9-year-old with a history of taking these medications since before he began kindergarten, just like the children profiled in the highly publicized report in The Journal of the American Medical Association on the increasing rates of prescribing psychotropic drugs to American preschoolers. Even as a toddler, Ricky showed signs of excessive impulsivity. The long medical chart that followed Ricky to my clinic revealed that his parents had been concerned enough about his behavior to begin searching for professional help by the end of his third year. As a 4-year-old, and several times since, Ricky underwent a battery of neuropsychological tests that strongly suggested attention deficit disorder with hyperactivity and depression. And while such tests are hardly as exact a yardstick as those that measure blood sugar, they were done by highly regarded child psychologists and psychiatrists with whom I work on many difficult cases. The overwhelming consensus of medical and parental opinion has been to put Ricky on Ritalin and Prozac. The goal, of course, is to control or change behaviors that seriously interfere with the normal progression of childhood. Sometimes it is overworked pediatricians handing out drugs to get frenetic children out the door. In other cases, it is harried teachers demanding that difficult students be medicated into submission. But plenty of parents, like Ricky's, ask for powerful psychotropic drugs by brand name in hope of curing their children's poor school performance or behavior. What is so frustrating for all concerned is the wide gulf of uncertainty among doctors, regardless of their specialties, mental health professionals and parents over when to use psychotropic drugs and, just as important, when to stop using them. Psychotropic drugs can work wonders for a wide range of serious behavioral or psychological problems. Every children's health professional, myself included, is familiar with cases of children who were able to experience a more normal childhood and adolescence because they took these medications. Sadly, however, there are many other children for whom these drugs are bandages that only mask gaping psychic wounds, serious and poorly understood disorders of neurochemistry, and even counterproductive parenting techniques that give rise to complex and destructive behaviors. Like the proverbial snowball rolling down a hill, these problems can be compounded with each turn and revolution, and discovering what is at the center eludes even the most perceptive physician or caring parent. I see Ricky at least every month, and during times of crisis as much as daily. Working with this family for so long, I know he has good, attentive parents. I do not always agree with their decisions and they do not always agree with my medical opinions. For example, I have repeatedly pleaded with them at least to try to wean him off some of his medications. Each time I make the suggestion, Ricky's parents vociferously object, terrified at the mere mention of a son not buffered by psychotropic medications. "You just do not know what Ricky was like before we put him on these medicines," his mother says. I usually rejoin that Ricky is not doing so well while on them. I must confess, however, that it is far easier for me in the confines of the clinic to suggest withdrawing the medications than for his parents to act on that suggestion. I do not know what it is like to have a violent 5-foot-10 teenager in the house. Chronic disease is disruptive for all members of a family it touches, but a chronic disease that manifests itself with hitting others, or worse, is downright dangerous. I continue to work with Ricky and his family and have incorporated other approaches, including special school and counseling programs, into his treatment plan. I also like to think that the hours we have spent together rehearsing how he will react to challenging situations have helped matters, but I have no proof that any of these methods are really working. Ricky's parents and his psychiatrist, far more impressed than I by pharmacologic approaches, continue to hope that some new medication will soon be developed that better controls his attention deficit hyperactivity disorder depression and violent outbursts. Ricky's story reflects just a few of the many problems that result from prescribing these powerful medications to young children and their continued use well into early adulthood. It is a story replete with complicated diagnoses and, so far, without conclusion. We do not know if these psychotropic medications are helping or harming Ricky. We have long lost touch with the original psychopathology that brought about these interventions. And, frighteningly, we simply do not know if he will outgrow his more destructive impulses before any permanent harm results. In his more receptive moments, when Ricky and I are alone in the examination room simply talking to each another, I counsel him not merely to count to 10 before expressing anger or acting out but instead, to try counting to 1,000. Ricky always smiles at this advice, promises to try harder and bids me goodbye. But within a week, maybe two or three, I know I will receive a frantic call from Ricky's parents reporting his latest misadventure. Published: April 18, 2000 Introduction: Addiction as a Disease Crossing the Line to Addiction: How and When Does It Happen?
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