have been treating a young girl since her
father's sudden death six months ago. One Saturday night, while her
mother is out with her new gentleman friend, she makes what we in the
business call a "suicidal gesture," which is much less than a
full-fledged attempt, but obviously a sign that all is not well, and
not likely to be, anytime soon. She is in the hospital from Sunday to
Friday. On Friday, the "discharge planner" calls to notify me that my
young patient will be returning home that afternoon. Her five days of
covered hospitalization are now up, and since she is no longer a
threat to herself (no suicidal gestures during the four full days of
her hospital stay), and was never a threat to others, the H.M.O. says
it is time to go and, by the way, it won't pay for family therapy. I
suggest that a weekend of hanging around with her mother and the new
beau is not a great treatment plan for an impulsive, nonverbal kid. A
few more days might give her a chance to connect to the other kids on
the unit, to have several sessions of family therapy with her mother,
to come to terms with having found herself in a hospital in the first
place. I tell the planner what a great girl this is (she is not a
great girl yet; right now she is a sad, confused, self-pitying and
irritable girl, but she might become a great girl, with some help) and
the planner sighs.
"Well," she says, "how about medication?"
It is the consensus of her treatment team, including me, that what
is needed is more talking, more strolling around the grounds with the
sympathetic nurse's aide, whose own father died in a car accident,
some intensive help for her and Mom at the hospital and more room to
"Medication for what?" I ask.
"For whatever. We could probably keep her another 11 days with a
Amy Bloom, a psychotherapist, is the author of the
novel "Love Invents Us."
Prescribing psychotropic medications for school-age children is a
booming business these days. Ritalin's production alone is up 700
percent since 1990, and stories like mine are commonplace. As a
result, a battle has arisen between the pro-medication and
anti-medication camps: heated, public and utterly spurious. Some
children need medication; others don't. The real trouble lies in how
we make that assessment.
This process begins before the doctor ever sees the patient. The
person with the cash, the power and even the transportation usually
gets to identify the patient, setting the stage for all subsequent
decisions. Which is why women without children were called "barren"
and men without were just unlucky; why Freud treated the obstreperous
Doras but not their parents; why aged, uncertain parents find
themselves in nursing homes against their will. It is especially so
when the murky questions of behavior and psychology are raised: is it
adolescent moodiness or pre-Columbine sociopathy? Was she born that
way or did we make her that way?
The theoretical basis of family therapy -- and common sense --
holds that the most vulnerable point in the family structure will
reveal its stress first. And the way children show stress is often
called "symptoms." Parents, of course, do not always wish to interpret
the symptoms, nor are family doctors always trained to read them. Even
well-intentioned parents who wish to make things better, quickly, may
override their child's experience and capacity to express it. For
American children right now -- especially the fidgety, the
distractable and the extra-lively -- their vulnerability is made worse
by a ghastly convergence of social anxiety, overwhelmed and uninspired
schools and widespread fixation on the bottom line.
Find a symptom, find a treatment,
treat it and, in a modern twist, make it no one's fault. Fix
them, we say.
Find a symptom, find a treatment, treat it and, in a modern twist,
make it no one's fault. Fix them, we say. And these new drugs do "fix"
them -- quickly, inexpensively and inappropriately. We fix them at a
younger and younger age -- these days even when they're toddlers. And
we do so even when we use medications intended for adults. As a
result, 4 million children are on Ritalin and 2.5 million are on
Attention deficit disorder and hyperactive disorder (both formerly
known as minimal brain damage, but nicely renamed by the drug
companies) do exist, and it would be cruel to withhold Ritalin from
children who suffer from them. Just as it would be unfair to
stigmatize them as spoiled brats and ridiculous to blame their
concerned parents. But these drugs are being wildly prescribed because
they are cheaper and less time-consuming than psychotherapy and much
easier to sell, both to the consumer and to the average family doctor.
Prescriptions are less work than conversation and careful evaluation.
And handing out medication at lunchtime is easier than creating
classes that keep intelligent and curious kids from squirming,
daydreaming and talking back. Most of all, we prescribe medications
for children who don't need them because the medications are
available, and a cure for parental vanity and irresponsibility - along
with the single-minded greed of H.M.O.'s -- is not.
couple come into
my office. They tell me they are happily married and need only a
consult on their child, who is "out of control." The husband says that
he is a fair disciplinarian (although it seems to me that it must be
difficult to get much disciplining done between his arrival home at 8
p.m. and the child's bedtime at 8:15) and that the mother, full time
at home, is a pushover who can neither keep to a schedule nor follow
through with suitable consequences. She says that he has no idea what
he is talking about, since he is never home, and that he makes
unreasonable demands on her and their 6-year-old. I suggest that their
family is both under stress and producing it. They cancel the next
appointment. They call a year later: their daughter is on Ritalin
because of A.D.D., which is now official, and the kids make fun of her
for the daily trip to the nurse. Can I suggest someone who will help
boost her self-esteem?