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Generation Rx

Throwing pills at kids is bad, but it's only a symptom of the real problem. By AMY BLOOM


"We too have tried Adderall and Dexedrine and have the same effects. I am interested in learning more about when the F.D.A. is approving the Ritalin patch!! Our main thing with our daughter is she is a living nightmare in the mornings . . . because no meds are in her system, with the patch that would solve this up and down reactions they have! . . . My son age 5 was just put on clonidine for his A.D.H.D. . . . It is working wonderfully for calming him down and making him THINK before acting for once in his life!! . . . My daughter used to take that only before bedtime to get her to sleep!! So I guess that just proves how each med is different for each child!" -- From the newsgroup, an online forum for discussing attention deficit disorders

Photograph by John-Pierre Lescourret/Corbis

I 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 grieve.

"Medication for what?" I ask.

"For whatever. We could probably keep her another 11 days with a medication trial."

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 antidepressants.

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.

A 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?

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March 12, 2000

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