THE DRUG DILEMMA

*The increased use of powerful psychiatric medicines in children under
6 has raised concerns about over-medication and long-term effects.

With so many unknowns, parents face an agonizing choice.

Teri Burley realized her 2-year-old son, Tanner, was out of control
when he threw his brother, Tayler, off the jungle gym in the
schoolyard playground, breaking the older child's arm.

From the time he was a baby, Tanner had been a blur of activity. "He
was into everything and rarely slept," says Burley, adding that she
and her husband took turns staying up throughout the night because
they never knew when their overactive child would awaken. "But we
figured he was just energetic."

The playground incident was a watershed, however, and preschool
officials felt compelled to expel Tanner.

"They said he was too much of a liability," recalls Burley. Desperate
for answers, the Burleys shuttled their child from one pediatrician
and psychologist to another near their home in Whittier.

But no one could determine what was wrong in a child so
young.

Finally the Burleys were referred to a clinic at UC Irvine, where
Tanner was diagnosed with attention deficit hyperactivity disorder, or
ADHD. The UC Irvine doctor prescribed Ritalin, a stimulant that has a
calming effect on hyperactive kids and helps them to focus.

Burley kept the prescription in her purse for days before she filled
it, and it took her several days more before she could bring herself
to give her toddler the drug. "My husband and I agonized, but we felt
we had no choice," recalls Burley. "It was either remove him
completely from society or dope him up with drugs to make him
manageable."

The Burleys are not alone in their dilemma.

Parents of very young children who show signs of mental disturbance
face a difficult choice.

Should they do nothing, in hopes that this is merely a phase--the
so-called terrible 2s and 3s--that their child will outgrow?

Or should they give their toddlers psychiatric drugs--none of which
have been tested on children under 6--to control what may seem to
outsiders to be garden-variety problems of childhood?

Growing numbers of parents are choosing the latter option, though
often reluctantly.

A study published in the Journal of the American Medical Assn. in
February revealed an alarming rise in the use of powerful,
mood-altering psychotropic drugs among children ages 2 to 6. The use
of stimulants like Ritalin in this age group more than tripled from
1991 to 1995. Further, prescriptions for antidepressants such as
Prozac doubled, and those for clonidine, an adult blood pressure
medication used as a sleep aid for kids with ADHD, spiked
significantly.

These troubling results prompted First Lady Hillary Rodham Clinton
last month to announce plans for a $5-million research project to be
conducted by the National Institute of Mental Health, or NIMH, on the
use of these medications in preschoolers, and to convene a conference
on the issue in the fall.

'Everyone Wants to Point Fingers'

Some blame the sharp increase on managed care, saying pediatricians
who aren't trained to spot symptoms of mental illness are encouraged
to dispense pills rather than refer children for costly therapy.

Others accuse harried parents of being too busy to adequately
discipline rambunctious kids. Teachers and day-care workers share the
blame, they say, for insisting that toddlers be docile in their
overcrowded classrooms. But some experts and parents say the increase
in prescriptions for young children is a legitimate trend, driven by
the increasing sophistication and diagnostic accuracy of mental health
professionals.

"Everyone wants to point fingers," says Julie Magno Zito, the
principal author of the JAMA study and a professor of pharmacology at
the University of Maryland in Baltimore. "But it's really the result
of a confluence of [these] factors."

The sharp uptick in the use of these drugs in very young kids "does
seem to neatly coincide with the ascendancy of HMOs," says Joseph T.
Coyle, chairman of the department of psychiatry at Harvard Medical
School in Boston. But it is also true that scientists now have a much
better understanding of the delicate mechanisms of brain chemistry, an
advance that in turn has engendered more acceptance of the use of
drugs to treat behavioral disorders.

Additionally, the diagnostic guidelines for ADHD and its milder
cousin, ADD (attention deficit disorder), once considered problems
that only affected boys, have broadened.

Now many young girls who aren't hyperactive but do have persistent
problems concentrating take Ritalin too, which may account for some of
the increase. Further, with public school resources steadily
shrinking, parents complain that they are under tremendous pressure to
make their kids conform.

Clearly, medication is called for to help severely impaired kids. But
they're a tiny fraction of the population, say experts, certainly not
the 1% to 2% of preschoolers now taking such medication.

Lack of Test Data Troubles Experts

One of the things that disturbs experts most is that these drugs have
never been tested on such young children.

Consequently, there's no data on their safety and efficacy, their
potential side effects (Ritalin, for instance, can cause nervousness
and insomnia, and clonidine used in combination with stimulants has
been linked to heart problems in children) or their long-term
consequences in this age group.

"Essentially, this is a vast uncontrolled experiment," says Larry D.
Sasich, a pharmacist and research analyst for Public Citizen, a
health-care watchdog group in Washington, D.C., "and these children
are the guinea pigs."

What's equally alarming is that early childhood is the key stage of
neurological maturation, with the brain undergoing 90% of its growth
during the first five years of life. "The chemical messenger system
that is affected by these drugs plays an important role in regulating
brain development," says Coyle. "Where will these kids be in 10 or 20
years?

We just don't know."

Despite the lack of scientific proof, however, desperate parents feel
the benefits far outweigh whatever future risks there may be.

"Sure, we worry about the long-term effects," says Burley, whose older
son, Tayler, now 10, was later diagnosed with ADD (the disorder seems
to run in families). "But at age 2, Tanner was already a social outcast.

No one wanted to play with him, not even his cousins, because he was
too rough.

It was pitiful.

Now, at age 9, he's happy and in control.

So we've made a conscious decision that it's better to have a shorter,
enjoyable life, than [possibly] a long, miserable one."

Although there is no reason to believe that the medicines could
shorten a child's life span, Shelley Dorman understands the fear of
the unknown when deciding what is best for her child.

She too, however, has chosen to give her child psychiatric
medication.

Her 10-year-old daughter, Holly, had been a precocious child who
started walking at 6 months.

But by 5, Holly would throw such intense temper tantrums that she was
suspended from kindergarten. "At first, I thought she was bored and
people were picking on her--until she flew into a rage at home," says
Shelley, who lives in Palm Springs.

Months of intensive counseling didn't help, and Holly's behavior
veered wildly between violently destructive and suicidal. "When you're
pulling your 6-year-old out from underneath a car because she wants to
kill herself, you have to do something," says Shelley, who, like other
parents in similar circumstances, was criticized by friends and family
for giving her child drugs.

After several years of experimenting with different combinations,
Holly, who was diagnosed with bipolar illness, was finally stabilized
by two powerful psychiatric medications, neurontin and seroquel. "Now
she acts like a normal child," says Shelley. "The medication has truly
saved her life."

When Is Misbehavior a Clinical Disorder?

Still, some physicians worry that kids are indiscriminately being
given prescriptions rather than counseled to manage their behavioral
problems.

"With very young children, it's hard to distinguish hyperactivity from
just being a nuisance, but everybody rushes in to fix and nobody tries
to understand," says Barbara M. Korsch, a professor of pediatrics at
USC and a pediatrician at Children's Hospital. "Are we now giving
youngsters Prozac when they have a bad hair day or using Ritalin as a
new solution for poor classroom etiquette?"

Despite the lingering question of whether we're truly over-medicating
young kids, a 1999 NIMH survey revealed that 5.1% of children meet the
diagnostic criteria for ADHD, yet only 12.5% of those kids were being
treated with stimulants.

"I know no one believes this, but we're probably under-prescribing,"
says Richard L. Ferman, an Encino psychiatrist who specializes in ADD.
"Of the estimated 10 million children and teenagers in the United
States who suffer from mental illnesses, studies have shown that only
one in five are being given medication."

The upcoming NIMH study, which will track youngsters taking Ritalin
and other psychiatric drugs, may clear up some of the confusion
surrounding the use and effects of these mood-altering medications.
But the test results are at least five years away. In the meantime,
anxious parents with toddlers exhibiting abnormal behavior will have
to look elsewhere for guidance.

"They should be seen by a specialist in psychiatric disorders in
children," cautions Harvard's Dr. Coyle. Teachers and pediatricians
aren't trained to make these diagnoses, he adds, "and drugs should be
used only as a last resort when everything else has failed."

That was the strategy Elizabeth Harris, a Los Angeles psychologist,
adopted when her 5-year-old was diagnosed with ADD.

"I was adamantly opposed to using drugs," says Harris, who instituted
an intensive behavioral management plan for her child.

The program worked well at home, but her child continued to act up at
school.

So she tried neurofeedback, a form of biofeedback, to help her child
concentrate. It worked for several months, but soon her child's
problems came rushing back. At that point, Harris felt medication was
the only alternative, and her child now takes Adderall, a stimulant
similar to Ritalin.

"I was at the end of my rope," says Harris, whose 7-year-old is now
doing well. "But I feel comfortable with my decision because I
exhausted every other option."

Resources

* National Alliance for the Mentally Ill, 200 North Glebe Road, Suite
1015, Arlington, VA, 22203, (800) 950-6264, http://www.nami.org.

* National Depressive and Manic-Depressive Assn., 730 N. Franklin St.,
Suite 501, Chicago, IL, 60610, (800) 826-3632, http://www.ndmda.org.

* Children and Adults With Attention-Deficit/Hyperactivity Disorder,
8181 Professional Place, Suite 201, Landover, MD, 20785, (800)
233-4050, http://www.chadd.org.

* Child and Adolescent Bipolar Foundation, http://www.cabf.org.

To find the study on children's psychiatric drug use, published in the
Feb. 23 issue of the Journal of the American Medical Assn., go to
http://jama.ama-assn.org, click on "past issues," click on Feb. 23,
then scroll down to the study.