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Help for Children in Distress: Is Medication the Answer?

Bullied, stressed by pressures of examinations, and otherwise finding it hard to cope with life, a recent article [1] highlighted the plight of thousands of British children.  Unfortunately, the Brits are not alone.   

In 2000, the U.S. Surgeon General estimated that during the course of a year, approximately one in five children and adolescents in the United States experience the signs and symptoms of a recognized psychiatric disorder.  More recent studies [2] support this finding, arguing that a majority of such disorders have their beginnings before 14 years of age, with a significant portion already manifest in pre-schoolers [3].  Of perhaps most concern, is that in the U.S. these children often are placed on prescription drugs at a rate [4] that far exceeds that of the rest of the world.  Even among experts in the field, growth in the use of psychotropic drugs in pediatric populations has given rise to multiple controversies [5], ranging from concerns over off-label use and long-term safety, to debates about the societal value and cultural meaning of pharmacological treatment of childhood behavioral and emotional disorders. 

The question for many parents and all those who care about the future of children is more directly put: Are children being drugged as a Band-Aid or means of control, while the deeper underlying issues in child and family development go neglected?

The Bio-Psycho-Social-Spiritual Model

The common understanding of mental illness or emotional problems in children emphasizes that, typically, there are multiple, interdependent factors involved: 
(1) Biological and genetic predispositions (e.g., depression and alcoholism tend to “run in families”);
(2) Psychological factors (one’s personality impacts how one perceives the world and impacts how one reacts);
(3) Social or environmental factors (family culture, parenting styles, peer relationships, and educational milieu can all shift a child’s self-perception, mood, and behavior); and
(4) Spiritual beliefs (often also related to family culture, beliefs can set a context for the expectations for behavior as well as influence feelings of hope for the future).

Unfortunately, in many situations the complexity of these factors is all but ignored as children are placed on psychotropic medications in an effort to expediently bring under control or better manage some undesired behavior (ADHD is the most common and infamous example) or mood (sadness or worry, for example).  The reasons for this approach are as complex as children’s problems:  overwhelmed parents plead with doctors to prescribe; busy doctors pull out the script pad because they lack time to review and develop interventions for the psychological or social components of a difficulty; educational systems pressure parents to have their child controlled.  Nevertheless, while the American Academy of Child and Adolescent Psychiatry Medication begins its “Facts for Families [6]” by stating that medication can be an effective part of the treatment for several psychiatric disorders of childhood and adolescence, it also advocates that clinicians provide full explanations of the benefits, risks, and adverse effects of medications, as well as options for treatment alternatives.  Furthermore, it emphasizes that psychiatric medication should not be used alone, but rather be one part of a comprehensive treatment plan.  As mentioned earlier, however, this is often not the case.

An Effort by the Medical Community

The Hastings Center, a bioethics research institute in New York, conducted a series of workshops wherein experts discussed the most controversial [5] aspects of medicating children for psychological or emotional problems.   Some experts were concerned with interventions that merely try to alter the child to fit a particular environment, rather than getting to the root of the problem in the community, school, or family.  Others were more concerned that the mental health professions were at risk for dabbling in areas where values and morals were the key issues, not medical science.  One observer noted, that “just because we can measure a behavior, label it as disordered, and treat it, does not mean that it ‘is’ a disorder”; another called for “[t]he mental health field (to) draw stricter boundaries between mental disorders and vice” to avoid confusing the public about the fundamental difference between ‘badness’ and ‘madness.’ 

Several suggested areas for improvement seem to be relevant to our question, among them: the need to understand all of the interacting factors in a child’s condition as they emerge over time and the need to consider fully the cultural milieu and parenting styles in which the child is living.  What is referred to as culture here is particularly important when it comes to understanding how it is that a child in one country might be deemed functioning well, or well-enough, while in another he is placed on mind- and mood-altering substances such as Ritalin or Adderral—drugs which have the addictive potential of morphine or oxycontin.  (Each are substances under Schedule 2 [7] of the DEA, and are said to “have a high potential for abuse which may lead to severe psychological or physical dependence.”)

With experts still struggling to define the diagnoses, much less the preferred approach to treatment, it is difficult to provide absolute clarity on all of the issues.  Nevertheless, from a perspective of valuing each human life, and respecting the family as the primary educator and proper context for a child’s development, some conclusions can be drawn.  Given the complex origins of psychiatric conditions for the majority of troubled children, prescribing drugs should be the last resort rather than the first choice.  While a daily pill can treat high blood pressure quite well, and while there are psychiatric conditions for which this medical analogy holds, for most children, the need for more healing, not more medication, is at the root of the problem.  Whether that ‘root’ is planted in the community, school, family, or peer group, no medication prescribed will touch it. 

Worse yet, a medicated child may internalize a sense of blame or shame, and begin feeling defective or lacking in some way.  Although his behavior may improve for a time or he may be relieved temporarily of some sadness or worry, the price paid in terms of his sense of self-worth and dignity can be high.  Furthermore, the long-term consequences of altering a person’s biochemistry through psychiatric medication are unknown, and of particular concern for a developing child. 

Children suffering from emotional and mental distress need consistent relationships in which they experience care and nurture, whatever other problems they may have.  It is only within this context of peace and security that the youngster can begin, with the help of others, both professional and nonprofessional, to find a path for healing.

Bioethics
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Bullied, stressed by pressures of examinations, and otherwise finding it hard to cope with life, a recent article highlighted the plight of thousands of British children. Unfortunately, the Brits are not alone.
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