Pathologizing Childhood Behavior

Several weeks ago the New York Times published a disturbing front-page story on the use of psychiatric medications in very young children. The article, by Alan Schwarz, describes a sharp uptick in the number of prescriptions for antipsychotics and antidepressants to address violent or withdrawn behavior in children under the age of two. I’ve written on Schwarz’s superb prior reporting on the increasing prevalence of psychiatric diagnoses in children and the aggressive role of pharmaceutical companies in promoting medications to treat them. But his latest work reveals an alarming new trend in addressing behavioral disorders in children, encapsulating much of what’s wrong with the American healthcare system and our contemporary attitudes toward illness.

The risks of using psychiatric medications such as Haldol and Prozac on neurologically developing brains are not known, because the experiments have never been done in children—and won’t be, for ethical reasons. In adults, antipsychotics are generally used to treat symptoms of schizophrenia and can have long-term, debilitating side effects. These range from feelings of numbness and a lack of emotion to a condition called tardive dyskinesia, which is characterized by involuntary, repetitive movements, usually facial twitching, and is often permanent and irreversible.

While children as young as eighteen months or two years are obviously not ideal candidates for cognitive behavioral therapy, which can be extremely effective in addressing behavioral disorders in adults, there are still ways to attend to the underlying issues and attempt to determine what's causing them. As one of the experts quoted in the article notes, however, this takes time and money at all levels, as well as patience. The system of health insurance reimbursement in the United States favors shorter physician visits over longer ones, making it faster and thus more profitable to write a prescription than to address a patient’s issues in a lengthier, more wide-ranging way. It’s far easier to medicate away a symptom than it is to address its source, especially for overworked, stressed-out parents and for physicians who are not necessarily rewarded financially for emphasizing a social rather than a biomedical approach to the treatment of behavioral disorders.

Finally, there’s the idea that physicians are more likely to prescribe something for a particular condition if a medication to address its symptoms is readily available. This makes intuitive sense: if a patient has high blood pressure or high cholesterol, then prescribing an antihypertensive or a statin would presumably follow. Similarly, a person with signs of depression might receive a prescription for an antidepressant, as someone who suffers from migraine headaches could benefit from a drug that addresses the condition’s multiple symptoms. But the very existence of a medication to treat an illness can contribute to perceptions of that illness’s prevalence. In some instances, medication can create illness; in others, it can make it more visible. Take, for example, menopause and erectile dysfunction. Until recently, both were considered ordinary consequences of aging. Then hormone replacement therapy and Viagra emerged as pharmaceutical remedies for each condition, medicalizing them and rendering them abnormal. (Recommendations for hormone replacement therapy in post-menopausal women changed abruptly in 2002 when the Women’s Health Initiative study found that the standard regimen increased a woman’s risk of heart disease and breast cancer.) And what’s abnormal must be made normal, whether the deviation is physiological, hormonal, or numerical. But behavioral disorders are harder to define, and therefore the threshold of who needs treatment will vary.

I’m not suggesting that doctors stop prescribing psychiatric medications to children altogether, as experts agree that antianxiety drugs such as Klonopin are an appropriate way to treat seizures in young patients; although the long-term side effects are unknown, the consequences of leaving the seizures untreated are even worse. But it’s the increasing use of these medications for an ever-expanding list of behavioral disorders that’s of concern, both in what it indicates about our contracting sense of normal childhood conduct and in the reluctance of physicians to take a more expansive approach to addressing it. We should embrace a broader, more forgiving view of what it means to be a child and work to ensure that our healthcare system considers psychiatric care in a comprehensive way. Utilizing counseling and social support instead of instinctively reaching for a prescription pad may be a more time-consuming and expensive way to treat behavioral disorders, but it's one that involves fewer long-term and unknown risks to very young brains.