We all know (or were) the kid who makes us wish for the invention of a Ritalin blow dart. But is it a good idea to put kids on psychiatric meds? And once they’re on, how long is long enough? The Savvy Psychologist tackles the topic of psychiatric drugs that start early and last a lifetime.
This topic comes by request on the Savvy Psychologist Facebook page from listener Anita M. of Detroit. Anita works with foster kids and, too often, sees disadvantaged kids who have been on a cocktail of psychiatric medications from as early as age 6. She asks, does such early use alter a child’s brain or body? And have the effects of lifelong psychiatric medication been studied?
Childhood mental illness (and resulting medication) is equally overblown and under-recognized. Approximately 21% of American kids - that’s 1 in 5 - will battle a diagnosable mental illness before they reach the age of 17, whether or not they actually get treatment.
The problem is anything but simple. Some childhood illnesses - ADHD and autism, for example - often get misused as “grab-bag” diagnoses when something’s wrong but no one knows what. This leads to overdiagnosis and sometimes, overmedicating. Other illnesses, like substance abuse, get overlooked or written off as rebellion or experimentation, leading to underdiagnosis and kids slipping through the cracks.
But the most common problem is inconsistent diagnosis. For example, a 2008 study found that fewer than half of individuals diagnosed with bipolar disorder actually had the illness, while 5% of those diagnosed with something completely different actually had bipolar disorder.
But let’s get back to Anita’s questions: Does early psychotropic medication alter a child’s brain? The short answer is yes, but the long answer might be different than you think.
A 2012 review from Stanford researchers analyzed over 50 studies that used neuroimaging - that is, MRI, fMRI, magnetic resonance spectroscopy (MRS), diffusion tensor imaging (DTI), and anything else that takes before-and-after pictures of the brain - to examine the brains of kids with a variety of mental illnesses: anorexia, ADHD, autism, bipolar disorder, depression, OCD, and schizophrenia. They found that overall, medication does indeed affect brain structure and function to a degree detectable by imaging.
But probably not in the way you expect.
Do Psychiatric Drugs Alter the Brain?
Usually, when we think “brain changes” we think it means something bad, like damage or stunting. But it’s important to remember that untreated mental illness can also harm brain development. Early medication can help prevent the illness from getting worse or becoming neurally entrenched.
Let’s look at the anorexia group, for example. Before medication and therapy, teenagers with untreated anorexia displayed different brain activation than a control group, but after 7 months of treatment, the differences disappeared. As the anorexic group regained weight and got better, their brains changed to be more like “normal.”
Likewise, a 2012 study on kids and adults with ADHD revealed that, over time, treatment has a positive effect on brain structure. As a group, kids who received treatment had fewer brain structure abnormalities than those who were left untreated.
Now, does all this mean it’s acceptable to put 6-year-olds on antipsychotics?
The answer? We don’t know.
But it’s no coincidence that medication overload starts at age 6, because this is when kids start school. When one child constantly disrupts the learning of 20-30 others, medication unfortunately can get called in as a neutralizing ray.
But, just like adults shouldn’t substitute coffee for sleep, or alcohol for relaxation, psychiatric medication should never be a substitute for teaching kids self-regulation, dealing with a stressful family situation, or to sedate a child who is causing problems.
In addition, psychiatric medication should never be a stand-alone treatment for kids. Meds should always play a secondary role to behavioral treatment, a school-based Individualized Education Program (IEP), and/or family therapy.
That said, there are considerable barriers to making ideal - or even adequate - care happen, and regrettably, kids fall through the cracks as a result. On the professional side, psychiatrists who specialize in child and adolescent care are rare in some places and swarming in others (and sadly, availability often maps on to socioeconomic distribution). In addition, things aren’t perfect on the family side either. Parents often work inflexible shifts and can’t participate in family therapy, have other kids at home who need attention, or might be struggling with psychiatric problems of their own.
To sum up, as with most issues, there are multiple sides to this story. Over-medicating kids for the convenience of adults can and does happen. Medication does change sensitive young brains, and an inappropriately dosed or unmonitored child, like those our listener Anita is worried about, gets sent into uncharted waters.
When Psychiatric Drugs Are Necessary
But consider an adolescent who is cutting or starving herself, a child with OCD so severe it keeps him from participating fully in school, or a kid with an ADHD diagnosis based on a comprehensive workup (not just some late-night internet research). These kids can truly benefit from well-considered medication prescribed by a child or adolescent psychiatrist. It would be a disservice (not to mention poor health care) to deny medication to kids who need it.
In addition, before treatment, it’s also common for anger, blame, and labels to become entrenched: “This kid is a bad seed,” “My child won’t amount to anything.” Proper treatment, including medication, can give families relief from symptoms and a chance to undo these crippling labels.
Now let's look at the second part of Anita's question: Is it OK to be on psychiatric medication for a lifetime?
As always, the answer is: it depends.
For some adults with severe and chronic illnesses, like accurately diagnosed bipolar disorder, schizophrenia, or severe chronic depression, lifelong medication is not only OK, it can be an important part of good care.
But to complicate matters, it’s impossible to tell at the outset who needs an initial course of medication and can then taper off, versus those who need medication monitoring for a lifetime. Psychiatry is as much art as science.
Is it Safe to Take Medication for Your Whole Life?
But what about kids? Is it OK to start psychiatric medication as a kid and take it forever?
In reality, no one knows. Most long-term studies of pediatric medication only track kids for a few months or maybe up to a couple of years. The reason is funding: research grants are most often given out in 2-5-year chunks, and it takes time to get up and running and recruit participants, leaving only a few years to properly follow the kids.
Plus, there’s the question of adherence - most people are really bad about taking their medication consistently. Plus, prescriptions often change over time. So the more accurate question to ask is, “What are the long term effects of taking a variety of psychiatric medications sporadically?”
It’s anyone’s guess. For now, that answer is beyond the cutting edge of science. All we can do is our best.
Now, for this episode in particular, it’s important to note I’m a psychologist, not a psychiatrist, so I don’t prescribe medication and am not trained to do so. However, I am trained as a researcher, and I know my way around a medical library - check out below for references for the studies I mentioned.
Do you have experience with medicating children? Share your insights with us in Comments below or on the Savvy Psychologist Facebook page.
Frances, A. (2010). Normality is an endangered species: Psychiatric fads and overdiagnosis. http://www.psychiatrictimes.com/blogs/dsm-5/normality-endangered-species-psychiatric-fads-and-overdiagnosis
Opler, M., Sodhi, D., Zaveri, D., & Madhusoodanan, S. (2010). Primary psychiatric prevention in children and adolescents. Annals of Clinical Psychiatry, 22, 220-34.
Silverman, W.K., & Hinshaw, S.P. (2008). The second special issue on evidence-based psychosocial treatments for children and adolescents: A ten-year update. Journal of Clinical Child & Adolescent Psychology, 37, 1-7.
Singh, M.K. & Chang, K.D. (2012). The neural effects of psychotropic medications in children and adolescents. Child & Adolescent Psychiatric Clinics of North America, 21, 753-771.
Zimmerman, M., Ruggero, C.J., Chelminski, I. & Young, D. (2008). Is bipolar disorder overdiagnosed? Journal of Clinical Psychiatry, 69, 935-40.