Are drugs always the answer?

Is your seven-year-old sleepy, irritable, or keeping you awake at nights? Do the tears come too readily, and does he or she have difficulty with concentrating or with finishing meals? It could, of course, be just part of growing up, but it might also be seen now as a package of symptoms suggesting a diagnosis of paediatric depression with a course of anti-depressant drugs as the treatment.

Is your seven-year-old sleepy, irritable, or keeping you awake at nights? Do the tears come too readily, and does he or she have difficulty with concentrating or with finishing meals? It could, of course, be just part of growing up, but it might also be seen now as a package of symptoms suggesting a diagnosis of paediatric depression with a course of anti-depressant drugs as the treatment.

Children are increasingly being prescribed drugs for a range of different behavioural problems, from sleep disturbances and anxiety, to school phobia, depression and hyperactivity. Researchers in America have found that children as young as two are being prescribed drugs for hyperactivity, while in the UK, the numbers of youngsters getting such medication has increased twelve-fold in the last six years.

In the wake of the huge growth in the use of psychiatric drugs for young people, there is a growing concern that the line between behavioural differences and behavioural disorders has become blurred. There is also concern that medication is being used for some children not to cure but to conform, and that children are being brought up to depend on drugs.

"There is a tendency nowadays to over-medicalise people who are different. We tend to think that if people are different in any way there must be something wrong with them. Added to that, we also now have so many health professionals out there popping up with a lot of ideas and new syndromes, and getting a lot more diagnoses," says Professor Steven Reiss.

There is no doubt that some children do suffer with mental illness and that they can benefit enormously from the appropriate drugs, but the concern is that medication is cascading down to those who are not at the extremes. It is now estimated that one in five children has a mental or emotional illness at any one time, and that one in 20 suffer from depression.

In the UK, the Department of Health keeps no separate figures for anti-depressants prescribed to children, although it said yesterday it was reviewing that.

In America, where data is available, more than 500,000 prescriptions for one group of anti-depressant drugs alone are written each year. Researchers have found too that the use of psychiatric drugs like Prozac and Ritalin in pre-school children has increased significantly in five years.

"Rapid expansion of medication use for a particular problem raises questions about appropriateness, effectiveness and long-term safety," cautions Professor Magno Zito who led the research.

"The use of medication to treat behavioural problems is highly controversial. There is widespread concern that medication is being used inappropriately for treating a wide range of behavioural difficulties in young children," says a report in the current issue of the British Medical Association's Western Journal of Medicine.

A report in the Journal of the American Medical Association says that the use of some psychotropic medication in two to four-year-olds had risen threefold in five years. One of the reasons, say the researchers, is that there is mounting pressure for children to conform to society's standards of behaviour.

Doctors at the University of North Carolina say psychoactive drugs are being prescribed even though the long-term effects of them on a child's developing central nervous system are still unknown. They point out too that side effects of the drugs themselves can cause behavioural changes, as well as sleep disturbances.

"There is a fear that these medications will supplant or replace other therapies, like counselling, family intervention, and behavioural therapies. They should be used with caution and monitored closely, not used haphazardly for transient symptoms - not for school problems, nor nebulous behavioural problems," says Dr Jerry Rushton, the lead researcher.

Others, however, point to the successes of medication. A study at the University of Texas found that of 97 depressed children aged seven upwards, more than 50 per cent responded positively to Prozac. The National Alliance for the Mentally Ill, however, says that the research also showed that 33 per cent of the children responded to placebo.

Anti-anxiety drugs like benzodiazepines and beta-blockers, are also being used and are said to work quickly to even out problems that can include panic disorder and agoraphobia. But of all the drug therapies for children, it is that for attention deficit hyperactivity disorder (ADHD) which attracts the most controversy, largely because of the numbers of children involved. In the UK, the number of prescriptions for the drug Ritalin has increased from 3,500 in 1993 to 158,000 in the last 12 months.

The International Narcotics Control Board says the rates of prescribing the drug have gone up in another 50 countries, and the UN has asked for monitoring to detect over-diagnosing of ADHD. In America treatment rates in some schools are as high as 40 per cent of all pupils.

"The difficulty with a lot of childhood disorders is that they are quantitatively rather that qualitatively different from normal behaviour. Therefore the point at which your treat becomes a quantitative decision rather than because you are seeing abnormal pathology. It is because something has excessive, disruptive and persistent and causes a negative response in the child and in the environment," says Dr Sandra Scott, a child psychiatrist at the Institute of Psychiatry in London.

Professor Steven Reiss of Ohio State University and author of Who Am I? says one of the problems is that individual differences are being forgotten. "Education systems are built on the premise that all children are naturally curious and have the same potential desire for learning. But not everyone is naturally curious. A child may be very smart but still not interested in school. They keep saying they don't like school but people don't believe it, they think there must be something wrong.

"But they don't need to be fixed because there is nothing wrong with them. It is their basic nature. We shouldn't medicalise it when it is just a natural variation. We are individuals to a much greater extent than psychologists have realised."

Some specialists believe there is sometimes a temptation to use drugs as a cheap quick-fix in the absence of counselling and other therapy. "I think there's a tendency to use drugs on children because we don't have the resources to treat them. We need the right approach to get at the source of the problem where there is one," says psychologist Professor Cary Cooper of the University of Manchester Institute of Science and Technology.

"Many of these drugs are not side-effect-free and may dull the senses and make children less sociable. I am not sure that that is healthy for their long-term development. The drugs may not be addictive but people may become dependant on them." The age at which behavioural problems are being diagnosed is also reported to be coming down. In America, children aged seven and downwards are being recruited for trials of new anti-depressants at the University of Texas in Dallas. And at Michigan State University, researchers have found that ADHD is being diagnosed in children as young as 12 months. As Dr Marsha Rappley who carried out that research said, "To find children labelled with ADHD as this age is surprising."