Andrew Rios’s seizures began when he was 5 months old and only got worse. At 18 months, when an epilepsy
medication resulted in violent behavior, a neurologist prescribed him
the antipsychotic Risperdal, a drug typically used to treat schizophrenia and bipolar disorder in adults, and rarely used for children as young as 5 years.
When
Andrew screamed in his sleep and seemed to interact with people and
objects that were not there, his frightened mother researched Risperdal
and discovered that the drug was not approved, and had never even been
studied, in children anywhere near as young as Andrew.
“It
was just ‘Take this, no big deal,’ like they were Tic Tacs,” said
Genesis Rios, a mother of five in Rancho Dominguez, Calif. “He was just a
baby.”
Cases
like that of Andrew Rios, in which children age 2 or younger are
prescribed psychiatric medications to address alarmingly violent or
withdrawn behavior, are rising rapidly, data shows. Many doctors worry
that these drugs, designed for adults and only warily accepted for
certain school-aged youngsters, are being used to treat children still
in cribs despite no published research into their effectiveness and
potential health risks for children so young.
Photo
Angela Davis, a speech-language pathologist, working with Andrew at home in Rancho Dominguez, Calif.Credit
Jenna Schoenefeld for The New York Times
Almost
20,000 prescriptions for risperidone (commonly known as Risperdal),
quetiapine (Seroquel) and other antipsychotic medications were written
in 2014 for children 2 and younger, a 50 percent jump from 13,000 just
one year before, according to the prescription data company IMS Health. Prescriptions for the antidepressant fluoxetine (Prozac) rose 23 percent in one year, to about 83,000.
The
company’s data does not indicate how many children received these
prescriptions, but previous studies suggest that the number is at least
10,000. IMS Health researched the data at the request of The New York
Times.
The
data did not indicate the condition for which these prescriptions were
written. Doctors are generally free to prescribe any medication for any
purpose they see fit, so some drugs can occasionally be used in unproven
and debatable ways. But the volume and rapid rise in psychotropics such
as antipsychotics and antidepressants in children 2 and younger suggest a trend.
In
interviews, a dozen experts in child psychiatry and neurology said that
they had never heard of a child younger than 3 receiving such
medication, and struggled to explain it. They presumed that parents and
doctors, probably desperate and well meaning, were trying to alleviate
thrashing temper tantrums
— the kind that get children kicked out of day care — or an overly
depressed disposition, like being strikingly inhibited, nonverbal or
lethargic.
“People are doing their very best with the tools available to them,” said Dr. Mary Margaret Gleason,
a pediatrician and child psychiatrist at Tulane University School of
Medicine. “There’s a sense of desperation with families of children who
are suffering, and the tool that most providers have is the prescription
pad.”
But
Dr. Gleason said that children with ages measured in months had brains
whose neurological inner-workings were developing too rapidly, and in
still unknown ways, to risk using medications that can profoundly
influence that growth. She said the medications had never been subject
to formal clinical trials in infants and toddlers largely because of
those dangers.
“There are not studies,” Dr. Gleason said, “and I’m not pushing for them.”
Dr.
Martin Drell, former president of the American Academy of Child and
Adolescent Psychiatry, said he was “hard-pressed to figure out what the
rationale would be” for the prescriptions. Similarly taken aback, some
experts wondered if the medicine was never actually consumed by the
child, or if it was issued in the name of a child covered by Medicaid but in fact taken by an ill parent who was uninsured.
“But
where there’s smoke, there’s fire,” Dr. Drell said. “For the protection
of kids, we should evaluate this. We should identify who these cases
are. Maybe it’s not 10,000, but I’ll be unhappy if it’s even in the
hundreds.”
Most
experts suspected that the trend of medicating younger and younger
children for suspected psychiatric disorders was trickling down to very
young children. Last year, a report from the Centers for Disease Control and Prevention found that health care providers had given a diagnosis of attention deficit hyperactivity disorder to at least 10,000 children age either 2 or 3 and then prescribed medications such as Adderall outside American Academy of Pediatrics guidelines.
“I think you simply cannot make anything close to a diagnosis of these types of disorders in children of that age,” said Dr. Ed Tronick,
a professor of developmental and brain sciences at the University of
Massachusetts Boston. “There’s this very narrow range of what people
think the prototype child should look like. Deviations from that lead
them to seek out interventions like these. I think it’s just nuts.”
Prozac is approved by the Food and Drug Administration for depression
in children 8 and older and for obsessive compulsive disorder in those
age 7 and older. Most antipsychotics, which treat schizophrenia and
bipolar disorder, are indicated only for children 10 and older. Risperdal is approved for children as young as 5, but only for irritability associated with autism.
Some
other psychiatric medications, such as the anti-anxiety drugs Valium or
Klonopin, are widely accepted to control intractable seizures in the
very young. Although their effects on the young brain remain unknown,
stopping a child’s seizure warrants their occasional one-time use, said
Dr. Amy R. Brooks-Kayal, the head of pediatric neurology at Children’s Hospital Colorado and president of the American Epilepsy Society.
Antidepressants
and antipsychotic medications, however, have no established use in
young people beyond tempering chronically disruptive behavior, experts
maintained, suggesting that the drugs were probably used for that
purpose.
The
American Academy of Pediatrics, the American Academy of Child and
Adolescent Psychiatry, and the American Academy of Neurology have no
guidelines or position statements regarding use of antidepressants and
antipsychotics in children younger than 3.
Finding
specific examples of such children taking the drugs can be difficult,
because of family privacy or because the practice remains controversial.
IMS Health records but does not release the names of prescribing
physicians.
Mrs.
Rios said that after Andrew began taking the epilepsy medication
felbamate, he became strikingly erratic and aggressive: He pushed his
siblings down and destroyed toys. She said that Andrew’s neurologist, at
Children’s Hospital of Orange County, Dr. Lily Tran, then prescribed Risperdal, medication that can temper severe mood swings in older children.
Andrew
took the medication for four months before his mother decided it was
causing harmful side effects — behavior he had never shown before — and
took him off it. “Everything became worse,” Mrs. Rios said.
Dr. Tran declined an interview request.
The
use of Risperdal for children has been hotly debated among child
psychiatrists, with some experts — many financially backed by the
pharmaceutical industry — citing positive effects among suffering young
people, and others criticizing their use as shortsighted responses to
complex problems.
“There are behavioral ways of working with the problems rather than medication,” said Dr. Tronick, who runs a program
that teaches health care providers to assist families with troubled
children. “What is generating such fear and anger and withdrawal in the
child? What is frustrating or causing stress in the parent? These are
the things that have to be explored. But that takes time and money.”
Many
experts say that the rise in the use of all psychotropics in children
of all ages derives from the scarcity of child psychiatrists — only 8,350
practice in the United States, many of them with long waiting lists and
higher cost than a family’s established pediatrician. Those
pediatricians receive little training in child psychiatry but are then
asked to practice it.
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