It is useful to think of the brain as a system of message networks that are connected to one another, like a telephone network. Behavior is determined when one part of the brain dials the "phone number" of another part of the brain. The "phone call" is transmitted through the nerves. A message from one nerve cell to another nerve cell in the brain is transmitted by means of chemicals. These chemicals, called neurotransmitters neurotransmitters, trigger the electrical signals that produce our thoughts, our emotions, our memories, our sleep patterns, and our will. When everything goes as it should, the phone calls made in our brains are completed as dialed; when something goes wrong-when there's too much or too little of one of the necessary neurotransmitters-we get a wrong number or a busy signal.

The brain has literally millions of nerve cells, each of which sends messages within itself by means of electricity. That electricity, which is generated chemically, moves from one end of the nerve to the other end. When it gets to the end, the nerve does not connect directly to another nerve. Nerves end in a s.p.a.ce called a synapse. synapse. That's where the neurotransmitters come in. They float across that s.p.a.ce, touch other nerves, and cause a chemical reaction that creates more electricity and sends the message on. The body is very careful about protecting and saving everything it produces, so once a nerve has sent its signal, it will attempt to take the chemicals back and store them until they're needed again-a kind of "recycling" project in the brain. The process is called That's where the neurotransmitters come in. They float across that s.p.a.ce, touch other nerves, and cause a chemical reaction that creates more electricity and sends the message on. The body is very careful about protecting and saving everything it produces, so once a nerve has sent its signal, it will attempt to take the chemicals back and store them until they're needed again-a kind of "recycling" project in the brain. The process is called reuptake. reuptake.

The messages that the neurotransmitters send from nerve to nerve are governed by three factors: first, which specific nerves are connected by these chemicals; second, the intensity of the connection, which in turn governs the strength of the signal; and third, the pattern of connections: where a set of nerves goes and to what part of the brain it sends messages. In describing the significance of the signal's strength, a colleague of mine uses a model he calls "I'm a Little Teapot." As he describes it, the rate at which someone pouring tea from a teapot sends the liquid into the cup depends on how much he tips the teapot; similarly, a strong signal in the brain results in a lot of messages. If the pourer of the tea puts his finger in the spout, no tea will come out no matter how much he tips the teapot, not unlike what happens when a brain signal is blocked by chemicals. If he tips the teapot over too fast, the tea will probably slosh out over the lid. Again, too strong a signal will send too many messages in the brain, and to the wrong destination.

The critical factor here is to regulate the strength of the signal that is "poured" into the synapse. While there are literally dozens of chemicals capable of transmitting their own messages, three seem to be the most critical, because we can measure them easily, because their actions are consistent with our hypotheses about the physiology of brain disorders, and because we have medications that can alter their functions. The three basic chemicals-neurotransmitters-that affect the process are: Serotonin. This neurotransmitter is related to anxiety, depression, and aggression. This neurotransmitter is related to anxiety, depression, and aggression.

Dopamine. This neurotransmitter affects the perception of reality. This neurotransmitter affects the perception of reality.

Norepinephrine. This neurotransmitter affects attention and concentration. This neurotransmitter affects attention and concentration.

There are other important neurotransmitters in the brain, such as hormones, which send messages that bring on a woman's premenstrual syndrome, among other things; catecholamines (including adrenaline), which affect arousal patterns (the "fight or flight" reactions) and raise blood pressure; and histamine, which stops up the ears and makes the nose run. All of these neurotransmitters can be affected and often are (with hormone replacement therapy or antihistamines, for instance), but in the treatment of child and adolescent psychiatric disorders we are dealing mostly with the Big Three: serotonin, dopamine, and norepinephrine. Those words will come up many times in these pages as we examine the psychiatric disorders that affect children and adolescents.

THE DELICATE BALANCE.

Every muscle in the body has an opposing muscle. For example, the biceps muscle makes the arm go up, and the triceps muscle makes it go down. The same is true for the central nervous system. Every nerve or nerve action has an opposing nerve action. When the sides are evenly balanced, everything runs smoothly; but when one side is stronger than the other, there are problems. In psychopharmacology psychopharmacology-the treatment of psychiatric disorders with medication-we try to restore the brain's chemical balance, so that the body and the brain may maintain some equilibrium. Someone driving a car on which the wheels on the right are spinning faster than the wheels on the left will go around in circles, never getting anywhere. The only way to get the car moving forward is to balance the motion of the wheels. That's roughly what we try to do-adjust the brain so that all of its wheels are spinning forward at the same rate of speed.

Good psychopharmacology effects changes that are subtle. It doesn't mean sedating a patient or making him super-alert; it involves getting the patient back on an even keel. When we treat a child with attention deficit hyperactivity disorder (see Chapter 7 Chapter 7), our goal is to increase the child's ability to pay attention. If he pays too much attention, he may become suspicious or obsessive and not be able to get anything done. If he pays too little attention, he can't be productive either. In treating the child with ADHD, usually with daily doses of Ritalin or some other stimulant, we try to find the middle ground, where balance is restored and a child is paying exactly the right amount of attention. This is true of all the brain disorders that we treat with medication. Our aim is always the same: to restore a chemical balance in the brain.

Pulling off this balancing act is often easier said than done. The body has many ways to regulate itself. In correcting a balance problem we choose one place to regulate the neurotransmission, but that one place is not necessarily the only spot that will work. There's more than one way to increase or decrease a specific neurotransmitter. Different drugs may work at different sites on the brain and achieve the same effect.

Furthermore, there is virtually no such thing as a "norepinephrine disease" or a "serotonin disorder" or a "dopamine disease." Most disorders are the result of more than one neurotransmitter malfunction. It's as if we have a man and a woman in an office building in different elevators, and we want them to get to the same floor at the same time so that they can meet and work together. The man is on an elevator-the serotonin elevator-that is stopped on the fourth floor; the woman is on the eighth floor in the dopamine elevator. In order to get them to the same level, we can do one of three things: raise the serotonin elevator up to the eighth floor; bring the dopamine elevator down to the fourth floor; or adjust both elevators so that the man and woman have their meeting on the sixth floor. Any of these is a satisfactory solution; any is possible. Our job is to find the best strategy to restore balance.

It's important to realize that we are talking about very small amounts of chemicals here. We measure the neurotransmitter serotonin in nano-grams, which is about one 10-billionth of a pound. Dopamine is measured in picograms, roughly 10 trillionths of a pound. Brain chemicals are powerful stuff, and a minute discrepancy can have a substantial impact on a child's behavior.

Every brain is different, of course. A drug may work beautifully for one child and do nothing for another even if both children have exactly the same disorder. Sometimes drugs have only a temporary effect. The medicines increase the level of a neurotransmitter, but over time the brain compensates for the change and says, "Wait. There's too much of that chemical coming through," and instinctively makes the adjustment by cutting it back. The short-term result of treatment is an increase of that neurotransmitter, but over the long term there may be an actual decrease. For all of these reasons and more it takes time and sometimes several careful trials to determine which medication, at which dosage, a child needs. The challenge is to find the right balance for each child.

OUTSIDE AGITATORS.

Medicine isn't the only thing that can bring about a chemical change in the brain. Environmental experiences may also have an effect on the neurotransmitters. There is strong evidence that stress alters brain chemistry, especially in a brain that is vulnerable. Not everyone reacts the same way to a stressful or painful situation. The death of a loved one makes everyone sad, sometimes very sad for an extended period of time, but only in a few people does such an event lead to the persistent, debilitating symptoms of clinical depression (see Chapter 14 Chapter 14). Severe illness, divorce, a change of location, physical or mental abuse-all of these will take their toll on a child's brain. If the chemical makeup of his brain makes him vulnerable to a psychiatric disorder, outside stimuli may well bring it on.

The brain is not a constant. It adapts and changes according to the environment. One of my colleagues compares the process to a home thermostat that is always set at 68 degrees. In the winter the temperature starts to drop, so the heat goes on, brings the house back to 68 degrees, and shuts off. In the heat of summer, when the temperature rises, the air conditioner kicks on and cools the house to 68 degrees again. The brain has a kind of thermostat too. In times of stress we may get anxious or sad, but our thermostats keep us from straying too far away from our ideal set point. We're anxious when we have to give a speech or a little depressed when we go to a funeral, but we bounce back.

Those unpleasant feelings don't last forever, any more than the elation a.s.sociated with good news lasts forever. A man who gets a promotion and a raise is ecstatic. He and his wife go out to dinner to celebrate, and they drink champagne. For a few days he's on top of the world, but a week later things are pretty much back to normal. He doesn't stay on top of the world for the rest of his life. His thermostat does its job.

However, some children have thermostats that aren't set quite right, so their ability to keep their emotions and their behavior within normal boundaries is seriously impaired. Perhaps they can't sit still or pay attention in cla.s.s. Maybe they're overanxious or depressed. They could be compulsive or have involuntary tics. In psychopharmacology we're in the business of resetting children's thermostats so that their heating and air conditioning systems keep the temperature just right.

PSYCHOPHARMACOLOGY 101.

Our lives are basically divided into three spheres: love, run, and work. In the case of children those spheres are translated into the relationship with their parents, social interactions with their friends, and learning in school. A mild imbalance in a child's brain-a little too much norepinephrine, for instance-usually will not cause any real distress or dysfunction. He'll still love his parents, he'll have friends, and he'll function perfectly well in school. No treatment will be necessary. However, if the chemical imbalance is severe and a child's activities in any of these areas are significantly altered for an extended period of time, we take a closer look. We may decide to alter the chemical makeup of the child's brain with medication.

Each of the three essential chemicals in the brain is affected by different categories of drugs: Serotonin is affected by groups of drugs called SSRIs SSRIs (selective serotonin reuptake inhibitors). The best known of the SSRIs are Prozac, Zoloft and Paxil. (selective serotonin reuptake inhibitors). The best known of the SSRIs are Prozac, Zoloft and Paxil.

Dopamine is affected by drugs called neuroleptics neuroleptics, among them Hal-dol, Thorazine, and Mellaril.

Norepinephrine and dopamine are affected by a group of drugs called psychostimulants psychostimulants or, more often, just or, more often, just stimulants. stimulants. Ritalin and Dexedrine are the two most frequently prescribed stimulants. Ritalin and Dexedrine are the two most frequently prescribed stimulants.

Norepinephrine and serotonin are affected by the TCAs TCAs (tricyclic antidepressants). The best known of the TCAs are Tofranil, Elavil, and Norpramin. (tricyclic antidepressants). The best known of the TCAs are Tofranil, Elavil, and Norpramin.

Norepinephrine is affected by the antihypertensive agents. antihypertensive agents. Developed originally for patients with high blood pressure, the antihypertensives, especially Catapres and Tenex, are now used in the treatment of children's brain disorders. Developed originally for patients with high blood pressure, the antihypertensives, especially Catapres and Tenex, are now used in the treatment of children's brain disorders.

Serotonin and dopamine are affected by the atypical antipsychotics. atypical antipsychotics. The most commonly prescribed drugs in this category are Risperdal and Clozaril. The most commonly prescribed drugs in this category are Risperdal and Clozaril.

All three of the neurotransmitters-serotonin, dopamine, and nor-epinephrine-are affected by a category of drugs called the MAOIs MAOIs (monamine oxidase inhibitors), which slow the metabolism of the brain's neurotransmitters. Nardil and Parnate are the most commonly prescribed MAOIs. (monamine oxidase inhibitors), which slow the metabolism of the brain's neurotransmitters. Nardil and Parnate are the most commonly prescribed MAOIs.

(When I talk about various medicines in these pages, I usually refer to them by brand name, because in my experience that is the name with which people are most familiar. Appendix 3 Appendix 3, Psychopharmacology at a Glance, lists the generic as well as the brand names of all the major psychiatric drugs.) All the medicines prescribed for the treatment of brain disorders do one of four things: (1) they block the metabolism of the neurotransmitter, so that more of the neurotransmitter is available; (2) they block the place where the neurotransmitter connects, making it more difficult for the message to be sent; (3) they block the reuptake of the neurotransmitter, making the neurotransmitter more available; and (4) they block the release of the neurotransmitter. We can put this even more simply and reduce the functions to two. Either the drugs increase the availability of these chemicals and send more of a message, or they decrease the availability of the chemicals and send less of a message. We prescribe a medicine depending on whether we want to facilitate or to block the neurotransmitter message. Ritalin is a facilitator. Thorazine and Haldol are blockers. Prozac and Paxil block the reuptake, or recycling, of the neurotransmitter.

In a perfect world we would be able to zero in on a specific chemical in a particular synapse and make the change that's needed, but the drugs available to us aren't advanced enough at this point to treat a specific disorder. The brain is complex, and very few medications are "clean"; that is, when a patient takes a drug, it is rare that the level of only one brain chemical is affected in only one part of the brain. If a drug we prescribe affects serotonin, it will affect the serotonin everywhere in the brain, not just in the areas of the brain that are responsible for a child's compulsions or his depression. A drug that affects dopamine levels won't work its magic just on the area of the brain that is responsible for schizophrenia; it affects all the parts of the brain that use dopamine.

Brain disorders aren't "clean" either. We often encounter comorbidity comorbidity, a situation in which children have two or even more brain disorders at the same time. For example, attention deficit hyperactivity disorder may be co-morbid with co-morbid with conduct disorder; separation anxiety disorder is often conduct disorder; separation anxiety disorder is often co-morbid co-morbid with major depressive disorder; and obsessive compulsive disorder is sometimes linked with Tourette syndrome. To complicate matters even further, brain disorders often involve more than one neurotransmitter, and there is interaction among the neurotransmitters; when we change the level of one, it may have an impact on the others. These neurotransmitters don't react in a vacuum. Increasing the brain's level of serotonin may, as a side effect, decrease the level of dopamine. with major depressive disorder; and obsessive compulsive disorder is sometimes linked with Tourette syndrome. To complicate matters even further, brain disorders often involve more than one neurotransmitter, and there is interaction among the neurotransmitters; when we change the level of one, it may have an impact on the others. These neurotransmitters don't react in a vacuum. Increasing the brain's level of serotonin may, as a side effect, decrease the level of dopamine.

Unfortunately, much of what we know about brain chemistry can't be diagnosed with blood tests, X rays, or other tools. If there's something wrong with a child's liver, we can give him a local anesthetic, use a long needle, do a biopsy, and find out exactly what the problem is. There's no such thing as a routine brain biopsy; that procedure would be far too drastic for these purposes. Still, there has been some progress in the field, largely in the neuroimaging techniques neuroimaging techniques, which give us new insights by allowing us to examine certain physiological and chemical processes that take place in the brain basically by producing three-dimensional images of the brain.

Neuroimaging techniques have helped us reach an important conclusion: there are brain abnormalities in adults who have brain disorders. Although studies of children and adolescents are in the very early stages, there is already reason to think that they have brain differences too. These techniques can also be very useful in helping us understand how the brain works and especially how various medicines affect the brain's function. For all of their value, however, neuroimaging techniques are not used for diagnosis. For diagnosis the best tool always has been and probably always will be behavioral observation. No matter how many tests a child undergoes, we base our diagnosis on a child's history and his behavioral symptoms. These tools allow us to diagnose a brain disorder as precisely and as reliably as physicians diagnose diabetes and hypertension.

The fact is, there is a lot of information about the brain that we don't yet have. We know that children with psychiatric disorders have a chemical imbalance in the brain that is caused by a genetic abnormality, but we don't know what the specific abnormality is. And we don't know precisely why why these medicines work. We just know that they these medicines work. We just know that they do do work. That's nothing new to medicine, of course. Digitalis has been around for hundreds of years. We've been using it for heart attacks for decades, but until relatively recently we had no idea why it works. We just knew that it did. work. That's nothing new to medicine, of course. Digitalis has been around for hundreds of years. We've been using it for heart attacks for decades, but until relatively recently we had no idea why it works. We just knew that it did.

CHAPTER 6.

The Great Medication Debate According to his mother, 10-year-old Adam had always been a "difficult child." When Adam and his parents came to my office for the first time, I learned that the little boy had been seeing a psychologist three times a week for five years. That's roughly 750 sessions. 750 sessions. Adam was still having serious trouble with his behavior. He wasn't doing well in school, and he didn't have any friends to speak of. I asked the parents what had taken them so long to bring their child to a psychiatrist. Adam was still having serious trouble with his behavior. He wasn't doing well in school, and he didn't have any friends to speak of. I asked the parents what had taken them so long to bring their child to a psychiatrist.

"Well, Adam's psychologist has been telling us for several years that he probably needs medication for his attention deficit hyperactivity disorder, but we were afraid to do it," the mother replied. "We thought that it would change his personality," added the father. "And besides, we don't like the idea of medicating a child."

I've met a lot of parents who don't like the idea of medicating a child for a brain disorder-or anything else, for that matter-but that was the first time I had ever encountered parents who preferred 750 sessions of psychotherapy that didn't work to a daily dose of medication that does work. After two weeks of a moderate dose of Ritalin Adam was a lot better. His parents, his teacher, and his peers noticed the change right away.

FOOLING MOTHER NATURE.

Adam's parents are not alone, of course. Many fathers and mothers are adamantly opposed to the idea of psychopharmacology for their children. "My kid on drugs? Never!" Never!" is something I've heard more than a few times. Parents who wouldn't think twice about giving their children insulin to treat diabetes or an inhaler to ease the symptoms of asthma balk at the prospect of giving their child medication for a mental disorder, for any number of reasons. They worry that the child will become addicted to the medication or will be encouraged to abuse other drugs. They fear that the child will be stigmatized by taking medication. They're concerned about the negative side effects. Some parents regard giving a child medication as taking the easy way out. They think that a more "natural" approach-for example, withholding sugar and caffeine, or using discipline, or trying to get to the root cause of every problem-is the more desirable, even the morally superior, course of treatment. is something I've heard more than a few times. Parents who wouldn't think twice about giving their children insulin to treat diabetes or an inhaler to ease the symptoms of asthma balk at the prospect of giving their child medication for a mental disorder, for any number of reasons. They worry that the child will become addicted to the medication or will be encouraged to abuse other drugs. They fear that the child will be stigmatized by taking medication. They're concerned about the negative side effects. Some parents regard giving a child medication as taking the easy way out. They think that a more "natural" approach-for example, withholding sugar and caffeine, or using discipline, or trying to get to the root cause of every problem-is the more desirable, even the morally superior, course of treatment.

"Isn't it a crutch?" some concerned parents ask, and I have to say yes, I suppose medication is a kind of crutch. But if a child's leg is broken, what's wrong with a crutch? If a youngster has a broken limb, he can't be expected to get around without some help. If a child has an infection, doesn't he take antibiotics? If a child's brain isn't functioning the way it's supposed to, shouldn't he be given whatever a.s.sistance is available to make it easier for him to lead a normal life, free of distress and dysfunction? Parents have to understand that brain disorders must be taken as seriously as asthma, diabetes, or any other organic problem. A child with a brain disorder is suffering, and there is nothing wrong with using medication to relieve a child's suffering.

Many parents who come to see me don't need to be persuaded about the virtues of medication. This is especially true of parents who have been helped by some of these medications themselves. When I recently prescribed a low dosage of Zoloft, an antidepressant, for a little girl with selective mutism, her parents didn't hesitate for a moment to follow my advice. "You know, a year ago I started taking Zoloft for depression, and it completely changed my life," the little girl's mother said. "There was a time I would never have dreamed of giving my child psychiatric medicine, but I don't feel that way anymore."

The father of a little boy with severe obsessive compulsive disorder put his feelings about medication even more succinctly: "Our son's life began the day he started taking his medicine."

THE STIGMA OF MEDICINE.

It's all very well for my colleagues and me to equate brain disorders with diabetes and to say that giving a child Ritalin shouldn't be any different from making sure he takes his insulin. We know that there is is a difference. A pediatrician looks in a child's ears, detects an infection, and prescribes ampicillin. Parents give the child his medicine without missing a beat. Do they ask the pediatrician about its long-term side effects or question him closely about what caused the infection? Probably not, or at least not at any length. They might even tell their friends about it. There's no stigma attached to having an ear infection. Most parents won't keep a child's diabetes a secret. There is, unfortunately, a stigma attached to having a brain disorder, and as a result many parents are secretive about their children's problems and the fact that they're taking medication. a difference. A pediatrician looks in a child's ears, detects an infection, and prescribes ampicillin. Parents give the child his medicine without missing a beat. Do they ask the pediatrician about its long-term side effects or question him closely about what caused the infection? Probably not, or at least not at any length. They might even tell their friends about it. There's no stigma attached to having an ear infection. Most parents won't keep a child's diabetes a secret. There is, unfortunately, a stigma attached to having a brain disorder, and as a result many parents are secretive about their children's problems and the fact that they're taking medication.

When I hear stories of how some people react, I can't really blame parents for keeping the news to themselves. One worried mother called me because the princ.i.p.al at her child's school said her son shouldn't be taking the Ritalin I had prescribed (and to which he was responding wonderfully well). The Ritalin is a crutch, the princ.i.p.al said; what the child really needed was a lighter school schedule and a different teacher. I was shocked by the princ.i.p.al's ignorance, not to mention his colossal nerve. If I had prescribed two puffs of an inhaler to keep a child with asthma from wheezing during gym cla.s.s, I doubt that the princ.i.p.al would have suggested that the child forget the medicine and be excused from gym instead.

Another mother showed up at my office in tears. Her daughter's teacher had told her that medicine-in this case an antidepressant for separation anxiety disorder-is the worst possible thing for a growing child. "I can't believe you're giving her drugs," the teacher said to the mother. (This was the same teacher who, only a few months earlier, had told the mother that her six-year-old daughter Ellen had some real problems, that all she did all day in cla.s.s was stare down at her desk, cry, and ask to go home to her mommy.) Ellen's mother sputtered a response to the teacher: "But you told me there was a problem. I'm trying to fix it." The teacher's response: "I told you to do something, but I didn't mean this." The fact that with the medication Ellen was able to attend cla.s.s all day without chronic worries and fears didn't affect the teacher's att.i.tude.

Teachers aren't the only people who routinely second-guess child and adolescent psychiatrists who prescribe medication. Most relatives aren't shy about giving their medical opinions either. We're always being told that Aunt Judy heard that Zoloft is better than Prozac or Grandpa read somewhere that Lithium doesn't really work. And then there are the well-meaning family members who just blame the parents.

"When we told my family that Josh is taking medication, they completely flipped out," said the mother of a four-year-old. "They think that we should be able to handle Josh ourselves. My sister gave me a long lecture about how I spoil my son and how he would be perfectly fine if I would just stop paying so much attention to him." The attention that she'd been lavishing on her son involved preventing Josh from overturning tables and pulling down drapes at family gatherings. Before the medication she couldn't turn her back on Josh for a minute. He would literally climb the walls.

When children are on medication, it's not just the parents who are judged. Teachers and others sometimes look askance at the children themselves. That's why one mother waited until halfway through the school year to tell the school that her eight-year-old daughter was taking Prozac. "I wanted them to get to know Maria first, without hearing about the Prozac. If they knew about the medicine from the beginning, they'd have all these preconceived notions about her. That's all they would think about. Once they know she's a great kid, they won't think about her as the little girl who takes the medicine. When I finally got around to telling them she was taking Prozac, their reaction was, 'Why? She seems fine to us.'"

Other parents flatly refuse to tell the school about a child's medication. The father of a 13-year-old girl who has been taking Cylert for many years says that he has been burned so often by unsupportive, uncooperative school officials that he has decided not to tell them about it anymore. "We lied on the health form, and we've encouraged our daughter not to say anything about her treatment," the man, himself a doctor, said to me. "This isn't how we want it to be, but we're tired of hearing lectures from people who don't know what they're talking about. I don't want my daughter to suffer because people are ignorant and prejudiced."

Naturally no one can force parents to confide in teachers or other school officials, but schools do usually require full disclosure, and I recommend it too, in theory at least. A collaborative approach should be the goal. I advise the parents of my patients to let me work with the school psychologist and the school nurse to coordinate the child's treatment. I believe that teachers should be involved in the treatment whenever possible, especially if a child's symptoms affect his behavior in the cla.s.sroom. It is a teacher's job to help all all the kids in cla.s.s, but before teachers can help, they have to know what the problem is. the kids in cla.s.s, but before teachers can help, they have to know what the problem is.

I've known many teachers who are immensely helpful to these troubled kids; it's not unusual, in fact, for a teacher to be instrumental in identifying problems or persuading parents to seek help. One school princ.i.p.al I know, a seasoned professional, arranged to meet two parents near the end of their eight-year-old son's academic year. The princ.i.p.al suggested gently to the parents that their child's behavior was out of the normal range and that he should be evaluated by a child and adolescent psychiatrist. The princ.i.p.al went on to say that the child might need medication.

"Oh, we've had him looked at," the mother said.

"Yes, the psychiatrist said he needed drugs, but we don't believe in them for kids," the father added.

"I believe you should reconsider," countered the princ.i.p.al. "If your son had a vision problem, you'd get gla.s.ses, wouldn't you? You wouldn't just expect him to squint." squint." The parents showed up in my office the following week. The parents showed up in my office the following week.

Most very young children in treatment for a brain disorder hardly give a thought to the fact that they have to take medication on a regular basis, except perhaps to regard it as a minor inconvenience. However, as kids get a little older, they may become embarra.s.sed or even ashamed about needing medicine. Many children don't want their friends to find out. They're fearful that what happened to a 14-year-old boy I treated will happen to them: when he told his friends he was taking medicine, they laughed at him and called him "Psycho." No one ever said that children are overly sensitive to the vulnerabilities and shortcomings of their peers. Kids can be brutal sometimes. They can also be remarkably supportive, especially if a good example is set for them. Children follow the lead of the significant adults in their lives-Mom, Dad, teacher. If the adults treat taking medication as perfectly normal, children will usually follow suit.

Each child is different, of course, but in general I find nothing wrong with a child's desire to keep his illness and medication private, provided that the child truly understands and appreciates that there's nothing wrong with taking a medicine that fixes the brain. The way I explain it is that people, grown-ups as well as children, aren't always educated about these kinds of disorders. They don't understand what makes people sick and why they need medicine to get well. That's why they call people names and say silly things that hurt other people's feelings. Perhaps it is is better not even to tell them about it. Besides, it's none of their business. A visit to any doctor is a private matter. Many of the kids I treat with medication never even mention it to their friends and cla.s.smates. Others are very open about it. The decision about how to handle this should be made by the parents, the child, and the psychiatrist. better not even to tell them about it. Besides, it's none of their business. A visit to any doctor is a private matter. Many of the kids I treat with medication never even mention it to their friends and cla.s.smates. Others are very open about it. The decision about how to handle this should be made by the parents, the child, and the psychiatrist.

Children, even very young ones, usually find it easier to accept the fact that they take medication if they understand their disorder and accept some responsibility for taking the medicine. One of my colleagues says that when he prescribes medication, he makes a speech to his young patients that goes something like this: "This is your your medicine. It is not your mom's medicine. It's not your dad's medicine. It is not your teacher's medicine. It is your medicine, and it's going to make you feel better. It will help you stop worrying all the time. Even if you don't always want to, you have to take it every day, so I want you to know the name of the medicine. It's called medicine. It is not your mom's medicine. It's not your dad's medicine. It is not your teacher's medicine. It is your medicine, and it's going to make you feel better. It will help you stop worrying all the time. Even if you don't always want to, you have to take it every day, so I want you to know the name of the medicine. It's called Zoloft. Zoloft. I don't want you coming in here next time and telling me that you take little blue pills. I want you to tell me you take Zoloft. And I want you to know how much you are taking, when you take it, and what it's doing for you." Involving a child in his own treatment in this way helps to remove the stigma. I don't want you coming in here next time and telling me that you take little blue pills. I want you to tell me you take Zoloft. And I want you to know how much you are taking, when you take it, and what it's doing for you." Involving a child in his own treatment in this way helps to remove the stigma.

THE MEDICATION Q AND A.

Not all mental disorders should be treated with medication, of course. Sometimes the recommended treatment is psychotherapy, and most often a combination of medication and psychotherapy is the solution. The psychotherapy I recommend most strongly for children and adolescents is behavioral therapy, which is characterized by its direct, supportive quality. In this kind of therapy we target specific symptoms and goals, and every aspect of the treatment is geared toward minimizing symptoms and achieving those goals. This is not psychoa.n.a.lysis. We don't try to unearth trauma and repair it. We don't "regrow" the child. We focus on getting rid of a child's symptoms and improving his ability to function. This kind of therapy may involve relaxation techniques (which include deep breathing and visual imagery), behavior modification, parent counseling, and family therapy. A child's problems aren't just a child's problems. They affect the entire family.

Medication should be prescribed only after careful diagnostic evaluation. Just as antibiotics are prescribed for bacterial infections but not for viruses, the medicines I prescribe are effective only for specific disorders. Diagnosis drives treatment Diagnosis drives treatment is one of the most important maxims of any physician. Before any treatment begins, a physician must make a diagnosis. is one of the most important maxims of any physician. Before any treatment begins, a physician must make a diagnosis.

Parents have to make it their business to understand their child's disorder and the recommended treatment by asking questions. Here are a handful of drug-related questions that any child and adolescent psychiatrist should be prepared to answer when prescribing medication: What is the diagnosis?

What is the medicine, and how does it work?

Have studies been done on the medication?

Which tests need to be done before my child starts the medication?

How soon will I see an improvement?

How often will his progress be monitored, and by whom?

How long will he have to take the medicine?

How will the decision be made to stop it?

What are the negative side effects of the medicine?

What will happen if my child doesn't take it?

Doctors won't be able to answer all of the questions with precision, of course. "How long will he have to take the medicine?" is an especially hard one. Adults who take medication for high blood pressure can never be sure how long they'll have to keep taking it. With diet and exercise and a lot of luck perhaps they can discontinue the medication after six months or a year, but it's also possible they'll have to take it for the rest of their lives. Regular checkups with the doctor tell the tale. The same goes for children's brain disorders. Many kids need medication for an extended period of time; others thrive without it after a short "trial." Regular evaluation and monitoring of a child's progress will tell the physician and the parents what they need to know.

Careful, individual t.i.tration t.i.tration is also vital to the treatment; the prescribed dose of any psychiatric medication given to a child may have to be adjusted, perhaps many times, before we get the results we're looking for. Too often a child is given a dose of a medicine that is not sufficient. When the behavior doesn't change and the child doesn't get better, it shouldn't be a.s.sumed that the drug isn't working. The child may simply need a little more of it. is also vital to the treatment; the prescribed dose of any psychiatric medication given to a child may have to be adjusted, perhaps many times, before we get the results we're looking for. Too often a child is given a dose of a medicine that is not sufficient. When the behavior doesn't change and the child doesn't get better, it shouldn't be a.s.sumed that the drug isn't working. The child may simply need a little more of it.

The answer to another question, "Have studies been done on the medication?" may not be what parents want to hear. We have several ways of gauging the effectiveness of a medicine. The simplest is the case study case study method, in which we follow the progress of one case. We give a child medicine, see what effect it has on certain symptoms, stop the medicine, see what happens, and then start it again. method, in which we follow the progress of one case. We give a child medicine, see what effect it has on certain symptoms, stop the medicine, see what happens, and then start it again. Open clinical trials Open clinical trials are more sophisticated. We take a group of kids with the same disorder, give them all the same medicine, and measure their progress after six weeks. The gold standard of tests is the are more sophisticated. We take a group of kids with the same disorder, give them all the same medicine, and measure their progress after six weeks. The gold standard of tests is the placebo-controlled double-blind trial placebo-controlled double-blind trial We choose a fairly large group of children with the same disorder-96 children from ages 8 to 18 who have major depressive disorder, for instance-and give half of them medication and half of them a placebo. Neither doctor nor patient knows who is getting what. That's why the study is called We choose a fairly large group of children with the same disorder-96 children from ages 8 to 18 who have major depressive disorder, for instance-and give half of them medication and half of them a placebo. Neither doctor nor patient knows who is getting what. That's why the study is called double-blind. double-blind. After eight weeks we measure and compare the progress of both groups. After eight weeks we measure and compare the progress of both groups.

Unfortunately we do not have placebo-controlled double-blind trials for many of the drugs we routinely prescribe for children's brain disorders, but this doesn't mean that a child or adolescent shouldn't take them. It does mean that both parents and physicians should be careful to examine all options before starting a child on any medication.

DRUGS AND PERSONALITY.

Here's how one mother reacted to the changes in her son that were brought about by medication: "When Allen takes his medicine, he's so much quieter than he was before. He seems to listen to me a lot more carefully, and our conversations are much deeper and more enjoyable. He's practically a different person. I hate to admit it, but I like him better when he's on the medicine. He's more in tune, more attentive, more interesting. What worries me is, Is this really my child?" Is this really my child?"

The answer is yes, the new Allen is really her child. The medications that we prescribe don't change children's personalities; they simply free kids up so that they can be themselves. A brain disorder disguises a child's true nature and hampers his abilities. Medicine lets him use his a.s.sets.

Children with brains that don't work quite right are like kids whose thermostats are out of whack. They're always a little colder than everyone else. The other kids are running around in the sunshine in shorts and T-shirts, but the child with the disorder always has on a bulky sweater, mittens, a scarf, perhaps even a coat. Because he's weighed down by all the extra clothing, the child with the disorder finds it difficult to run and play with the other kids. He looks different. He tends to stand on the outskirts of the activity, away from the others. He knows how to run and play, of course, but it's a lot harder for him to manage than it is for his peers. When this child takes the medication that repairs his thermostat, he's finally able to take off the coat, the mittens, and the extra layers. Unenc.u.mbered, he can run faster and play more vigorously, more happily, than he did before. He seems different, and in some ways he is different.

The real question is: Who's the real real child-the unhappy, sluggish one swathed in sweaters or the carefree, gleeful one running around in his shirtsleeves? As far as I'm concerned, there's no contest; the one without the sweater is the child as he is meant to be. He's the one who's functioning properly. He pays attention in school, interacts well with his friends, and, like the new Allen, has a fruitful, fulfilling, loving relationship with his parents. He's the one with a real chance for a happy, healthy life. child-the unhappy, sluggish one swathed in sweaters or the carefree, gleeful one running around in his shirtsleeves? As far as I'm concerned, there's no contest; the one without the sweater is the child as he is meant to be. He's the one who's functioning properly. He pays attention in school, interacts well with his friends, and, like the new Allen, has a fruitful, fulfilling, loving relationship with his parents. He's the one with a real chance for a happy, healthy life.

Once in a while parents give undue credit to their child's medicine. That was certainly the case with the mother and father of 12-year-old Libby. "I remember the first year we sent Libby to camp after she started taking her medication," her father told me. "When we went to see her for Parents Day, she seemed very subdued. All the other kids were running around, but she was quiet. I said to my wife, 'It's the medicine that's making her like this. What are we doing to our child?' My wife looked at me with a funny expression on her face and said, 'She didn't take the medicine today. She knew we were coming, so she didn't take it.'"

THE SIDE EFFECTS.

"What will this medicine do to my kid?" is almost always the first question that pa.s.ses any parent's lips, and it's a good one. If a child with a fever takes too much Tylenol, it may cause inflammation of the kidneys. The ampicillin that cures a child's ear infection often causes diarrhea. All medicines, including those prescribed for children's brain disorders, have side effects, and parents should know in advance what to expect. (Specific medications and specific side effects are described in Part Three, which covers individual disorders, and summarized in Appendix 3 Appendix 3, Psychopharmacology at a Glance.) However, parents should also be mindful that the adverse effects of not not taking a drug are often far more unpleasant than the possible side effects of taking it. The long-term effects of an taking a drug are often far more unpleasant than the possible side effects of taking it. The long-term effects of an untreated untreated brain disorder-distress, low self-esteem, dropping out of school, unsatisfying interpersonal relationships, and many others-can be truly devastating. brain disorder-distress, low self-esteem, dropping out of school, unsatisfying interpersonal relationships, and many others-can be truly devastating.

Little Billy, a seven-year-old child with a brain disorder-attention deficit hyperactivity disorder-comes to me in severe distress and obvious dysfunction. He's inattentive, hyperactive, agitated. He can't focus on anything in school, and he drives everyone crazy with his obnoxious behavior. His teacher doesn't like him; the other kids don't want to play with him; even his parents find his behavior intolerable. He's the only one in the cla.s.s who doesn't get invited to the birthday parties. He's not learning anything, and he's not having any fun. With the correct dose of a stimulant he can focus in school and follow the lessons. He can play with his friends and go places with his parents.

To be sure, the stimulant may cause a decrease in little Billy's appet.i.te, alter his sleep patterns slightly, or cause an occasional headache. But without the stimulant this child is heading for trouble that's a lot more serious than a headache. To me the choice seems clear: the child needs the medication.

THE BOTTOM LINE.

A colleague of mine says that the most important task that children have is to choose the right parents. Carefully chosen parents not only accept their children's a.s.sets and deficits; they also do whatever is necessary to make sure that their kids have plenty of opportunities to use their a.s.sets and are given whatever help they need to compensate for those deficits. That's what parenting is all about.

A child's brain disorder is not a parent's fault, but finding the right treatment for the disorder is a parent's responsibility. If a son is diagnosed with diabetes, it is a parent's job to give the child his medication, work out a proper diet, and give him the moral support he needs to keep himself well. If a daughter has an allergy, a parent should make sure she takes her shots, keep the house allergen-free, and offer moral support. The same rules apply to a brain disorder. A parent's job is to find the right treatment, work with the doctor and the child to implement it, build the child's self-confidence, and make the child's life easier along the way. Often the right treatment will include medication.

There are hundreds of thousands of success stories a.s.sociated with pediatric psychopharmacology. "We got our life back" and "We finally could think about having another child" and "It was a miracle" are the kinds of comments heard every day from parents whose children's lives have been turned around by medication. Like Adam's parents, who took their child to a therapist 750 times before deciding to give medicine a try, they probably don't like like the idea of giving a child medicine, but they like it a lot more than the alternative. The story that Margaret's parents tell, which describes a journey from despair to optimism, sums it all up. the idea of giving a child medicine, but they like it a lot more than the alternative. The story that Margaret's parents tell, which describes a journey from despair to optimism, sums it all up.

"Our daughter Margaret was always different, not like the other kids. When she was six-that's seven years ago now-we had her independently tested, and we got this 28-page report telling us that she had terrible problems and needed full-day special education. At this point Margaret was completely miserable. She didn't have any friends, and everything she did was wrong. Her self-esteem was incredibly low. I remember asking the psychologist who tested her what cla.s.s or activity we could sign Margaret up for that she would be most likely to succeed at. We wanted to make her feel good about herself. I'll never forget his answer: 'Don't sign her up for anything. She will never succeed at anything.' Those were his exact words. We were completely devastated.

"That was in January. By April we had seen a psychiatrist who put Margaret on Ritalin, and after two days on the medicine she was able to focus for the first time. The change in her was so dramatic that we called her the new Margaret. It was as if she rose from the dead. By the end of the school year she was getting perfect scores on all her tests and having sleepover dates with her cla.s.smates. Today, seven years later, she makes straight As in school, plays French horn in the band, and has plenty of friends. She still takes Ritalin three times a day for her ADHD. I can't say we like giving her the medicine, but we know she needs it. We can't imagine her life without it."

PART THREE.