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Chapters 7, 8, and 9 of this book; were largely directed to adults who want to withdraw from drugs. However, as nearly all of the principles outlined in those chapters are relevant to children, they must be read prior to this one.
The most general of these principles include gradual withdrawal, the involvement of family members and a support system, and guidance from an experienced professional. We also emphasized the importance of paying attention to your own feelings, and of personally planning and managing your own withdrawal experience. Obviously, children - especially young children - cannot plan or control their own medical care: They need parents and other adults to do it for them. But they can and should play a major role in every step of the planning, and, as with adults, their feelings should be given special attention throughout the process. Precisely because children have immature or even impaired competence, their caregivers are obligated to try hard to seek and be responsive to children's views and feelings.
Since children who receive stimulants are by far the largest group of minors on psychiatric drugs, we will focus on stimulant withdrawal among children diagnosed with "attention deficit hyperactivity disorder". However, most of the observations that follow apply equally well to children being withdrawn from any psychoactive drug. It is now increasingly common for children to receive atypical antipsychotics and anticonvulsants.
The emphasis in this chapter is on younger children - preadolescents who are too young to participate effectively in treatment decisions and who cannot easily describe in words their responses to the drugs they are taking. Older children who are better able to communicate and make decisions can become actively involved in a manner more similar to that of adults. Indeed, depending on their maturity older children can help to monitor the rate of their withdrawal from drugs in much the same way as adults do.
Children are often given drugs for sedation that pose special problems if stopped abruptly. Regardless of whether they have epilepsy youngsters taking sedatives and drugs used for the treatment of seizures can experience seizures during withdrawal. These drugs include all the minor tranquilizers such as Klonopin and Xanax, as well as anticonvulsants such as Depakote, Tegretol, Dilantin, Lamictal, and Topamax. Even among children who have never been manic, lithium can cause mania during withdrawal. And even among children who have never been hypertensive, abrupt clonidine (Catapres) withdrawal can trigger a hypertensive crisis. Withdrawal from stimulants such as Ritalin and Adderall, and antidepressants such as Paxil, Celexa, Effexor, Prozac, and Zoloft, can cause "crashing" accompanied by depressed and even suicidal feelings.
To learn about adverse effects and withdrawal effects associated with any drug your child is taking, be sure to review the information in earlier chapters of this hook as well as in other resources.
Children, like adults, vary greatly in terms of the intensity of their withdrawal response when taken off stimulant drugs. Some children experience little more than rebound hyperactivity or tension for a few hours. Others, especially after months or years of exposure to drugs, may undergo an extensive and uncomfortable withdrawal. The manifestations of withdrawal also vary. Some children may exhibit increased rebelliousness, hyperactivity, and insomnia; others may display apathy and a greater need to sleep.
Many children are routinely taken off stimulant drugs every weekend. If this is the case with your child, acute symptoms of withdrawal are probably not going to be a problem after the child's drug use has permanently ceased. Nonetheless, previous problems may resurface after a few weeks or even months as you, your child, and the school deal with this new drug-free experience.
Have you ever gone on vacation and forgotten to bring your child's drugs along, or stopped the drugs for some other reason? Such experiences should give you a sense of what your child's response will be during the acute phase of the upcoming planned withdrawal. However, keep in mind that withdrawal reactions can vary from one time to the next even in the same child.
Some doctors tell parents that children and adults "react differently" to stimulants. This is untrue. Any withdrawal reaction can occur in both children and adults.
As previously described, children commonly experience withdrawal symptoms from stimulants within a few hours after taking the last dose. If they take Ritalin at 3 P.M., for example, they are likely to be more nervous, anxious, and "hyper" by evening. This stage of drug withdrawal is called rebound.
Some doctors tell parents that rebound cannot start after a delay of several hours following the last dose and that it cannot persist for a prolonged period of time. In fact, rebound routinely starts as long as five to ten hours after the last dose. And if no more stimulant is administered, the rebound can become a long-term withdrawal reaction that lasts days or weeks. In some cases, it may take a month or more for children to calm down after stopping stimulants during the summer vacation. These withdrawal effects would manifest themselves even longer if the children were subjected to the more demanding and stressful regimen of a typical school.
When planning your child's withdrawal, you must take into account how and why your child was put on drugs in the first place. If your child was medicated because of "school problems" in the absence of "home problems", then you may have fewer or less severe parenting issues to deal with during withdrawal. Nonetheless, new parent-child conflicts are likely to develop during this process.
On the other hand, if you agreed to medicate your child because of his or her behavior around you, then you will almost certainly need to work very hard on parenting issues as your child comes off the drugs. This work will require a serious self-examination of your own behavior, along with openness to constructive criticism from your spouse or other family members and careful attention to any opinion your child is able to voice. In addition, you will have to work closely with anyone who shares caregiving responsibilities with you, since consistency is an important part of successful childrearing.
Useful parenting books can be found at bookstores and libraries. Look at a variety of such books and then select one or two for careful reading and reference. You may also want to attend parent training classes and seek consultations with an expert in parenting144.
If it turns out that your own confusion or inconsistency in parenting is a main cause of your child's difficulties, you should greet this as good news-indeed, the best possible news! It means that being a parent matters, that there's nothing wrong with your child that can't be fixed through your efforts and those of your family. Although it may initially seem easier to think that someone or something else is the cause of your child's problems, such thinking ultimately wrests the power out of your hands. In making the decision to stop medicating your child, you should reaffirm yourself as a parent and retake responsibility for your child.
When children have been on psychiatric drugs for years, their psychological and social development may be suppressed. Instead of struggling through the normal developmental stages, these children are pushed through their growing-up period in a drug-induced state of conformity. They may not learn to know and to express themselves, to handle emotional pain, to work out conflicts with others, and to take charge of their own behavior. Their sense of autonomy and personal responsibility is almost always impaired. All these issues may surface acutely during withdrawal and require special parental attention.
None of us are born good parents: We have to learn this complex, subtle array of skills "on the job". In effect, we go through the same developmental stages as our children, but from our own perspective and with our own specific learning processes. However, when our children are medicated, we don't have the opportunity to learn the skills involved in raising a drug-free child. We become accustomed to turning to medication as the answer. At the same time, we might cease examining ourselves and our own parenting skills. Parents and children have to learn new skills during and after drug withdrawal.
Doctors, teachers, school psychologists, and other child welfare workers often recommend medication to parents when they should instead recommend or offer a consultation or seminar on parenting skills. Even parents who have successfully raised several children may have trouble finding the right approach to another of their offspring. Every child is a new challenge. In fact, your child's special assets, such as high energy and an independent nature, may be testing your parenting skills. And every new challenge in a family's life presents new stresses and opportunities for you and your children. Consultations with a family-oriented therapist who is skilled at identifying your vulnerabilities as a parent at this particular time in your life, and with this particular child, can be the critical factor in helping your child withdraw from drugs.
Many parents keep their children on drugs because they feel too guilty or ashamed to face the mistakes they have made. They feel so humiliated by criticism of their parenting that they cannot face the need to learn new approaches. By contrast, the most successful parents are those who freely admit that they routinely make mistakes and need to make constant readjustments in the ways that they relate to their children. Give up any pretense you may have about being a "perfect" parent, and assume that you've got a lot to learn. It's a matter of accepting the axiom that were all human.
Other parents keep their children on medication because they have been told that their child suffers from a "severe neurobehavioral disorder" that will worsen unless treatment is instituted with drugs. Virtually every childhood distress, delayed achievement, or misbehavior has been labeled a disorder. Ask your doctor what medical tests or evidence, besides the child's behavior, necessitates a medical-sounding diagnosis.
Preadolescent children are incredibly responsive to any improvement in parental behavior. Sometimes just a few good consultations with a parenting expert can help you significantly change your child's life for the better. Especially in regard to managing difficult behaviors, such as anger and resentment, new parental approaches can transform a young child's responses overnight.
Most parents suffer from "parent attention deficit disorder". They rarely find enough time to give their children all the attention they need and deserve. In effect, their children get leftover time.
In modern society; with it's increasing economic pressures on families and it's many single-parent homes, drugs have become a kind of babysitter; children make fewer demands on parents while on drugs. If you are going to take your child off psychiatric drugs, be prepared to spend additional time with him or her. This can be the single most important and potentially satisfying decision of your life - to spend more time with your child on a routine basis throughout the period of your child's dependency on you.
Many if not most children routinely seen for medication have fathers who are not sufficiently involved in their children's lives. Especially in cases involving boys who are disobedient and resent authority, the father is often the main source of the difficulty - and thus the main source of potential improvement. Such boys need a stronger father-son bond through which to learn disciplined and respectful behavior. However, in cases where dad is spending time with the child but a corresponding behavioral improvement is not taking place, he may be acting too much like a pal and not enough like a parent. When a father is lax as a disciplinarian, the child is encouraged to take advantage of his mother or other caregivers, imposing an impossible burden upon them.
In addition to the principles of slow and cautious withdrawal that we emphasize, it is important that you pay special attention to your child's feelings. Every single day during the withdrawal period, talk and play with your child, and fine-tune your sense of how your child feels.
Bedtime presents a good opportunity for visiting with your child, especially if he or she is having trouble falling asleep during drug withdrawal. But be sure to check in before and after school as well. If you're at work during the day call in every day when your child gets home from school. Like our other suggestions, this one can become a deeply satisfying habit that lasts throughout childhood and contributes to the love and trust that you share with your child.
Make clear to your child that withdrawal from drugs can be difficult and that you want to hear about any unusual or uncomfortable feelings or thoughts. Reassure your child that you will pay attention, respond, and perhaps alter the medication schedule if necessary.
Playing games can help a young child express potentially delicate feelings and thus help you communicate with the child. For instance, you can have two stuffed animals chat with each other. Start by making up any subject matter you can imagine, especially if it's cute and funny. Then ask your child to have the animals talk with each other. At an opportune time, introduce the topic of "feelings" into the conversation between the animals. Eventually you can ask them how they feel now that they are taking fewer pills. You may be astonished to hear your previously reticent child begin to reveal information in the form of a dialogue between the two stuffed animals.
Another playful approach involves storytelling. Ask your child - with lots of prompting, if necessary - to make up a story about a little girl or boy. After the story begins, you can suggest that the child in the story is having trouble getting along at home or in school. Then direct the story to what happens if the little girl or boy starts and then stops taking medications. You may find that your child tells you about herself in her story.
Another way to enlist your child's cooperation is to inform him about the potential difficulties he may experience during withdrawal. Children often become more responsible when responsibility is entrusted to them. And the prospect of coming off their drugs often motivates children to improve their conduct.
Don't worry about giving your child too much opportunity to voice his or her feelings and wishes; you can still remain in charge as the parent. If anything, your increased interest in your child's feelings will encourage your child to be more responsive to yours.
Children are most often put on stimulants because of pressure from school. Many schools encourage parents to seek medical consultations in order to medicate the children and control their classroom behavior. In the past, hyperactivity and other forms of disruptive actions were the major target behaviors. More recently, schools have begun advocating drugs on the assumption that they also contribute to improved learning and academic performance. However, there is no body of scientific evidence to support this hope. Most reviews and panels have concluded that stimulants have not been shown to improve learning or academic performance145. Like other psychoactive agents, they are far more likely to impair mental function.
If your child's main problems at school are daydreaming, forgetting things, and otherwise acting "inattentively" you should be able to stop the stimulant drugs with relative ease. Simply explain to the teacher that you'd rather have a child who daydreams than a child who can't daydream. You might also point out that there are no scientific data confirming the usefulness of stimulants for treating inattention146.
Ask the teachers support in increasing your child's attention in school, perhaps through more individualized instruction aimed at stimulating your child and addressing specific educational needs. In addition, spend time outside of school cultivating your child's academic interests in a fun manner. Take your child to the library and to museums, movies, concerts, and other educational activities. But do not resort to drugs to "improve" your child's attention. Drugs only blunt imagination and fantasy life without making any genuine improvement in the child's actual ability to focus.
Some teachers give better grades to children on drugs because the drugs make them more conforming. But better grades are not worth the price of drug-induced conformity. And, as already noted, drugs do not improve actual academic achievement or learning.
Many well-meaning parents have chosen to medicate their children to improve their grades. If you are among them, we urge you to reconsider your priorities. Your personal relationship to your child should be a much higher priority than grades. Indeed, your child will benefit much more from feeling loved and appreciated by you than from getting good grades. Stop struggling with your child about homework and focus on enjoying parenthood. Let the teacher, a tutor, or a relative or friend help with homework if doing so relieves some of the tension between you and your child. A month or two of relief from conflict over studies may enable you to improve not only your relationship but also your perspective on whats important in the long run for your child. In our opinion, nothing is more important than the quality of your personal relationship with your child.
We also urge you to place a higher priority on the integrity of your child's brain than on good grades. As your child grows up, he or she will have multiple opportunities to develop an interest in school and in education. For that matter, some people don't settle down to studying until they are adults, and others, of course, do very well in life despite doing very poorly in school. So, whereas future opportunities for school abound, your child will never be able to get a new brain unaffected by drugs.
If your child is in danger of flunking a grade, you may feel a particular urgency about correcting the situation. This concern is understandable, but do not let it override two of the most important aspects of your child's life - the relationship between the two of you, and his or her ownership of a brain unimpaired by drugs.
Maintaining patience with children who underachieve is a far more positive action than medicating them. And, in any case, there are many other ways to help children perform better in school. The best one is to spend time with your child - playing interesting games, going to museums, and, in general, engaging in activities that make learning a part of your family life. Tutoring, especially in reading, is often the most effective educational intervention available. Reading with your child is not only academically beneficial but it can improve your relationship.
As noted, many schools pressure parents to put their children on medication, especially if they are disruptive in class or require more attention than the teacher is willing or able to give. Private schools may threaten to expel the children. Public schools use other forms of psychological pressure that can be equally threatening.
If you are a parent who is determined not to drug your children, you can put your energy into considering the many better alternatives that exist. First, work closely with the school on improving your child's disruptive behavior. Spend time in class observing your child's behavior, or have a friend or relative do so. Your visits will have the added advantage of making clear to your child - and to the teacher - that you take these difficulties seriously. Do everything you can to ensure that the school meets your child's needs.
Resistance from schools is to be expected. Dealing with teachers and school officials who understandably resist changing their habits in order to accommodate your child's needs requires time, effort, patience, and ingenuity. But, as an alternative to medicating your child, it has the clear advantage of squarely framing the difficulty in educational terms, and of encouraging adults around your child to come up with solutions.
We sometimes advise parents to tell the school authorities something along these lines; "I know that Ritalin has a good chance of making my child more compliant in class, but that's just not the kind of `improvement' I want for my child. I do not beat my child if he suffers a setback in class, and I refuse to drug my child for the same purpose." You may also express your concern about exposing your child to drugs that cause agitation, growth stunting, and heart problems that the FDA has explicitly warned about.
Second, discuss your child's problems at school with an independent counselor, psychologist, or educational consultant. If the professional is unwilling to visit the school, you may want to find another resource.
Third, remember that many wonderful children who become creative adults were not meant to spend day after day in large groups learning rote material. Consider other schools as well as the wide variety of home-schooling programs that are available.
In Chapter 8 we discussed the principles involved in choosing which drug or which dose to start reducing. Recall that if a second drug has been given for a side effect caused by the original drug, the second drug should not be withdrawn until after the dose of the original one has been reduced. Thus, for example, if your child was given Klonopin to overcome Ritalin-induced insomnia, cutting back on the Ritalin should be your initial step.
Alternatively, if a specific drug dose is causing adverse effects, you might begin by reducing that dose. For example, if the afternoon dose of clonidine is making your child too sleepy - or the afternoon dose of Ritalin is making your child too wide awake at bedtime - start reducing it.
Sometimes one or another dose may be the more practical one to reduce. If your child's behavior at home is relatively easy to manage compared to his or her school behavior, then start by reducing the dose that you give after school.
Your child should be withdrawn from psychiatric drugs of any kind as soon as possible. They are detrimental to your child's growing brain and overall development. Even if you and your child's doctor believe that the psychiatric drugs have been helpful, they should be stopped as soon as feasible. In cases where drugs are being used to treat children or adults, the smallest possible dose for the shortest possible time is always the best practice. In children with growing, vulnerable brains, the need to avoid toxic exposures is especially critical.
Remember, your child's behavior may temporarily worsen during withdrawal. A positive, loving, patient, engaging environment is very important at this time. If your child is going off to summer camp or some other activity away from home, withdrawal ideally should be complete at least a few weeks beforehand.
If your child has been on drugs for a year or longer, and if school behavior is a major problem, you may want to wait until summer vacation to begin to withdraw the drugs. Or you may want to begin a slow, cautious withdrawal during the school year. If the school reports that the child is "getting out of control", you might have to hold off until summer.
As parents ourselves, we would rather take our children out of school than to drug them for the purpose of staying in school. We would prefer any viable alternative to giving psychoactive drugs to our children, including major changes in our own lifestyle in order to provide better for our children's needs.
We recommend reading Peter Breggin's "Talking Back to Ritalin" (Breggin, 1998a [57]) as a part of any decision to start or stop stimulant drugs for the behavioral control of children. His book discusses many subjects covered in the present chapter, in considerably greater detail - including how to deal with schools and how to develop your parenting skills.