Troubled Children
Proof Is Scant on Psychiatric Drug Mix for Young
By GARDINER HARRIS
Published: November 23, 2006
Their rooms are a mess, their trophies line the walls, and both have profiles on MySpace.com. Stephen and Jacob Meszaros seem like typical teenagers until their mother offers a glimpse into the family’s medicine cabinet.
Bottles of psychiatric medications fill the shelves. Stephen, 15, takes the antidepressants Zoloft and Desyrel for depression, the anticonvulsant Lamictal to moderate his moods and the stimulant Focalin XR to improve concentration. Jacob, 14, takes Focalin XR for concentration, the anticonvulsant Depakote to moderate his moods, the antipsychotic Risperdal to reduce anger and the antihypertensive Catapres to induce sleep.
Over the last three years, each boy has been prescribed 28 different psychiatric drugs.
“Sometimes, when you look at all the drugs they’ve taken, you wonder, ‘Wow, did I really do this to my kids?’ ” said their mother, Tricia Kehoe of Sharpsville, Pa. “But I’ve seen them without the meds, and there’s a major difference.”
There is little doubt that some psychiatric medicines, taken by themselves, work well in children. For example, dozens of studies have shown that stimulants improve attentiveness. A handful of other psychiatric drugs have proven effective against childhood obsessive compulsive disorder, among other problems.
But a growing number of children and teenagers in the United States are taking not just a single drug for discrete psychiatric difficulties but combinations of powerful and even life-threatening medications to treat a dizzying array of problems.
Last year in the United States, about 1.6 million children and teenagers — 280,000 of them under age 10 — were given at least two psychiatric drugs in combination, according to an analysis performed by Medco Health Solutions at the request of The New York Times. More than 500,000 were prescribed at least three psychiatric drugs. More than 160,000 got at least four medications together, the analysis found.
Many psychiatrists and parents believe that such drug combinations, often referred to as drug cocktails, help. But there is virtually no scientific evidence to justify this multiplication of pills, researchers say. A few studies have shown that a combination of two drugs can be helpful in adult patients, but the evidence in children is scant. And there is no evidence at all — “zero,” “zip,” “nil,” experts said — that combining three or more drugs is appropriate or even effective in children or adults.
“There are not any good scientific data to support the widespread use of these medicines in children, particularly in young children where the scientific data are even more scarce,” said Dr. Thomas R. Insel, director of the National Institute of Mental Health.
Psychiatrists who prescribe drug combinations say that the ability to mix and match medications improves their chances of being able to help children who are seriously, even desperately, ill.
Dr. Joseph Biederman, a professor of psychiatry at Harvard, said that doctors commonly used multiple medicines to treat heart disease, diabetes, cancer and AIDS. “Child psychiatry is not any different,” Dr. Biederman said. “These drugs have revolutionized how we treat severe psychopathology in children.”
The controversy leaves parents in a terrible bind. Desperate to help, many agonize over whether to medicate their children.
Mothers and fathers sometimes disagree, with the dispute straining or even ending marriages. Since some psychiatric drugs can cause worrisome physical effects, parents say that they must on occasion make a terrifying choice between their child’s physical health and his mental health.
The parents interviewed for this article told their stories, they said, in hopes of gaining greater acceptance for their children and themselves. Nearly all recalled being in a store when their child threw a tantrum and feeling that onlookers branded them as bad parents. They also said they hoped to help others negotiate what many said were unequal and often fraught relationships with psychiatrists.
“We struggled so much, made so many mistakes and felt so stigmatized, I hope our story can make it easier for others,” said Jacquie Erickson of Anchorage. Her daughter, Kaitlyn Johnston, 10, has taken psychiatric drugs since she turned 5 for diagnoses that include bipolar disorder.
On Shaky Ground
Stimulants like Ritalin are by far the most commonly prescribed psychiatric medicines in children. But doctors routinely pair stimulants with antidepressants, antipsychotics and anticonvulsants, even though some of these medications can cause serious side effects, have few proven pediatric psychiatric benefits and lack clear evidence about how they interact or influence mental and physical development.
Last year, the Food and Drug Administration required drug makers to warn on their labels that antidepressants can cause suicidal thoughts and behavior in some children. Anticonvulsant drugs carry warnings about liver and pancreas damage and fatal skin rashes. The side effects of antipsychotic medicines can include rapid weight gain, diabetes, irreversible tics and, in elderly patients with dementia, sudden death. When drugs are combined, these risks compound.
Ms. Kehoe, who receives government financial and child-care assistance because her children are considered mentally ill, said she knew that there were risks to the drug cocktails. Both her sons are short and underweight for their age — a common side effect of stimulants — and she fears that the drugs have affected their health and behavior in other ways.
“But I don’t think the insurance would pay for it if the F.D.A. didn’t decide that children should use it,” said Ms. Kehoe, who herself takes psychiatric medication.
In fact, the drug agency has specifically warned against the use of Lamictal, one of the drugs Stephen takes, in children who, like him, do not suffer from seizures because in 8 out of 1,000 children the drug causes life-threatening rashes.
Stephen and Jacob’s psychiatrist did not reply to telephone messages left with an office secretary on three different days. Ms. Kehoe said that she asked him to speak to this reporter but that he refused. The boys have had 11 psychiatrists over the last three years, according to prescription records, and many more before that, Ms. Kehoe said.
In interviews, Stephen and Jacob said they hated taking their drug cocktails.
“Everybody hates meds,” Jacob said.
Ms. Kehoe said her youngest son, Lucas Keck, was showing signs of attention deficit disorder and might soon need to start medication.
“I see the hyperness in him,” she said. “My pediatrician has said that he would venture to say that Lucas will be A.D.H.D.”
Stephen and Jacob were Lucas’s age — 6 — when they were given their first prescriptions.
The F.D.A. requires drug makers to prove that their drugs work safely before the agency will approve them for sale in the United States. But doctors can prescribe and combine approved medicines as they see fit. Such mixing is common in medicine but rarely studied by drug makers.
Psychiatrists started mixing psychiatric medications because the drugs were only moderately effective and often caused terrible side effects, said Dr. Steven E. Hyman, the provost of Harvard University and former director of the National Institute of Mental Health. “None of these drugs by themselves do an adequate job of controlling symptoms,” Dr. Hyman said.
If one drug failed, many psychiatrists assumed that two or more drugs used together might succeed. For decades, no one studied whether this was accurate. But in recent years, a trickle of studies have examined the question, with mixed results.
In studies in adults, some combinations of two drugs have been shown to work better than single medications to improve the symptoms of depression, obsessive-compulsive disorder and the mania associated with bipolar disorder. For example, a recent large government-financed study in adults, published in The New England Journal of Medicine, found that two antidepressants worked a bit better than one for adults who suffered from chronic, severe depression. But other studies have found no benefit from commonly prescribed drug combinations.
The use of two-medicine combinations in children is on much shakier ground. Even for single drugs, the effectiveness of some psychiatric medications in younger patients is questionable: most trials of antidepressants in depressed children, for instance, fail to show any beneficial effect. But hardly any studies have examined the safety or the effectiveness of medicine combinations in children. A 2003 review in The American Journal of Psychiatry found only six controlled trials of two-drug combinations. Four of the six failed to show any benefit; in a fifth, the improvement was offset by greater side effects.
“No one has been able to show that the benefits of these combinations outweigh the risks in children,” said Dr. Daniel J. Safer, an associate professor of psychiatry at Johns Hopkins University and an author of the 2003 review.
If the evidence for two-drug combinations is minimal, for three-drug combinations it is nonexistent, several top experts said.
“The data is zip,” Dr. Hyman said.
Many psychiatrists said that they turned to drug cocktails only in desperate circumstances. “If you’ve got a 15-year-old who is cutting up her arms, you’ve got a barn on fire and what are you supposed to do?” asked Dr. Alexander Lerman, a child and adolescent psychiatrist in New York, who said he rarely prescribed combinations.
Billy and Jackie Igafo-Te’o of Jackson, Mich., are among the desperate. In the last seven years, their 12-year-old son, Michael, “has been on just about everything you can put a child on,” Mrs. Igafo-Te’o said. He is now taking four medications: an antipsychotic, an anticonvulsant, an antidepressant and a sleep medicine.
Despite the medications, Michael’s behavior has grown increasingly disruptive. He has kicked and punched holes in almost every wall of the Igafo-Te’o home. He wrenched the sink off the wall in the upstairs bathroom and pulled two bedroom doors off their hinges, damaging the frames. The family no longer fixes the damage.
During a recent visit, Michael and Mr. Igafo-Te’o were sitting on the living-room floor. Michael wanted the phone. His father held it out of reach to prevent Michael from playing with it. Michael became increasingly desperate. He cried. He cursed.
“That’s it, you have a timeout,” Mr. Igafo-Te’o said.
“No, no, no,” Michael answered. “You pimp!”
He slapped his father in the face, hard. Mr. Igafo-Te’o hustled Michael into the kitchen and forced him to sit for 20 minutes.
“What’s the purpose of all this medication if I still have to do that?” Mr. Igafo-Te’o asked.
He said he wanted to end Michael’s drug therapy. Among other side effects, the drugs have made Michael obese, which has led to asthma.
Mrs. Igafo-Te’o quietly disagreed. “I’m afraid he wouldn’t be able to focus,” she said. “I’m afraid he would regress socially.”
“Regress socially? Look at him!” her husband responded, motioning to their son, crying uncontrollably on the kitchen floor.
“I have to believe in something,” his wife mumbled and walked out of the room.
Mr. Igafo-Te’o watched her go and then smiled apologetically.
“We always debate meds,” he said.
Divergent Views
Most experts agree that some children are so violent or suicidal that a combination of psychiatric drugs is worth trying. But recently, more psychiatrists have been asking whether in some cases drugs are being prescribed for children who do not need them, or for problems that fall within the spectrum of normal behavior. The doubters are especially concerned with the growing use of drug combinations for preschoolers.
Fate Riske, 3, of Fond du Lac, Wis., takes two antipsychotics and a sleeping medicine to control what her mother, Elizabeth Klein-Riske, said were hours-long tantrums, a desire to watch the same movies repeatedly and an insistence on eating the meat, cheese and bread in her sandwiches separately.
On a recent visit, Fate played sweetly for four hours as her parents, who both have trouble walking, sat in front of a television. Sucking on a pacifier, Fate showed off her pink dress and matching shoes.
Mrs. Klein-Riske credited the drugs for Fate’s cherubic behavior during the visit. But a few weeks on a different antipsychotic led Fate to become aggressive, talk rapidly and “run around wild, totally out of control,” said Mrs. Klein-Riske, who receives government financial and child-care assistance because her daughter is considered mentally ill.
Fate’s weight ballooned in five months to 48 pounds from 30.
Dr. Gary Sachs, director of the Bipolar Clinic and Research Program at Massachusetts General Hospital in Boston, estimated that half the children referred to his clinic for research in recent years — including many who took drug combinations — had the wrong diagnosis and often did well on fewer drugs. “Even among properly diagnosed bipolar patients, many come to our program already taking medicines that interfered with each other,” Dr. Sachs said.
But Dr. Judith Rapoport, a senior investigator in child psychiatry at the National Institute of Mental Health, said that in her experience, few children were overmedicated. Dr. Rapoport studies children with schizophrenia. Before entering her study, children must be drug-free for three weeks.
“We’ve had a handful of cases who are completely normal when they get off drugs,” Dr. Rapoport said. “But most of these kids become very, very sick and unmanageable without drugs.”
The first psychiatric problem diagnosed in most children is attention deficit disorder, treated with stimulants — drugs that improve attentiveness. But when children’s problems persist, parents’ relatively good experience with stimulants often convinces them to agree to try other medicines — in some cases drugs like the antipsychotic Risperdal or the anticonvulsant Depakote that have few proven benefits in children and greater dangers, said Dr. Ranga Krishnan, chairman of the department of psychiatry and behavioral science at Duke University.
“After you get them on one drug, parents don’t seem to mind the second,” said Dr. Krishnan, who said that he had grave doubts about the growing use of psychiatric drug cocktails in children.
Antidepressants are commonly paired with stimulants, but antidepressant use has declined over the last year after the F.D.A. warning about suicide risk. In their place, physicians are prescribing combinations that include antipsychotic and anticonvulsant drugs, according to Medco. From 2001 to 2005, the use of antipsychotic drugs in children and teenagers grew 73 percent, Medco found. Among girls, antipsychotic use more than doubled.
On Again, Off Again
Andrew Darr of Caldwell, Idaho, whose sons took medications, said that he was opposed to it from the start. “When you come home from work and instead of getting them clawing at your feet and yelling, ‘Daddy, Daddy,’ you get a lethargic grunt, it just kills you,” Mr. Darr said.
His wife, Leslie Darr, eventually agreed to stop the medicines, but only after a family tragedy.
The Darrs have four children, Nicholas, 16, Nathan, 15, Becky, 12, and Benjamin, 9. At 3, Nicholas suffered a mild brain injury when undiagnosed appendicitis led him to suffer weeks of high fever, Mrs. Darr said.
Mrs. Darr said that she was pressured by school officials to give Nicholas a stimulant at age 6. Nathan soon followed.
Three years later, the boys had a traumatic weekend away with relatives. A month after that, Mrs. Darr said, both were hospitalized for a week and given a diagnosis of bipolar disorder and prescriptions for antipsychotic, antidepressant and sleeping medicines.
Over the next three years, Nicholas’s weight ballooned to 140 pounds from 52. Nathan went to 115 pounds from 48. Neither boy got much taller, Mrs. Darr said. They did poorly in school.
Then Becky developed a brain tumor. A nurse practitioner gave Mrs. Darr free samples of an antipsychotic drug to help her cope. After starting it, she said, she could not sleep or think straight. She realized that she had been giving similar medicines to her sons for years and she decided to wean the boys off the pills.
Their behavior immediately worsened. At one point, Nicholas left the house during a blizzard wearing only boxer shorts, Mrs. Darr said. They found him in a tire swing saying, “Baaa.”
“There were several times that we almost gave up,” Mr. Darr said.
But after four months off medication, the boys’ behavior normalized, the Darrs said, and they were transferred out of special education and into regular classes. The Darrs recently allowed the boys to spend their first evening at a mall without supervision, and in July they gave both boys their first bicycles. “They’ve come a long way,” Mrs. Darr said.
In an interview, Nicholas said the drugs “were not cool.”
“You go to school and everybody thinks, ‘Look at that retard,’ ” he said.
Still, most of the parents interviewed for this article said their children’s behavior deteriorated rapidly without medication.
Joanne Johnson of Hillsborough, N.J., described a psychiatrist’s effort to wean her 17-year-old son, Brad, off of all five of his psychiatric medicines as “the biggest mistake of our lives.”
Brad, then 13, became suicidal and was hospitalized for weeks, Ms. Johnson said.
“He went into the hospital on five drugs and came out on five different ones, but he was unstable,” she said. “It took a little over two years to find the right match again.”
Brad is now taking lithium, an antipsychotic, an anticonvulsant, an antidepressant, a stimulant and a sleeping pill.
“He’ll probably be on these for the rest of his life,” Ms. Johnson said.
Troubled Children
烦恼的儿童
Proof Is Scant on Psychiatric Drug Mix for Young
儿童精神类药物混合使用证据不足
By GARDINER HARRIS
GARDINER HARRIS撰写
Published: November 23, 2006
2006年11月23出版
Their rooms are a mess, their trophies line the walls, and both have profiles on MySpace.com. Stephen and Jacob Meszaros seem like typical teenagers until their mother offers a glimpse into the family’s medicine cabinet.
在MySpace.com的网站上的写照：他们乱七八糟的房间和他们墙上排成行的战利品。Stephen和Jacob Meszaros似乎是典型的青少年，直到他们的母亲让他们看了一眼家里的药品柜。
Bottles of psychiatric medications fill the shelves. Stephen, 15, takes the antidepressants Zoloft and Desyrel for depression, the anticonvulsant Lamictal to moderate his moods and the stimulant Focalin XR to improve concentration. Jacob, 14, takes Focalin XR for concentration, the anticonvulsant Depakote to moderate his moods, the antipsychotic Risperdal to reduce anger and the antihypertensive Catapres to induce sleep.
精神类药品塞满了药柜架，15岁的Stephen服用抗抑郁药物舍曲林和曲唑酮治疗抑郁症，抗惊厥药拉莫三嗪来缓和他的情绪，刺激剂Focalin XR来改善注意力。14岁的Jacob服用Focalin XR来改善注意力，抗焦虑药双丙戊酸钠缓解情绪，安定药维思通来减少发怒，抗高血压药可乐定来诱导睡眠。
Over the last three years, each boy has been prescribed 28 different psychiatric drugs.
在过去的3年内，每个男孩都被开了28种不同的精神类药品。
“Sometimes, when you look at all the drugs they’ve taken, you wonder, ‘Wow, did I really do this to my kids?’ ” said their mother, Tricia Kehoe of Sharpsville, Pa. “But I’ve seen them without the meds, and there’s a major difference.”
他们的母亲Tricia Kehoe说：“有时候，当你看到他们所吃的所以的药物，你不禁要问自己，哇，我是不是真的要这样对待我的孩子？但是，他们不吃药的情况我已经见过，确实有很大的不同。”
There is little doubt that some psychiatric medicines, taken by themselves, work well in children. For example, dozens of studies have shown that stimulants improve attentiveness. A handful of other psychiatric drugs have proven effective against childhood obsessive compulsive disorder, among other problems.
毫无疑问，孩子们吃一些精神类药物对他们有好处。例如，许多研究表明，刺激剂可改善注意力。一些其他的精神类药物证实可有效抵御强制性障碍以及其他问题。
But a growing number of children and teenagers in the United States are taking not just a single drug for discrete psychiatric difficulties but combinations of powerful and even life-threatening medications to treat a dizzying array of problems.
但是，在美国越来越多的少年儿童服用一种以上的针对不同类型精神障碍的药物，这些强大的甚至是致命性的药物联合应用来治疗这些令人昏乱的问题。
Last year in the United States, about 1.6 million children and teenagers — 280,000 of them under age 10 — were given at least two psychiatric drugs in combination, according to an analysis performed by Medco Health Solutions at the request of The New York Times. More than 500,000 were prescribed at least three psychiatric drugs. More than 160,000 got at least four medications together, the analysis found.
应纽约时报之邀，美国卫生部卫生决议部门分析的结果发现，全国去年大约有160万少年儿童服用至少两种以上的精神类药物，其中28万年龄在10岁以下，服用至少3种精神类药物的超过50万，至少4种的超过16万。
Many psychiatrists and parents believe that such drug combinations, often referred to as drug cocktails, help. But there is virtually no scientific evidence to justify this multiplication of pills, researchers say. A few studies have shown that a combination of two drugs can be helpful in adult patients, but the evidence in children is scant. And there is no evidence at all — “zero,” “zip,” “nil,” experts said — that combining three or more drugs is appropriate or even effective in children or adults.
许多精神科医生和父母认为，这样的药物联合，又叫药物鸡尾酒，的治疗是有益的。但是，研究者们说，事实上没有任何科学证据能够证明这些药物叠加使用的效果。有一些研究已经显示，两种药物联合使用对成年人有益，但是，儿童的研究结果很少。专家说，根本没有任何证据——完全没有，是零，能够证明3种或更多的药物治疗对儿童或成年人是否合适或甚至有效。
“There are not any good scientific data to support the widespread use of these medicines in children, particularly in young children where the scientific data are even more scarce,” said Dr. Thomas R. Insel, director of the National Institute of Mental Health.
国家精神卫生研究所的主任，Thomas R. Insel博士说：“没有任何好的科学数据能够支持儿童广泛使用这些药物，尤其是少年儿童的数据更少。”
Psychiatrists who prescribe drug combinations say that the ability to mix and match medications improves their chances of being able to help children who are seriously, even desperately, ill.
支持药物联合的精神科医生说，混合和搭配药物治疗能够减少情况严重、甚至绝望、生病的儿童发生意外。
Dr. Joseph Biederman, a professor of psychiatry at Harvard, said that doctors commonly used multiple medicines to treat heart disease, diabetes, cancer and AIDS. “Child psychiatry is not any different,” Dr. Biederman said. “These drugs have revolutionized how we treat severe psychopathology in children.”
哈佛精神病学教授，Joseph Biederman博士说，医生经常使用多种药物治疗心脏病、糖尿病、癌症和艾滋病。但儿童精神病是不同的，这些药物已经彻底改变了我们治疗儿童严重精神病的方法。
The controversy leaves parents in a terrible bind. Desperate to help, many agonize over whether to medicate their children.
这场争论把父母置于了可怕的盲区，许多父母在无助的情况下，很苦恼是否要去治疗他们的孩子。
Mothers and fathers sometimes disagree, with the dispute straining or even ending marriages. Since some psychiatric drugs can cause worrisome physical effects, parents say that they must on occasion make a terrifying choice between their child’s physical health and his mental health.
父母之间有时候也要争论，争论使他们很疲惫，有的甚至因此离婚。父母们说，既然一些精神类药物可引起烦人的生理效应，那么有时候我们就必须在孩子生理和心理健康两方面作痛苦的选择。
The parents interviewed for this article told their stories, they said, in hopes of gaining greater acceptance for their children and themselves. Nearly all recalled being in a store when their child threw a tantrum and feeling that onlookers branded them as bad parents. They also said they hoped to help others negotiate what many said were unequal and often fraught relationships with psychiatrists.
他们说，希望能够获得更大程度上的对他们自己和他们孩子的接受，他们愿意配合这篇论文的采访并讲述了他们的故事。几乎所有的人都回忆起同样一个情形，在商场里，当他们的孩子发脾气的时候，旁观者都认为他们是坏父母。他们也说，他们希望帮助其他人商议，许多人说的话是不同的，并且他们与精神科医生有关系。
“We struggled so much, made so many mistakes and felt so stigmatized, I hope our story can make it easier for others,” said Jacquie Erickson of Anchorage. Her daughter, Kaitlyn Johnston, 10, has taken psychiatric drugs since she turned 5 for diagnoses that include bipolar disorder.
来自Anchorage的Jacquie Erickson说：“我们的经历太痛苦了，犯了如此多的错误，感到如此的耻辱，希望我们的故事能够使其他人不再重蹈覆辙。”他10岁的女儿Kaitlyn Johnston在5岁被诊断为包括双相性精神障碍在内的精神疾病，自从那时起，就一直服用精神类药物。
On Shaky Ground
在摇晃的地面上
Stimulants like Ritalin are by far the most commonly prescribed psychiatric medicines in children. But doctors routinely pair stimulants with antidepressants, antipsychotics and anticonvulsants, even though some of these medications can cause serious side effects, have few proven pediatric psychiatric benefits and lack clear evidence about how they interact or influence mental and physical development.
象哌甲酯这样的刺激剂是儿童最常用的精神类药物。医生常规将刺激剂与抗抑郁药、抗精神病药、抗惊厥药配对使用，但是其中这些药物能引起严重的副反应，而且这样使用没有证明其有益，也不知道药物之间的相互作用或对生理和心理发育的影响。
Last year, the Food and Drug Administration required drug makers to warn on their labels that antidepressants can cause suicidal thoughts and behavior in some children. Anticonvulsant drugs carry warnings about liver and pancreas damage and fatal skin rashes. The side effects of antipsychotic medicines can include rapid weight gain, diabetes, irreversible tics and, in elderly patients with dementia, sudden death. When drugs are combined, these risks compound.
去年，食品药品监督局规定，药物制造商必须在药品标签上明示警告，抗抑郁药可引起一些儿童出现自杀念头和行为；抗惊厥药可引起肝脏、胰腺损伤和致命的皮疹；抗精神病药可引起体重快速增加、糖尿病、不可逆的抽搐，老年人可出现痴呆、猝死；当药物联合使用时，这些危险混合在一起。
Ms. Kehoe, who receives government financial and child-care assistance because her children are considered mentally ill, said she knew that there were risks to the drug cocktails. Both her sons are short and underweight for their age — a common side effect of stimulants — and she fears that the drugs have affected their health and behavior in other ways.
Kehoe夫人获得了政府财政资助和儿童保健设备，因为她的孩子们被认为有精神疾病，她知道鸡尾酒药物治疗的危险性。她的两个儿子因刺激剂的副作用而导致与同年龄的儿童相比，身材矮小，体重偏轻。她害怕，这些药物会在其他方面影响他们的健康和行为。
“But I don’t think the insurance would pay for it if the F.D.A. didn’t decide that children should use it,” said Ms. Kehoe, who herself takes psychiatric medication.
Kehoe夫人自己正在服用精神类药物，她说：“如果FDA不明文规定不准儿童使用精神类药物，那么我认为，保险公司不会支付相应的费用。”
In fact, the drug agency has specifically warned against the use of Lamictal, one of the drugs Stephen takes, in children who, like him, do not suffer from seizures because in 8 out of 1,000 children the drug causes life-threatening rashes.
事实上，药物代理商已经特别警告过，象Stephen这样的儿童使用拉莫三嗪不会引起疾病发作，因为只有8‰的儿童使用该药物可出现致命性的皮疹。
Stephen and Jacob’s psychiatrist did not reply to telephone messages left with an office secretary on three different days. Ms. Kehoe said that she asked him to speak to this reporter but that he refused. The boys have had 11 psychiatrists over the last three years, according to prescription records, and many more before that, Ms. Kehoe said.
Stephen和Jacob的精神病医生没有回复电话短信，并在不同日子的3次与一个办公室秘书离开。Kehoe夫人说，她让医生对记者说，但是被拒绝了。Kehoe夫人说，在此之前，根据处方记录，男孩在过去的3年共有11个精神病医生。
In interviews, Stephen and Jacob said they hated taking their drug cocktails.
在采访中，Stephen和Jacob说，他们讨厌服用鸡尾酒药物。
“Everybody hates meds,” Jacob said.
Jacob说：“每个人都讨厌药物。”
Ms. Kehoe said her youngest son, Lucas Keck, was showing signs of attention deficit disorder and might soon need to start medication.
Kehoe夫人说，她的小儿子Lucas Keck正表现出注意力缺陷障碍的症状，也许不久也要开始药物治疗。
“I see the hyperness in him,” she said. “My pediatrician has said that he would venture to say that Lucas will be A.D.H.D.”
她说：“我看他很紧,我的儿科医生大胆的说，Lucas将来会是A.D.H.D.”
Stephen and Jacob were Lucas’s age — 6 — when they were given their first prescriptions.
Stephen和Jacob开始治疗的年龄和现在Lucas的年龄一样，都是6岁。
The F.D.A. requires drug makers to prove that their drugs work safely before the agency will approve them for sale in the United States. But doctors can prescribe and combine approved medicines as they see fit. Such mixing is common in medicine but rarely studied by drug makers.
FDA要求药物制造商在代理商确认在美国上市前，要证实其安全性。但是医生如果觉得合适，可以应用和联合这些确认的药物。这种药物混合是常见的，但药物制造商很少研究。
Psychiatrists started mixing psychiatric medications because the drugs were only moderately effective and often caused terrible side effects, said Dr. Steven E. Hyman, the provost of Harvard University and former director of the National Institute of Mental Health. “None of these drugs by themselves do an adequate job of controlling symptoms,” Dr. Hyman said.
哈佛大学校长，前任国家精神卫生研究所主任，Steven E. Hyman博士说，精神病医生开始混合精神类药物治疗的原因是，这些药物只是中度有效而且经常有可怕的副作用，没有一个药物能够单独完全控制症状的。
If one drug failed, many psychiatrists assumed that two or more drugs used together might succeed. For decades, no one studied whether this was accurate. But in recent years, a trickle of studies have examined the question, with mixed results.
如果一个药物失败，许多精神病医生认为，两个或更多的药物一起治疗可能会成功。几十年来，没有人研究这是否是准确的。但是，近年来，一系列的研究检验了这个问题，结果不统一。
In studies in adults, some combinations of two drugs have been shown to work better than single medications to improve the symptoms of depression, obsessive-compulsive disorder and the mania associated with bipolar disorder. For example, a recent large government-financed study in adults, published in The New England Journal of Medicine, found that two antidepressants worked a bit better than one for adults who suffered from chronic, severe depression. But other studies have found no benefit from commonly prescribed drug combinations.
在成年人研究中，用两个药物联合在改善抑郁症症状、强制性障碍和双相性精神障碍相关躁狂症方面，优于单药治疗。例如，最近一项政府资助的成年人大研究，其结果发表在新英格兰医学杂志上，其研究发现，慢性严重的成年抑郁症患者应用两种抗抑郁药比一种稍好。但是，没有其他的研究发现，经常使用的联合治疗有任何益处。
The use of two-medicine combinations in children is on much shakier ground. Even for single drugs, the effectiveness of some psychiatric medications in younger patients is questionable: most trials of antidepressants in depressed children, for instance, fail to show any beneficial effect. But hardly any studies have examined the safety or the effectiveness of medicine combinations in children. A 2003 review in The American Journal of Psychiatry found only six controlled trials of two-drug combinations. Four of the six failed to show any benefit; in a fifth, the improvement was offset by greater side effects.
儿童使用两种药物联合治疗更加没有依据。甚至一些精神类药物单药对年轻人治疗的有效性都值得怀疑。例如，抗抑郁药在儿童患者中的大部分试验显示均没有任何效果。但是，几乎没有任何研究检测这些药物对儿童的安全性或有效性。美国精神病学杂志2003年的一篇综述发现，只有6个两个药物联合治疗的对照研究。其中4个没有任何效果，而第5个的效果被更严重的副反应抵消了。
“No one has been able to show that the benefits of these combinations outweigh the risks in children,” said Dr. Daniel J. Safer, an associate professor of psychiatry at Johns Hopkins University and an author of the 2003 review.
该综述的作者，约翰霍普金斯大学精神病学副教授，Daniel J. Safer博士说：“没有人能够证明这些联合治疗对儿童的好处会大于危险。”
If the evidence for two-drug combinations is minimal, for three-drug combinations it is nonexistent, several top experts said.
几个顶级专家说，如果两个药物联合的证据都这么少，三个药物联合就根本不存在。
“The data is zip,” Dr. Hyman said.
Hyman博士说：“没有任何数据。”
Many psychiatrists said that they turned to drug cocktails only in desperate circumstances. “If you’ve got a 15-year-old who is cutting up her arms, you’ve got a barn on fire and what are you supposed to do?” asked Dr. Alexander Lerman, a child and adolescent psychiatrist in New York, who said he rarely prescribed combinations.
许多精神科医生说，他们只是在危急的情况下才使用鸡尾酒药物治疗。纽约的儿童青少年精神科医生，Alexander Lerman博士问道：“如果你的15岁的病人正在自己断臂，在这种危急的情况下，你该这么办？”他说他自己很少应用联合治疗。
Billy and Jackie Igafo-Te’o of Jackson, Mich., are among the desperate. In the last seven years, their 12-year-old son, Michael, “has been on just about everything you can put a child on,” Mrs. Igafo-Te’o said. He is now taking four medications: an antipsychotic, an anticonvulsant, an antidepressant and a sleep medicine.
Jackson, Mich的Billy和Jackie Igafo-Te’o也处在绝望之中。Igafo-Te’o夫人说，在过去的7年，他们12岁的儿子Michael已经发生了所有孩子发生的事情，现在，她的儿子服用4种药物，抗精神病药、抗惊厥药、抗抑郁药和安眠药。
Despite the medications, Michael’s behavior has grown increasingly disruptive. He has kicked and punched holes in almost every wall of the Igafo-Te’o home. He wrenched the sink off the wall in the upstairs bathroom and pulled two bedroom doors off their hinges, damaging the frames. The family no longer fixes the damage.
尽管进行药物治疗，但是Michael的行为已经很快分裂了。他乱踢，在家里的几乎每一面强上打洞，把楼上洗手间的水龙头扭烂，把卧室的门从铰链上脱下，损坏房屋构架。家里已经不再修理损坏了。
During a recent visit, Michael and Mr. Igafo-Te’o were sitting on the living-room floor. Michael wanted the phone. His father held it out of reach to prevent Michael from playing with it. Michael became increasingly desperate. He cried. He cursed.
在最近的一次访问，Michael和Igafo-Te’o先生正坐在起居室的地板上。Michael想要电话。他的父亲把它放到够不到的位置，防止Michael玩电话。Michael因此很越来越绝望。他哭了，咒骂。
“That’s it, you have a timeout,” Mr. Igafo-Te’o said.
Igafo-Te’o先生说：“好了，你已经玩够了。”
“No, no, no,” Michael answered. “You pimp!”
Michael回答：“不，你个拉皮条的。”
He slapped his father in the face, hard. Mr. Igafo-Te’o hustled Michael into the kitchen and forced him to sit for 20 minutes.
他打他父亲的脸和手。Igafo-Te’o先生把Michael推进厨房，强迫他坐了20分钟。
“What’s the purpose of all this medication if I still have to do that?” Mr. Igafo-Te’o asked.
Igafo-Te’o先生问：“如果我仍然不得不那么作，那还要药物治疗干什么？”
He said he wanted to end Michael’s drug therapy. Among other side effects, the drugs have made Michael obese, which has led to asthma.
他说他想让Michael停止药物治疗，在其他副反应中，药物引起的肥胖导致了哮喘。
Mrs. Igafo-Te’o quietly disagreed. “I’m afraid he wouldn’t be able to focus,” she said. “I’m afraid he would regress socially.”
Igafo-Te’o夫人平静的反驳：“我恐怕他不能集中注意力，将在社交方面退步。”
“Regress socially? Look at him!” her husband responded, motioning to their son, crying uncontrollably on the kitchen floor.
“社交退步？看看他吧！”她的丈夫回答，同上监视着他们的正在厨房地板上无法控制的哭喊的儿子。
“I have to believe in something,” his wife mumbled and walked out of the room.
“我不得不相信了。”他的妻子嘟囔着走出房间。
Mr. Igafo-Te’o watched her go and then smiled apologetically. “We always debate meds,” he said.
Igafo-Te’o先生看着她走开，任何道歉的微笑说：“我们总是为了药物争吵。”
Divergent Views
不同的观点
Most experts agree that some children are so violent or suicidal that a combination of psychiatric drugs is worth trying. But recently, more psychiatrists have been asking whether in some cases drugs are being prescribed for children who do not need them, or for problems that fall within the spectrum of normal behavior. The doubters are especially concerned with the growing use of drug combinations for preschoolers.
大多数专家同意，对一些暴力的或有自杀性的儿童，联合治疗值得尝试。但是，最近更多的精神科医生一直在问，是否有些儿童病例所开的要不是他们需要的，或者他们的问题都是在正常行为范围之内。
Fate Riske, 3, of Fond du Lac, Wis., takes two antipsychotics and a sleeping medicine to control what her mother, Elizabeth Klein-Riske, said were hours-long tantrums, a desire to watch the same movies repeatedly and an insistence on eating the meat, cheese and bread in her sandwiches separately.
Fond du Lac, Wis的3岁的孩子服用两种抗精神病药物和一种睡眠药物，她的母亲Elizabeth Klein-Riske说，她发脾气可长达数小时，要求反复观看同样的电影，强烈要求在她的三明治中间分别夹肉、奶酪和面包。
On a recent visit, Fate played sweetly for four hours as her parents, who both have trouble walking, sat in front of a television. Sucking on a pacifier, Fate showed off her pink dress and matching shoes.
在最近的一次采访中，Fate愉快的玩了4个小时，而她的父母都不能走路，坐在电视机前。Fate一边吸吮着假乳头，一边展示她的粉红色连衣裙和搭配鞋子。
Mrs. Klein-Riske credited the drugs for Fate’s cherubic behavior during the visit. But a few weeks on a different antipsychotic led Fate to become aggressive, talk rapidly and “run around wild, totally out of control,” said Mrs. Klein-Riske, who receives government financial and child-care assistance because her daughter is considered mentally ill.
在采访中Klein-Riske夫人称Fate天真无邪的行为是药物治疗的结果，但是，应用不同的抗精神病药治疗几周后，Fate病情恶化，讲话快速、到处乱跑，完全失去控制。Klein-Riske夫人因其女儿的精神病而获得政府财政资助和儿童保健辅助设备。
Fate’s weight ballooned in five months to 48 pounds from 30.
Fate的体重在5个月从30镑快速增长至48镑。
Dr. Gary Sachs, director of the Bipolar Clinic and Research Program at Massachusetts General Hospital in Boston, estimated that half the children referred to his clinic for research in recent years — including many who took drug combinations — had the wrong diagnosis and often did well on fewer drugs. “Even among properly diagnosed bipolar patients, many come to our program already taking medicines that interfered with each other,” Dr. Sachs said.
波士顿麻省综合医院双极诊所和研究计划主任，Gary Sachs博士估计，近年来到他的诊所就诊的儿童，包括许多接受联合药物治疗的，有一半的诊断是错误的，经常可以用更少的药物治好。即使是诊断正确的双相性精神障碍患者，来他们诊所的有许多都已经服用了有相互作用的药物。
But Dr. Judith Rapoport, a senior investigator in child psychiatry at the National Institute of Mental Health, said that in her experience, few children were overmedicated. Dr. Rapoport studies children with schizophrenia. Before entering her study, children must be drug-free for three weeks.
但是，国家精神卫生研究所的儿童精神病学高级研究员，Judith Rapoport说，根据他的经验，很少有儿童过度服药的。Rapoport博士研究儿童精神分裂症，进入他的研究的儿童，必须3周没有吃药。
“We’ve had a handful of cases who are completely normal when they get off drugs,” Dr. Rapoport said. “But most of these kids become very, very sick and unmanageable without drugs.”
Rapoport博士说：“我们有一些病例停药后完全恢复正常，但是大多数变得非常非常严重，不用药物根本不能控制。”
The first psychiatric problem diagnosed in most children is attention deficit disorder, treated with stimulants — drugs that improve attentiveness. But when children’s problems persist, parents’ relatively good experience with stimulants often convinces them to agree to try other medicines — in some cases drugs like the antipsychotic Risperdal or the anticonvulsant Depakote that have few proven benefits in children and greater dangers, said Dr. Ranga Krishnan, chairman of the department of psychiatry and behavioral science at Duke University.
儿童的第一位精神问题是注意力缺陷障碍，用刺激剂治疗可改善注意力。杜克大学精神和行为科学部主席，Ranga Krishnan博士说，但是当问题持续存在，父母曾用过更好的刺激剂的就会说服医生去尝试其他的药物，一些病例用例如抗精神病药维思通、抗惊厥药双丙戊酸钠等药物，这些药物不但没有益处，而且对儿童有较大危险。，
“After you get them on one drug, parents don’t seem to mind the second,” said Dr. Krishnan, who said that he had grave doubts about the growing use of psychiatric drug cocktails in children.
Krishnan说：“当你给他们用了一个药物后，父母不会介意去用第二个。”他过去曾高度怀疑精神类药物鸡尾酒疗法在儿童中使用的增长。
Antidepressants are commonly paired with stimulants, but antidepressant use has declined over the last year after the F.D.A. warning about suicide risk. In their place, physicians are prescribing combinations that include antipsychotic and anticonvulsant drugs, according to Medco. From 2001 to 2005, the use of antipsychotic drugs in children and teenagers grew 73 percent, Medco found. Among girls, antipsychotic use more than doubled.
抗抑郁药通常与刺激剂配对使用，但是在FDA警告了它的自杀危险性后，去年抗抑郁药使用已经下降。根据卫生部的结果，医生应用联合治疗包括抗精神病药和抗惊厥药。从2001到2005，抗精神病药在儿童和青少年中的使用增加了73％，女孩抗精神病药的使用翻了一番还多。
On Again, Off Again
时开时关
Andrew Darr of Caldwell, Idaho, whose sons took medications, said that he was opposed to it from the start. “When you come home from work and instead of getting them clawing at your feet and yelling, ‘Daddy, Daddy,’ you get a lethargic grunt, it just kills you,” Mr. Darr said.
来自爱达荷州Caldwell的Andrew Darr，他的儿子们服药多种药物，他从一开始就反对。Darr s先生说：“当你下班回家，孩子不是跑过来踩着你的脚大叫爸爸，而是在那里打呼噜睡觉的时候，我几乎崩溃了。”
His wife, Leslie Darr, eventually agreed to stop the medicines, but only after a family tragedy.
他的妻子，Leslie Darr逐渐也同意停药，但是那必须经过一番家庭斗争之后才行。
The Darrs have four children, Nicholas, 16, Nathan, 15, Becky, 12, and Benjamin, 9. At 3, Nicholas suffered a mild brain injury when undiagnosed appendicitis led him to suffer weeks of high fever, Mrs. Darr said.
Darrs一家有4个孩子，16岁的Nicholas，15岁的Nathan，12岁的Becky和9岁的Benjamin。Darr夫人说，Nicholas在3岁时因未能诊断的阑尾炎使其高烧数周，导致了轻微脑损伤。
Mrs. Darr said that she was pressured by school officials to give Nicholas a stimulant at age 6. Nathan soon followed.
Darr夫人说，当时迫于学校官员的压力给当时6岁的Nicholas使用了刺激剂。不久Nathan也开始使用。
Three years later, the boys had a traumatic weekend away with relatives. A month after that, Mrs. Darr said, both were hospitalized for a week and given a diagnosis of bipolar disorder and prescriptions for antipsychotic, antidepressant and sleeping medicines.
3年后，男孩们和亲戚出去渡周末时受伤。Darr夫人说，一个月后，他们两个双双住院，被诊断为双相性精神障碍，使用抗精神病药、抗抑郁药和睡眠药物。
Over the next three years, Nicholas’s weight ballooned to 140 pounds from 52. Nathan went to 115 pounds from 48. Neither boy got much taller, Mrs. Darr said. They did poorly in school.
在随后的3年，Nicholas体重从52镑猛增到140镑；Nathan从48镑猛增到115镑。Darr夫人说，他们两个都没有再长高，而且在学校成绩很差。
Then Becky developed a brain tumor. A nurse practitioner gave Mrs. Darr free samples of an antipsychotic drug to help her cope. After starting it, she said, she could not sleep or think straight. She realized that she had been giving similar medicines to her sons for years and she decided to wean the boys off the pills.
然后，Becky长了个脑瘤。一个从业护士给了Darr夫人一些免费的抗精神病药的样品来帮助Becky治病。她说，开始吃药后，Becky就不能睡眠或正确的思考。她意识到，她已经让她的儿子们服药类似的药物数年了，她觉得让儿子们停药。
Their behavior immediately worsened. At one point, Nicholas left the house during a blizzard wearing only boxer shorts, Mrs. Darr said. They found him in a tire swing saying, “Baaa.”
他们的行为迅速恶化。Darr夫人说，有一次，Nicholas在暴风雪天穿着拳击短裤离开了家。他们最后发现他在一个轮胎内说：“Baaa。”
“There were several times that we almost gave up,” Mr. Darr said.
Darr先生说：“有很多次我们真的几乎要放弃了。”
But after four months off medication, the boys’ behavior normalized, the Darrs said, and they were transferred out of special education and into regular classes. The Darrs recently allowed the boys to spend their first evening at a mall without supervision, and in July they gave both boys their first bicycles. “They’ve come a long way,” Mrs. Darr said.
Darr夫人说，但是在停药后4个月，儿子们的行为正常了，他们从特殊教育转回到正常班级。Darr一家最近允许儿子们不用监督和他们一起晚上去商业区，7月他们给儿子们都买了第一辆自行车。Darr夫人说：“我们走了很长一段弯路。”
In an interview, Nicholas said the drugs “were not cool.”
在采访中，Nicholas说，药物真的不好。
“You go to school and everybody thinks, ‘Look at that retard,’ ” he said.
他说：“你去学校，其他人都认为，‘看那个痴呆。‘”
Still, most of the parents interviewed for this article said their children’s behavior deteriorated rapidly without medication.
然而，本文中受访的大多数父母说，他们的孩子的行为在停药后迅速恶化。
Joanne Johnson of Hillsborough, N.J., described a psychiatrist’s effort to wean her 17-year-old son, Brad, off of all five of his psychiatric medicines as “the biggest mistake of our lives.”
来自Hillsborough, N.J的Joanne Johnson描述，一个精神科医生试图让她17岁的儿子停用所有5种精神类药物是他们生活最大的错误。
Brad, then 13, became suicidal and was hospitalized for weeks, Ms. Johnson said.
Johnson夫人说，13岁的Brad变得有自杀性，因此住院数周。
“He went into the hospital on five drugs and came out on five different ones, but he was unstable,” she said. “It took a little over two years to find the right match again.”
她说：“他住院的时候用了5种药物，出院时用另外5种不同的药物。花了2年多的时间才又找到合适的药物组合。”
Brad is now taking lithium, an antipsychotic, an anticonvulsant, an antidepressant, a stimulant and a sleeping pill.
现在Brad服用锂剂、抗精神病药、抗惊厥药、抗抑郁药、刺激剂和睡眠药。
“He’ll probably be on these for the rest of his life,” Ms. Johnson said.
Johnson夫人说：“他很可能要靠这些药物来维持他的余生了。”
编译：（字数5898）烦恼的儿童
儿童精神类药品混合使用证据不足
GARDINER HARRIS撰写
2006年11月23出版
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在MySpace.com的网站上的写照：他们乱七八糟的房间和他们墙上排成行的战利品。Stephen和Jacob Meszaros似乎是典型的青少年，直到他们的母亲让他们看了一眼家里的药品柜。
精神类药品塞满了药柜架，15岁的Stephen服用抗抑郁药物舍曲林和曲唑酮治疗抑郁症，抗惊厥药拉莫三嗪来缓和他的情绪，刺激剂Focalin XR来改善注意力。14岁的Jacob服用Focalin XR来改善注意力，抗焦虑药双丙戊酸钠缓解情绪，安定药维思通来减少发怒，抗高血压药可乐定来诱导睡眠。在过去的3年内，每个男孩都被开了28种不同的精神类药品。
他们的母亲Tricia Kehoe说：“有时候，当你看到他们所吃的所以的药物，你不禁要问自己，哇，我是不是真的要这样对待我的孩子？但是，他们不吃药的情况我已经见过，确实有很大的不同。”
毫无疑问，孩子们吃一些精神类药物对他们有好处。例如，许多研究表明，刺激剂可改善注意力。一些其他的精神类药物证实可有效抵御强制性障碍以及其他问题。
但是，在美国越来越多的少年儿童服用一种以上的针对不同类型精神障碍的药物，这些强大的甚至是致命性的药物联合应用来治疗这些令人昏乱的问题。
应纽约时报之邀，美国卫生部卫生决议部门分析的结果发现，全国去年大约有160万少年儿童服用至少两种以上的精神类药物，其中28万年龄在10岁以下，服用至少3种精神类药物的超过50万，至少4种的超过16万。
许多精神科医生和父母认为，这样的药物联合，又叫药物鸡尾酒，的治疗是有益的。但是，研究者们说，事实上没有任何科学证据能够证明这些药物叠加使用的效果。有一些研究已经显示，两种药物联合使用对成年人有益，但是，儿童的研究结果很少。专家说，根本没有任何证据——完全没有，是零，能够证明3种或更多的药物治疗对儿童或成年人是否合适或甚至有效。
国家精神卫生研究所的主任，Thomas R. Insel博士说：“没有任何好的科学数据能够支持儿童广泛使用这些药物，尤其是少年儿童的数据更少。”
支持药物联合的精神科医生说，混合和搭配药物治疗能够减少情况严重、甚至绝望、生病的儿童发生意外。
哈佛精神病学教授，Joseph Biederman博士说，医生经常使用多种药物治疗心脏病、糖尿病、癌症和艾滋病。但儿童精神病是不同的，这些药物已经彻底改变了我们治疗儿童严重精神病的方法。
这场争论把父母置于了可怕的盲区，许多父母在无助的情况下，很苦恼是否要去治疗他们的孩子。
父母之间有时候也要争论，争论使他们很疲惫，有的甚至因此离婚。父母们说，既然一些精神类药物可引起烦人的生理效应，那么有时候我们就必须在孩子生理和心理健康两方面作痛苦的选择。
他们说，希望能够获得更大程度上的对他们自己和他们孩子的接受，他们愿意配合这篇论文的采访并讲述了他们的故事。几乎所有的人都回忆起同样一个情形，在商场里，当他们的孩子发脾气的时候，旁观者都认为他们是坏父母。他们也说，他们希望帮助其他人商议，许多人说的话是不同的，并且他们与精神科医生有关系。
来自Anchorage的Jacquie Erickson说：“我们的经历太痛苦了，犯了如此多的错误，感到如此的耻辱，希望我们的故事能够使其他人不再重蹈覆辙。”他10岁的女儿Kaitlyn Johnston在5岁被诊断为包括双相性精神障碍在内的精神疾病，自从那时起，就一直服用精神类药物。
在摇晃的地面上
象哌甲酯这样的刺激剂是儿童最常用的精神类药物。医生常规将刺激剂与抗抑郁药、抗精神病药、抗惊厥药配对使用，但是其中这些药物能引起严重的副反应，而且这样使用没有证明其有益，也不知道药物之间的相互作用或对生理和心理发育的影响。
去年，食品药品监督局规定，药物制造商必须在药品标签上明示警告，抗抑郁药可引起一些儿童出现自杀念头和行为；抗惊厥药可引起肝脏、胰腺损伤和致命的皮疹；抗精神病药可引起体重快速增加、糖尿病、不可逆的抽搐，老年人可出现痴呆、猝死；当药物联合使用时，这些危险混合在一起。
Kehoe夫人获得了政府财政资助和儿童保健设备，因为她的孩子们被认为有精神疾病，她知道鸡尾酒药物治疗的危险性。她的两个儿子因刺激剂的副作用而导致与同年龄的儿童相比，身材矮小，体重偏轻。她害怕，这些药物会在其他方面影响他们的健康和行为。
Kehoe夫人自己正在服用精神类药物，她说：“如果FDA不明文规定不准儿童使用精神类药物，那么我认为，保险公司不会支付相应的费用。”
事实上，药物代理商已经特别警告过，象Stephen这样的儿童使用拉莫三嗪不会引起疾病发作，因为只有8‰的儿童使用该药物可出现致命性的皮疹。
Stephen和Jacob的精神病医生没有回复电话短信，并在不同日子的3次与一个办公室秘书离开。Kehoe夫人说，她让医生对记者说，但是被拒绝了。Kehoe夫人说，在此之前，根据处方记录，男孩在过去的3年共有11个精神病医生。
在采访中，Stephen和Jacob说，他们讨厌服用鸡尾酒药物。
Jacob说：“每个人都讨厌药物。”
Kehoe夫人说，她的小儿子Lucas Keck正表现出注意力缺陷障碍的症状，也许不久也要开始药物治疗。
她说：“我看他很紧,我的儿科医生大胆的说，Lucas将来会是A.D.H.D.”
Stephen and Jacob were Lucas’s age — 6 — when they were given their first prescriptions.
Stephen和Jacob开始治疗的年龄和现在Lucas的年龄一样，都是6岁。
FDA要求药物制造商在代理商确认在美国上市前，要证实其安全性。但是医生如果觉得合适，可以应用和联合这些确认的药物。这种药物混合是常见的，但药物制造商很少研究。
哈佛大学校长，前任国家精神卫生研究所主任，Steven E. Hyman博士说，精神病医生开始混合精神类药物治疗的原因是，这些药物只是中度有效而且经常有可怕的副作用，没有一个药物能够单独完全控制症状的。
如果一个药物失败，许多精神病医生认为，两个或更多的药物一起治疗可能会成功。几十年来，没有人研究这是否是准确的。但是，近年来，一系列的研究检验了这个问题，结果不统一。
在成年人研究中，用两个药物联合在改善抑郁症症状、强制性障碍和双相性精神障碍相关躁狂症方面，优于单药治疗。例如，最近一项政府资助的成年人大研究，其结果发表在新英格兰医学杂志上，其研究发现，慢性严重的成年抑郁症患者应用两种抗抑郁药比一种稍好。但是，没有其他的研究发现，经常使用的联合治疗有任何益处。
儿童使用两种药物联合治疗更加没有依据。甚至一些精神类药物单药对年轻人治疗的有效性都值得怀疑。例如，抗抑郁药在儿童患者中的大部分试验显示均没有任何效果。但是，几乎没有任何研究检测这些药物对儿童的安全性或有效性。美国精神病学杂志2003年的一篇综述发现，只有6个两个药物联合治疗的对照研究。其中4个没有任何效果，而第5个的效果被更严重的副反应抵消了。
该综述的作者，约翰霍普金斯大学精神病学副教授，Daniel J. Safer博士说：“没有人能够证明这些联合治疗对儿童的好处会大于危险。”
几个顶级专家说，如果两个药物联合的证据都这么少，三个药物联合就根本不存在。
Hyman博士说：“没有任何数据。”
许多精神科医生说，他们只是在危急的情况下才使用鸡尾酒药物治疗。纽约的儿童青少年精神科医生，Alexander Lerman博士问道：“如果你的15岁的病人正在自己断臂，在这种危急的情况下，你该这么办？”他说他自己很少应用联合治疗。
Jackson, Mich的Billy和Jackie Igafo-Te’o也处在绝望之中。Igafo-Te’o夫人说，在过去的7年，他们12岁的儿子Michael已经发生了所有孩子发生的事情，现在，她的儿子服用4种药物，抗精神病药、抗惊厥药、抗抑郁药和安眠药。
尽管进行药物治疗，但是Michael的行为已经很快分裂了。他乱踢，在家里的几乎每一面强上打洞，把楼上洗手间的水龙头扭烂，把卧室的门从铰链上脱下，损坏房屋构架。家里已经不再修理损坏了。
在最近的一次访问，Michael和Igafo-Te’o先生正坐在起居室的地板上。Michael想要电话。他的父亲把它放到够不到的位置，防止Michael玩电话。Michael因此很越来越绝望。他哭了，咒骂。
“
Igafo-Te’o先生说：“好了，你已经玩够了。”
Michael回答：“不，你个拉皮条的。”
他打他父亲的脸和手。Igafo-Te’o先生把Michael推进厨房，强迫他坐了20分钟。
Igafo-Te’o先生问：“如果我仍然不得不那么作，那还要药物治疗干什么？”
他说他想让Michael停止药物治疗，在其他副反应中，药物引起的肥胖导致了哮喘。
Igafo-Te’o夫人平静的反驳：“我恐怕他不能集中注意力，将在社交方面退步。”
“社交退步？看看他吧！”她的丈夫回答，同上监视着他们的正在厨房地板上无法控制的哭喊的儿子。.
“我不得不相信了。”他的妻子嘟囔着走出房间。
Igafo-Te’o先生看着她走开，任何道歉的微笑说：“我们总是为了药物争吵。”
不同的观点
大多数专家同意，对一些暴力的或有自杀性的儿童，联合治疗值得尝试。但是，最近更多的精神科医生一直在问，是否有些儿童病例所开的要不是他们需要的，或者他们的问题都是在正常行为范围之内。
Fond du Lac, Wis的3岁的孩子服用两种抗精神病药物和一种睡眠药物，她的母亲Elizabeth Klein-Riske说，她发脾气可长达数小时，要求反复观看同样的电影，强烈要求在她的三明治中间分别夹肉、奶酪和面包。
在最近的一次采访中，Fate愉快的玩了4个小时，而她的父母都不能走路，坐在电视机前。Fate一边吸吮着假乳头，一边展示她的粉红色连衣裙和搭配鞋子。
在采访中Klein-Riske夫人称Fate天真无邪的行为是药物治疗的结果，但是，应用不同的抗精神病药治疗几周后，Fate病情恶化，讲话快速、到处乱跑，完全失去控制。Klein-Riske夫人因其女儿的精神病而获得政府财政资助和儿童保健辅助设备。
Fate的体重在5个月从30镑快速增长至48镑。
波士顿麻省综合医院双极诊所和研究计划主任，Gary Sachs博士估计，近年来到他的诊所就诊的儿童，包括许多接受联合药物治疗的，有一半的诊断是错误的，经常可以用更少的药物治好。即使是诊断正确的双相性精神障碍患者，来他们诊所的有许多都已经服用了有相互作用的药物。
但是，国家精神卫生研究所的儿童精神病学高级研究员，Judith Rapoport说，根据他的经验，很少有儿童过度服药的。Rapoport博士研究儿童精神分裂症，进入他的研究的儿童，必须3周没有吃药。
Rapoport博士说：“我们有一些病例停药后完全恢复正常，但是大多数变得非常非常严重，不用药物根本不能控制。”
儿童的第一位精神问题是注意力缺陷障碍，用刺激剂治疗可改善注意力。杜克大学精神和行为科学部主席，Ranga Krishnan博士说，但是当问题持续存在，父母曾用过更好的刺激剂的就会说服医生去尝试其他的药物，一些病例用例如抗精神病药维思通、抗惊厥药双丙戊酸钠等药物，这些药物不但没有益处，而且对儿童有较大危险。，
Krishnan说：“当你给他们用了一个药物后，父母不会介意去用第二个。”他过去曾高度怀疑精神类药物鸡尾酒疗法在儿童中使用的增长。
抗抑郁药通常与刺激剂配对使用，但是在FDA警告了它的自杀危险性后，去年抗抑郁药使用已经下降。根据卫生部的结果，医生应用联合治疗包括抗精神病药和抗惊厥药。从2001到2005，抗精神病药在儿童和青少年中的使用增加了73％，女孩抗精神病药的使用翻了一番还多。
On Again, Off Again
时开时关
来自爱达荷州Caldwell的Andrew Darr，他的儿子们服药多种药物，他从一开始就反对。Darr s先生说：“当你下班回家，孩子不是跑过来踩着你的脚大叫爸爸，而是在那里打呼噜睡觉的时候，我几乎崩溃了。”.
他的妻子，Leslie Darr逐渐也同意停药，但是那必须经过一番家庭斗争之后才行。
Darrs一家有4个孩子，16岁的Nicholas，15岁的Nathan，12岁的Becky和9岁的Benjamin。Darr夫人说，Nicholas在3岁时因未能诊断的阑尾炎使其高烧数周，导致了轻微脑损伤。
Darr夫人说，当时迫于学校官员的压力给当时6岁的Nicholas使用了刺激剂。不久Nathan也开始使用。
3年后，男孩们和亲戚出去渡周末时受伤。Darr夫人说，一个月后，他们两个双双住院，被诊断为双相性精神障碍，使用抗精神病药、抗抑郁药和睡眠药物。
在随后的3年，Nicholas体重从52镑猛增到140镑；Nathan从48镑猛增到115镑。Darr夫人说，他们两个都没有再长高，而且在学校成绩很差。
然后，Becky长了个脑瘤。一个从业护士给了Darr夫人一些免费的抗精神病药的样品来帮助Becky治病。她说，开始吃药后，Becky就不能睡眠或正确的思考。她意识到，她已经让她的儿子们服药类似的药物数年了，她觉得让儿子们停药。
他们的行为迅速恶化。Darr夫人说，有一次，Nicholas在暴风雪天穿着拳击短裤离开了家。他们最后发现他在一个轮胎内说：“Baaa。”
Darr先生说：“有很多次我们真的几乎要放弃了。”
Darr夫人说，但是在停药后4个月，儿子们的行为正常了，他们从特殊教育转回到正常班级。Darr一家最近允许儿子们不用监督和他们一起晚上去商业区，7月他们给儿子们都买了第一辆自行车。Darr夫人说：“我们走了很长一段弯路。”
在采访中，Nicholas说，药物真的不好。
他说：“你去学校，其他人都认为，‘看那个痴呆。‘”
然而，本文中受访的大多数父母说，他们的孩子的行为在停药后迅速恶化。
来自Hillsborough, N.J的Joanne Johnson描述，一个精神科医生试图让她17岁的儿子停用所有5种精神类药物是他们生活最大的错误。
Johnson夫人说，13岁的Brad变得有自杀性，因此住院数周。
她说：“他住院的时候用了5种药物，出院时用另外5种不同的药物。花了2年多的时间才又找到合适的药物组合。”
现在Brad服用锂剂、抗精神病药、抗惊厥药、抗抑郁药、刺激剂和睡眠药。
Johnson夫人说：“他很可能要靠这些药物来维持他的余生了。”
个人意见，仅供参考：
Focalin XR
盐酸右哌甲酯缓释胶囊
Over the last three years, each boy has been prescribed 28 different psychiatric drugs.
在过去的3年内，每个男孩都被开了28种不同的精神类药品。
在过去的3年里，每个男孩都开了28种精神类药物。
antipsychotic
安定药
抗精神病药
stimulants
刺激剂
兴奋剂
Sometimes, when you look at all the drugs they’ve taken, you wonder, ‘Wow, did I really do this to my kids?
有时候，当你看到他们所吃的所以的药物，你不禁要问自己，哇，我是不是真的要这样对待我的孩子？
当你看到他们所吃的所有药物，有时你会疑惑：哇，我是不是真的应该全给孩子们吃呢？
some psychiatric medicines, taken by themselves, work well in children
孩子们吃一些精神类药物对他们有好处
在孩子们所吃的精神类药物中，有些对他们确有好处
have proven effective against
有效抵御
有效治疗
childhood obsessive compulsive disorder
强制性障碍
儿童强迫症
