Photo by Rory Mcnamara

Child Welfare: Dr. John Leipsic, who specializes in pediatric psychopharmacology,uses medication in conjunction with psychotherapy and behavioral therapy.

Generation Rx

Can troubled kids find mental health at the local pharmacy?

By Patrick Sullivan

Once upon a time, Morgan was a boy in a box. Back in fourth grade, this gregarious child became so talkative and disruptive at school that his teacher finally took a desperate measure. “I didn’t know anything about it at the time,” explains Zoe, Morgan’s mom, who lives in a small town in Marin County. “But the teacher told me later that he had arranged a three-sided cardboard box around [Morgan’s] desk so he wouldn’t turn around and talk to the kids behind him.”

That wasn’t Morgan’s only problem. He couldn’t finish his homework, and he was getting into big arguments on the playground. “His thought process was odd,” recalls Zoe, who prefers not to give her last name. “He saw everything in black and white. There was no gray. He knew all the rules to baseball, and if someone wasn’t playing exactly right, he’d want to kick him out of the game. So he’d get into trouble.”

Morgan, now 13, is out of the box. The family’s pediatrician believed the boy had attention deficit hyperactivity disorder, a mental health condition usually marked by hyperactivity, impulsiveness, and an inability to focus. A specialist agreed, and Morgan began taking Ritalin, an amphetamine-derived stimulant widely used to treat ADHD. Later, Morgan was switched to a new ADHD drug called Adderall.

His mother says the medication has reduced Morgan’s discipline problems at school, improved his social life, and helped him get his homework done.

But Zoe says the medication created new challenges for her son. He has trouble sleeping. His appetite is poor. He has experienced uncomfortable tics such as constant eye blinking.

Is the cure worse than the disease? Zoe doesn’t think so, but she worries about side effects, struggles with guilt about her parenting, and tries to find time to help her son manage his condition and his medication.

Her dilemma is faced by a growing number of parents across the country as modern medicine increasingly turns to drugs to treat childhood mental disorders and behavioral problems. A flood of recent studies has demonstrated that children’s use of stimulants like Ritalin, antidepressants like Prozac, and other psychiatric drugs has soared over the past two decades.

Among the most dramatic findings shows that about 6 percent of American kids 19 and younger are now taking some form of psychiatric medication, according to a high-profile study published in a recent issue of Archives of Pediatric & Adolescent Medicine. Another widely reported study found that the use of psychiatric drugs in kids two to four years old has increased sharply. And regulators don’t seem to be hitting the brakes. In January, the Food and Drug Administration formally approved the use of Prozac for children eight and older, though doctors have long prescribed it off-label for young patients.

California, curiously, appears to be at the back end of this trend. The state that so enthusiastically embraced medical marijuana has one of the lowest per capita rates of prescriptions for psychostimulants like Ritalin, according to the Drug Enforcement Administration.

Still, some mental health professionals in Northern California say they’ve seen a steep increase in the use of psychiatric drugs in kids over the past decade. And there’s no question that the North Bay is prime Ritalin country: The white, middle-class suburbs of Marin, Sonoma, and Napa counties are chock-full of the demographic that in other communities across the country has leapt into the comforting arms of the drug.

What this trend means is a matter of deep dispute. Nationally, the discussion about kids and psychiatric drugs has been a tangled mess. One side points an accusing finger at profiteering drug companies and irresponsible parents. The other complains of media sensationalism and discrimination against the mentally ill.

In the North Bay, the debate seems more polite, more focused on discovering the best way to help children in trouble. But there are still sharp disagreements and strong emotions on both sides of the issue.

Meeting in the Middle

It’s a rainy February night in Corte Madera, and some 35 adults have gathered in a windowless conference room. A more typical Marin County crowd would be hard to imagine. Nearly everyone is white, and the average age is about 40. Clothing ranges from slacks and sports jackets to an animal-rights T-shirt and tinted glasses. Somebody forgets to turn off her cell phone and has to leave the room when it starts to warble.

They’re here for a meeting of Children and Adults with Attention Deficit Hyperactivity Disorder, a national support group with hundreds of chapters around the country. The main attraction at tonight’s meeting is a speech by Dr. Michael Freeman, a Marin County psychiatrist. Freeman offers a broad overview of ADD, ADHD, and bipolar disorder, and then takes questions from the audience.

At the national level, CHADD suffered a major blow to its reputation back in 1995 when a television documentary revealed that the pharmaceutical company that makes Ritalin had donated nearly $900,000 to the organization–and that CHADD had not come clean about that funding to most of its members.

But no drug-company-financed campaign to push Ritalin seems evident at this Marin County meeting, which features a frank discussion of both nondrug alternatives and the side effects of psychostimulants. “Medication is just a piece of the answer,” Dr. Freeman tells the crowd. “A lot of it is acquiring life-management skills.”

In the audience is Randy, a middle-aged man with a slightly manic manner who hails from nearby Larkspur. Randy, who has ADHD himself, has a son who was diagnosed with the same condition at age eight.

“The kid was really suffering,” Randy says. “He couldn’t sit still. He couldn’t do his homework. He was going nuts. Then he knocked a little girl down at school and the teachers freaked.”

Now 11, Jeremy is taking both Adderall and the antianxiety drug Paxil. Randy says he and his now ex-wife thought long and hard before deciding to go with medication. They tried nondrug treatments like counseling first but didn’t see many results. These days Randy calls medication a magic bullet. “It has made a huge difference,” he says.

Randy isn’t the only firm believer in medication in the audience. Connie De Propris, 50, is an Oakland resident who attends Marin CHADD meetings and works as a career coach in the county. She says she has suffered from ADHD since childhood but only began taking medication two and a half years ago. It changed her life. “The barriers were gone,” she says. “I was, like, wow, I can do the dishes, I can do my homework, I can do all these tedious tasks around the house.”

Growing up as an untreated ADHD child, says De Propris, is extraordinarily painful. When she was in high school, De Propris had poor social skills, few friends, often couldn’t do her homework, and accumulated a stack of failing grades. She felt lonely and incompetent.

Leaving such psychiatric conditions untreated is profoundly dangerous, De Propris argues. “If we trained psychiatrists to recognize mental problems and weren’t afraid to medicate, we probably wouldn’t have half the drug problems that we have in this country,” she says. “I’m sure there are a lot of people in prison who wouldn’t be there if they had been diagnosed correctly and medicated correctly.”

Body Count

Untreated psychiatric conditions do have a social cost–and, in their cruelest manifestations, even a body count. Depression, for instance, is a cold-blooded killer. Suicide claims the lives of approximately 3,000 people a year in California, and kids are not immune. Nationwide, suicide is the third leading cause of death for young people aged 15 to 24, according to the Centers for Disease Control.

In the United States, one in five children and adolescents suffers from mental health problems at any given time, according to the American Psychiatric Association. The APA says that psychiatric disorders in children remain underrecognized, underdiagnosed, and undertreated–and the results are often tragic.

Even young children can suffer dangerous despair, as Dr. John Leipsic can attest. A child and adolescent psychiatrist who practices in Santa Rosa, Leipsic specializes in pediatric psychopharmacology. In an e-mail, he recalls one eight-year-old girl named Sarah who became so upset after the death of the family dog that she missed a week of school because she couldn’t stop crying.

“Her mother found writings in her diary about not wanting to be alive anymore,” Leipsic explains. Sarah was diagnosed with depression, began taking a low dose of antidepressants, and, Leipsic says, “three months later, she was well on the road
to recovery.”

But if untreated mental illness can wreak havoc, so can medicating an illness that isn’t there. Leipsic puts it this way: “Take ADHD for example,” he says. “Estimates are that it occurs in 6 to 8 percent of kids. Thus, if 6 to 8 percent of kids are on medication treatment for ADHD, it is an appropriate rate. The key is getting the right 6 to 8 percent.”

Leipsic sees medication as a valuable tool, but he uses it in conjunction with psychotherapy and behavioral therapy. And he sees some disturbing trends in diagnosis and prescription writing for children.

Other psychiatrists take their criticism a few steps further. For Dr. Lawrence Diller, the rising pediatric use of psychiatric drugs reveals painful problems in the way contemporary society looks at kids. “It raises a big question,” says Diller, speaking by phone from his office in Walnut Creek. “Is children’s behavior becoming worse, or has our view of children’s behavior changed? Do we simply have less tolerance for personality diversity?”

Diller is a behavioral pediatrician and author who has become one of the country’s best-known critics of society’s move to medication. In his most famous book, Running on Ritalin, Diller explained why he’s concerned: “Valium, Prozac, Ritalin–all these are drugs that smooth the edges off human diversity, making our culture less rich and interesting, and perhaps affecting, in ways we cannot predict, the time-honored eco-evolution of personality and society.”

Diller acknowledges that some kids do need pharmacological help; he writes prescriptions for psychiatric drugs in his own practice. But he argues that only about 10 percent of the children who are given drugs like Ritalin really need them.

“We have a much larger group of Huck Finns and Pippi Longstockings and Tom Sawyers out there who for a variety of personality and talent reasons have difficulty in school or at home,” Dr. Diller says. “These children do not have mental disorder in the sense that I think of mental disorders. We have drugs that take these round kids and make them fit into square holes.”

Diller, who has two sons of his own, is especially well-known for making the case against the boom in Ritalin and other psychostimulants. One major reason he believes that the drug is overprescribed is the tremendous regional variation in its rate of use around the country and across the world. Above all, a child is most likely to be on Ritalin if he or she is American; the United States consumes around 80 percent of the world’s supply of the drug.

But it’s not just Ritalin that’s getting the hard sell. For proof of that, Diller points to a survey of child psychiatry practices by the Yale Child Study Center, published in the Journal of the American Academy of Child and Adolescent Psychiatry. According to the survey, only one in 10 children who visit a child psychiatrist’s office leaves without some kind of psychiatric drug prescription.

What are the long-term physical and psychological effects of such medications on children? The answer to that question, says Diller, is that no one really knows. That’s because most of these drugs have not been tested in large groups of children for more than a few months. Even Ritalin, which has been in use for decades, has been studied no more than 18 months for safety. As more and more kids use psychiatric drugs, Diller says there’s a corresponding expansion in the potential for dramatic disaster or subtle but damaging side effects.

Substitute Parents

Diller offers many reasons behind this booming new trade in psychiatric medications for kids. He cites poor parenting skills, increasingly rigid school curriculums, aggressive marketing by drug companies, and the strong preference of HMOs to pay for a quick pharmacological fix instead of months of family therapy.

“This is a money-driven phenomenon,” Diller says. “It’s not that I believe that Ritalin doesn’t work. The problem is that it works too well. It becomes a substitute for helping parents parent better or teachers teach better.”

That kind of talk frustrates a parent like Zoe. “People tell me that I should not be giving my son medication, that it’s just a parenting issue, that he just needs more structure, that he needs more hugs.”

But the drugs have improved her son’s life, Zoe says. And though she wonders whether Morgan will ever outgrow ADHD and be able to stop taking his pills, she’s not holding her breath.

“I don’t see it happening anytime real soon.”

Ritalin Underground

“The high was incredible, better than anything you can get on the street,” says Amber with a sigh. Now in her 30s, Amber (not her real name), is a recovering Ritalin addict. In her teens and 20s, this Santa Rosa resident got her kicks close to home: She stole medication that was prescribed to her little brother, who had been diagnosed with attention deficit disorder. Ritalin wasn’t the only drug Amber abused, but it’s the one she seems to have the fondest memories of.

She has plenty of company. The federal government classifies Ritalin and other trademarked versions of methylphenidate as a Class II controlled substance. That puts these drugs in the same category as cocaine and opium, and the Drug Enforcement Administration emphasizes that the potential for abuse is serious.

The DEA’s website says that Ritalin abuse is limited but has increased along with the availability of the drug. Some areas of the country where Ritalin and other psychostimulants are widely prescribed also display disturbing levels of recreational abuse of the drugs. Among the related studies the DEA lists on its website is a 1998 Indiana University survey of 44,232 high school students in which nearly 7 percent reported using Ritalin illicitly at least once, and 2.5 percent reported using it monthly or more often.

Zoe and her son Morgan know about the problem firsthand. When a boy approached Morgan in his Marin County school about buying some Ritalin, Morgan told him no. Then he told his mother what had happened. “I said that he could get into a huge amount of trouble, and so could the other child,” Zoe recalls. “He assured me that he would never do that. But I was a little concerned because he does like money.”

On the hand, some recent research may relieve another of Zoe’s concerns about Ritalin. She worries that the drug might predispose her son to addiction, but new studies appear to show that kids with ADHD who are medicated with psychostimulants are actually less likely to become addicted to illegal drugs later in life.

–P.S.

From the March 6-12, 2003 issue of the North Bay Bohemian.

© Metro Publishing Inc.

Photograph by Nita Winter

Community Building: Nita Winter’s ‘Faces of the Canal’ series includes Angel and his son Benjy.

A Picture’s Worth

Nita Winter’s banners celebrate Marin’s diverse communities

By Stephanie Hiller

When people come here, they fall in love.” Jeannette Sotomajor has set aside her lunch to talk with me at the front desk in the Pickleweed Community Center in San Rafael, where she works as an administrative assistant. “Sometimes people ask me if it is safe here. But once they’re here, they fall in love.”

It’s true. The Canal District of San Rafael, on the spit of land north of Interstate 580 near the Richmond Bridge (known better for San Quentin than for park space), captivated me immediately as I drove past square, green lawns and tidy buildings on the way to Pickleweed Park.

Inside the typical block-style community center, the atmosphere is welcoming and the building hums with life. In one classroom, a group of Latinos study citizenship. Down the hall, Vietnamese adults practice their English. Bridge players from all over the Bay Area gather around a buffet before their tournament. Mothers come through with their children on the way to the playground.

And then there are the banners. In jaunty, varicolored letters, “Faces of the Canal” adorn the light posts in the parking lot, inviting us to look into the smiling faces of the people who live in San Rafael’s poorest neighborhood. Down the hall, a huge display case teems with more pictures. Many are children.

“I have friends from everywhere, and it’s the same thing with everybody here,” says Sotomajor, a woman bringing up her two small children on her own in a foreign country. Sotomajor came here in 1985 from Nicaragua. This year she was named Woman of the Year by assemblyman Joe Nation.

“We have no problem communicating with everybody,” Sotomajor says. “If the Vietnamese have a big celebration, we’re all invited. At the Dia de los Muertos, thousands come. You see Latinos, African Americans, Vietnamese–all kinds. Teens organize parties for the Kids Club.

“When we make a memorial celebration,” she adds, “we try to make it very general. If we’re going to pray, we try to do it in a way that God is recognized in every religion. Jewish, Christian, Indian–no problem at all.”

Documenting the Faces

Bay Area photographer Nita Winter–the woman responsible for the “Faces of the Canal” project–moved from Corte Madera to Marin City with her partner, Rob Badger, over five years ago. Friends wondered why. But despite the picture others retained, Winter and Badger liked living there.

Marin City is a pocket of poverty in otherwise affluent Marin County. To change the negative image of the community she loved, Winter decided to photograph the faces she saw around her and display them to public view. “Faces of Marin City” was her first project, in 2000; “Faces of Novato” came next. “Faces of the Canal” is her most recent, and she’s working on “Faces of Vallejo.”

Communities of color acquire bad reputations. White Americans share a fear of the dark. A little crime in a black neighborhood goes a long way to convince whites that the place is dangerous, and they stay away. While the neighborhood changes unseen, the negative image sticks like a tarnished decal on an old car window.

Turning her camera’s eye on misrepresented neighborhoods was not new to Winter. When she lived in San Francisco’s Mission District, she photographed people at the Bay Area Women’s Resource Center for the Women’s Foundation’s annual report.

“They really liked the work, so they asked me to do the ‘Children of the Tenderloin,’ which included two major exhibits and a book. It was the first to educate people, decision makers, about what a community is really like, rather than what they thought it was like.” The second exhibit was called “Children, Children Everywhere, and Not a Place to Play.” At the time, there were no schools in the neighborhood. The exhibit inspired the creation of a playground and an elementary school.

Later, in San Rafael, Winter did a photographic display at St. Vincent’s Dining Hall, which, under Sue Brown’s direction, was serving 300 free meals a day downtown. The city was trying to move St. Vincent’s out–there was that image problem about the hungry. “Where there’s an image problem, call in Nita,” Winter smiles.

The exhibit included 60 images up to 40 inches by 60 inches. As with the “Faces” series, they were captioned with first names only. Portraits of staff and volunteers were intermingled with those of the clients who frequent the dining hall. Viewers didn’t know who was who. “It made people really think about what their image of the hungry is,” Winter says. “One 82-year-old woman went there because it got her out of the house and among people she knew. She was afraid without that, she might end up in a nursing home.”

Winter says the display changed peoples’ images of those who needed the dining hall’s services and created community pressure to put the brakes on what the city was up to. “The exhibit confirmed my belief in the power of the photograph as a powerful tool for change–changing self-image, the image of the community, and creating a sense of community.”

That sense of community is so important. “Wherever I have lived–in the Mission, in the Castro–I always knew my neighbors,” says Winter. “It’s something we have lost. Now with automatic garage-door openers, people never have to get out of their cars to see their neighbors.

“If you have strong communities, you don’t have many of the problems we are faced with now.”

Winter originally got the idea for creating photographic banners from an article about a New York City photographer who had enhanced a construction site with poster photos of people passing through Times Square. Using a storefront at the new Marin City shopping center for her studio, she took thousands of photos. The 7-by-3-foot banners were hung throughout the shopping center, and large prints were displayed in empty storefronts. Eight 4-foot square light boxes with photos still stand outside Long’s.

“There was a great deal of appreciation,” Winter says. “One person told me she was afraid to shop there, but when she saw the photos, she felt welcomed. A vocal few felt I was trying to turn it into a white community. For me it was a celebration of the people who had been there, as well as a welcome mat for new people.”

Soon, Marin City was in the papers again, but this time the news was quite different. The San Francisco Chronicle did a front page story in its Metro section on the banner project. The Marin Independent Journal also covered it, and Wayne Friedman did a two-minute spot on the 6 o’clock news.

With her banner project in Marin City, Winter shed light on the murky picture outsiders hold of what goes on in diverse communities, a living reality often obscured by rumors and fears.

Mr. Man’s Celebrity

The truth is, communities of color are all about kids.

“Two little kids, a small Latino kid and his American friend, they saw my picture,” says Man Phan, who is depicted in the “Canal” series. “They came running, ‘Mr. Man! Mr. Man! I see your picture.’ That made me so happy.”

Phan, a Vietnamese language instructor and respected community activist, moved from Saigon with his wife 12 years ago to a house across the street from the Pickleweed Community Center, where he lives still. “In Vietnam, I worked with the U.S. Army from 1965 to 1972. American soldiers helped me to speak English.”

Phan was in the army for 21 years. He then spent six years in a communist prison. “That was terrible,” Phan recalls. “But God loved me and God got me here, so that’s why I have to share with everyone.

“I love the language,” Phan continues. “The language is the most important for the people. That’s why I have ESL classes. It helps.” Language is the ticket to jobs. But the Pickleweed Center also offers Vietnamese language for the kids, in order to help them remember their native culture. Mr. Man, as he is known to all, is now on the center’s advisory board.

The Pickleweed Center has grown so busy that it is getting ready to embark on a remodel that will expand its facilities. Dr. Tom Peters, director of the Marin Community Foundation, which has contributed generously to all of Winter’s banner projects, said the center used to be a tomb. “If you had come down five years ago, people in the community would say [they] don’t know who runs it or what it is for.” He credits the community and the involvement of city officials with the area’s transformation. “It does illustrate what can happen when a city is mobilized and supported.”

Nancy Rosa of the Canal Ministry, an interfaith ministry in the neighborhood, has lived in the Canal for 34 years. “A lot of us really like the Canal. We want to live here.” The Canal Ministry runs a leadership program, Canal Healthy Neighborhood, now in its third year. The program did all the recruitment and organizing for Winter’s photo shoot.

“It’s really been a source of community pride,” says Rosa. “Residents spend 10 to 15 minutes looking at the pictures. People come to see them and start talking. Perceptions change about what this neighborhood is.”

Picturing Novato

Annan Paterson, school psychologist for the Novato Unified School District, saw “Faces of Marin City” at a Martin Luther King celebration in 2000. “I thought, ‘Oh my gosh, this is such a powerful visual message.'” A volunteer with the city of Novato’s Multicultural Commission, she suggested a banner project for Novato.

“I moved to Novato in 1995, the same year a hate crime occurred against an Asian-American man,” says Paterson. Then there was an incident at the high school when a student yelled “nigger.” “It was a huge incident. Initially, people couldn’t believe that could actually happen here. It was painful for our community to realize that, yes, it did.” The city responded with sensitivity and diversity trainings.

“I saw the banners as a way of showing that Novato is not just a white community,” Paterson says. “It is about 80 percent white with a mix of Asians, blacks, and Hispanics. I’m a mom, and as a school psychologist–and as a person–I think it’s just vital that we recognize the diversity in our community.”

With funding from Marin Community Foundation and the Institute of Noetic Sciences, and a budget of $45,000, Winter set up studios in schools and the city council chamber for one afternoon. There are at least 500 photos on the two-sided banners that line the downtown street of Grant Avenue. Since the banners are taken down for holidays and then rehung, they show up in different locations. “Kids will say, ‘My banner used to be by the bakery and now it’s by the bank!'” says Winter. The whole project engenders a spirit of civic pride.

But there’s a down side to all this. “The saddest part,” says Rosa, “is that those who are able to buy a home . . . have to go to Richmond or Vallejo. So you’re losing your leadership people all the time.”

“In the Canal,” says Peters, “we have participated in the effort to stem the tide by supporting the city and its redevelopment agency by purchasing some building to hold rents lower than they would be. But the hand of the market is a strong one,” he adds, describing “a dilemma that is faced time and again.” When a neighborhood improves, it becomes unaffordable to the people whose spirit and dedicated effort improved it. Redevelopment projects in Marin City and San Rafael have contributed to the improvement, and, Peters admits, the “unintended consequence” is rising rents.

“Marin City has got all the potentially developable features,” Peters says, with its proximity to the big city, its views of the bay, and county median house prices at $700,000. Though the Marin Community Foundation, a coalition of 300 families, 98 percent of them local, draws from $1 billion in assets to support neighborhood projects, it is not enough to hold back what Peters sees as the “significant upward pressure” that south Marin faces.

Eastern Expansion

It’s logical to assume that when Vallejo is “discovered,” the same process of rising rents will occur. But for now, the diversity and vitality of that Solano County city is still a secret.

Gail Manning wants to let the world know that Vallejo is a “wonderful community” with old heritage homes and a widely mixed population in which “whites are the minority.” She saw the banners in Marin and invited Nita Winter to set up her studio at Vallejo’s Unity Day last year, an annual cultural event on the waterfront, with music, ethnic food, and performing artists in celebration of diversity.

Manning and her family moved to Vallejo from the city. She owns a pilates studio downtown, the Vallejo Movement Center. “People just buzz by on the freeway,” she says. Outsiders seem to view it as “the armpit of the Bay Area. People kind of got a complex about living here. But there’s lots to be proud of.”

Manning’s plan is to pay for the banners through fundraising, but unlike the other cities, she expects most of the funding to come from downtown businesses, and to that end she will display the name of each sponsoring firm. The banners cost $600 each; she is asking $750 so the extra money can go back into the fund. Her focus is the downtown area, but the city also wants to put them along Highways 37 and 29 to improve the highway corridor.

Some of the people moving to Vallejo are seasoned community activists from places like Marin City, the Canal, and Novato. They bring with them their positive experience in their previous communities.

But when Vallejo’s prices go up too, will there be one more unknown Bay Area city to receive the immigrants? Or will the market drive out all but the lucky few who benefit from its relentless expansion favoring the hardy and the well-to-do?

From the February 27-March 5, 2003 issue of the North Bay Bohemian.

© Metro Publishing Inc.