Diagnoses
of childhood depression bring a rush to treatment
Dec.
29, 2003
By BENEDICT CAREY
Los Angeles Times
Over
the past two years, doctors have diagnosed Andrea Robinson
with a half-dozen severe mental disorders and prescribed
her a series of strong medications, including antidepressants
and an antipsychotic.
Her parents are beside themselves. Andrea is 5 years old.
“It’s a very difficult situation,” Tammy
Robinson of Ottawa said about her daughter, who appears
to suffer the telltale mood swings of bipolar disorder
and is now responding well to a mood-stabilizing drug.
“Right from birth we knew there was something with
Andrea that was not normal.”
Doctors are diagnosing mental illness in children at younger
ages than ever, including in those who are barely out
of diapers. The diagnoses include diseases once thought
to appear almost exclusively in adults and adolescents,
such as major depression and bipolar disorder, and have
prompted a surge of new research in preschoolers. Treatment
is surging, too. The number of very young children who
take psychiatric drugs has more than doubled in the past
15 years, a recent study found.
But this push to illuminate the earliest signs of mental
trouble has also exposed serious dilemmas about the diagnosis
and treatment of psychiatry’s youngest patients.
Getting a proper diagnosis in a preschooler can be difficult,
and many treatments now in use haven’t been adequately
tested in young children for effectiveness or safety.
In June, the Food and Drug Administration warned doctors
not to prescribe the popular antidepressant Paxil to children
for depression, citing evidence that the drug could increase
the risk of suicide. The announcement sent shudders through
the profession.
“The fact is, many community psychiatrists are out
ahead of the evidence in terms of the use of these drugs
in very young children,” said Dr. James McCracken,
director of child and adolescent psychiatry at the University
of California-Los Angeles’ Neuropsychiatric Institute.
He said his clinic gets referrals every day of children
who are on several medications at once, from anticonvulsants
to antidepressants and antipsychotics, often unnecessarily.
The reason: Doctors striving to help desperate families
have too little research to guide their decisions about
diagnosis or treatment in this age group. “It leaves
us in a quandary about what to do in some cases,”
he said. “That’s why research into the early
manifestations of these diseases is so important.”
A generation ago, most doctors considered early childhood
to be a sanctuary from serious mood problems such as depression.
In the absence of an early traumatic experience, such
as physical or mental abuse or abandonment by a parent,
researchers believed that preschoolers didn’t have
the emotional maturity to plunge into emotional darkness.
Today, child psychiatrists dismiss this perception as
idealized.
“Clinicians who work with young children know that
sometimes they have many troubling psychiatric symptoms,”
said Dr. Charles Zeanah, a psychiatrist at Tulane University
in New Orleans. As a rule, he said, the public is “uncomfortable
with the idea of serious psychopathology in young children
— it violates our idealized images of babyhood and
toddlerhood as carefree, innocent, and as a time when
all things are possible.”
Doctors know, too, that such illnesses as schizophrenia
and bipolar disorder tend to run in families, and that
the vast majority of the 1 percent to 5 percent of young
children at high risk get no treatment at all. “This
is a group which cannot, does not, speak up and ask for
help,” said Dr. Elizabeth Berger, a Philadelphia
psychiatrist who specializes in child-development issues.
The problem is, those who do get help can be very difficult
to treat — and diagnose. Children who appear depressed
or anxious often are reacting normally to some big change
in their lives, such as a separation from their primary
caregiver, even the loss of a favorite preschool teacher.
Most will bounce back on their own, and some will need
treatment; but it’s not always easy to tell which
is which. Especially when their persistent moodiness could
also be the first glimmer of bipolar disorder, or ADHD,
a learning disability.
Distinguishing between ADHD — attention deficit hyperactivity
disorder — and early bipolar disorder is particularly
problematic. By observing a hyperactive youngster, and
having parents answer a battery of questions about the
child’s behavior, some doctors insist they can clearly
distinguish bipolar disorder, or manic depression, from
ADHD, in kids as young as 3. Others are more skeptical,
and consider bipolar disorder to be extremely rare before
the teen years.
“There is so much confusion about this subject, because
for a long time in child psychiatry there was a vacuum
of knowledge about manias in such young children,”
said Dr. Joseph Biederman, chief of pediatric psychopharmacology
at Massachusetts General Hospital. “We are now building
a scientific basis for how to diagnose and treat bipolar
syndromes in these children, but we are still a few years
away.”
In the meantime, patients and their families often ride
a carousel of diagnoses and medications. Valerie Hesse,
42, a first-grade teacher living near Greenville, S.C.,
took her daughter Celeste to a children’s clinic
after the 6-year-old got suspended from school for spells
of aggression mixed with trance-like states. Doctors diagnosed
her with ADHD and prescribed the stimulant Ritalin —
which made Celeste even more aggressive. She was then
switched to another stimulant, with the same effect; and
then to Paxil, for depression. Celeste “went into
orbit” on Paxil, her mother said.
It appears now that both Celeste and 5-year-old Andrea
Robinson have a bipolar syndrome (they have responded
well to mood-stabilizing drugs, such as lithium); and
it is well known that antidepressants such as Prozac and
Paxil can prompt intense manias in adults with bipolar
disorder, when given without mood-stabilizing drugs.
“These are things I wish doctors had told us before
prescribing the drugs,” said Andrea’s mother,
Tammy. “I now believe that bipolar is something that
should be ruled out at the very beginning, before treating
for depression and all these other things.”
Researchers are just beginning to understand and define
what constitutes major depression in young children, however.
In a five-year trial focusing on 174 preschoolers, Dr.
Joan Luby and a team of investigators at Washington University
in St. Louis compared children with persistent low moods
to those who were mentally untroubled, or who had been
diagnosed with ADHD. They reported that depression in
this age group looks in some ways like the adult variety:
Kids become listless; they lose interest even in playing;
the joy runs out of life.
But Luby said her research also suggested that the current
criteria for diagnosing major depression were appropriate
only for adults and adolescents, not preschoolers. And
without good diagnostic criteria, no one can tell how
common this earliest form of depression is, how often
it leads to adolescent or adult problems, or whether drugs
or counseling helps. It’s little wonder that while
some doctors swear by antidepressants, Luby and others
are leery, and still others mix counseling with medication.
This catch-as-catch-can approach cries out for some central
forum where psychiatrists and families can readily keep
up with what is clearly a frontier science, said Dr. Gregory
Fritz, medical director of Bradley Hospital, a children’s
psychiatric clinic in Providence, R.I. “Right now,
we’ve got a situation in which there are very active
pharmaceutical companies producing more and more drugs,
and more ads, and there’s pressure from the public
to get quick results based on scattered reports, or anecdotal
information — it’s a nightmare,” he said.
“We ought to have a more centralized series of protocols
for these illnesses in young kids so we can pull all this
information together.”
It will not happen soon enough for the Robinsons. During
her nearly two years of needless medication, Andrea Robinson
went for months without riding her purple five-speed.
“It’s her favorite thing to do,” Tammy
Robinson said. “I know something’s very wrong
if she’s not out riding that bike.”
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Published by uticaOD.com and the Observer-Dispatch.
Over
the past two years, doctors have diagnosed Andrea Robinson
with a half-dozen severe mental disorders and prescribed
her a series of strong medications, including antidepressants
and an antipsychotic.
