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July 14, 2003
DURING 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.
Doctors are diagnosing mental
illness in children at younger ages than ever, including in those 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 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.
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"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.
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.
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