Medicating Young Minds

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: Drugs have become increasingly popular for treatingkids with mood and behavior problems. But how willthat affect them in the long run? Time, November 3,2003 Issue By Jeffrey Kluger Oct 28, 2003, 08:42Getting by is hard enough in middle school. it'sharder still when you've got other things on yourmind-and Andrea Okeson, 13, had plenty to distracther. There were the constant stomach pains toconsider; there was the nervousness, thedistractibility, the overwhelming need to be alone.And, of course, there was the business of repeatedlychecking the locks on the doors. All these thingsgrew, inexplicably, to consume Andrea, until by thetime she was through with the eighth grade, she seemedpretty much through with everything else too."Andrea," said a teacher to her one day, "you looklike death." The problem, though neither Andrea nor her teacherknew it, was that her adolescent brain was beingtossed by the neurochemical storms of generalizedanxiety, obsessive-compulsive disorder (OCD) andattention-deficit/hyperactivity disorder (ADHD)-adecidedly lousy trifecta. If that was what eighthgrade was, ninth was unimaginable. But that was then. Andrea, now 18, is a freshman atthe College of St. Catherine in St. Paul, Minn.,enjoying her friends and her studies and lookingforward to a career in fashion merchandising, allthanks to a bit of chemical stabilizing provided by apair of pills: Lexapro, an antidepressant, andAdderall, a relatively new anti-ADHD drug. "I feelexcited about things," Andrea says. "I feel like I gotme back." So a little medicine fixed what ailed a child. Goodnews all around, right? Well, yes-and no. Lexapro isthe perfect answer for anxiety all right, providedyou're willing to overlook the fact that it does itswork by artificially manipulating the very chemicalsresponsible for feeling and thought. Adderall is theperfect answer for ADHD, provided you overlook thefact that it's a stimulant like Dexedrine. Oh, yes,you also have to overlook the fact that the Adderallhas left Andrea with such side effects as weight lossand sleeplessness, and both drugs are being pouredinto a young brain that has years to go before it'sfinally fully formed. Still, says Andrea, "I'm justglad there were things that could be done." Those things-whether Lexapro or Ritalin or Prozac orsomething else-are being done for more and moreAmerican children. In fact, they are being done withsuch frequency that some people have justifiably begunto ask, Are we raising Generation Rx? Just a few years ago, psychologists couldn't say withcertainty that kids were even capable of sufferingfrom depression the same way adults do. Now, accordingto PhRMA, a pharmaceutical trade group, up to 10% ofall American kids may suffer from some mental illness.Perhaps twice that many have exhibited some symptomsof depression. Up to a million others may suffer from the alternatelydepressive and manic mood swings of bipolar disorder(BPD), one more condition that was thought untilrecently to be an affliction of adults alone. ADHDrates are exploding too. According to a Mayo Clinicstudy, children between 5 and 19 have at least a 7.5%chance of being found to have ADHD, which amounts tonearly 5 million kids. Other children are receivingdiagnoses and medication for obsessive-compulsivedisorder, social-anxiety disorder, post-traumaticstress disorder (PTSD), pathological impulsiveness,sleeplessness, phobias and more. Has the world-and American society inparticular-simply become a more destabilizing place inwhich to raise children? Probably so. But otherfactors are at work, including sharp-eyed parents anddoctors with a rising awareness of childhood mentalillness and what can be done for it. "While we don'tknow exactly why the incidence of psychopathology isincreasing in children and adolescents, it probablyhas to do with better diagnosis and detection," saysDr. Ronald Brown, professor of pediatrics at theMedical University of South Carolina. Also feeding the trend for more diagnoses is thearrival of whole new classes of psychotropic drugswith fewer side effects and greater efficacy thanearlier medications, particularly the selectiveserotonin reuptake inhibitors (SSRIS), orantidepressants. These have been rolled out withhighly visible, to-the-consumer ad campaigns. While an earlier generation ofantidepressants-tricyclics like Tofranil-didn't workin kids, SSRIS do. According to a study by ProfessorJulie Zito of the University of Maryland School ofPharmacy, use of antidepressants among children andteens increased threefold between 1987 and 1996. Andthat use continues to climb. Nobody, not even the drugcompanies, argues that pills alone are the idealanswer to mental illness. Most experts believe thatdrugs are most effective when combined with talktherapy or other counseling. Nonetheless, the American Academy of Child andAdolescent Psychiatry now lists dozens of medicationsavailable for troubled kids, from the comparativelyfamiliar Ritalin (for ADHD) to Zoloft and Celexa (fordepression) to less familiar ones like Seroquel,Tegretol, Depakote (for bipolar disorder), and moreare coming along all the time. There are stimulants,mood stabilizers, sleep medications, antidepressants,anticonvulsants, antipsychotics, antianxieties andnarrowcast drugs to deal with impulsiveness andpost-traumatic flashbacks. A few of the newest medswere developed or approved specifically for kids. Themajority have been okayed for adults only, but arebeing used "off label" for younger and youngerpatients at children's menu doses. The practice iscommon and perfectly legal but potentially risky. "Weknow that kids are not just little adults," says Dr.David Fassler, professor of psychiatry at theUniversity of Vermont. "They metabolize medicationsdifferently." Within the medical community-to say nothing of thefamilies of the troubled kids-concern is growing aboutjust what psychotropic drugs can do to stilldeveloping brains. Few people deny that mind pillshelp-ask the untold numbers who have climbed out ofdepressive pits or shaken off bipolar fits thanks tomodern pharmacology. But few deny either that we're aquick-fix culture, and if you give us a feel-goodanswer to a complicated problem, we'll use it withlittle thought of long-term consequences. "The problem," warns Dr. Glen Elliott, director of theLangley Porter Psychiatric Institute's children'scenter at the University of California, San Francisco,"is that our usage has outstripped our knowledge base.Let's face it, we're experimenting on these kidswithout tracking the results." The Case For MedicationThose experiments, however, are often driven by direneed. When a child is suffering or suicidal, is itfair not to turn to the prescription pad inconjunction with therapy? Is it even safe? Untreated depression has a lifetime suicide rate of15%-with still more deaths caused by related behaviorslike self-medicating with alcohol and drugs. Kids withsevere and untreated ADHD have been linked, accordingto some studies, to higher rates of substance abuse,dropping out of school and trouble with the law.Bipolar kids have a tendency to injure and killthemselves and others with uncontrolled behavior likebrawling or reckless driving. They are Which is why Teresa Hatten of Fort Wayne, Ind.,hesitated little when it came time to put hergranddaughter Monica on medication. Hatten's growndaughter, Monica's mom, suffers from bipolar disorder,and so does Monica, 13. To give Monica a chance at astable upbringing, Hatten took on the job of raisingher, and one of the first things she had to do was getthe violent mood swings of the bipolar disorder undercontrol. It's been a long, tough slog. An initial drugcombination of Ritalin and Prozac, prescribed whenMonica was 6, simply collapsed her alternatingdepressed and manic moods into a single state with sadand wild features. By the time she was 8, her behaviorwas so unhinged, her school tried to expel her. Next Monica was switched to Zyprexa, an antipsychotic,that led to serious weight gain. "At 12 years old shehad stretch marks," says Hatten. Now, a year later,Monica is taking a four-drug cocktail that includesTegretol, an anticonvulsant, and Abilify, anantipsychotic. That, at last, seems to have solved theproblem. "She's the best I've ever seen her," saysHatten. "She's smiling. Her moods are consistent. I'mcautiously optimistic." Monica agrees: "I'm in abetter mood." Next up in the family's wellnesscampaign: Monica's 8-year-old cousin Jamari, who is onZyprexa for a mood disorder. All along the disorderspectrum there are such pharmacological successstories. In the October issue of the Archives ofGeneral Psychiatry, Dr. Mark Olfson of the New YorkState Psychiatric Institute reports that every timethe use of antidepressants jumps 1%, suicide ratesamong kids 10 to 19 decrease, although only slightly.But that doesn't include the nonsuicidal depressedkids whose misery is eased thanks to the same pills. Are We Meddling With Normal Development?For children with less severe problems-children whoare somber but not depressed, antsy but not clinicallyhyperactive, who rely on some repetitive behaviors forcomfort but are not patently obsessive compulsive-thepros and cons of using drugs are far less obvious."Unless there is careful assessment, we might startmedicating normal variations (in behavior)," saysStephen Hinshaw, chairman of psychology at theUniversity of California, Berkeley. The world would be a far less interesting place if allthe eccentric kids were medicated toward some goldenmean. Besides, there are just too many unansweredquestions about giving mind drugs to kids to feelcomfortable with ever broadening usage. What worriessome doctors is that if you medicate a child'sdeveloping brain, you may be burning the village tosave it. What does any kind of psychopharmacologicalmeddling do, not just to brain chemistry but also tothe acquisition of emotional skills-when, for example,antianxiety drugs are prescribed for a child who hasnot yet acquired the experience of managing stresswithout the meds? And what about side effects, fromweight gain to jitteriness to flattenedpersonality-all the things you don't want in thesocial crucible of grade school and, worse, highschool. Adding to the worries is a growing body of knowledgeshowing just how incompletely formed a child's braintruly is. "We now know from imaging studies thatfrontal lobes, which are vital to executive functionslike managing feelings and thought, don't fully matureuntil age 30," says Hinshaw. That's a lot of time fordrugs to muck around with cerebral clay. For that reason, it may not always be worth pullingthe pharmacological rip cord, particularly whensymptoms are relatively mild. Child psychologistspoint out that often nonpharmaceutical treatments canreduce or eliminate the need for drugs. Anxietydisorders such as phobias can respond well tobehavioral therapy-in which patients are gentlyexposed to graduated levels of the very things theyfear until the brain habituates to the escalatingrisk. Depression too may respond to new, streamlined therapytechniques, especially cognitive therapy-a treatmentaimed at helping patients reframe their view of theworld so that setbacks and losses are put in lesscatastrophic perspective. "The therapist teachesrelaxation skills and positive thinking," says DeniseChavira, clinical psychologist at the University ofCalifornia at San Diego. "It goes beyond talktherapy." Unfortunately, medical insurance pays morereadily for pills than these other treatments foradults and children. For kids with more serious symptoms, experts areworried that undermedicating is a bigger risk thanovermedicating. "Say you've got a kid who's severelyobsessive and literally can't leave the home becauseof the fears and rituals he's got to perform," saysucsf's Elliott. "Think about what anyone age 2 to age16 has to learn to function in our society. Then thinkabout losing two of those years to a disorder. Whichtwo would you choose to lose?" Also on the side ofintervention is the belief that treating more kidswith mental illness could reduce its incidence inadults. Dr. Kiki Chang at Stanford University is trying toshow that this is true with bipolar kids. He recentlypublished a study in the Journal of ClinicalPsychiatry that looked at kids from bipolar familieswho had only early signs of the disease. Pre-emptivedoses of Depakote eased early symptoms in 78% of casesbefore the illness ever had a chance to take hold."You can sit and watch it develop or intervene andpossibly prevent the disorder," says Chang. While theresearcher is excited about his results, he admitsthat treating kids who are not yet truly sick iscontroversial. "There's a chance some of the kidsmight not develop bipolar at all," says Chang. "Weneed to have more genetics, more brain imaging, morebiological markers to know which direction the kidsare going." How Can We Measure the Result?Preventing symptoms, of course, is not everything. Asleeping child is completely asymptomatic, forexample, but that's not the same as being fullyfunctioning. If the drugs that extinguish symptomsalso alter the still developing brain, the cure maycome at too high a price, at least for kids who areonly mildly symptomatic. To determine if this kind ofdamage is being done, investigators have been turningmore and more to brain scans such as magneticresonance imaging (MRI). The results they're gettinghave been intriguing. MRIs had already shown that the brain volumes of kidswith ADHD are 3% smaller than those of unafflictedkids. That concerned researchers since nearly allthose scans had been taken of children already beingmedicated for the disorder. Were the anatomicaldifferences there to begin with, or were they causedby the drugs? Attempting to answer that, Dr. F. XavierCastellanos of the New York University Child StudiesCenter took other scans, this time using only kidswith ADHD and comparing those who were takingmedication with those who were not. Reassuringly, hediscovered that they all shared the same structuralanomaly, a finding that seems to exonerate the drugs. Dr. Steven Pliszka, chief of child psychiatry at theUniversity of Texas Health Center in San Antonio, wentfurther. He conducted scans that picked up not justthe structure but the activity of the brains ofuntreated ADHD children, and compared these imageswith those from children who had been medicated for ayear or more. The treated group showed no signs of anydeficits in brain function as measured in blood flow.In fact, he says, "we saw hints of improvement towardnormal." The news was less positive when it came to bipolardisorder. Chang has looked at the brains of kidstreated with Depakote, and while his study is as yetunpublished, he says he noticed some anatomicaldifferences that could result from treatment-and hewasn't necessarily happy with them. "We are seeingthat medications do affect the brain acutely," hesays. "Is that a good thing, a bad thing? We justdon't know." What nobody denies is that more research is needed toresolve all these questions-and that it won't be easyto get it started. The first problem is one of time.It was only in the early 1990s that the antidepressantProzac exploded into pharmacies. It's hard to do alifetime of longitudinal studies on a drug that's beenwidely used for just over a decade. And each time theindustry invents a new medication, the clock rewindsto zero for that particular pill. Even if it were possible to conduct extended studies,getting volunteers for the work is difficult. Theattrition rate is high in any years-long research,especially so when the subjects are kids, who boreeasily and, at any rate, eventually go away tocollege. On average, 40% of children will drop out ofa long-term study before the work is done. And thatassumes their parents will even sign them up in thefirst place. Some brain scans involve at least alittle bit of radiation-something most parents arereluctant to expose their children to, particularly ifthose kids have no emotional disorders and are simplybeing used as a baseline to establish the look of ahealthy brain. Getting good scans from kids who havediagnosable conditions isn't easy, as any radiologistwho has ever tried to conduct a lengthy MRI on a childwith ADHD can attest. "Holding still is not exactlywhat they do well," says Elliott. Ethical questions hamstring research too. Anygold-standard study requires that some of the kids whoare suffering from a disorder receive no drugs so thatthey can be compared with the kids who do. But if youbelieve the medications are helpful, how can youwithhold them from a group of symptomatic children whoneed them? Despite such obstacles, research is movingahead, if haltingly. The National Institute of MentalHealth is conducting a study called the Preschool ADHDTreatment Study, in which researchers will track ADHDkids between 3 and 8 years old to determine thebenefits and side effects of stimulant medications.Castellanos and N.Y.U. colleague Rachel Klein aretaking things further, calling back subjects who wereenrolled in an ADHD-treatment study that began in 1970to scan their now late-30s and early-40s brains forthe long-term effects of drugs. Castellanos is alsoplanning a study of young rats treated with varyingamounts of psychotropic drugs, conducting dosing andanatomical studies that cannot be performed on humans. The Risk of Hasty PrescriptionsJust as important as getting the research rolling isfixing the health-care system kids rely on to getwell. Like adults taking mind meds, children often gettheir drugs not from a specialist in psychiatry andpsychopharmacology but from any M.D. with the power ofthe prescription pad. Usually this means thepediatrician or family doctor, who isn't likely tohave the time or training necessary for the extensiveevaluations needed before drugs can be properlyprescribed-much less the required follow-up visits."There's no way you can screen for side effects in a10-year-old in five minutes," says Miami neurologistSara Dorison. "You have to chat about their summer,their friends." Part of the reason for all the hurry-up drugging, saypsychiatrists, is managed care, which, alreadydisinclined to pay for longer, more costly talktherapy, is equally reluctant to foot the bill to makesure patients on pills are well monitored. In aperfect-or at least better-world, says Elliott,parents considering meds for their kids would haveaccess not to one specialist but three: apediatrician, a behavioral pediatrician and achild-adolescent psychiatrist. "Insurance companiestalk about second opinions," he says, "but they don'tactually like them." The pharmaceutical companies could be doing bettertoo-and if they don't, the government must push themto do it. There is a lot of money to be made indeveloping the next Prozac, but there is less profitif you test it for longer than the law demands. TheFood and Drug Administration (FDA) doesn't requirelong-term studies that follow patients over decades.Its only requirement is toxicity trials that span sixto eight weeks. In an effort to entice companies toconduct lengthier studies, the agency now grants anextension of six months of exclusive marketing rightsto any company engaging in studies of a drug's effectson a minimum of 100 children for more than six months."It's a relatively small amount of data," acknowledgesDr. Thomas Laughren, a psychiatrist with the FDA'spsychopharmacology division, "but it's better thanwhat we had before, which was nothing." Until all these things happen, the heaviest liftingwill, as always, be left to the family. Perhaps themost powerful medicine a suffering child needs is theeducated instincts of a well-informed parent-one whohas taken the time to study up on all thepharmaceutical and nonpharmaceutical options and pickthe right ones. There will always be dangersassociated with taking too many drugs-and also dangersfrom taking too few. "Like every other choice you makefor your kids," says Chang, "you make right ones andwrong ones." When the health of a child's mind is onthe line, getting it wrong is something that no parentwants. -With reporting by Dan Cray/Los Angeles, AlicePark/New York, Kathie Klarreich/Miami, and LeslieWhitaker/ Jefferson City http://www.time.com/time/covers/1101031103/story.html New Photos - easier uploading and sharing.«¤»¥«¤»§«¤»¥«¤»§«¤»¥«¤»§«¤»¥«¤»§«¤»¥«¤»§«¤»¥«¤«¤»¥«¤»§«¤»¥«¤»§«¤»¥«¤»§«¤»¥«¤»§ - PULSE ON WORLD HEALTH CONSPIRACIES! §Subscribe:......... - To :.... - Any information here in is for educational purpose only, it may be news related, purely speculation or someone's opinion. Always consult with a qualified health practitioner before deciding on any course of treatment, especially for serious or life-threatening illnesses.**COPYRIGHT NOTICE**In accordance with Title 17 U.S.C. 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