Independent Perspective News - Medicating Young Minds

The Case For Medication

Those experiments, however, are often driven by dire need. When a child is suffering or suicidal, is it fair not to turn to the prescription pad in conjunction with therapy? Is it even safe?

Untreated depression has a lifetime suicide rate of 15%—with still more deaths caused by related behaviors like self-medicating with alcohol and drugs. Kids with severe and untreated ADHD have been linked, according to 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 kill themselves and others with uncontrolled behavior like brawling or reckless driving.

Which is why Teresa Hatten of Fort Wayne, Ind., hesitated little when it came time to put her granddaughter Monica on medication. Hatten's grown daughter, Monica's mom, suffers from bipolar disorder, and so does Monica, 13. To give Monica a chance at a stable upbringing, Hatten took on the job of raising her, and one of the first things she had to do was get the violent mood swings of the bipolar disorder under control. It's been a long, tough slog. An initial drug combination of Ritalin and Prozac, prescribed when Monica was 6, simply collapsed her alternating depressed and manic moods into a single state with sad and wild features. By the time she was 8, her behavior was 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 she had stretch marks," says Hatten. Now, a year later, Monica is taking a four-drug cocktail that includes Tegretol, an anticonvulsant, and Abilify, an antipsychotic. That, at last, seems to have solved the problem. "She's the best I've ever seen her," says Hatten. "She's smiling. Her moods are consistent. I'm cautiously optimistic." Monica agrees: "I'm in a better mood." Next up in the family's wellness campaign: Monica's 8-year-old cousin Jamari, who is on Zyprexa for a mood disorder. All along the disorder spectrum there are such pharmacological success stories. In the October issue of the Archives of General Psychiatry, Dr. Mark Olfson of the New York State Psychiatric Institute reports that every time the use of antidepressants jumps 1%, suicide rates among kids 10 to 19 decrease, although only slightly. But that doesn't include the nonsuicidal depressed kids whose misery is eased thanks to the same pills.

Are We Meddling With Normal Development?

For children with less severe problems—children who are somber but not depressed, antsy but not clinically hyperactive, who rely on some repetitive behaviors for comfort but are not patently obsessive compulsive—the pros and cons of using drugs are far less obvious. "Unless there is careful assessment, we might start medicating normal variations (in behavior)," says Stephen Hinshaw, chairman of psychology at the University of California, Berkeley.

The world would be a far less interesting place if all the eccentric kids were medicated toward some golden mean. Besides, there are just too many unanswered questions about giving mind drugs to kids to feel comfortable with ever broadening usage. What worries some doctors is that if you medicate a child's developing brain, you may be burning the village to save it. What does any kind of psychopharmacological meddling do, not just to brain chemistry but also to the acquisition of emotional skills—when, for example, antianxiety drugs are prescribed for a child who has not yet acquired the experience of managing stress without the meds? And what about side effects, from weight gain to jitteriness to flattened personality—all the things you don't want in the social crucible of grade school and, worse, high school.

Adding to the worries is a growing body of knowledge showing just how incompletely formed a child's brain truly is. "We now know from imaging studies that frontal lobes, which are vital to executive functions like managing feelings and thought, don't fully mature until age 30," says Hinshaw. That's a lot of time for drugs to muck around with cerebral clay. For that reason, it may not always be worth pulling the pharmacological rip cord, particularly when symptoms are relatively mild. Child psychologists point out that often nonpharmaceutical treatments can reduce or eliminate the need for drugs. Anxiety disorders such as phobias can respond well to behavioral therapy—in which patients are gently exposed to graduated levels of the very things they fear until the brain habituates to the escalating risk.

Depression too may respond to new, streamlined therapy techniques, especially cognitive therapy—a treatment aimed at helping patients reframe their view of the world so that setbacks and losses are put in less catastrophic perspective. "The therapist teaches relaxation skills and positive thinking," says Denise Chavira, clinical psychologist at the University of California at San Diego. "It goes beyond talk therapy." Unfortunately, medical insurance pays more readily for pills than these other treatments for adults and children.

For kids with more serious symptoms, experts are worried that undermedicating is a bigger risk than overmedicating. "Say you've got a kid who's severely obsessive and literally can't leave the home because of the fears and rituals he's got to perform," says ucsf's Elliott. "Think about what anyone age 2 to age 16 has to learn to function in our society. Then think about losing two of those years to a disorder. Which two would you choose to lose?" Also on the side of intervention is the belief that treating more kids with mental illness could reduce its incidence in adults.

Dr. Kiki Chang at Stanford University is trying to show that this is true with bipolar kids. He recently published a study in the Journal of Clinical Psychiatry that looked at kids from bipolar families who had only early signs of the disease. Pre-emptive doses of Depakote eased early symptoms in 78% of cases before the illness ever had a chance to take hold. "You can sit and watch it develop or intervene and possibly prevent the disorder," says Chang. While the researcher is excited about his results, he admits that treating kids who are not yet truly sick is controversial. "There's a chance some of the kids might not develop bipolar at all," says Chang. "We need to have more genetics, more brain imaging, more biological markers to know which direction the kids are going."

How Can We Measure the Result?

Preventing symptoms, of course, is not everything. A sleeping child is completely asymptomatic, for example, but that's not the same as being fully functioning. If the drugs that extinguish symptoms also alter the still developing brain, the cure may come at too high a price, at least for kids who are only mildly symptomatic. To determine if this kind of damage is being done, investigators have been turning more and more to brain scans such as magnetic resonance imaging (MRI). The results they're getting have been intriguing.

MRIs had already shown that the brain volumes of kids with ADHD are 3% smaller than those of unafflicted kids. That concerned researchers since nearly all those scans had been taken of children already being medicated for the disorder. Were the anatomical differences there to begin with, or were they caused by the drugs? Attempting to answer that, Dr. F. Xavier Castellanos of the New York University Child Studies Center took other scans, this time using only kids with ADHD and comparing those who were taking medication with those who were not. Reassuringly, he discovered that they all shared the same structural anomaly, a finding that seems to exonerate the drugs.

Dr. Steven Pliszka, chief of child psychiatry at the University of Texas Health Center in San Antonio, went further. He conducted scans that picked up not just the structure but the activity of the brains of untreated ADHD children, and compared these images with those from children who had been medicated for a year or more. The treated group showed no signs of any deficits in brain function as measured in blood flow. In fact, he says, "we saw hints of improvement toward normal."

The news was less positive when it came to bipolar disorder. Chang has looked at the brains of kids treated with Depakote, and while his study is as yet unpublished, he says he noticed some anatomical differences that could result from treatment—and he wasn't necessarily happy with them. "We are seeing that medications do affect the brain acutely," he says. "Is that a good thing, a bad thing? We just don't know." What nobody denies is that more research is needed to resolve all these questions—and that it won't be easy to get it started. The first problem is one of time. It was only in the early 1990s that the antidepressant Prozac exploded into pharmacies. It's hard to do a lifetime of longitudinal studies on a drug that's been widely used for just over a decade. And each time the industry invents a new medication, the clock rewinds to zero for that particular pill.

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