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Psychiatry and preschoolers

More young children are being diagnosed with mental ailments and treated with drugs even as doctors grapple with a lack of research.

June 30, 2003|Benedict Carey | Times Staff Writer

Over the last two years, doctors have diagnosed Andrea Robinson with half a 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."

Across the U.S., 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 last 15 years, a recent investigation 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. This month, 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.

For The Record
Los Angeles Times Thursday July 03, 2003 Home Edition Main News Part A Page 2 National Desk 1 inches; 42 words Type of Material: Correction
Children's mental health -- An article in Monday's Health section about psychiatry and young children incorrectly stated that Celeste Hesse, a 6-year-old in South Carolina, was suspended from school because of behavior problems. She was not suspended, but disciplined by the school.
For The Record
Los Angeles Times Monday July 07, 2003 Home Edition Health Part F Page 8 Features Desk 1 inches; 42 words Type of Material: Correction
Children's mental health -- An article last Monday about psychiatry and young children reported incorrectly that Celeste Hesse, a 6-year-old in South Carolina, was suspended from her school because of behavior problems. She was not suspended, but was disciplined by the school.

"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 UCLA's 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% to 5% 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 even 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."

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