In 1999, researchers published a ground-breaking scientific study call the MECA Study (Methodology for Epidemiology of Mental Disorders in Children and Adolescents). It estimated that almost 21 percent of U.S. children ages 9 to 17 had a diagnosable mental or addictive disorder that caused at least some impairment. When diagnostic criteria were limited to significant functional impairment, the estimate dropped to 11 percent, for a total of 4 million children who suffer from a psychiatric disorder that limits their ability to function.
It is easy to overlook the seriousness of childhood mental disorders, but some clinicians believe the pendulum may have swung too much in the other direction — to overdiagnosis and treatment. In children, mental disorders may present with symptoms that are different from or less clear-cut than the same disorders in adults. Younger children, especially, and sometimes older children as well, may not talk about what is bothering them. For this reason, it is important to have a doctor, another mental health professional, or a psychiatric team examine the child.
Many treatments are available to help these children. The treatments include both medications and psychotherapy — behavioral therapy, treatment of impaired social skills, parental and family therapy, and group therapy. The therapy used is based on the child’s diagnosis and individual needs.
When the decision is reached that a child should take medication, active monitoring by all caretakers (parents, teachers, and others who have charge of the child) is essential. Children should be watched and questioned for side effects because many children, especially younger ones, do not volunteer information. They should also be monitored to see that they are actually taking the medication and taking the proper dosage on the correct schedule.
Childhood-onset depression and anxiety are increasingly recognized and treated. However, the best-known and most-treated childhood-onset mental disorder is attention deficit hyperactivity disorder (ADHD). Children with ADHD exhibit symptoms such as short attention span, excessive motor activity, and impulsivity which interfere with their ability to function especially at school. The medications most commonly prescribed for ADHD are called stimulants. These include methylphenidate (Ritalin, Metadate, Concerta), amphetamine (Adderall), dextroamphetamine (Dexedrine, Dextrostat), and pemoline (Cylert). Because of its potential for serious side effects on the liver, pemoline is not ordinarily used as a first-line therapy for ADHD. Some antidepressants such as bupropion (Wellbutrin) are often used as alternative medications for ADHD for children who do not respond to or tolerate stimulants.
Based on clinical experience and medication knowledge, a physician may prescribe to young children a medication that has been approved by the U.S. Food and Drug Administration (FDA) for use in adults or older children. This use of the medication is called “off-label.” Most medications prescribed for childhood mental disorders, including many of the newer medications that are proving helpful, are prescribed off-label because only a few of them have been systematically studied for safety and efficacy in children.
Medications that have not undergone such testing are dispensed with the statement that “safety and efficacy have not been established in pediatric patients.” The FDA has been urging that products be appropriately studied in children and has offered incentives to drug manufacturers to carry out such testing. The National Institutes of Health and the FDA are examining the issue of medication research in children and are developing new research approaches.
Antidepressants and Teens
Following a thorough and comprehensive review of all the available published and unpublished controlled clinical trials of antidepressants in children and adolescents, the U.S. Food and Drug Administration (FDA) issued a public warning in October 2004 about an increased risk of suicidal thoughts or behavior (suicidality) in children and adolescents treated with SSRI antidepressant medications. In 2006, an advisory committee to the FDA recommended that the agency extend the warning to include young adults up to age 25.
Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders. The study, partially funded by NIMH, was published in the April 2007, issue of the Journal of the American Medical Association.
In the FDA review, no completed suicides occurred among nearly 2,200 children treated with SSRI medications (the most commonly prescribed type of antidepressants). However, about 4 percent of those taking SSRI medications experienced suicidal thinking or behavior, including actual suicide attempts — twice the rate of those taking placebo, or sugar pills.
In response, the FDA adopted a “black box” label warning indicating that antidepressants may increase the risk of suicidal thinking and behavior in some children and adolescents with MDD. A black-box warning is the most serious type of warning in prescription drug labeling.
The warning also notes that children and adolescents taking SSRI medications should be closely monitored for any worsening in depression, emergence of suicidal thinking or behavior, or unusual changes in behavior, such as sleeplessness, agitation, or withdrawal from normal social situations. Close monitoring is especially important during the first four weeks of treatment. SSRI medications usually have few side effects in children and adolescents, but for unknown reasons, they may trigger agitation and abnormal behavior in certain individuals.