The address is letters@latimes.com

  Fred A. Baughman Jr., MD comments on:
 
    http://www.latimes.com/la-he-kidsdepress30jun30,0,3327225.story
    LOS ANGELES TIMES
    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.

    By Benedict Carey
    Times Staff Writer
   
    June 30, 2003
   
    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.
   
    "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." 

    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., brought 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
    says.
   
    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 including
    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 are mentally untroubled, or who have ADHD. They report that depression
    in this age group looks in some ways like the adult variety: Kids become
    listless; they lose interest even in playing; the joy runs out of life.
   
    But Luby said her research also suggests that the current criteria for
    diagnosing major depression are 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, how often it leads to adolescent
    or adult problems, or whether drugs or counseling helps. It's little wonder
    that while some doctors swear by antidepressants, Luby and others are leery,
    and still others mix counseling with medication.
   
    This catch-as-catch-can approach cries out for some central forum where
    psychiatrists and families can readily keep up with what is clearly a
    frontier science, said Dr. Gregory Fritz, medical director of Bradley
    Hospital, a children's psychiatric clinic in Providence, R.I.
  

"Right now,
    we've got a situation in which there are very active pharmaceutical
    companies producing more and more drugs, and more ads, and there's pressure
    from the public to get quick results based on scattered reports, or
    anecdotal information - it's a nightmare," he said. "We ought to have a more
    centralized series of protocols for these illnesses in young kids so we can
    pull all this information together." 

    It will not happen soon enough for the Robinsons. During her nearly two
    years of needless medication, Andrea Robinson went for months without riding
    her purple five-speed. "It's her favorite thing to do," said Tammy Robinson.
    "I know something's very wrong if she's not out riding that bike."