DC Child Accident & Safety Blog

Mental illness. Depression. Suicide. The dark side of the human condition is sad whenever and whomever it strikes. But when the victims are young people, it seems unacceptably unnatural. Yet suicide is the third most common cause of death among teenagers.

So programs such as TeenScreen that survey young people to determine their risk of depression make sense. Those who seem to be at risk are referred for treatment. But John Horgan, writing in Scientific American, raises profound questions about whether screening teens for mental illness is really a good idea for them, or only for a society that wants to feel as though it is doing something.

Some people are opposed to this mental health screening, contending that these issues are private for the youngsters and their families. They contend that they also promote overprescribing of psychiatric medications.

Horgan agrees with the latter concern, noting that:

• Psychiatrists say that more than 1 in 10 children suffer from mental illnesses — from attention-deficit disorder to full blown psychosis. In 2008, the General Accounting Office estimated that 1 in 16 children is “seriously mentally ill.”


• The number of children so mentally disabled that their families are eligible for government assistance has swelled from 16,200 in 1987 to 561,569 in 2007, a 35-fold increase. During the same period, those requiring government assistance for all other ailments declined from 728,110 to 559,448.


• 3.5 million U.S. children take Ritalin and similar medications for (attention deficit hyperactivity disorder) ADHD, up from only 150,000 or so in the late 1970s -- or about 1 in 23 children from 4 to 17.


• U.S.children consume three times as many ADHD medications as the rest of the world’s children combined.


• A 2002 study estimates that 1 in 40 children 18 or younger takes antidepressants. Numerous studies indicate that whereas antidepressants can provide short-term relief for some children, some treated with antidepressants may experience side effects ranging from anxiety and insomnia to full-blown mania and psychosis.


• Since 1995, the number of children diagnosed with bipolar disorder has multiplied more than 40-fold to roughly 800,000.


• Children diagnosed as bipolar are treated with drugs — notably antipsychotics normally prescribed for adult schizophrenics — that have severe physiological as well as mental side effects, including obesity, diabetes and involuntary tremors.


• More than 500,000 children (including infants) ingest antipsychotics, a trend The New York Times reported has been aggressively promoted by manufacturers of antipsychotics.

The promoters of TeenScreen, Horgan writes, have ties to the pharmaceutical industry.
Some psychiatrists advocate medicating young people deemed to be “at risk” of schizophrenia based on behavior less than compelling or because they have schizophrenic relatives.

"Mental illness is devastating for children as well as adults," Horgan concludes, "and medication, when used wisely and sparingly, can help. But clearly our current approach to treating disturbed young people is broken."

Certainly, a disturbed, dangerously unhappy teenager deserves medical attention and appropriate intervention. But before parents agree to an aggressive regimen of psychotropic drugs, they should fully inform themselves of the side effects and risks. There are a lot of ways to treat depression. Drugs is only one.

It’s parental instinct to want to make a child’s world as safe and normal as possible. And when that world is different from the one most other children live in, parents want to know why.

When a pediatrician’s patient lives in the world of autism, explaining the whys and whats to the parents is particularly daunting. Writing in the New York Times recently, Dr. Perri Klass addressed how she relates to parents of autistic children who want to know the cause and, for prospective parents, how they can reduce the risk for children they’re planning to have.

“[A]lthough there is more research in this area than ever before,” she writes, “it sometimes feels as if it’s getting harder, not easier, to provide answers that do justice to the evidence and also offer practical guidance.”

Autism is a complex disorder that research has shown is driven by both genetic and environmental factors. As Klass describes, “Genes matter, but we usually can’t tell how. Environmental exposures matter, but we usually don’t know which.”

Not much there for parents to work with.

A study of autism in twins showed that fraternal twins were both likely to have the disorder, which seems to compromise the strength of the genetic component (since fraternal twins share fewer genes than identical twins).

A couple of generations ago, when ignorance about all mental disorders was evident far more than common sense, autism was blamed on remote parenting. More recently, a noisy campaign was based on fake science supposedly indicating an association between childhood vaccinations and autism, a theory that has been wholly discredited.

But the genetic influences have been proved scientifically sound, and autism spectrum disorder has been described by the American Psychiatric Association as “among the most heritable of psychiatric disorders.”

This evolution of understanding has led scientists to accept that autism results both from genetic predisposition and from environmental influence. But “environment” is a fluid concept.

As one researcher quoted by Klass put it, it’s “everything that’s not the inherited DNA.” Parents might wonder about the chemical ingredients of the placenta’s soup, about the mother’s nutritional profile, her stress level, about the caustic cleaning products under the sink … They’re all part of a developing fetus’s environment.

According to Klass, “The causal links most strongly supported by research include rubella (measles) infection during pregnancy and prenatal exposure to medications like thalidomide and valproic acid, an anti-seizure drug.” Air pollution and exposure to pesticides have an association with autism, but there’s no evidence of causality.

Phthalates, which are chemicals found in flexible plastic products such as shower curtains and other household furnishings such as carpet and shampoo, can leach out in microscopic amounts and disrupt a variety of developmental processes, including brain development. But, again, they haven’t been shown to be a cause of autism, only as an association with its symptoms.

Bottom line: Autism is a custom-made disorder, and probably the result of several factors.
“So it’s hard — and frustrating — to offer prospective parents advice about avoiding risks we still can’t clearly identify,” Klass observes, “and factors that may differ from family to family.”

You can’t completely sanitize your environment, you can’t turn your uterus into a scientific “clean” room — potential toxins are simply a part life. But Klass does offer prospective parents concerned about autism some advice that’s more a prescription of common sense than a prophylactic:

• Take prenatal vitamins before trying to conceive.


• Ensure your immunizations are up to date.


• Get good prenatal care.


• Discuss the risks and benefits of any medications you take with your doctor.


• Avoid pesticides.


• Don’t microwave food plastic containers.


• Use fragrance-free personal products.

“Still, Klass concludes, “it’s hard to talk about this without terrifying parents. And I wonder if in giving advice about prevention, we risk repeating the errors of the past, making parents feel they’re to blame for a child’s autism because they failed to micromanage an environment full of complex agents with potential to interact with fetal genes in a range of damaging but poorly understood disruptions.”

A new study published in the journal Pediatrics offers insight into why children with attention-deficit/hyperactivity disorder (ADHD) are able to observe safety measures when crossing the street, but often fail to do so.

Seventy-eight children from 7 to 10 years years old were involved in the study. Thirty-nine were diagnosed with ADHD and 39 were typically developing children. Researchers looked at three things: (1) how they evaluated their environment before crossing the street; (2) how they decided to begin crossing; and (3) how safe was the environment after the decision to cross was made.

No significant differences emerged in the latter two factors, but the children with ADHD chose riskier pedestrian environments in which to cross. Researchers concluded that this reflected trouble within the brain's "executive function" -- that is, the kids with ADHD were less able to process perceived information necessary to permit a safe cross.

Many adolescents diagnosed with depression and attention deficity-hyperactivity disorder (ADHD) are prescribed both methylphenidate (Ritalin) and fluoxetine (Prozac). A study on rats given the two drugs might give humans pause.

As reported in the Los Angeles Times, the study showed that adult rats who got that drug combination as pups were more likely than those with no early exposure to psychotropic drugs to choose highly sugared water over plain water, and to linger in a compartment where they had gotten a dose of cocaine, which suggests they were hoping for more. Those are disturbing signs of developing addiction.

"Taking Ritalin and Prozac together during adolescence appears to set in motion subtle changes in brain function that, in adulthood, makes an individual more sensitive to reward as well as to stress, and more likely to exhibit the pessimism and hopelessness seen in depression," was how The Times summarized the study published in the Journal of Neuroscience.

The study's authors wrote, "combining methyphenidate and fluoxetine early in life may lead to lifelong behavioral and chemical abnormalities." They said the drugs--one a stimulant, one an anti-depressant--in combination appeared to act on the brain in much the same way as does cocaine.

Those drugs affect production of certain proteins in the brain's reward circuitry. If it's disrupted during adolescence, the adult later might struggle with the ability to regulate mood and to moderate reward-seeking behavior such as eating or sexual activity.

Baby rats who got only Prozac seemed more sensitive to rewards as adults, but were also more resilient to stress than those who didn't. The rats who got only Ritalin demonstrated less inclination toward sugar water, as well as a "significant aversion to cocaine" as adults--a sign that treating ADHD might thwart drug abuse later. But they also showed greater sensitivity to stress later on.

A rat is not a kid, and a trial subject rat is not depressed or afflicted with ADHD. So no straight line can be drawn between the study results and a child with these disorders who takes these drugs. If the study is notable, it is too preliminary for parents to withhold these drugs if they've been prescribed for their children with mood and behavioral problems. It's never too early, however, for a conversation with your doctor about the appropriate use of prescription drugs, and alternative treatments.

Of all neurodevelopmental disorders, autism has been deemed the one most likely to be inherited. But this study shows that genes exert only moderate susceptibility for autism, and that its environmental component is substantial.

Autism is a complex disorder whose signature is the disruption of the normal course of social, communicative and cognitive development. Diagnosis is made in early childhood, and symptoms manifest by the time a child is 3 years old. In the last generation, a substantial increase in the prevalence of autism has been reported, from 4 or 5 per 10,000 in the 1960s to around 40 per 10,000 children today. It's even more common to be somewhere on the "autism spectrum" -- as many as one in 100 children qualify. The increase in recent years often is ascribed to better recognition, not necessarily to a greater occurrence.

The study appears to be the largest "population-based twin study of autism that used contemporary standards for the diagnosis of autism," a standard necessary to examine genetic influences. As the authors report, "The results suggest that environmental factors common to twins explain about 55% of the liability to autism. Although genetic factors also play an important role, they are of substantially lower magnitude than estimates from prior twin studies of autism."

In another study related to autism published in in the Archives of General Psychiatry, prenatal exposure to the most widely prescribed kind of antidepressants--including Celexa, Lexapro, Prozac, Paxil and Zoloft— is associated with a modest increase in the risk of developing autism, especially during the first trimester.

"The potential risk associated with exposure," the authors wrote, "must be balanced with the risk to the mother or fetus of untreated mental health disorders. Further studies are needed to replicate and extend these findings."

Prescriptions of anti-psychotic drugs like Risperdal for pre-school kids have doubled in the last few years, according to a recent study from Columbia University. Now there are an estimated 500,000 children and adolescents receiving such drugs in the United States. Is it too much?

Only four in ten of the preschoolers who receive prescriptions for these powerful drugs have been given a proper mental health assessment, according to the Columbia study. That worries some experts. As one told the New York Times:

“There are too many children getting on too many of these drugs too soon.”

This quote was from Dr. Mark Olfson, professor of clinical psychiatry at Columbia and lead researcher in the new study, which was financed by the government.

Olfson and other researchers worry that the drugs can interfere with physical and mental development in young children. What many kids need is talk therapy, but it's cheaper and more convenient to medicate them, they say.

Read more in the Times' article here.

An article recently published in the Journal of American Medical Association documents findings that associate atypical antipsychotics to weight gain in children who are first-time users of the drugs. The study, headed by Dr. Christoph Correll in New York, includes 272 youths age 4 to 19 and is “the largest and most definitive to date to establish a link between the drugs and weight gain,” writes Jonathan Rockoff of the Wall Street Journal.

The JAMA study examined four top-selling atypical antipsychotics (powerful drugs prescribed to treat schizophrenia and bipolar disorder): Abilify, Risperdal, Seroquel and Zyprexa. Among them, Zyprexa was found to cause the most weight gain: 19 pounds in 11 weeks. It was also found to “significantly raise levels of blood sugar, cholesterol, insulin and triglycerides,” thereby increasing users’ risk of diabetes and heart problems. Patients taking other three medications had an average of 10 to 13 pounds of weight gain.

Dr. Correll, the lead author of the study, recommends using extra caution in prescribing these atypical antipsychotics to youths under the age of 18, and encourages psychiatrists to frequently monitor the weight and metabolic rate of those who are taking these drugs.

One in five American teenagers have an episode of depression before they turn 18. If untreated, adolescent-onset depression often returns during adulthood and becomes a chronic and persistent condition that is crippling and even life-threatening. One of the risk factors is having a depressed parent: that increases the odds of becoming depressed in one's teen years by two- to three-fold.

But an article appearing in the latest Journal of American Medical Association has good news, as reported by Shirley Wang of The Wall Street Journal: a multicenter trial conducted in 4 U.S. cities found that a group prevention program effectively reduced the risk of subsequent depression for a target group of teenagers.

The study involved 316 “at-risk” teenagers (ages 13-17). All had a history of clinical depression and parents who had had depressive disorders. The youths were assigned to either a group cognitive behavioral prevention program or usual mental health care. After 9 months of treatment, of the teenagers who were assigned to the group CB prevention program and whose parents were not depressed at the time of the study, only 11.7% had a new depressive episode. In contrast, among teenagers in usual care whose parents were not depressed at the time, 40% experienced another episode of depression.

Although the prevention program only worked for teenagers whose parents were not currently depressed, the new finding is still encouraging, shedding light on future research directions and clinical recommendations.

Nearly two million American teenagers are afflicted with depression, and major medical groups are now recommending that pediatricians give a simple but detailed questionnaire to all their teenage patients to try to detect this condition so that treatment can be offered.

About 1 out of 20 teens suffer from depression, which has been linked to lower grades, more physical illness and drug use, as well as early pregnancy.

Questionnaires can accurately identify teens prone to depression, plus there's new evidence that therapy and/or some antidepressants can benefit them, according to a report from the U.S. Preventive Services Task Force, published in the April 2009 edition of the journal Pediatrics .

Accompanying the task force advisory in Pediatrics is a research review saying there have been few studies on the accuracy of depression screening tests, but the tests "have performed fairly well" among adolescents. Treatment can help with symptoms of depression, say the reviewers from Kaiser Permanente and the Oregon Evidence-Based Practice Center in Portland, Ore.

But careful monitoring is vital since there's "convincing evidence" that antidepressants can increase suicidal behavior in teens, according to the Preventive Services Task Force report.

The new recommendation reverses what the task force said in 2002, when it reported that there was not enough evidence to recommend for or against routine screening of adolescents for depression.

Thirty-nine million prescriptions were written for American children in 2008 for drugs like Adderall and Concerta to treat attention deficit hyperactive disorder (ADHD), but new research suggests the drugs have only short-term benefit and may pose more harm to children than good if given for more than two years.

In a report in the Washington Post by Shankar Vendatam, scientists involved in a large federal study of the drugs sharply disagreed with one another about what the public should be told about their study results. One psychologist in the group of researchers said that parents needed to know that careful comparisons of the children in the study showed definite advantages of the drug treatment only in the first twenty-four months of use, and that longer use resulted in stunted growth, with drug-treated children typically an inch shorter and six pounds lighter than non-drug treated peers after 36 months of treatment. Another psychiatrist who participated in the study said long-term benefits were real but hard to demonstrate statistically.

The study is called the Multimodal Treatment Study of Children With ADHD (MTA). When its initial results were first published in 1999, a clear advantage was seen for behavior improvement in children who had taken the ADHD drugs in the first fourteen months of the study, compared to children who received only talk therapy or no treatment at all, and those results ignited a huge wave of popularity for the ADHD drugs with pediatricians and parents. But as the researchers have continued to follow the same children over the years, the advantage of drug therapy, at least as measurable statistically, disappeared.

Statistics, of course, do not necessarily apply in any one individual case. The take-away for parents is to be careful about any long-term use of drugs in their children and to continue to ask questions of doctors, and reach your own informed decisions about what to do.

Nearly every week, we hear more evidence that American children are over-medicated, especially with drugs that affect mood and behavior. Most recently, a panel of experts has denounced the overuse of Risperdal, a powerful antipsychotic drug, for attention deficit disorder. The drug has too many side effects, including potential development of permanent muscle twitching, to justify its use in mild conditions like ADD for which other options exist, according to the expert panel convened by the Food & Drug Administration to advise it on labeling changes.

What is behind the explosion in use of antipsychotic drugs in children (besides Risperdal, they include Zyprexa, Seroquel, Abilify and Geodon) is a drumbeat of support from leaders in child psychiatry. But that leadership is tainted by their ties to the drug industry -- ties that frequently don't get mentioned in public when these same doctors are lecturing their colleagues and advising worried parents. One leader, Dr. Joseph Biederman, a child psychiatrist at Harvard, was revealed by a Congressional investigation to have accepted $1.4 million from manufacturers of antipsychotic drugs that he did not disclose to his university. Another psychiatrist leader, Dr. Charles B. Nemeroff of Emory, had to step down as chair of psychiatry after it was revealed that much of his consulting pay from drug makers, which totaled over $2.8 million in seven years, had been hidden from his university.

Now another influential psychiatrist has been exposed for his secret ties to the drug industry. He is Dr. Frederick Goodwin, former chief of the National Institute of Mental Health, who hosted a popular show on National Public Radio, "The Infinite Mind." Senator Charles Grassley of Iowa released data to the New York Times showing that Dr. Goodwin received $1.3 million from drug manufacturers from 2000 to 2007 for giving marketing lectures to other doctors. The money was never mentioned on his radio show, and NPR now says the show has been canceled and all reruns will stop soon.

According to the Times' Gardiner Harris, on one day in 2005, Dr. Goodwin received $2,500 from GlaxoSmithKline to give a talk about its mood stabilizer drug Lamictal at a Ritz Carlton resort in Florida. On his radio show broadcast the same day, Dr. Goodwin said that children with bipolar disorder who did not get treatment could suffer brain damage (a controversial prognosis) but he reassured his listeners that mood stabilizer drugs were a safe and effective way to treat the problem.

Senator Grassley has sponsored legislation to require drug makers to post publicly all the payments they make to doctor consultants. That would help the public to know whether the recommendations they see from doctors for medicating their children are truly unbiased or should be taken with a grain of salt.

The largest study done yet of anxiety disorders in children and adolescents suggests that a combination of therapy and antidepressant medications is most effective tor treating disabling anxiety in these age groups.

The particular kind of therapy that was effective is called "cognitive behavior therapy" or "talk therapy." The difference between the combination of therapy and medication and each individual treatment alone was dramatic: 8 in 10 children who had the combination improved significantly, as opposed to 6 in 10 of those who had either the medication or the therapy alone.

The doctors who commented on the study in the article say this is something parents and insurance companies should both be very aware of.

Infants who have a sibling with autism are at higher risk of becoming autistic themselves. At the University of Washington, researchers are testing whether or not a special intervention can be done to reduce the chances of autism in these high-risk babies.

Half of the mothers in the study will be taught to notice subtle cues from the babies and how to seize on these cues as opportunities to engage and communicate with them. These cues, it is hypothesized, indicate when the baby is "reaching out" to its parents.

If the study confirms the hypothesis, it means we will have a non-biochemical way of reducing the risk of autism.

Sometimes children pose a greater risk to themselves than their surroundings do, as any mental health specialist could tell you. An alarming new study shows that the recent decline in the use of anti-depressants in children and teenagers has coincided with an increase in youth suicides.

Anti-depressant use among youths began to go down four years ago, when the Food and Drug Administration (FDA) issued an advisory regarding children and teens who were on anti-depressants and subsequently committed suicide. Later, in 2004, the FDA made a rule saying that anti-depressants had to be labeled for increased suicide risk in pediatric patients. In December 2006, the FDA expanded this rule so that it covered anti-depressant use in young adults as well.

Evidently there was cause for concern four years ago, but this new research suggests that these warnings are doing more harm than good. Prescriptions for these medications declined sharply after the FDA issued the warnings. But the youth suicide rates went up. Likewise, before 2003, an increase in anti-depressant prescription correlated with a decrease in youth suicide:

The researchers found that the reverse corollary was true. Increases in SSRI prescription rates coincided with decreases in suicide rates from 1998 to 2003. In the U.S., a 91 per cent increase in prescription rates coincided with a 33 per cent decrease in suicide rates.

The researchers therefore concluded that the FDA's analysis was flawed, pointing out that the FDA's study (suggesting a link between anti-depressant use and higher youth suicide rates) relied on a biased sample.

That said, there is always some ambiguity in this kind of research. That's why researchers must do multiple studies and why people need to get information from multiple sources. To find more information on mental health in children and teenagers, these links are a good place to start:

National Institute of Mental Health--Depression

National Institute of Mental Health--Children and Adolescents and Treatment of Children with Mental Disorders

Mental Health America--Disorders and Treatments