Psychiatry and preschoolers

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.”