Kids have more problems and much earlier than they did in the past -- but they're getting too little help, despite an increase in prescriptions.
By Daniel DeNoon
Reviewed By Brunilda Nazario
In 2002, hardly a week went by without another report of serious mental health problems in younger and younger children. Are we overreacting? Or is something going terribly wrong with our kids?
"Serious mental health problems do appear to be increasing in children and adolescents," Kelly J. Kelleher, MD, MPH, tells WebMD. "Whether this is the result of changes in society, upbringing, diet -- there is lots of speculation about why the trend is changing. But most observers believe there is an increase, especially among kids from difficult home situations and the kinds of difficult backgrounds that place more and more children at risk."
Kelleher, director of clinical sciences at Columbus Children's Research Institute and professor of pediatrics at Ohio State University, notes that there's been a trend toward the use of more serious diagnostic terms for child mental-health problems. That's true, says Marilyn B. Benoit, MD, president of the American Academy of Child and Adolescent Psychiatry.
"Maybe we are just beginning to come to terms with the problem," Benoit tells WebMD. "We in child psychiatry are becoming aware of the growing number of children who need mental-health services. So it's a combination of identification, the availability of more medications, and also we have been getting more press, which we think is very good. There are a lot of issues."
One of these issues is the events of Sept. 11, 2001. A concern over the disaster's effects on children led to more mental-health screening of young people, says Harold S. Koplewicz, MD. Koplewicz is founder and director of the New York University Child Study Center, vice-chairman of the NYU department of psychiatry, and director of child and adolescent psychiatry at the NYU/Bellevue Hospital Center.
"We found that a lot of kids are doing fine [in coping with the disaster], but that there are a lot of other problems kids suffer from," Koplewicz tells WebMD. "I think we are definitely getting better at finding psychiatric illnesses. Also, we are getting better at making America aware that child psychiatric illness is not rare and that it is very treatable."
In 1999, then-Surgeon General David Satcher reported that 12% of children younger than 18 years have a psychiatric illness -- and that only one in five of these children is getting help. Six months after the events of Sept. 11, Koplewicz and colleagues surveyed children in New York and found even higher rates of anxiety, depression, and even post-traumatic stress disorder.
"These are not things you are just going to bounce back from," Koplewicz says. "Treating these children is a priority. And we are not just talking about kids from evacuated schools in New York but kids from all over the U.S. who on Sept. 10 already were more anxious, more moody, and suffering more. The tragedy is that in the richest country in the world only 20% of kids with psychiatric illnesses get any help. There are only 7,000 child psychiatrists and 6,000 child psychologists -- but there are 10 million kids with problems."
"These numbers way exceed our treatment capacity," Kelleher says. "The U.S. mental-health service system is not set up to deal with these numbers. It is very frustrating."
Paradox: Too Little Treatment, Too Many Prescriptions
Despite the relatively small number of child psychiatrists, more and more children are getting prescriptions for psychiatric drugs. A major reason for this, Koplewicz says, is the arrival of Prozac and other members of the new class of antidepressant drugs known as SSRIs.
He notes that most studies show SSRIs to be very useful in treating depression in teens and even in children. That's led to an increase in use of these drugs. It's also led to a problem.
"If you look at the number of prescriptions, you recognize it has to be someone else beside child psychiatrists medicating America's youth," Koplewicz says. "We probably are talking about family practitioners that have a treatment that is relatively safe and relatively effective and patients who are symptomatic. But these medicines don't work unless you have the disease. So diagnosis has never been more important. Is the change in a child's mood due to depression, anxiety, or Lyme disease? Not all doctors will know."
Koplewicz, however, is not jumping on the anti-medication bandwagon. He believes the answer to the problem is to better train pediatricians and family practitioners. Correct use of SSRIs and other medications, he says, will avoid other problems later in life.
"The evidence is that kids with ADHD who take medication are less likely to abuse drugs later in life," he says. "Depressed teens who go untreated are more likely to use alcohol and substances, since their symptoms are irritability -- not sadness -- when depressed. So treating underlying psychiatric illness removes barriers to learning, to socialization, and to academic functioning."
On the other hand, Koplewicz says, drugs aren't usually the answer.
"I see 200 new kids every year, usually one time for evaluation or second opinion," he notes. "I find it fascinating that out of these 200 kids, only for 60% do I recommend medicine. And that is a skewed sample that comes to me, because all of these are kids with problems. But there isn't a medicine for everything. Sometimes life is crummy and we feel crummy. Sometimes kids have severe learning disabilities. Or they have low IQ, which makes it a struggle to be in school. But there is no pill for all these ills. We can't make kids just feel better -- that isn't the answer."
All of the experts consulted for this story strongly endorse psychotherapy for children with mental health problems.
"I think there still remains a major role for psychotherapy," Benoit says. "I hate to see people only address the role of medication. Medication is part of a plan that should include therapy. There are many kinds of therapy and a skilled clinician will know which to apply in which situation. And sometimes you mix it. People need better training in this."
"The role of psychotherapy is an incredibly important question," Koplewicz agrees. "We know that cognitive/behavioral treatment and treatment for younger children has been remarkably effective. And group treatment is effective for socially phobic kids -- kids who are pathologically self-conscious. This model was developed in adult psychology has been transferred to adolescents and children."
There's another issue that keeps children from getting the mental-health treatments they need: stigma.
"We need to get rid of the idea that mental illness is someone's fault," Kelleher says. "We understand increasingly that this kind of stigma prevents many people from getting successful care. We have a terrible failure rate because other people find out patients are in care and they quit coming. They quit coming! If you didn't finish a course of chemotherapy, you would fail those treatments. Yet most people fail to finish mental health therapy and are inadequately treated."
Stigmatizing messages start young, he notes.
"Children come home from school with pejorative terms like 'crazy' or 'loony' for people who aren't quite normal," Kelleher says. "I really think that children need to hear that we consider mental disorders just like other disorders. Just like you don't make fun of people in wheelchairs. And kids can be very compassionate. But they also learn these insidious messages. When children develop their own problems they remember those stigmatizing messages and don't get help."
Benoit says that people need to take mental health issues as seriously as other health issues.
"People say, 'Oh, that child must just need willpower," or 'That child just needs a spanking" -- but now we know these are real disorders," she says. "We are comfortable talking about people with heart disease and kidney disease. Well, now we have brain disease, too."
Benoit sees the earlier recognition of serious mental health problems in children as a great opportunity.
"We in child psychiatry are particularly excited because when we find a problem with a younger brain it gives us an opportunity to intervene early and abort a pathological process that can halt a person's adaptive function in life," she says. "Sure we need more child psychiatrists and more research, but there is a lot we can do now."
Koplewicz says child mental health isn't just a problem for parents -- it's vital to our national well-being.
"You don't have to worry about your child only -- if the child next to yours has a problem he or she will be more likely to take up the teachers' time, to drop out and not pay taxes, and to have trouble with legal system," he argues.
"As a nation, for the sake of the health of our nation, we should be concerned about child mental health. Kids with depression become adults with depression. Children with anxiety become adults with panic disorder. A generation ago we didn't wear seatbelts. Now kids all put on seatbelts. Fifteen years ago we had trouble believing that AIDS was not a gay disease. Now kids are being taught about safe sex. If we do the same for child mental health, it would make a large difference in mortality among teens, in high-school and college graduations, and in the economic health of our nation. I am remarkably optimistic."
Published Dec. 26, 2002.
SOURCES: Marilyn B. Benoit, MD, president, American Academy of Child and Adolescent Psychiatry, director of child psychiatry training, Howard University Hospital, Washington • Harold S. Koplewicz, MD, founder and director, New York University Child Study Center, vice-chairman of the department of psychiatry and professor of clinical psychiatry and pediatrics, New York University School of Medicine, director of the division of child and adolescent psychiatry at New York University/Bellevue Hospital Center • Kelly J. Kelleher, MD, MPH, director of the office of clinical sciences and professor of pediatrics, Columbus Children's Research Institute, Ohio State University • American Academy of Child and Adolescent Psychiatry.
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