Childhood depression is believed to be increasing, based on the rising number of suicides among young people. In 2008, statistics showed that suicide was the third leading cause of death among people aged 15 to 24, and the sixth leading cause of death among 5 to 14 year olds.
Antidepressants have been hailed as safe and effective miracle drugs that can cure depression, but critics argue that antidepressants are often given needlessly. Others maintain that depression should be treated by behavioral therapy instead of drugs, and many charge that antidepressants themselves are responsible for suicides among children and adolescents.
Also increasing is the rate of attention-deficit hyperactivity disorder (ADHD), which makes it hard for children to control impulses or pay attention. Statistics show that more than 6 million children in the United States have been diagnosed with ADHD. Stimulants have been found to have a converse effect in ADHD sufferers, calming them down and helping them to focus. The best-known stimulant is Ritalin; others include Strattera and Adderall. These medications have been given to children as young as fifteen months.
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While all experts agree that depression and ADHD must be treated, many are cautious about drug treatment. These critics argue that behavior drugs are often prescribed for children “off-label,” meaning that the medications have been approved for adults and older children, but have not been tested for younger ones.
In recent years, the United States Food & Drug Administration (FDA) has mandated warning labels for drugs such as Prozac, Paxil, and Zoloft, to inform doctors and patients of the danger of increased suicidal thoughts in children and adolescents taking these medications. The FDA advisory panel has also recommended a label warning that ADHD drugs can cause heart problems in some patients.
Attention-Deficit Hyperactivity Disorder (ADHD): Children with this condition have intense, sustained difficulty paying attention and/or controlling their behavior.
Monoamine Oxidase Inhibitors (MAOI): Antidepressants in this category block the activity of monoamine oxidase, the enzyme in nerve cells that breaks down neurotransmitters.
Neurotransmitters: Nerve cells communicate using neurotransmitters, chemicals in the brain that travel from one nerve cell to another, across the synapse (a tiny gap between the cells). An imbalance or lack of neurotransmitters in the synapse is associated with depression. Types of neurotransmitters include dopamine, norepinephrine and serotonin.
Psychotherapy: The process of treating mental and emotional problems with professional counseling, as in cognitive behavioral therapy (CBT) or interpersonal therapy (IPT).
Reuptake: The process by which a receiving nerve cell releases the neurotransmitter back into the synapse, where it is taken up again by the sending cell.
Ritalin: Common name for the stimulant methylphenidate hydrochloride, used to treat ADHD.
Selective Serotonin Reuptake Inhibitors (SSRI): Antidepressants that work to keep serotonin active in the synapse longer.
Tricyclics: These antidepressants are given to inhibit the reuptake of both serotonin and norepinephrine and possibly other neurotransmitters.
Both critics and supporters of behavior drugs agree on the importance of treating depression and ADHD in children to prevent serious, and possibly lifelong, harm. But there is wide disagreement on what type of treatment is effective or even safe.
Until the 1990s, it was believed that children and adolescents were not emotionally mature enough to suffer true depression. New drugs as Prozac, developed in 1989, appeared to be much safer than the earlier tricyclic antidepressants, so doctors began prescribing them widely, and soon began prescribing them for off-label use by teens and younger children.
Since then, the use of antidepressants among children, adolescents, and even infants has increased. Critics maintain that medicating such young children is one example of widespread over-prescribing. Further, they worry that many prescriptions are written by medical doctors without psychiatric consultation or treatment. From 1996 to 1998, the number of prescriptions written by non-psychiatrists doubled, while those written by psychiatrists increased by only 18 percent.
Mental health experts maintain that nobody should ever be given behavior drugs without psychotherapy. In fact, some advocate a no-drug approach, preferring cognitive behavioral therapy or interpersonal therapy alone. In addition, critics are concerned because these medications have not been thoroughly tested for children.
Some mental health critics also reject the entire theory of depression as a biological disease. Drugs, they assert, treat only the symptoms; they are not a cure for the problem that caused the depression. Each depression is individual, they argue, so a single drug cannot be generally effective. These critics tend to consider the whole idea of antidepressants as a marketing ploy rather than a source of real help.
In addition, critics of drug therapy argue that even the best antidepressants have unpleasant and even dangerous side effects which can cause lasting damage. Many violent crimes, say some experts, are committed not by depressed people, as reported in the media, but by people under the mind-altering influence of antidepressants.
What we now call ADHD was first described in 1845 by Dr. Heinrich Hoffman, whose son exhibited typical hyperactive behavior. Sir George F. Still undoubtedly relieved the minds of many parents in 1902, when he published a series of lectures on children with behavioral problems that were caused by organic dysfunction rather than by poor parenting. Thousands of scientific papers have been written on the subject since.
While ADHD strikes in early childhood, 70-80 percent of children with the disorder continue to suffer as teens, and 60 percent continue to experience symptoms of the disorder into adulthood. ADHD is often associated with other problems, such as learning disabilities, depression and bipolar disorder. Left untreated, ADHD can increase the risk of other problems, such as substance abuse. As with depression, neurotransmitters are involved.
Proponents of Ritalin, which has been in use for fifty years, maintain that the medication is safe, its side effects are minor and it can prevent later drug abuse. Critics complain that giving children an amphetamine-like substance sends a message that contradicts anti-drug warnings. They also worry about the long-term effects of such strong medication, even if it is necessary. The drugs used to treat ADHD, they point out, have numerous known side effects, including loss of appetite, insomnia and stunted growth. Furthermore, the drugs have not been thoroughly tested for very young children. Even with these problems, Ritalin has been given to children as young as fifteen months.
Most specialists agree that true ADHD is a medical problem and requires medication. The major concern is that many children may be incorrectly diagnosed and given drugs for trivial behavior problems or for problems resulting from trauma such as sexual abuse.
Additionally, many specialists are concerned that physicians prescribe ADHD medications alone, as is often done with antidepressants. The US National Institute of Mental Health (NIMH) reports that combined treatment with drugs and behavioral therapy works best. Combined treatment also often means that drug dosages can be reduced.
Recent FDA actions have added fuel to the debate. In 2005, the FDA mandated warning labels for SSRIs cautioning doctors and patients of the dangers posed to children and adolescents taking Prozac, Zoloft, Paxil, and other drugs. It further recommended that one of the SSRIs, paroxetine (Paxil), not be used for children and adolescents at all. At the same time, the FDA maintains that adolescents can benefit substantially from antidepressants, under careful observation. Only Prozac has been approved for use by children as young as eight. In 2009, Lexapro became FDA-approved for the treatment of depression in individuals ages 12-17. Most prescriptions for younger children are off-label.
Critics worry about physical and mental problems, such as antisocial and violent behavior, that they say are side effects of antidepressants. At the same time, many parents have become active in opposing ADHD medications. Hundreds of popular books have been written on the subject, warning against hasty diagnosis for children who are simply highly energetic. Critics contend that most of the behavior labeled ADHD actually results from medical conditions, the tensions of modern life, or trauma.
Proponents of drug therapy argue that no study has yet provided convincing evidence that Ritalin causes addiction. Critics, however, say that studies show the use of Ritalin leads to addictive behavior such as smoking. Also, they point out that there have been no studies of the long-term effects of ADHD medications.
Some critics, including medical experts, do not believe that ADHD even exists. The American Medical Association (AMA), on the other hand, charges that groups such as Scientologists have inflamed the debate with colorful public relations campaigns. Critics of ADHD medication were given a boost in late 2006 when an FDA advisory panel recommended that medications for ADHD include a “black-box’ label, the strongest warning, that the drugs present a cardiac risk to some patients.
According to the Wall Street Journal, 25 percent of children in the United States are now on prescribed medications.
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These essays and any opinions, information, or representations contained therein are the creation of the particular author and do not necessarily reflect the opinion of EBSCO Information Services.
By Ellen Bailey
Co-Author: Rosalyn Carson-Dewitt
Rosalyn Carson-Dewitt received an MD from Michigan State University in 1991. She is a medical and scientific writer and was editor-in-chief for Drugs, Alcohol and Tobacco: Learning about Addictive Behavior and Encyclopedia of Drugs, Alcohol and Addictive Behavior published by Macmillan Reference USA. Carson-Dewitt also worked on the Merck Manual of Diagnosis and Therapy, 18th edition.
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