Children’s mental health care untested, unknown

LOS ANGELES — Sixty years ago, jamming an ice pick through the eye socket and striking it against the brain was a popular treatment for mental illness.

However, frontal lobotomies, electroconvulsive therapy and insulin shock therapy fell out of favor in the 1950s with the advent of psychiatric medications.

Now, half a century later, health care professionals are still fine tuning their methods.

About one in five American children and adolescents has a mental illness, according to the U.S. Surgeon General. Treatment options for the mentally ill include medications, therapies or a combination of both, but the mental health community is still in the early stages of developing treatments for children, who are often left with inadequate help.

Children’s youth and undeveloped bodies slow medical testing while difficulty in diagnosing children has stunted treatment plans.

In Nebraska, about one in 20 children under 17 has a mental illness, but two-thirds are not getting the help or treatment they need, according to Project Relate, a public service campaign that joins mental health service providers, advocacy groups and non-profit organizations in Nebraska.

The State Mental Health Agency’s expenditures in 2001 totaled more than $86.5 million, which breaks down to about $50 per person.

Where primary and preventive health care is favored, especially for the poor and uninsured, mentally ill patients may be missing out.

Of the children in the U.S. with mental illness, 62 percent have anxiety disorders, 49 percent have disruptive disorders, 30 percent have mood disorders and 10 percent have substance abuse disorders, according to a 1996 report from the Surgeon General; some of these children have more than one disorder.

The type of illness strongly dictates treatment plans.

“We know that cognitive-behavioral therapy and biofeedback is very, very, very good for anxiety disorders and even panic disorders,” said Herbert Schreier, a psychiatrist at the Children’s Hospital and Research Center Oakland in Oakland, Calif. “For bipolar disorders, obviously, not so good.”

Biofeedback uses blood pressure, heart rate and other bodily functions to reveal and make patients aware of unconscious physical activities so the patient can learn to control them.

Cognitive-behavioral therapy is one of the principal treatments in the modern school of thought. It’s a combination method that teaches patients to retrain their thinking by recognizing and redirecting certain thoughts.

Some of the applications of this kind of therapy include exposure therapy for people with anxiety disorders or having children play out the decision between healthy and unhealthy decisions in a video game.

“Cognitive-behavioral therapy is probably one of the treatments of choice – with medication – for adults and kids,” said Randall Hagar, director of government relations for the California Psychiatric Association.

Slowly but surelY

Across the board, though, the mental health community is still in the early stages of developing treatments for children.

“The studies that demonstrate what to do in any of these cases are coming out, but they’re coming out very slowly,” Schreier said.

A significant obstacle in developing children’s treatment is a lack of testing for child-appropriate doses of many medications. Before the Pediatric Research Equity Act of 2003, the Food and Drug Administration didn’t have authority to require proof of drugs’ safety and effectiveness.

In the years since the legislation, testing still lags because of a fear of experimenting on children.

Mental health medications fall into four categories: antipsychotic, antimanic, antidepressant and antianxiety. In a list of 29 mental health medications, more than half were approved only for ages 10 and older.

The majority of medications approved for children younger than 10 were stimulant medications for Attention Deficit Disorder and Attention Deficit Hyperactive Disorder.

“It will always be slower to get prescriptions for kids,” Hagar said. “What has developed in place of a body of research is ... expert consensus.”

When there’s no FDA-approved child dose for a mental health medication, experts in the field discuss their own experiences with various drugs and doses and develop guidelines, called off-label prescriptions.

However, the process isn’t as accurate as testing, and health care providers are not required to follow the guidelines.

“The big-deal issue arises when you think about age,” Schreier said. “(The ADD medication) Ritalin is suggested not to start until you’re 6 years old, but that’s only because the drug companies only did their studies down to that (age).”

But a lack of testing alone doesn’t mean medication would not be beneficial or shouldn’t be used for a child, he said.

“You have a 3-year-old kid in preschools – and we have many of them – getting thrown out of preschool because they’re so aggressive, hitting a kid with a chair, and you say we need to wait three years,” Schreier said.

“Some people say 3-year-olds are all active,” he continued. “Well, yeah, they’re more active than 10-year-olds, perhaps, or a 15-year-old, but the fact is (if) you can distinguish an ADD kid ... it’s crazy, then, to wait.”

The medication debate

Some people hesitate to use drugs for fear of unnecessarily medicating or over-medicating their children. Unneeded medication can result from misdiagnosis or drugs’ tempting simplicity.

“It’s a lot easier to take a pill than sit through therapy,” said Rusty Selix, the executive director and legislative representative for the Mental Health Association in California.

Conduct disorder can accompany other mental disorders or appear independently. Parents and health care providers sometimes treat a disorder their children don’t have just to get them under control.

However, some parents also resist medication when it could be a valuable treatment.

Sitting in his office, surrounded by toys, a large doll house, an easel and other therapy tools, Schreier told the story of a 3-year-old girl with a panic disorder. The patient’s anxiety was so severe that she stopped eating.

When Schreier prescribed antianxiety medication, the girl calmed down, but her parents, who were opposed to medications, took her off the drugs a year later. Her anxiety returned.

At the age of 10, after her symptoms had persisted for years, her parents called to put her back on the medication. She became a “carefree and much less anxious child,” Schreier said.

“So people would argue maybe you shouldn’t mess around with symptoms that are this small, but this is life transformative for this kid,” he said.

In cases like this one, Schreier favors prescribing medication because being passive may have more detrimental long-term consequences than the drugs’ side effects. Some evidence suggests that people with bipolar disorder lose brain cells at a faster rate than those without the disorder. In this way, medications can be used to prevent long-term problems.

“We have found, with a judicious use of medications, you can prevent major longitudinal childhood problems,” Schreier said.

Although drugs can be a valuable and effective treatment, mental health patients must make sure they receive a whole treatment, whether it includes therapy or alternative treatment, instead of just a part.

A tendency toward primary rather than specialty care in many states means children are receiving the quick fix – medications – rather than tailored treatments.

“They’re getting medication and that’s what they’re getting. That’s it,” Hagar said. “That’s a valid solution in the system, but it’s not the best for the kids.”

Even when children are getting more than drugs, creating a personalized treatment is an art, not a science, said Michael Levin, a developmental psychiatrist and psychopharmacologist, and former professor at the University of California, Los Angeles and Stanford University.

 “(Treatment) is not the balance (between therapy and medication), it is knowing the disorder and knowing the child and knowing what would be the best course of treatment for this child,” Levin said. “There are many passionate psychotherapists and many caring people, but that’s not the same as skill level.

“There are very, very few of them who understand what they’re doing.”

Improvement in this area could spawn from health care reform. When primary clinics include psychological clinics, it allows for a warm handoff, meaning primary care doctors can send their patients down the hall for psychological care. Warm handoffs increase the chance of patients receiving the help they need because it’s immediate and convenient.

But policy is coming slowly, Hagar said.

“Front and center is stigma,” he said. “Mental illness is really scary to a lot of people. People would choose anything else but (mental illness).”

Out-of-the-box options

Arnulfo Medina is the program director for the California Youth Empowerment Network, part of the Mental Health Association of California. Medina works with transition-age youth, 16- to 25-year-olds, who have a mental illness or know a mentally ill peer and teaches them to be self-advocates to the public and legislature.

“We have to decide, what do we want to share and communicate with the public about what (mentally ill) transition-age youth are going through,” Medina said.

Participants put a face to a condition and have the power to directly tell legislators what will and will not be helpful for them. Some of their suggestions include more funding for alternative and community-based treatment programs, Medina said.

One such program is Beats, Rhymes and Life in Oakland, Calif., a city with low-performing public schools and a large population of inner-city youth. BRL is a “therapeutic hip-hop program ... dedicated to creating, implementing and evaluating innovative prevention programs designed to foster mental wellness and promote positive youth development,” according to its Web site.

“In mental health, a lot of what people think of treatment is this,” Medina said, motioning at himself sitting, talking. “There are a lot of new types of outside-the-box thinking about how to help transition-age youth recover.”

Despite alternative medicine’s capacity to help mentally ill youth, the method is still “alternative.” Many health care providers see these treatments as a supplement, not a substitute, to medication or therapy.

Some even shun alternative methods.

“Alternative medicine is not medicine, it’s just an alternative way of doing something,” Levin said.

Too much emphasis on alternative methods can be detrimental to people with serious mental illnesses, he said.

“(There is a) differentiation between healthy people who want to be healthier and people with disorders who need to be treated,” he said.

Psychological stigma

Some mental health patients’ choice to side with alternative treatment might be influenced by a misconception of the dangers of psychiatric medications, especially for children.

In some cases, psychiatric medications have to be highly regulated, though other, more dangerous medications don’t require such close supervision, Hagar said. Cancer medications, for example, can be toxic to children but are not court-supervised.

“People automatically assume psychotropic medications aren’t good for kids,” Hagar said. “That’s an indication that we’re still dealing with some unfortunate concepts.”

Before children even get to the scary medications, they have to overcome something scarier: their diagnosis.

Many treatment professionals are reluctant to give a conclusive diagnosis, Hagar said. Hagar has three close relatives with mental illness: a mother with obsessive-compulsive disorder, a brother with an anxiety disorder and major depression and a son who was diagnosed with schizophrenia at age 16.

Such as in the case of Hagar’s son, societal stigma and weighty connotations can hinder accurate diagnoses, especially when the patient is young.

“You don’t want to use the ‘s’ word (schizophrenia) because it’s a lifetime sentence,” Hagar said.

But when children know the diagnosis, they and their families can seek the proper treatment and begin transitioning their lives to accommodate it.

On the other hand, if a family fails to adapt to a child’s mental illness, the pressure can cause stress disorders in the family and worsen the child’s illness. Education about the disorder and how to adjust for it can be the antidote for that pressure.

“A competent and together family will get help on how to live with this child’s problems and maximize what’s best for both the kid and balancing the other kids in the family and parents,” Schreier said.

Mental illness is a major life adjustment for anyone, especially children. As the research base widens and treatment methods become more refined, mental health patients are in a better position to lead normal, fully functional lives.

Treatment should not just “get (patients) through the day,” Medina said, “but what helps them instill some kind of hope that they should get through the day.”