Thursday, Oct. 21, 2010

Keeping Young Minds Healthy

Bethany hated fifth grade. She didn't much care for sixth, seventh or eighth either, but fifth grade was when the trouble really started.

Fifth grade was the year Bethany started to notice boys — and to wonder if she was noticing them quite enough. The girls she knew were already swooning over Kirk Cameron, Michael J. Fox and other teen heartthrobs of the day. She was swooning too, she guessed, but in the same way her friends were? And what about when it came time to kiss a real boy in her own world? Would she want to?

Tales of boys and girls who doubt their sexual stirrings this way often end with their discovering — and eventually embracing — the fact that they're gay. But Bethany (not her real name) wasn't gay, and she knew it instinctively, even if she doubted it constantly. Her anxiety grew from an increasingly common form of obsessive-compulsive disorder (OCD) in which people who may have no moral or cultural qualms about homosexuality suddenly begin despairing of the possibility of ever knowing with blood-test certainty just what their sexuality is. Uncertainty is the fuel for OCD, and the harder a sufferer tries to answer the unanswerable, the hotter the obsessional bonfire burns.

"The preoccupation grew until it became a 20-year nightmare," Bethany says. "I obsessed constantly — looking at other girls to check my reactions, looking at boys and asking myself if I wanted to kiss them. I couldn't shake it."

It wasn't until Bethany was 30 that she found a website for an OCD institute, read about the multiple expressions of the disorder and found that one of them fit her precisely. Her treatment, cognitive-behavioral therapy that taught her to embrace uncertainty rather than fight it, began shortly afterward. Three years later, she's at last enjoying peace and, like so many other adult sufferers of childhood-onset emotional disorders, also grieving the decades she lost to her condition.

All of us, in many ways, are born insane. Our emotions are unregulated; our moods are explosive; we are consumed by irrational fears, erupt into manic happiness, dissolve into inexplicable tears. It takes years — decades really — for an internal emotional governor to come fully online, and in that time, young minds can be prey to all manner of disorders and pathologies. Parents don't always fully grasp that fact, and even doctors may underestimate it, which is understandable. It's not easy even for professionals to separate the normal storms of childhood behavior from the less normal ones. But the numbers tell a clear story.

About one in five children in the U.S. suffers from some sort of emotional or behavioral condition, according to a new study led by the National Academy of Sciences (NAS). Among adults with confirmed ills, 50% were diagnosed before the age of 14 and 75% before 24. The estimated annual price tag for the treatment and consequences of juvenile psychological disorders is $250 billion, with those whose conditions are not caught early contributing to that total for years.

Worse than the money lost to mental illness is the joy lost to it. Epidemiologists speak of what are known as disability adjusted life years (DALYs) — years compromised or diminished by ill health. Among Americans under 25, mental disorders account for 30% of all DALYs; in the 14-to-25 group, it's 48%. For someone like Bethany, two-thirds of her pretreatment lifespan would be considered disability adjusted.

"Childhood is a canary-in-the-coal-mine time," says Dr. Lynn Wegner, an associate professor of pediatrics at the University of North Carolina. "If early signs of mental-health problems aren't correctly managed, they may stay with kids for life."

The good news is that intervention can work, early detection can work and so can a range of gentle, kid-friendly therapeutic techniques that are increasingly being practiced on the young. And that benefits everyone. According to the NAS, every dollar spent by Medicaid or other public-health programs on prevention of mental illness among kids may be paid back as much as 28 times over the course of a lifetime in disability benefits never claimed, adult psychiatric care never needed and, in some cases, crimes never committed, though even public-policy experts don't always recognize that fact. "The savings are often later, and they may be in the jails or in special-ed programs, so we don't always notice them," says professor of psychology Marc Atkins of the University of Illinois at Chicago. "As a society, we don't do a very good job of looking at these factors."

For families the questions are far more intimate and harder to reduce to balance sheets. Parents worried about the most common childhood-onset disorders — phobias, generalized anxiety, OCD, depression, bipolar disorder, attention-deficit/hyperactivity disorder, autism — rarely know exactly what to look for or what to do if they spot something. Is a child obsessive or just fastidious? Depressed or ruminative? Hyperactive or high-spirited? Overdiagnose and you may attach a stigmatizing label to a healthy child; underdiagnose and you may leave a condition to worsen on its own.

"Since you're talking about kids, whose brains change a lot over time, illnesses are simply harder to diagnose," says Dr. David Axelson, an associate professor of psychiatry and the director of the Child and Adolescent Bipolar Services program at the University of Pittsburgh. What parents — and doctors — need are clear guidelines of what the trouble signs are and up-to-date information about how to avoid problems before they start and fix them if they do.

Sweating the Small Stuff
The first question parents need to ask themselves when they notice worrisome behavior in their kids is "So?" The temperament of all humans is complex and messy — especially when they are immature — and each will develop quirks that may be harbingers of trouble or may just as easily not be. It depends on whether those quirks interfere with functioning.

"It's a fine line, since we don't have any lab tests," says Dr. Ben Vitiello, director of the child and adolescent treatment and prevention branch at the National Institute of Mental Health (NIMH). "If a child bites his nails but is otherwise functioning socially, it's not likely to be a sign of an anxiety disorder. If biting his nails is all he ever does in a social situation, that's something else. The same is true for a child who is prone to be aggressive. Can he control it when he has to, or is he unable to stay in school?"

Context also makes a difference. American parents are scared out of their wits about autism these days — partly with cause, partly because of media hysteria and myths about the perils of vaccines. But being aware of the signs of the condition is always wise. By 18 months, babies should interact with parents and caregivers, exchanging smiles and pointing at objects. An absence of such reciprocity may be troubling, but it's not necessarily a problem if it doesn't occur in all settings. Kids who engage at home and disconnect in day care may be anxious or shy — and may eventually be diagnosed with an anxiety condition — but autism is less likely. The same is true for language delay, hyperactivity and aggression, all of which are red flags for autism but can be situational.

In some cases, including those involving anxiety or mood disorders, it may not be the kids' welfare but the parents' that is in play. There's a vanity component to parenting: Who doesn't want the prettiest, cleverest, most personable kid in the room? It's hard to admit that maybe your baby is simply awkward. "It's true that you look for distress or impairment," says Torrey Creed, a clinical child psychologist at the University of Pennsylvania. "But who's distressed, the parent or the child? Sometimes parents actually want something diagnosed but it doesn't need to be."

Age is a critical variable as well. Psychologists are reluctant to diagnose OCD in kids younger than 8, for example, simply because so much of what young children do looks obsessional or compulsive. Inviolable nighttime routines (a certain story read a certain number of times in a certain chair) or seemingly pointless exercises (lining up toy cars in a precise sequence, messing them up and starting all over) are usually just normal rituals that help create a sense of order in a too big, too random world. The need for such rituals fades as kids begin to feel that they have some control over their environment. Only if compulsive behavior continues after that should parental eyebrows be raised.

Anxiety conditions may have a similar shelf life. At about 8 months, babies start to develop what's known as object permanence — an understanding that just because something is out of sight doesn't mean it no longer exists. When the object in question is a caregiver, babies become much less tolerant of being left alone, since they understand better that if they howl loudly enough, whoever has left the room will return. Separation anxiety peaks again at about 2 years old and once more at around 5. Here too, it's only after children are outside of that normal range that parents should worry.

"This is when you get what we call Velcro kids," says Creed, "the ones who can't let go because they fear for their own or a parent's safety." Another sign of a broader condition known as generalized anxiety disorder is a child who never seems to run out of what Creed describes as what-if questions: What if there's a fire? What if there's a hurricane? What if terrorists or other bad people attack? Shielding kids from TV may prevent some fears from getting seeded in the first place, but it can't prevent them all because what-if questions are limited only by the child's imagination — a resource that is effectively unlimited.

Things get trickier when the condition in question is bipolar disorder, usually characterized by a cycling between hyperkinetic highs and deep, depressive lows. As recently as seven or eight years ago, the accepted wisdom was that parents did not have to worry about kids being bipolar because it doesn't strike until later in life. That position changed as doctors began acknowledging that some kids have symptoms that can't be explained any other way. "In psychiatry, if you don't ask the questions, you're not going to get the diagnosis," says Axelson. "A lot of things that were labeled as conduct problems may be bipolar."

But once doctors and parents began looking for bipolar disorder, they started finding it everywhere — even when it wasn't there. In 2002 researchers reported that within a single generation, the average age of onset of the disorder had fallen from the early 30s to the late teens. Few conditions change their nature so suddenly, and many of those bipolar cases were surely misdiagnoses. Today, says Axelson, the thinking is that about 1% of kids in the 15-to-17 age group suffer from true bipolar disorder, about the same prevalence as in adults.

Parents concerned that their child may be exhibiting bipolar symptoms can probably stop worrying if all they notice is that the child is sometimes very gloomy and sometimes exceedingly active. For one thing, the same can be said of all human beings. What's more, the symptoms of ADHD resemble the symptoms of bipolar disorder's manic stage. That's not to say that ADHD isn't its own kind of problem, but it's a less severe one than bipolar. The key to distinguishing between the two, Axelson explains, may be "episodicity," or a clear cycling of moods, with hyperactive symptoms largely disappearing during low periods. Ultimately, as with all psychological conditions, it takes a professional — sometimes two — to provide a good diagnosis. In the case of bipolar disorder, with so many moving parts and symptoms, this is particularly true.

The Best Medicine
Treatment for childhood emotional ills are as varied as the conditions themselves, and many can be administered with a very light touch. Anxiety conditions, including phobias and OCD, respond well to a technique known as exposure and response prevention. Kids are exposed to graduated levels of the thing they fear while a therapist or parent remains nearby to help them habituate to the anxiety and resist the impulse to flee.

In the case of a child with a phobia of dogs, for instance, treatment might involve first looking at a drawing of a dog, then a photograph, then a video. Finally, the child might be encouraged to look at a dog from inside a closed car and to eventually approach one. "The pace of the exposure," says Wegner, "depends on the temperament of the child."

Bethany overcame her obsessive-compulsive anxiety about her sexuality by first looking at pictures of sexy actresses and trying to notice feelings of actual arousal. If she thought she felt something (and after years of self-scrutiny, that was all but certain), she tried to accept — and shrug at — the questions it raised. Next she began going to movies about lesbian couples, like The Kids Are All Right, and reading magazine stories about women who discovered their homosexuality later in life — accepting the possibility that their story could be hers.

The same kinds of exercises would not have been appropriate if Bethany had begun treatment in childhood. But other steps, such as talking openly about homosexuality, getting to know gay couples or even, say, looking at pictures of the celebrity wedding of Ellen DeGeneres and Portia de Rossi, could have the same effect. With all forms of OCD, this kind of therapy has a habituating and disarming effect. Spend a lifetime running from trigger situations, and they'll always have power over you. Seek them out and learn to tolerate them and you're back in charge.

Clinical depression can be a bit more of a challenge. It usually does not emerge until the early teen years and may involve not just gloom but also anxiety. For both kids and adults, cognitive therapy can be an effective treatment. Rather than spending years peeling back the onion skin of the psyche, cognitive therapists help patients reframe problems so they're seen not as disasters worthy of a bout of depression but challenges that can be overcome. For kids, therapy need not be structured as weekly meetings in a doctor's office — at least not at first. Intervention by parents and teachers who help children resist catastrophizing and get them to surf through setbacks may be a good start.

When formal therapy for any condition does seem called for, more and more professionals agree that it's best if the family gets involved. The Journal of the American Academy for Child and Adolescent Psychology now makes a point of listing practice parameters not just for diagnosing and treating kids but also for evaluating the entire household. "Those two things are absolutely critical for young children," says Wegner, "because more so than adults, children exist principally in the context in which they're being raised."

This means that not only is a child's defiant, depressive or anxious behavior explored but so are the circumstances that trigger episodes. Parents with volatile or poorly regulated moods cannot fairly expect better from their kids; the same may be true for parents who despair when confronted with obstacles.

A new study published in the Archives of General Psychiatry showed that family therapy can even help when teens suffer from eating disorders, with parents helping encourage healthy dietary habits and changing behaviors of their own that lead to dysfunction in the home. Among anorexics who successfully completed family treatment, 49% maintained weight gains after 12 months, compared with 23% of kids who underwent solo therapy. "When parents are part of therapy, they've typically served in more of a coaching role for the kids," says Creed. "But it seems more effective if the parents are also learning and practicing cognitive-behavioral skills themselves."

A wild card whenever children are being treated is the question of medication. A child's brain is a work in progress, and introducing outside chemistry could, many fear, alter its development in untold ways. In some cases, the drug question is easy to answer and is governed by the severity of the sickness. Schizophrenia is well-nigh impossible to treat without drugs, though the disease is not common in childhood. Bipolar disorder, similarly, typically calls for meds as part of the mix. The problem is, bipolar medications, which include mood stabilizers, antipsychotics and anticonvulsants, can be brutal on the body, causing weight gain and motor-control disorders and contributing to high triglycerides and diabetes.

"It's been our clinical experience that kids are more sensitive to these things," says Axelson. "On the positive end, the drugs often work relatively well and can be lifesavers." In some cases, Axelson says, bipolar kids and adults can come off drugs, at least for a while, provided the weaning takes place under a doctor's supervision. "That doesn't mean they don't have bipolar anymore," he cautions. "It's possible the disease just goes into remission for a time."

For other anxiety, mood or behavioral disorders, doctors are nearly unanimous in their opinion that it's best to try nonchemical interventions first and see if drugs are needed to fill the gaps. "First you provide support," says Vitiello, whose branch of the NIMH specializes in evaluating the efficacy and safety of treatments for kids. "If that's not sufficient, you consider drugs."

But consider carefully. Antidepressants like Paxil have come under fire as studies found that they can lead to an increase in suicidal thoughts — particularly among patients 25 or under. In 2004 the FDA ordered that all such meds carry black-box warnings disclosing this risk. Experts, including Vitiello, however, stress that antidepressants also have a protective effect and may actually prevent some people from committing suicide. The key is balancing the risks of medicating with those of not medicating — a complex calculus that patients, parents and doctors need to conduct with care and exactness.

Into the Breach
With kids' lives and welfare on the line, most parents would welcome all the help they can get, and increasingly it's available from independent, academic and government groups. For example, Roger Weissberg, a professor of psychology and education of the University of Illinois at Chicago, leads a program called the Collaborative for Academic, Social and Emotional Learning (CASEL), which advocates for school programs that teach relationship skills, self-management and other basic abilities that undergird mental health. CASEL also rates 80 nationwide, often commercial programs that offer schools seminars and course materials.

Psychologist Mark Greenberg at Penn State University has similarly launched the PATHS (Promoting Alternative Thinking Strategies) Curriculum. Yet another program, called New Beginnings, headed by psychologist Irwin Sandler of Arizona State University, offers specialized programs of six to 12 sessions for families in which parents are getting divorced or a parent has died. Familial crises such as these can usher in a powder-keg period for kids' emotional health.

"We've followed up families six years after they went through the program and, in cases of divorce, found a 36% reduction in the likelihood of diagnosed mental illness among kids," says Sandler. "We've also seen lower rates of alcohol and drug use and high-risk sex."

Ultimately, no amount of pre-emptive attention can ensure that a child will never come down with a mental illness, just as no amount of bundling up or eating right will ever provide absolute protection against colds or other physical ailments. What prevention, treatment and therapy can do is reduce the risk and, if you are unlucky and get sick anyway, improve the odds of getting well. Kids have a lifetime of experiences ahead of them. It's a healthy mind — the repository of the puzzles and charms and giddy riddles that make children such a joy — that can help them make the most of that time.