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What nobody denies is that more research is needed to resolve all these questions--and that it won't be easy to get it started. The first problem is one of time. It was only in the early 1990s that the antidepressant Prozac exploded into pharmacies. It's hard to do a lifetime of longitudinal studies on a drug that's been widely used for just over a decade. And each time the industry invents a new medication, the clock rewinds to zero for that particular pill.
Even if it were possible to conduct extended studies, getting volunteers for the work is difficult. The attrition rate is high in any years-long research, especially so when the subjects are kids, who bore easily and, at any rate, eventually go away to college. On average, 40% of children will drop out of a long-term study before the work is done. And that assumes their parents will even sign them up in the first place. Some brain scans involve at least a little bit of radiation--something most parents are reluctant to expose their children to, particularly if those kids have no emotional disorders and are simply being used as a baseline to establish the look of a healthy brain. Getting good scans from kids who have diagnosable conditions isn't easy, as any radiologist who has ever tried to conduct a lengthy MRI on a child with ADHD can attest. "Holding still is not exactly what they do well," says Elliott.
Ethical questions hamstring research too. Any gold-standard study requires that some of the kids who are suffering from a disorder receive no drugs so that they can be compared with the kids who do. But if you believe the medications are helpful, how can you withhold them from a group of symptomatic children who need them?
Despite such obstacles, research is moving ahead, if haltingly. The National Institute of Mental Health is conducting a study called the Preschool ADHD Treatment Study, in which researchers will track ADHD kids between 3 and 8 years old to determine the benefits and side effects of stimulant medications. Castellanos and N.Y.U. colleague Rachel Klein are taking things further, calling back subjects who were enrolled in an ADHD-treatment study that began in 1970 to scan their now late-30s and early-40s brains for the long-term effects of drugs. Castellanos is also planning a study of young rats treated with varying amounts of psychotropic drugs, conducting dosing and anatomical studies that cannot be performed on humans.
THE RISK OF HASTY PRESCRIPTIONS
Just as important as getting the research rolling is fixing the health-care system kids rely on to get well. Like adults taking mind meds, children often get their drugs not from a specialist in psychiatry and psychopharmacology but from any M.D. with the power of the prescription pad. Usually this means the pediatrician or family doctor, who isn't likely to have the time or training necessary for the extensive evaluations needed before drugs can be properly prescribed--much less the required follow-up visits. "There's no way you can screen for side effects in a 10-year-old in five minutes," says Miami neurologist Sara Dorison. "You have to chat about their summer, their friends."