Before the elementary student from Toledo, Ohio, started taking Prozac, teachers said he was unmanageable in class. He would kick and scream, tip over in his chair, and crawl to his desk when the bell rang.
The boy, who was diagnosed at age 5 with both depression and attention-deficit hyperactivity disorder, or adhd, took the anti-depressant for three years. Now, he is calmer in class and is excelling academically, said Kathy Riley, a behavior specialist with the Toledo public schools. “Once he began medication, his life turned around.”
Many teachers see anti-depressant medications, such as Prozac--which have been used successfully to treat depression in adults for a decade--as a long-needed remedy for children and adolescents with chronic behavior problems in the classroom. Yet some school nurses and psychologists worry that these are too often being used as quick fixes to treat young people with complicated emotional problems.
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And adding to some school administrators’ unease is the potential liability for dispensing medications when there is scant research on their long-term effects on children.
While anti-depressants have yet to be approved formally by the U.S. Food and Drug Administration for use in children, doctors have the authority to dispense them to minors because the pills have been cleared for use in adults.
And doctors are doing so in rapidly growing numbers. Last year, more than 600,000 children and adolescents were prescribed Prozac, Paxil, or Zoloft, according to IMS America, a New York City-based research group that monitors the pharmaceutical industry. Prescriptions for Prozac alone increased 47 percent in one year for 13- to 18-year-olds, from 1995 to 1996, the group says.
Anti-depressants as a group are fast becoming the second-most-prescribed drug for mood and behavioral disorders in children behind Ritalin, which has been used for decades to treat ADHD. Drug companies are seeking FDA approval of anti-depressants, such as Prozac, for children, which would allow them to market their products specfically for youths.
A ‘Lifesaver’
Some physicians who work with depressed children say that the newest anti-depressants, which have been shown to have fewer short-term side effects than some other drugs, can often be a critical part of a child’s treatment.
Dr. David Steinberg, an assistant professor of clinical psychiatry at New York University and a child psychiatrist, said a 14-year-old patient of his with obsessive-compulsive disorder “would wash his hands 20 times a day and brush his teeth until they bled.” Now on the antidepressant Zoloft for three years, the teenager is able to function well enough to return to school.
“When used judiciously with therapy and school interventions, these medications can be lifesaving,” Dr. Steinberg said.
The National Institute of Mental Health estimates that about 4 million children in the United States--about 5 percent of the total population--suffer from some form of depression.
A stark indicator of the possible consequences of that condition is that the suicide rate for children younger than 12 has doubled in the past decade, while the rate among teenagers has risen to equal that of adults. A part of this dramatic climb may be due to better reporting of the problem in the youngest patients, researchers note.
Penny Frese, a mother of four who lives in Hudson, Ohio, fears what might have happened to her children without anti-depressant drugs. All of her children, now ranging in age from 15 to 26, have been taking either Zoloft or Prozac since their teenage years. They suffer from such severe, debilitating depression, Ms. Frese said, that some of them might not have survived without medical intervention.
“Therapy has not proved particularly helpful with our children because their disorder is biological,” Ms. Frese said. Her husband is a schizophrenic who has five siblings on anti-depressant drugs.
“It’s like trying to talk someone out of diabetes. It’s not going to make their illness go away to talk about it,” she said.
Adolescent Angst?
In addition to elevating students’ moods, anti-depressant treatments for youths can also help students excel academically, many teachers believe.
After starting on medications, “we will see kids who are lethargic or disinterested in school or social activities begin to achieve more in school,” said Ms. Riley, the Toledo teacher, who works with other teachers in the 40,000-student district to manage students’ behavior problems.
But some school psychologists are concerned that doctors may be overprescribing medications to teenagers who are simply suffering from a bout of adolescent angst.
“Are we treating normal adolescents because they are occasionally obnoxious? That’s a question nobody’s answered,” said Dwight P. Sweeney, a professor of educational psychology at California State University-San Bernadino.
Parents can sometimes be so eager for a solution to their child’s emotional problems or learning disabilities that they rush to a pharmaceutical answer, Mr. Sweeney said. “Parents need to ask questions. Have they tried appropriate behavioral interventions, ruled out other possible sources [of the emotional distress], or are people just trying a shortcut?”
Medical regimens, whether a last resort or a quick fix, inevitably complicate the work of school staff members, many administrators say. When young people began taking Ritalin for treatment of ADHD, for example, school nurses or other employees who dispensed the drug had to educate themselves about the possible side effects.
Dorris Luckenbill, the president of the National Association of School Nurses in Scarborough, Maine, said she is pleased that more children’s mental illnesses are being diagnosed and treated. But she said that parents need to keep nurses informed if their children are being medicated so that school health workers can effectively monitor side effects.
“Is this a huge burden? No,” Ms. Luckenbill said. “But we need to know if the child is taking it.”
Nearly 3 percent of all schoolchildren in the nation are on a stimulant such as Ritalin, an anti-depressant like Prozac, a mood stabilizer like Lithium, or an anti-convulsant medication like Tegretol. The newest anti-depressant drugs, Prozac, Zoloft, and Paxil--also called selective serotonin reuptake inhibitors or SSRI’s--can cause nausea, weight loss, sedation, and, less commonly, seizures.
Training Needed
Margie Bradford, a member of the board of directors of the National School Boards Association, said nurses and teachers who are dispensing these medications to students need to be prepared better to monitor the side effects of the drugs both to provide the best care for children and to protect districts from lawsuits.
“Every time you are dispensing medication, a school district is responsible,” Ms. Bradford said. Even administering nonprescription pain relievers, such as aspirin, to a student requires a certain amount of training, she said.
“When you don’t know what will happen in the long run [with anti-depressants], there is a concern,” Ms. Bradford added.
To facilitate the FDA’s approval of anti-depressants for children, the drugs’ manufacturers are conducting their own effectiveness studies. So far, only one major independent study has shown that anti-depressants have ameliorated the symptoms of severe depression in children.
Researchers at the University of Texas Southwestern Medical Center in Dallas found that Prozac was as effective in fighting depression in children as it is in combating adult depression. In a study of 96 children ages 7 to 17 conducted over a two-month period, researchers noted that half of the children got better taking Prozac, compared with one-third who showed improvement by taking a placebo. The results, released this month, matched those found in adult studies of the drug.
Because of the lack of research on the drugs’ long-term effects on children, however, parents and school staff need to understand that they are entering uncharted medical territory, some school health experts warn.
“People are not being told that this is experimental,” Mr. Sweeny said. “It needs to be monitored.”
