Untreated depression. It's the number one cause of suicide among teens and adults. Risk factors of teen suicide, and what to do if a child or adolescent may be suicidal.

The statistics are startling. As many as 8 percent of adolescents attempt suicide today. And completed suicides have increased by 300 percent over the last 30 years. (Girls make more attempts at suicide, but boys complete suicide four to five times as often as girls.) It is also known that 60-80 percent of suicide victims have a depressive disorder. A 1998 study showed, however, that only 7 percent of suicide victims are receiving mental health care at the time of their death.

Characteristics of Depression

Up until about 30 years ago, many in the field of psychology believed that children were incapable of experiencing depression. Others believed children could be depressed, but would most likely express their dysphoria indirectly through behavior problems, thereby "masking" their depression.

Three decades of research have dispelled these myths. Today, we know that children experience and manifest depression in ways similar to adults, albeit with some symptoms unique to their developmental age.

Children can experience depression at any age, even shortly after birth. In very young children, depression can manifest in a number of ways including failure to thrive, disrupted attachments to others, developmental delays, social withdrawal, separation anxiety, sleeping and eating problems, and dangerous behaviors. For the purposes of this article, however, we will focus on school-aged children and adolescents.

In general, depression affects a person's physical, cognitive, emotional/affective, and motivational well-being, no matter their age. For example, a child with depression between the ages of 6 and 12 may exhibit fatigue, difficulty with schoolwork, apathy and/or a lack of motivation. An adolescent or teen may be oversleeping, socially isolated, acting out in self-destructive ways and/or have a sense of hopelessness.

Prevalence and Risk Factors

While only 2 percent of pre-teen school-age children and 3-5 percent of teenagers have clinical depression, it is the most common diagnosis of children in a clinical setting (40-50 percent of diagnoses). The lifetime risk of depression in females is 10-25 percent and in males, 5-12 percent.

Children and teens who are considered at high risk for depression disorders include:

• children referred to a mental health provider for school problems
• children with medical problems
• gay and lesbian adolescents
• rural vs. urban adolescents
• incarcerated adolescents
• pregnant adolescents
• children with a family history of depression

Diagnostic Categories

Transient depression or sadness is not uncommon in children. For a diagnosis of clinical depression, however, it must be causing an impairment in the child's ability to function. Two primary types of depression in children are dysthymic disorder and major depressive disorder.

Dysthymic disorder is the less severe of the two, but lasts longer. The child exhibits chronic depression or irritability for more than a year, with a median duration of three years. Onset typically occurs at about 7 years of age with the child exhibiting at least two of six symptoms. A majority of these children go on to develop a major depressive disorder within five years, resulting in a condition known as "double depression." However, 89 percent of pre-teens with untreated dysthymic disorder will experience remission within six years.

Major depressive disorders have a shorter duration (greater than two weeks, with a median duration of 32 weeks) but are more severe than dysthymic disorders. A child with major depressive disorder exhibits at least five of nine symptoms, including a persistent depressed or irritable mood and/or a loss of pleasure. Typical onset for major depressive disorder is 10-11 years of age, and there is a 90 percent rate of remission (for untreated disorders) within one and a half years.

The prevalence of depression increases with age, affecting as many as 5 percent of all teenagers, and as many as one-in-four women and one-in-five men in adulthood. Fifty percent of those with a major depressive disorder will have a second episode in their lifetime.

In many cases, depressive disorders overlap with other diagnoses. These may include: anxiety disorders (in one-third to two-thirds of children with depression); attention deficit hyperactivity disorder (in 20-30 percent); disruptive behavior disorders (in one-third to one-half of patients); learning disorders; eating disorders in females; and substance abuse in adolescents.

The Risk of Suicide

As mentioned above, the rate of suicide has increased three-fold since the early 1970s, and is the major consequence of untreated depression. It is a trend that demands greater awareness, in order to prevent these deaths and better treat those at risk.

Completed suicides are rare before the age of 10, but the risk increases during adolescence. Risk factors for child and teen suicide include psychiatric disorders such as depression (often untreated), substance abuse, conduct disorders, and impulse control problems. There are many behavioral and emotional clues that can also be signs that a young person is at risk for suicide. A lack of coping skills and/or poor problem-solving skills are also risk factors that should not be overlooked. Drug and alcohol abuse is prevalent among those who commit suicide. Approximately one-third of young people who commit suicide are intoxicated at the time of their death. Other risks include access to firearms and lack of adult supervision.

Stressful life events, such as family conflict, major life changes, a history of abuse and or pregnancy are also factors that can trigger thoughts of suicide and even action. If a young person has attempted suicide in the past, there's a good chance they will try again. More than 40 percent will go on to make a second attempt. Ten to 14 percent will go on to complete a suicide.

Unfortunately, suicide can be difficult to predict. For someone at risk for suicide, a precipitant may be a shameful or humiliating experience such as the break-up of a relationship (19 percent), conflicts over sexual orientation, or failure in school. Another "trigger" for suicide may be ongoing stressors in life, with a sense that things will never get better.

Assessment, Treatment and Intervention

Assessment for childhood depression begins with initial screening, typically by a child psychologist, using a measure such as the Children's Depression Inventory (Kovacs, 1982). If the assessment is positive, classification includes further assessment for symptoms listed previously, the onset, stability and duration of symptoms, as well as family history. It is also important to assess the child for anxiety disorders, ADHD, conduct disorders, etc; school performance; social relationships; and substance abuse (in adolescents).

Alternative causes for the child's depression should also be considered and ruled out, including causes associated with the child's developmental and medical history.

Targeting those children and teens who are at high risk for depression, or who are facing high-risk transitions (such as moving from grade school to junior high) is key to prevention. Protective factors include a supportive family environment and an extended support system that encourages positive coping. The Optimistic Child, by Martin Seligman, 1995, is a good book to recommend to parents on preventing depression and building a child's coping skills.

Interventions for diagnosed clinical depression can be highly successful and include both medications and individual and family therapy.

If there are any concerns that a child or adolescent may be suicidal:

• Do not hesitate to refer them to a mental health professional for assessment. If immediate assessment is needed, take the child to the emergency room.
• Always take threats of suicide seriously.
• If the child has stated an intent to commit suicide, and has a plan and a means to carry it out, they are at very high risk and need to be kept safe and supervised in a hospital.

The major "treatment" for suicidal behavior is to find and treat the underlying cause of the behavior, whether it's depression, substance abuse, or something else.

Conclusion

While 2-5 percent of children and adolescents experience clinical depression (nearly as many kids as have ADHD), it is often "missed" by those around them, because it can be less obvious than other more disruptive behavior disorders. Left untreated, it can have a significant negative impact on development, well-being and future happiness, with untreated depression being the major cause of suicide. However, with treatment, including medications and/or psychotherapy, the majority of patients show improvement, with a shorter duration of their depression and a reduction in the negative impact of their symptoms.

Source: A Pediatric Perspective, July/August 2000 Volume 9 Number 4

For the most comprehensive information about Depression, visit our Depression Community Center here, at HealthyPlace.com.

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It's taken me almost 40 years to realize that activities take time. I know, I know, to you that's an obvious truth. But for me, time was expandable. I could fit anything in. Nothing took that long to do. I was going to do it all and make the time for it. After all, I am powerful beyond measure. I WILL make it all fit in. Throw another assignment on the pile.

"Did you know doing stuff takes time?"

Yesterday I took my cat to the vet. That sounds so simple a task ... and quick. The words are so short on my To Do List. "Cat to Vet." How short and sweet. One would think it would only take a moment to accomplish. Imagine my amazement when upon reflection I realized it had, in reality, taken three hours.

I hadn't taken into consideration the time to locate the cat carrier.

I hadn't considered that the cat would not want to go in the carrier.

I thought the drive should only take 10 minutes or so.

I didn't realize I would have to fill out a "new patient" form.

I assumed the vet would see me at the appointment time.

I had hoped she's examine the cat and make her recommendation.

I had no idea she was going to take blood from her jugular.

I couldn't have predicted the cat would get so stressed out.

I couldn't have predicted they'd hold her in the back until they were sure she wasn't having a heart attack.

I didn't calculate the additional time for making multiple trips to the car with it's new food.

I hadn't anticipated spending time with the cat once we got home to make sure it was okay.

I didn't know the sister cat would freak out at the smell of the vet when we returned home.

continue story below

"Cat to Vet." A moment of time. Three hours.

I still do want to do everything. There are so many things I enjoy doing, like reading, writing, re-designing a site, discussing a good book.

I could look at my pile and say I'm procrastinating on all the things I haven't finished or am not doing. I could and have at times done just that. But with this new realization that doing stuff takes time, I have a new perspective.

So if you don't hear from me, know that I'm doing a whole bunch of things that only take a moment to do. And the rest of the time, I'm procrastinating.

next: Meditation Experience~ back to: My Articles: Table of Contents

Chronically ill children tend to be more submissive and less socially outgoing than healthy children, a new study shows. Further, kids who live with pain and physical restrictions may be more likely to have problems relating to their peers.

Study author Susan Meijer, DrS, a behavioral researcher at Utrecht University Medical Center in the Netherlands, and colleagues explored the effect of disease on social development in children 8 to 12 years of age. More than 100 chronically ill children and their parents participated in the study, which was published in the Journal of Child Psychology and Psychiatry.

The children's diagnoses included cystic fibrosis (a hereditary disease characterized by lung disease and problems with the pancreas), diabetes, arthritis, the skin inflammation eczema, and asthma. The children and their parents were asked about the children's social activity, behavior, self-esteem, physical restrictions, and pain.

Compared with healthy Dutch children, the participants had fewer positive peer interactions and exhibited less aggressive behavior. Compared with other chronically ill participants, children with cystic fibrosis and eczema had more social anxiety. And kids with physical restrictions and pain had significantly less social involvement than others.

Researchers say the reasons for these findings are not yet clear. "Sick kids may unconsciously avoid aggressive exchanges that they're unable to deal with," Meijer says. "It's also possible that sick kids don't learn some social skills because they receive less feedback about inappropriate behavior than healthy kids."

Meijer says that intervention programs can boost social development in chronically ill children. Child psychiatrists say school involvement and parental strategies may be even more effective.

"When kids are out of school for long periods, they miss both cognitive and social learning," says Nina Bass, MD, a behavioral medicine specialist and assistant clinical professor of psychiatry at Emory University School of Medicine in Atlanta. "And no matter how hard they try, parents can't give kids the same social experience they get at school."

Bass maintains that chronically ill children need both individual and group social activities. "An example of an individual activity is corresponding with a pen pal; an example of a group activity is participating in a book club," Bass says. "And if the child can't keep pace, parents should identify some better alternatives."

Chronically ill children also are at increased risk for depression. "Kids with chronic illnesses are 30% more likely to become depressed," she says. "And even if it's just a side effect of medication, parents can help with symptom management." But an awareness of factors that may lead to depression helps tremendously, she says.

In fact, parents' intuition may be more useful than record keeping. "Diaries are helpful, but they can turn a child into a guinea pig," Bass says. "It's often more helpful just to compare adverse symptoms to the child's normal rhythms and routines."

Bass says questions remain about the study's findings, and the researchers agree.

"Because parents of the participants were highly educated, the results could be biased," Meijer says. "So in the future, longer studies with more participants may provide more insight."

Vital Information:

• Chronic illness can affect a child's social development; children who have physical restrictions and pain are particularly vulnerable.

• Psychiatrists recommend both individual and group social activities for chronically ill children.

• Children with chronic illnesses are 30% more likely to develop depression, but parents can help manage symptoms by being aware of a child's depression and of the factors that may lead to it.

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The Washington Post
Tom Graham
06-06-2000

The extensive memory loss described by Ann Lewis in the accompanying article reinforces some of the widespread negative impressions about electroconvulsive therapy. Even supporters of ECT acknowledge that memory loss is a common side effect, though they say it is typically far less severe than that reported by Lewis.

Juan Saavedra, the Bethesda psychiatrist who treated Lewis before she underwent ECT, says he generally considers this therapy only for a very old person who would have trouble tolerating medication or for a person who is "in danger of suicide [where] you really cannot wait for the antidepressants to be effective." In discussing this as an option, he says, "my approach will be to say that the most important thing is preservation of life."

"There is always a lot of fears, and it's understandable" in light of publicized cases of "people who have been mistreated," says Saavedra, who adds that in his experience the majority of patients who are urged to receive ECT agree to do so.

"There is no way to predict" the degree of memory loss from ECT, Saavedra says. "Every treatment has its possibilities of something going wrong," but ECT is "a very safe procedure these days." Not nearly safe enough, in the view of those who believe ECT remains more dangerous than it's worth.

"The shock induces an electrical storm that obliterates the normal electrical patterns in the brain, driving the recording needle on the EEG up and down in violent, jagged swings. This period of extreme bursts of electrical energy often is followed by a briefer period of absolutely no electrical activity. . . . The brain waves become temporarily flat, exactly as in brain death, and it may be that cell death takes place at this time."

That's the view of another Bethesda psychiatrist, Peter Breggin, in his book "Toxic Psychiatry." Breggin's Web site, breggin.com, is only one of many (ect.org, antipsychiatry.org, banshock.org, etc.) that warn about the nasty repercussions of ECT.

Last year's Surgeon General's Report on Mental Health gave ECT's opponents little solace, though it did acknowledge some of the scientific mysteries and past misuses of the therapy since it was developed in the 1930s:

"ECT consists of a series of brief generalized seizures induced by passing an electric current through the brain by means of two electrodes placed on the scalp. . . . The exact mechanisms by which ECT exerts its therapeutic effect are not yet known. . . . Accumulated clinical experience--later confirmed in controlled clinical trials . . .--determined ECT to be highly effective against severe depression, some acute psychotic states and mania. No controlled study has shown any other treatment to have superior efficacy to ECT in the treatment of depression."

On the issue of memory loss, the report suggests that most patients are far less affected than Lewis was: "The confusion and disorientation seen upon awakening after ECT typically clear within an hour. More persistent memory problems are variable. Most typical . . . has been a pattern of loss of memories for the time of the ECT series and extending back an average of six months, combined with impairment with learning new information, which continues for perhaps two months following ECT."

The report also reiterated the medical establishment's conclusion that ECT is a worthwhile tool for treating certain mental disorders:

"Although the average 60 to 70 percent response rate seen with ECT is comparable to that obtained with pharmacotherapy, there is evidence that the antidepressant effect of ECT occurs faster than that seen with medication, encouraging the use of ECT where depression is accompanied by potentially uncontrollable suicidal ideas and actions. However, ECT does not exert a long-term protection against suicide. Indeed, it is now recognized that a single course of ECT should be regarded as a short-term treatment for an acute episode of illness."

Or as Saavedra said last week, "ECT doesn't cure anything."

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Electroconvulsive therapy helped to treat her intractable, dangerous depression. But the author was surprised to find out how much of her memory was wiped out.

The Washington Post
Ann Lewis
06-06-2000

I've been asked over and over again whether undergoing electroconvulsive therapy -- also known as ECT or shock therapy -- was a good decision. And whether I would have ECT again under the same circumstances.

The only honest answer I can give is that I have no idea. To say whether ECT was the right treatment for me, I would have to compare my life before ECT to my life now. And I simply cannot remember life before ECT. In particular, I cannot remember much about the two years leading up to my ECT treatments. That period, along with much of the preceding years, is memory that I lost in exchange for the hoped-for benefits of ECT.

That loss was huge and painful and potentially crippling. And yet, when my therapist describes how I was just before ECT, I believe that ECT was probably the best option at the time. He says that I was spiraling down into a depression that wouldn't lift. He says that I was contemplating suicide. And I believe him. While I don't remember that particular depression, I remember others -- many paralyzing episodes of depression in my 37 years of living with mental illness.

My therapist also says that I was failing to respond to medications. And that I also believe. While I cannot remember specific experiences with the plethora of drugs I've tried over the years, I do know that I tried so many because I was constantly searching for one that would finally work.

I had 18 ECT treatments over a six-week period beginning in May 1999. Based on some vague recollections and on what I've been told, here's what happened: Three times a week I rose at dawn to be at the hospital first thing; I sat in a crowded waiting room until my name was called. Then I put on a hospital gown, lay down on a gurney and was wheeled into an operating room designated for ECT patients. Full anesthesia was administered intravenously, and the next thing I knew I'd be waking up in the recovery room, ready to be taken home, where I'd sleep for the rest of the day.

My boyfriend and my mother shared the burden of caring for me. On the days between treatments, she says, we sometimes went to museums, malls and restaurants. She says that I was a zombie, unable to make even the smallest decisions. My boyfriend says I asked the same questions over and over again, unaware that I was repeating myself.

Right after my last treatment--my mother made a note of this in her diary for July 8--I woke up. I can liken this only to what I expect a person coming out of a coma experiences. I felt like a newborn, seeing the world for the first time. But unlike the common notion of first sight as a thing of splendor and awe, for me it was complete frustration.

While I couldn't recall how I had felt before ECT, I couldn't imagine it was any worse than what I was experiencing now.

Every little thing told me that I had no memory. I couldn't remember who had given me the beautiful picture frames or the unique knickknacks that decorated my home. My clothes were unfamiliar, as were the jewelry and trinkets I had owned for years. I didn't know how long I had had my cat or who my neighbors were. I couldn't remember which foods I liked or what movies I had seen. I didn't remember people who greeted me on the street or others who called me on the telephone.

A former news junkie, I was especially frustrated to realize that I didn't even know who the president was or why someone named Monica Lewinsky was famous. I was floored when I found out about the impeachment hearings.

And I couldn't remember my boyfriend, although he practically lived with me. There was evidence all over the apartment that we loved each other, but I didn't know how or when we had met, what we liked to do together or even where we liked to sit while watching television. I didn't even remember how he liked to be hugged. Starting from scratch, I had to get to know him again while he had to accept the frustrating loss of what we once had together.

While continuing to battle my mental illness--ECT is no instant cure--I had to relearn how to live my life.

I didn't know my parents had moved. I had to be "reminded" about that great sub shop in Bethesda and about my favorite restaurant, the Lebanese Taverna. I spent 15 minutes in the cracker aisle in Safeway until I recognized the box of my favorite crackers, Stone Wheat Thins. I retrieved some clothes only by going to seven different cleaners to ask if they had an overdue order belonging to Lewis. Just yesterday I lost a contact lens: I've been wearing contacts for at least 10 years, but I have no idea who my eye doctor is, so replacing the lost one will be another tedious challenge.

Socializing was the hardest part of my recovery, since I had nothing to contribute to a conversation. While I had always been sharp-tongued, quick-witted and sarcastic, I now had no opinions: Opinions are based on experience and I couldn't recall my experiences. I relied on my friends to tell me what I liked, what I didn't like and what I'd done. Listening to them trying to reconnect me to my past was almost like hearing about someone who had passed away.

Before ECT I had been working for a legal concern in the District where the environment was exciting and the people were fun. That's what I've been told, anyway. Just before undergoing my treatment I informed my employer of my disability and requested time off. I estimated that I would need two weeks, unaware that the ECT would eventually stretch on for six weeks and that I would need months to recover.

As the weeks passed, I missed going to work, though I realized I had forgotten the names of major clients I had dealt with daily and even the names of the computer programs I had used routinely. And I couldn't recall the names--or the faces--of the people I had worked beside--people who had been to my house and with whom I had traveled frequently.

I didn't even know where my office building was located. But I was determined to get my life back on track, so I dug up all my work materials and began studying to catch up with my old life.

Too late: My therapist's request that the firm accommodate my extended absence failed. The company claimed that for business reasons it had been obliged to put someone else into my position and asked where my personal belongings should be sent.

I was devastated. I had no job, no income, no memory and, it seemed, no options. The thought of looking for a job scared me to death. I couldn't remember where I had saved my resume on my computer, much less what it actually said. Worst of all--and this is probably the most familiar feeling among those who suffer from depression--my self-esteem was at an all-time low. I felt completely incompetent and unable to handle the most minor of tasks. My resume--when I finally found it--described a person with enviable experiences and impressive accomplishments. But in my mind I was a nobody with nothing to hold onto and nothing to look forward to.

Perhaps due to these circumstances, perhaps due to my natural biological cycles, I fell back into depression.

Those first months after ECT were horrible. Having lost so much, I was facing another bout of depression--just what the treatments had been intended to correct. It wasn't fair and I didn't know what to do. Restoring my memory--or trying to accept its permanent loss--became the focus of my therapy sessions. I couldn't recall how badly I had felt before the treatment, but I knew now that I was desperate and completely demoralized.

At the edge of hopelessness, I somehow committed myself to hanging in there--not for me, but for the family members and friends who were working hard to make my life better. Daily thoughts of suicide were something I learned to ignore. Instead, I focused on making it through each day. I managed to get out of bed each morning and drive to the coffee shop, where I forced myself to read the entire newspaper, even if I couldn't remember much of what I had read. It was exhausting, but after a few weeks I was reading books and running errands. Soon I re-entered the world of computers and e-mail and the Web. Little by little, I was reconnecting to the world.

I also attended therapy religiously. The therapist's office was a safe place where I could admit just how bad I was feeling. Thoughts of suicide were a normal part of my life, but I felt it would be unfair to share those dark feelings with family and friends.

Through the Depression and Related Affective Disorders Association, I joined a support group, which became central to my recovery. There I realized that I was not alone in my plight and for once I had friends to whom I could talk honestly. Nobody was shocked to hear what the voice in my head was telling me.

And I began to run and exercise again. Before ECT I had been training for my first marathon. After, I couldn't run even a mile. But within a few months I was covering long distances, proud of my accomplishment and grateful for an outlet to deal with my stress.

In October I tried a new medication for depression, Celexa. Maybe it was this drug, maybe it was my natural cycle, but I began to feel better. I experienced days where death wasn't on my mind, and then I experienced days where I actually felt good. There was even a turning point when I began to feel hopeful, like something good could actually happen in my life.

The most poignant moment occurred a month after I changed medications. My therapist asked, "If you always felt the way you do today, would you want to live?" And I honestly felt that the answer was yes. It had been a long time since I had felt like living instead of dying.

It's close to a year now since I finished my ECT treatments. I am working full-time. I see my therapist only once every two to three weeks. I still attend DRADA meetings regularly. My memory is still poor. I cannot recall most of the two years before ECT, and memories prior to that time must be triggered and dug out of my mental archives. Remembering requires a great deal of effort, but my mind is sharp once again.

Friends and family say that I am less gloomy than I was, cheerful and less brash. They say I've softened a bit, though my basic personality has indeed returned. In part I attribute my gentler attitude to the truly humbling experience of having my self disappear. In part I attribute it to the loss of my well-honed vocabulary: I was reluctant to speak up when I couldn't find the right words. But in greatest part I attribute my change to a renewed desire for peace in my life. I am now dedicated to managing my depression and living a satisfying life day by day. I feel that if I can make the best of the moment, then the future will take care of itself.

As for my boyfriend, we're getting to know each other again. I'll be forever grateful for how he cared for the sudden stranger he met after my treatments.

Would I undergo ECT again? I have no idea. Where medication does not work, I believe the doctors' judgment that ECT is still the most effective treatment. For people who are sick enough to be considered for ECT--as I was--I believe the benefits justify the potential loss of memory. Losing my memory, my career, my connections to people and places may seem too much to bear, but I see all that as not a huge price to pay for getting better. What I lost was enormous, but if it is health I have gained, that is obviously far more valuable than what I lost.

While this year has been the hardest of my life, it has also provided me with a foundation for the next phase of my life. And I truly believe that this next phase will be better. Perhaps it will even be great. With a medication that seems to be working, a strong network of support and the ability to move forward, my life looks promising. I've learned to hang in there when it seemed impossible and to rebuild from a significant loss. Both are difficult. Both are painful. But both are possible. I am living proof.

next: Shocking Treatment
~ all Shocked! ECT articles
~ depression library articles
~ all articles on depression

Can a preschooler be diagnosed with ADHD? And a 20-year old sadly looks back at opportunities passed by because of ADHD and learning disabilities. What can a parent do to help? ADHD expert, Dr. David Rabiner has some answers.

1. How old does a child need to be for ADHD to be diagnosed?

2. How can I help my grown child not to be discouraged by ADHD?

I've several parents ask about their child being diagnosed with ADHD at three—or even two—and started on medication. I suggest that parents be very cautious about this. Although many children with ADHD will begin to display symptoms at such a young age, it is difficult to diagnose ADHD with any certainty in a child so young. This is because many extremely active toddlers will calm down as they develop and mature. In addition, excessive activity and impulsivity is characteristic of many toddlers, which makes it hard to determine when it is unusual enough to possibly reflect a disorder.

Here is a quote from DSM-IV—the publication that specifies the diagnostic criteria for all psychiatric disorders, including ADHD: "Most parents first observe excessive motor activity when the children are toddlers, frequently coinciding with the development of independent locomotion. However, because many overactive toddlers will NOT (emphasis mine) go on to develop ADHD, caution should be exercised in making this diagnosis in early childhood."

Now, if parents are having difficulty with a young toddler because of excessive activity and/or other symptoms that may possibly reflect ADHD, it certainly is important for these problems to be addressed. This is true regardless of whether or not that child turns out to have ADHD. In a child so young, however, many mental health providers believe it is more appropriate to begin with non-medical interventions. In fact, the treatment guidelines recently published by the American Academy of Child and Adolescent Psychiatry state the following:

"In this age group (i.e. preschoolers), stimulants have more side effects and lower efficacy and should therefore only be used in more severe cases or when parent training and placement in a highly structured, well-staffed treatment program has been unsuccessful or is not possible."

I would urge parents to be cautious about starting their preschooler on stimulant medication and to consult with their child's doctor about non-medical interventions that can be tried. If your child was diagnosed with ADHD at such a young age, and you are uncertain about the accuracy of the diagnosis, you might also want to consider having your child reevaluated.

" 20 year old daughter is feeling really frustrated because she is seeing what she might have become if not for her ADHD and learning disabilities. How can she learn to cope with this?"

This is an excellent and important question and one for which a definitive answer is not possible. I have worked with several adolescents and young adults who struggled with similar frustrations and disappointments. Because of the many difficulties that ADHD can cause, some look back and see years of squandered opportunity. Some individuals in this situation feel confused and uncertain about their ability to successfully handle the demands of higher education, developing a fulfilling career path, and handling the responsibilities of adulthood. This can be especially difficult when peers seem to be moving forward.

I'm afraid that anything I suggest here may sound somewhat trite, but here are some ideas to consider. First and foremost, talking about these feelings can help. Most of us have at least some regrets about the choices we've made or failed to make in our lives, and being able to discuss these openly with a supportive and empathetic listener - whether that be a family member, friend, or professional therapist - can be enormously helpful.

For someone with ADHD, it can be especially important to develop a realistic understanding of how this condition influenced the course of their development and may have contributed to some of their struggles. Although this can not change one's history, this understanding can help protect against unreasonably overemphasizing (e.g. blaming all one's difficulties on the condition) or under emphasizing (e.g. refusing to acknowledge that the disability played any role).

Through these discussions, a young adult can also gain a better understanding of their strengths and weaknesses. Ideally, this self understanding can help guide their future plans in a way that realistically incorporates the role that any ongoing ADHD symptoms could or should play in these plans. When this occurs, shying away from areas where one can succeed should be less likely, as should pursuing paths that may not be ideally suited for one's personality and temperament. This process would not be expected to be something that happens suddenly or even quickly; rather it would be expected to occur over a period of time, and at different rates for different individuals. Ideally, it will help someone develop a perspective on their past that enables them to look towards the future with a greater sense of confidence and purpose.

A very important issue raised by this question concerns a child's understanding of ADHD during their development. In my experience, children are often not told that they have ADHD, or may have heard that they have "it" but have no real idea what "it" is. Some children take medication for an extended period without every really understanding why. In these circumstances, it is not uncommon for a child to have a vague sense that something is wrong with him or her, and the teasing that some children experience when peers find out they take "hyper pills" certainly doesn't help.

My own feeling is that it is quite important for a child with ADHD to have a realistic understanding of what ADHD is and what it means to have it. Parents I have spoken with are often concerned about saying anything to their child because they don't want their child to think there is something wrong with them. When a child is provided with an age appropriate explanation about what it means to have ADHD, however, I believe that this is actually less likely to occur.

This knowledge can also help protect children against teasing they may receive from some insensitive classmates. It may also help them during adolescence and young adulthood when most individuals deal with the important developmental task of deciding about the type of future they hope to build for themselves. Because they have realistically incorporated the awareness of having ADHD into their overall self-understanding, they may be better equipped to deal with this task than if they first begin coming to terms with what it means to have ADHD at this at this time.

Deciding how, or even if, to discuss these issues with your child is an important decision for parents. Several very good books are available to help parents with this task. Among those that I would recommend are Shelley, The Hyperactive Turtle by Deborah Moss (written for children 3-7); Putting on the Brakes by Patricia O. Quinn and Judith Stern (for children 5-10); and Distant Drums, Different Drummers: A Guide for Young People with ADHD by Barbara Ingersoll.

About the author: Dr. Rabiner is Senior Research Scientist at Duke University and Director of Undergraduate Studies Dept. of Psychology and Neuroscience. Dr. Rabiner has extensive experience evaluating and treating children for ADHD and has written numerous published papers on the impact of attention difficulties on academic achievement. He is editor of the Attention Research Update newsletter.

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Study shows Adderall more effective than Ritalin in treating ADHD symptoms.

A new study published in this month's Journal of the American Academy of Child and Adolescent Psychiatry found that Adderall (R) (mixed salts of a single-entity amphetamine product) is significantly more effective at reducing inattention, oppositional behavior, and other symptoms of attention deficit/hyperactivity disorder (ADHD) than methylphenidate (Ritalin), an older ADHD treatment.

The study of 58 children with ADHD also found that the benefits of Adderall last longer than those of methylphenidate (which is sold under the brand name Ritalin(R)). In fact, 70 percent of patients taking a single morning dose of Adderall found significant improvement in ADHD symptoms, while just 15 percent of patients taking methylphenidate improved significantly with only one dose.

"In our study, children with ADHD showed more improvement after Adderall treatment compared with methylphenidate," said Steven Pliszka, M.D., lead investigator of the study and chief of child and adolescent psychiatry at The University of Texas Health Science Center at San Antonio. "It is important for children with ADHD to have effective treatment, because left untreated, ADHD can increase the risk of low self-esteem and social and academic failure."

In Dr. Pliszka's clinical study, 58 children diagnosed with ADHD were given Adderall, methylphenidate, or placebo for three weeks in a double-blind parallel-group design. All groups started week one on a once-daily dosing regimen. If the children's afternoon or evening behavior did not improve after week one, a mid-day or 4 p.m. dose was added for week two.

Teachers rated morning and afternoon behaviors, while parents rated evening behaviors. According to teacher ratings, Adderall produced more improvements in inattentive and oppositional behaviors than methylphenidate (p less than 0.05).

In addition, the psychiatrist-administered Clinical Global Impression Improvement scale, which is used to assess response to treatment, showed that more children found greater ADHD symptom relief with Adderall than with methylphenidate. In fact, 90 percent of children taking Adderall were found to be "very much improved" or "much improved" in behavior, when statistically compared with 65 percent of the methylphenidate group and 27 percent of the placebo group (p less than 0.01).

The study also showed that 70 percent of patients taking Adderall and only 15 percent of patients taking methylphenidate were still on once-daily dosing at the end of the study, based on a pre-defined dose titration scheme. "The higher response rate for Adderall is very encouraging," Dr. Pliszka said. "Our study suggests that Adderall can be the first option for the treatment of ADHD."

In the study, both medications were well tolerated, and side effects were similar to placebo. The most common side effects associated with stimulant use are insomnia, loss of appetite, stomach pain, headache, irritability, and weight loss.

The University of Texas study was funded with a grant from Shire Richwood Inc., which manufactures Adderall.

About ADHD

ADHD affects 3 percent to 5 percent of all school-age children, and is considered the most frequently diagnosed psychiatric disorder in children and adolescents. The most common behaviors exhibited by those who have ADHD are inattention, hyperactivity, and impulsivity.

Stimulant medications -- which stimulate areas of the brain that control attention, impulses, and self-regulation of behavior -- are among the most successful treatments for people with ADHD. In fact, at least 70 percent of children with ADHD respond positively to treatment with stimulant medication.

About Adderall

Adderall is a stimulant medication for the treatment of ADHD. It has been shown to improve attention span, decrease distractibility, improve the ability to follow directions and complete tasks, and decrease impulsivity and hyperactivity.

Adderall is generally well tolerated. While adverse reactions are rare, the most frequently reported adverse reactions include anorexia, insomnia, stomach pain, headache, irritability, and weight loss. These side effects are similar to those seen with other stimulant medications used to treat ADHD. As with most stimulant medications indicated for ADHD, the possibility of growth suppression and the potential for precipitating motor tics and Tourette's syndrome exists with Adderall treatment, and, in rare cases, exacerbations of psychosis have been reported. Since all amphetamines have a high potential for abuse, Adderall should be used only as part of a comprehensive treatment program under close physician supervision.

Rainy River Record
March 21, 2000

By Ken Johnston
Editor

Could you imagine drinking all night and then getting in your car and driving somewhere impaired?

While it does happen, most people are sensible and use a designated driver or get a ride some other way. However, for Kenora's Wayne Lax, driving impaired was something he said he did for 25 years.

Lax who suffered from deep depression and extreme alcoholism after the death of his brother was treated by doctors with two types of medical practises. One involved pharmaceuticals arid the other was electro-shock therapy. At one point he was on 17 different drugs per day and all the while was shock treated 80 times in that period of time. With that in mind one would think that he was incapable of driving and that medical professionals would have notified the Ministry of Transportation of his constant impairment.

Well until 1992, when Lax had a severe motor accident and he was charged with impaired driving he was never told he could not drive, at least as not as far as he can remember and the MTO was not notified of his condition.

Lax says that he knows now that he should never have been operating a motor vehicle, much less have been a taxi driver, while on all those medications, but he swears that he can not recollect much of those years due to the electro-shock treatments: treatments he calls barbaric.

He is now actively leading a two-pronged crusade to have electro-shock treatments banned and to raise awareness about medicated impaired driving. Lax has joined a MoT group called the CAR Committee that has members from Mothers Against Drunk Driving, police, pharmacists and the MoT on it. Through their and his efforts Lax has received the attention of former Minister of Transportation Tony Clement and current MoT David Turnball. They have taken his material into consideration and Lax says they plan to use it when they review MoT policies and laws. According to Lax that takes place every two years and he is optimistic that they will be reviewed this year.

Lax is pushing for the government to take a tougher stance on the mandatory reporting by doctors patients who should not be driving while on medication. While it is the law, he said be was never once reported to MoT.

He plans to continue his efforts to raise awareness about these two important issues by working with self-help groups, visiting schools to talk to students and continue writing letters to officials until things change in a way that lives are saved.

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SURGEON GENERAL DAVID Satcher's recently released position paper, "Mental Health: A Report of the Surgeon General," is inaccurate and misleading, because its conclusions are not the result of valid, scientific research. Satcher's report maintains that about one in five Americans - or 53 million people - are mentally ill during any given year, and that about 50 percent of Americans suffer from mental illness during their lifetimes. These assertions are neither new nor scientific.

In the early 1990s, the National Institute of Mental Health (NIMH) made precisely the same claims. The statistics came from surveys by "lay interviewers."

Along with the American Psychiatric Association, the NIMH recommended in the ill-fated 1993 Clinton health care plan that Americans should be insured for 30 outpatient psychiatric visits a year with unlimited psychotherapy sessions.

Let's do some math. If 53 million Americans had 30 outpatient visits, the insurance companies would have to pay for 1.6 billion psychiatric sessions a year. This would lead to the birth of what has been described by critics as "the Therapeutic Society."

If the recommendations and claims of the surgeon general's report were taken seriously, it also would mean that mental illness would rank as the most common chronic disease in America.

According to the latest "Statistical Abstract of the United States," it would surpass arthritis, which afflicts about 32.7 million, and hypertension, from which about 30 million suffer.

Psychiatrist Kay Redfield Jamison claimed in a Dec. 17 letter to the New York Times, "The science underlying the numbers and treatments in the surgeon's report ... is reliable and replicable." What she doesn't claim - what she cannot claim - is that the numbers are valid.

Psychiatry uses reliability of psychiatric disorders (testing to see if diagnosticians agree on which psychiatric disease patients suffer from) in the place of a search for validity (ascertaining whether psychiatric diagnosis measures what it claims to measure). This has been pointed out most recently by Dr. Paul McHugh of Johns Hopkins University in an article in last month's Commentary magazine.

The surgeon general's report maintains that mental health should not be viewed as "separate and unequal" to general health, and that there should be public support for the long-standing goal of "parity" for mental illness, which means insurers would have to treat mental illness on an equal basis with physical illness.

The costs of parity are widely disputed, but they are likely to be exorbitant.

In an article in The Washington Post, Carmella Bocchino, vice president for medical affairs of the American Association of Health Plans, said, "We've seen estimates that mental health parity would cost increases of 1 to 5 percent. ... Do we give up other parts of the benefits package, or are we looking to rising health care costs?" The Employee Benefit Research Institute, a nonprofit think tank, has determined that, at a minimum, parity will lead to increases in employer costs and possible elimination of other benefits in some cases, including health insurance coverage altogether.

The report also promotes the mental health system's second major goal in addition to the addressing of parity: the elimination of stigma, which produces public reluctance to pay for care and adds to the indignities of mental illnesses. In the words of the report, stigma "must be overcome."

There are three "severe mental illnesses" - schizophrenia, bipolar disorder and major depression - and they are arguably caused by brain disease. The stigma should be removed from them.

But stigma serves a useful purpose with the hundreds of other so-called mental disorders: It deters many who would frivolously claim to suffer from those "diseases."

One would think that the report's conclusions would be more tentative given its caveats, such as, "It is sometimes difficult to determine when a set of symptoms rises to a level of a mental disorder" and "No single gene has been found to be responsible for any specific mental disorder." Then there is this unqualified non sequitur: "For about one in five Americans, adulthood is interrupted by mental illness."

There is a reasonable alternative to the seemingly endless calls to expand the categories of mental illness and to exaggerate the incidence and prevalence of mental illness.

Instead of allowing a large number of Americans to get coverage for nebulous maladies such as "adjustment disorder" or "social anxiety disorder," the insurance companies should provide full coverage for everyone suffering from schizophrenia, bipolar disorder or major depression, all of which may result from authentic brain disease.

The American Psychiatric Association estimates that only about 3 percent to 4.5 percent of the public suffers from "severe mental illness." Focusing on the true brain disorders would save the nation millions of dollars and allow the money to be spent where it is really needed.

(Mr. Vatz is a professor of communications at Towson University and has written extensively on mental health issues.)

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Local shock treatment victim Wayne Lax is giving his support to a woman in Montreal who is suing the federal government for $4.6 million after most of her life was blanked out by shock therapy, induced comas and a mixture of drugs.

"I back this woman 100 per cent because I know what she went through," said Lax. "Shock therapy treatment was abused. It blanks the mind out and damages you permanently."

Gail Kastner, now 56, was admitted by her father to the Allan Memorial Institute when she was 19 for depression. She was given electroconvulsive therapy (ECT treatments) otherwise known as electroshock treatments in 1953 by a doctor notorious for his brainwashing experiments.

She is blaming the federal government for supporting Dr.Ewen Cameron's research, which left her with bizarre behaviour including screaming nightmares, persistent seizures and a complete blank about her past. Kastner was ostracized by her family and left nearly homeless after she reverted to childlike behaviour such as wetting the living room carpet, sucking her thumb, babytalk and wanting to be bottle fed. Her trial is presently underway in Montreal.

Lax, who currently lives in Kenora, is presently involved in his own series of lawsuits which he says are not out of revenge, but out of concern for others.

Lax said he spent 25 years in a state of confusion and despair, undergoing 108 admissions to mental institutions, 80 ECT treatments and taking up to 17 different pills per day.

"I am missing large portions of my memory and suffer from chronic, severe back pain when I broke a bone in my back because I didn't have enough muscle relaxant during ECT treatments," said Lax.

"People need to be aware of what shock does to human beings. And we are human beings, not just patients."

Lax is presently drug free and is a member of numerous psychiatric survivors groups.

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