Helping Kids Cope Without Antidepressants

Helping Kids Cope Without Antidepressants posted by Mel, selected from Natural Solutions magazine Nov 19, In the wake of reports on the potentially serious side effects of antidepressants on children and teens, parents and physicians are looking to alternative traditions to help kids cope with mental and emotional distress. Sofia never really had been a nervous or anxious child–until she suffered a mysterious illness five years ago, when she was seven. She ran a high fever for two solid weeks, and her parents and doctors never figured out exactly what had afflicted her. Was it back-to-back viral infections? An undetected strep infection? What became clear is that after her sickness ended, Sofia’s personality changed. “Coming out of the illness, she had an anxiety that was completely unlike her previous temperament,” says Joyce Wright, her mother. She didn’t want to separate from her parents or even let them out of her sight. She wouldn’t go to friends homes or allow her parents to leave her with a babysitter. As the weeks and months went by, Sofia’s anxiety grew steadily worse, and she began to suffer panic attacks. Her heart would race, she would become agitated and unable to sit, and she had an overwhelming sense of feeling trapped. During one attack at school, she told her parents she felt as if she were caught in a black hole, surrounded by monsters. Desperate to help their young daughter, her parents tried for a year and a half to figure out what was wrong. They consulted with a psychologist and worked at managing her fears, but nothing seemed to help. At the beginning of fourth grade, her anxiety worsened, and her parents took her to a psychiatrist. He prescribed Luvox (fluvoxamine), a selective serotonin reuptake inhibitor (SSRI) and antidepressant similar to Prozac (fluoxetine) that is approved by the Food and Drug Administration for the treatment of children with obsessive-compulsive disorder. The drug backfired almost immediately. They stopped the medication after only four days, but Sofia now was unwilling to go anywhere and was completely housebound for six weeks. “We could not leave the house, or she would escalate to full-blown panic,” Joyce says. A midcourse correction The psychiatrist then prescribed a second antidepressant from a different class of drugs, and while it did not trigger outright panic attacks, it, too, seemed to worsen Sofia’s anxiety, and she stopped taking it after two weeks. At that point, the family switched doctors and consulted a psychiatrist at Childrens Hospital and Research Center in Oakland, Calif. This time, they insisted on no medications. “It seemed so risky, and we were just not willing to put her through that,” Joyce says. The new psychiatrist suggested the family see Joanne Yeaton, a licensed clinical social worker in the psychiatry department who uses biofeedback. Yeaton at first treated Sofia at home, gaining her confidence after conducting several biofeedback sessions in the family’s kitchen. With Yeatons coaching, Sofia was able to slow her breathing and heart rate, and, as she relaxed, to increase the temperature in her fingers, generally considered a sign of improved blood flow. According to Joyce, after a few sessions, Sofia felt comfortable enough with Yeaton to visit her at the office, as long as her mother was present. Once there, however, she gradually allowed her mother to leave the room and wait in the hallway. Without medication, and after three months of working with Yeaton, Sofia was able to return to school on a limited basis. It’s important to note that Sofia’s symptoms are unique to her. Children suffering from mental and emotional disorders experience widely varying levels of distress. No matter the severity of the pain or panic, however, parents increasingly are looking for ways to help their children deal with their symptoms without psychiatric medications. Two sides of one coin? The number of children diagnosed with depression and anxiety has exploded in recent years. The use of antidepressants increased 50 percent between 1998 and 2002. In 2002, for example, some 11 million children and teenagers were prescribed antidepressants, according to the Food and Drug Administration, primarily for depression, anxiety or a combination of both. Although they often appear together, these two conditions manifest themselves quite differently. Like adults, children suffering from depression tend to feel sad and lethargic, often without knowing why. They have a hard time playing and engaging with friends and often do poorly in school because they lack energy and motivation. Depressed kids, more than adults, are often irritable and tend to act out as a result. Anxiety disorders cause a broad range of behaviors, but what they have in common is fearfear of people, animals, situations or events such as separating from parents. Rather than sending children hiding under the covers, these disorders overstimulate the central nervous system, send cortisol coursing through the body, and cause the heart to race, palms to sweat, and arms and legs to twitch. Despite the differences in these conditions, antidepressants are widely used to treat both. But families like the Wrights, dissatisfied with the results of these drugs, and alarmed by reports of adverse effects–including an increase in suicidal thinking among children and teens taking them–are looking to alternative approaches such as biofeedback, relaxation, nutritional changes and psychotherapy. For answers, they are turning to integrative medical doctors like Tim Culbert, MD, a behavioral/developmental pediatrician and medical director for the integrative medicine program at Childrens Hospitals and Clinics of Minnesota in Minneapolis, and Michael Cantwell, MD, MPH, a pediatrician at the Institute for Health and Healing at California Pacific Medical Center in San Francisco. These doctors are among a growing number of practitioners who mix alternative techniques into their often eclectic approaches to helping distressed children. While some practitioners dont rule out the use of psychiatric medication in some cases, most tend to see it as a last resort. Those who do use medications say that by combining them with other strategies, they can keep dosages low and get patients off the drugs more quickly. For Cantwell, the key to working effectively with depressed or anxious children is to understand whats going on in both their bodies and their liveseverything from what they eat to relationships and events in their families. “When you see a kid whos depressed, you have to ask, Whats the cause?” he says. Holistic medicine tries to look at causes a little more closely, not to just take depression and say, We have a pill for that. For some children, Cantwell says, the underlying problem may be biological: For some unknown reason, they are not making enough neurotransmitters, the brain chemicals that affect mood and emotion and are the targets of psychiatric medications. Other kids are depressed because of the stress or unhappiness in their lives, and the key to helping them is to aid them in addressing these life problems, he says. But the once sharp lines between environmental and biochemical factors increasingly are blurred; by now, it has become clear that they are not isolated from each other but rather are interactive. Grief from the death of a loved one can decrease the levels of the neurotransmitter serotonin; poor attachment between a mother and infant can have a lasting negative impact on the structure of a childs brain. “The question is not whether depression or anxiety is biological,” says James Gordon, a psychiatrist and director of the Center for Mind-Body Medicine in Washington, D.C. “The question is how you approach biology. For example, if you can use exercise to lower levels of cortisol or increase neurotransmitter levels, why use drugs?” Because he believes there are other more holistic ways to address childrens mental health problems, and because of the risk of side effects, Gordon almost never uses psychiatric medications with children. For some kids, rapid improvement can come from simple changes, “getting them off high-sugar diets and making sure they get more sleep,” Cantwell says. For most children, though, a combination of different approaches is likely to be needed, including dietary change, relaxation techniques, biofeedback and some form of counseling or therapy. In his practice, Cantwell refers many kids and families to therapists. But he also practices what he calls spiritual counseling, which explores with kids ways they can identify and use their own resources to both cope with stress and connect with friends and family. For example, he says he helped one depressed boy who was acutely sensitive to the judgments of others create a force field that meanness and judgments would hit and wouldnt penetrate. When Cantwell learned from a 9-year-old girl that her daily stomach aches often surfaced when her mother’s boyfriend, like the ex-husband before him, yelled at Mom, Cantwell worked with her using guided imagery–asking her to visualize a safe, peaceful place, he says. From those instructions, the girl visualized a favorite playground, and when she visited it in her imagination, she told him she got a nice, warm pink feeling. After three sessions, Cantwell says, she was free from pain. The road to recovery Sofia Wright’s journey back from panic came step-by-step. Driving with her mother to school she practiced relaxation techniques with a handheld biofeedback device, imagining situations that might make her anxious and visualizing how she would handle them. Sofia still feels nervous in some situations, her mother says, but she visits her friends at their homes and recently got on a subway for a class field trip. “She made a remarkable transformation,” Joyce says. She’s feeling much stronger and has a sense of accomplishment for everything she was able to do. She continues to visualize and problem-solve on the way to school, only now she does it without the biofeedback device. They returned it to Yeaton a few months ago. Helping kids cope without antidepressants A growing number of alternative practitioners employ a wide array of techniques to help children suffering from depression and anxiety problems. Here is a quick guide to some of the key approaches these practitioners use to help troubled kids. First: Assess the problem The first step in working with a depressed or anxious child is to do a thorough assessment, says Michael Cantwell, MD, a pediatrician at the Institute for Health and Healing at California Pacific Medical Center in San Francisco. He gets detailed information from both children and parents about what the child eats, when and how much he or she sleeps, what’s going on in the family and at school, and when his or her symptoms seem to manifest themselves. “These elements of a child’s life can be critical factors contributing to depression or anxiety but often get overlooked because theyre so basic,” Cantwell says. A lot of kids these days are overscheduled and theyre tired. Thats another cause for depression; some kids just dont get enough sleep. Diet: Check it, then change it When assessing diet, one of the first things Cantwell looks at is a child’s protein intake. “While most Americans consume more than enough protein, many kids dont get enough,” he says, “especially in the morning when they need it most.” Inadequate protein can contribute to depression because neurotransmitters are made of amino acids, the primary in-gredient of protein necessary to make these mood-enhancing chemicals. One tip-off that children may not be getting enough protein is if they are sleepy by mid-morning and crabby or very tired in the afternoon, Cantwell says. Unfortunately, the worst kind of breakfast in terms of triggering depression is also perhaps the most common: one with lots of sugar or highly refined carbohydrates–such as donuts, bagels and muffins–and little or no protein. Cantwell says there is mounting evidence that a high-sugar, low-protein diet can boost insulin levels and deplete serotonin, a virtual recipe for depression in many people. The general rule of thumb is that growing children need about one gram of protein for every two pounds of body weight. To treat depression, Cantwell suggests as much as double that amount, with one-third to one-half of a child’s protein intake coming at breakfast. Easy sources of protein at breakfast include milk (1 cup provides 8 grams of protein), eggs (1 egg contains 6 grams of protein) and yogurt (8 ounces provides nearly 11 grams of protein). Cantwell suggests making small changes to a depressed child’s diet, especially at breakfast, by incrementally boosting his or her protein consumption. If necessary, he says, keep a diary of what your child is eating along with notes on his or her mood and behavior. You may notice patterns, and youll be able to review these notes with a practitioner. Exercise: Get kids moving There’s plenty of evidence that exercise can ease depression in adults, but exercise scarcely has been studied as an intervention for depressed children. Still many experts believe it is likely to produce the same effect on kids. That exercise has a beneficial effect on mental health for children as well as adults is an attractive, intuitive and widely held notion, write Theodore Ganley and Carl Sherman in a 2000 article in the journal The Physician and Sports Medicine. What’s the mechanism by which exercise could affect mood and ease depression or anxiety? James Gordon, MD, a psychiatrist and director of the Center for Mind-Body Medicine in Washington, D.C., says that there is good evidence, again in adults, that exercise can cut cortisol levels and boost levels of serotonin. For these reasons, many alternative and mainstream practitioners will try to get kids to indulge in regular physical exercise. “We always try to get kids on an organized exercise program of some kind as opposed to being really sedentary, which a lot of them tend to be when theyre depressed,” says Tim Culbert, MD, a behavioral/developmental pediatrician and medical director of the integrative medicine program at Children’s Hospital and Clinics of Minnesota in Minneapolis. Omega-3 fatty acids Adults who don’t get enough omega-3 fatty acids, found mostly in cold-water fish, are at higher risk of depression. One study of hospitalized depressed patients found they had especially low levels of omega-3s and that their ratio of omega-3s to omega-6s was too low. Why shouldnt the same be true of children, alternative practitioners ask. I almost always recommend omega-3s for both children and adults because its really deficient in our current diet, Cantwell says. That being said, clear guidelines on dosages of omega-3s have not been established for children. Cantwell recommends that kids under 6 take supplements containing 500 mg of omega-3s a day, in the form known as docosahexaenoic acid or DHA; children over 6, like adults, can take 1,000 mg per day, he says. Culbert also generally recommends omega-3s for depressed children; he advocates 1,000 to 2,000 mg per day. But see your child’s healthcare provider for the dosage best for your child. Mind-body techniques Techniques that yoga and meditation teachers have long taught to adults also can do wonders to help children with anxiety slow down and relax. There are many ways kids can learn to achieve a more relaxed state, depending on what resonates with any given child. “I believe in the shotgun approach, so Ill train just about every kid I see with at least five or six different ways to achieve a relaxed, comfortable, balanced state of mind,” Culbert says. Offering that many options is important since many kids will not be at all interested in, or able to use, some techniques. For instance, many children have a tough time taking slow, belly breaths. By giving kids choices, they usually can find one or two techniques that work for them. For children, the most popular relaxation-inducing techniques on the smorgasbord include: Diaphragmatic or belly breathing. Depending on the age and lung capacity of the child, she can count to five or seven as she breathes in, first to her belly, then to her lungs. She then exhales at a slow, even pace, counting again to the same number. Progressive muscle relaxation. Working from toe to head or head to toe, children can squeeze each muscle group in their body for ten seconds, then relax for ten seconds. Culbert follows this practice with what he calls a body scan. With eyes closed, a child will do a mental check of his whole body, checking which muscles are relaxed and which are not. Then hell repeat the squeeze-and-relax technique until his whole body is relaxed. Visualization. Children close their eyes and form an image in their mind of a favorite place or activity that makes them happy. “The idea,” says Culbert, “is to bring up a positive emotional feeling or state like care, appreciation, love or support.” This is often combined with slow, rhythmic breathing. Biofeedback. For anxious children, biofeedback can be a life-saver. It works in two ways, says Joanne Yeaton, the clinical social worker who treated Sofia Wright in Oakland, Calif. The fact biofeedback uses a computer that contains interesting animation and graphics captures the interest of todays wired generation, but the softwares slow pace and Yeatons calm discourse slows them down. I like the irony of using a computer-based intervention because its a way of using some things that can be a problem for kids and use it to bring them back to themselves. It also gives her a chance to teach them deep breathing, visualization and other standard relaxation techniquesand then have them see the results instantly. Today, software programs such as The Journey to Wild Divine, a biofeedback game promoted by Deepak Chopra, MD, and Dean Ornish, MD, can be used at home to engage kids who might never otherwise be interested in attempting deep breathing or guided imagery. One thing to remember: Mind-body techniques are great for kids with anxiety and can help children with sleep disorders get to dreamland, but they are not particularly helpful for depressed children–unless their depression is mixed with anxiety. For some people with more severe depression, certain forms of relaxation like hypnosis or biofeedback are contraindicated because you dont want to bring them into states of deeper depression, Culbert says. Is it really a problem? From the terrible twos to the turbulent teens, childhood naturally involves some emotional volatility. That can make it difficult for parents to distinguish between normal mood fluctuations in their children and more serious health conditions such as depression. The Mayo Clinic identifies several possible warning signs for depression in adolescents. When evaluating a child, therapists consider the number of these symptoms the child demonstrates, as well as the duration, frequency and severity of these symptoms. What to Look For: Preschool Listlessness Decreased interest in playing Cries easily and more often than usual Elementary school Listlessness and moodiness More irritable than usual Looks sad Easily discouraged Complains of boredom More distant with friends and family Difficulty with schoolwork Talks about death Teenager Always tired Drops out of favorite activities Has more arguments with parents and teachers Refuses to do chores or homework Engages in harmful behavior, such as cutting himself or herself Has suicidal thoughts The Latest Research According to the National Institute of Mental Health (NIMH), the understanding of antidepressant treatments in youth, though growing substantially, remains limited when compared to what is known about treatment of depression in adults. According to the NIMH website, Recently, concerns have been raised that the use of antidepressant medications may induce suicidal behavior in youths. In fact, following a thorough and comprehensive review of all the available published and unpublished controlled clinical trials of antidepressants in children and adolescents, the FDA adopted a black box label warning that antidepressants were found to increase the risk of suicidal thinking and behavior in children and adolescents with major depressive disorders. A black-box warning is the most serious warning on prescription drug labels.

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Helping Kids Cope Without Antidepressants

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