Popping Pills in Preschool

Anywhere else, her revelation might have been a bombshell. But no one flinched when a child psychiatrist told a conference of parents and counselors last month that she had prescribed antidepressants to children as young as 3-1/2.

Audience members at the San Diego conference, after all, were quite familiar with the concept of preschoolers on Prozac. Many of the parents in the audience have children who suffer from a debilitating form of shyness called selective mutism, one of a handful of mental disorders thought to strike children younger than 6. And several had put their kids on the drugs despite their misgivings and well-publicized concerns about the effects of antidepressants upon teenagers.

"It's still one of those things that my husband and I struggle with," admitted Texas preschool teacher Jana Chapline, whose 7-year-old daughter takes Prozac. "We have to wonder if we're doing the right thing until we get the results."

According to experts, a growing number of parents are finding themselves in Chapline's position, reluctantly agreeing to treat their young children with antidepressants even though their effects on the brains of adults, let alone children, are little understood. "This is ignorance in the broadest sense of the term," said Dr. Glen R. Elliott, a child psychiatrist at the University of California at San Francisco. "We don't know if this is a good idea or not."

The antidepressant drugs most commonly prescribed to children, known as selective serotonin reuptake inhibitors, or SSRIs, are in the news this week as the Food and Drug Administration holds hearings on their safety for children. On Monday, parents of teens who killed themselves while taking antidepressants urged the government to ban their use with kids.

After hearing emotional testimonies, an advisory board called for better warnings. The United Kingdom already has outlawed the use of antidepressants -- with the exception of Prozac -- by minors.

The debate over the drugs, however, has largely left out kids under the age of 10, generally considered too young to kill themselves but not too young to suffer from disabling mental disorders.

Psychologists now suspect that young children, even toddlers or babies, can suffer from a short list of mental problems, including depression, bipolar disorder, anxiety and obsessive-compulsive disorder. "We now know that many of these disorders begin in childhood," said Dr. Kiki Chang, a psychiatrist at Stanford University.

In children under 3, psychiatric medication is still verboten. Since babies can't lie on couches and talk about their mothers, counselors turn to the parents. "With an infant, the first line of defense is making intimate body and emotional connections, building a secure, loving attachment by rubbing noses together, swinging, swaying and dancing with him in your arms," said Alice Sterling Honig, professor emerita of child development at Syracuse University.

But children over the age of 3 are a different story, especially during preschool and kindergarten years, when the pressures of social interaction test the mental stability of children. Even an advocate of love therapy like Honig acknowledges that drugs may help older kids in some cases. "Everybody reacts to medications differently," she said. "For some children, this could possibly help them get back some feeling of being in control in their own lives, so they can concentrate and focus on lessons and the requirements of parents and teachers."

A study released three years ago found that about three in every 1,000 American preschoolers were on antidepressants in 1995. Prozac and Paxil appear to be most common, said Dr. Joan Luby, a child psychiatrist at the Washington University School of Medicine in St. Louis who is studying depression and bipolar disorder in preschoolers.

For many parents, like Texas schoolteacher Chapline, the drugs are a last resort. Her daughter Emily suffers from selective mutism. Children who have this disorder become too afraid to speak in social situations like classrooms and doctor's offices. At home, however, they almost always regain their ability to interact with others.

"On her first day of kindergarten, teacher called me midway through first day, asking what she could do," Chapline said. "Emily was literally frozen. She couldn't do anything."

Researchers say selective mutism is caused by anxiety, not stubbornness, so many parents of children with the disorder turn to psychiatric drugs. After the call from the kindergarten teacher, Chapline said, "We made the decision right there that we had to try the medication to give her the chance to function in school."

Just as they do in adults, antidepressants cause a variety of side effects in children, and Chapline quickly took Emily off Paxil after the girl suffered intestinal problems. A switch to Prozac seemed to work much better, and Emily remains on the drug two years later.

According to Chapline, her daughter is still shy, but not silent. "She's a happy kid, she's bright, she loves school," Chapline said. "She has somewhat different relationships with her classmates because she doesn't speak with most of them. But she's making progress and on her way to becoming a normal girl."

While the chances of a preschooler committing suicide appear to be remote, experts say other risks could face preschoolers who take antidepressants. But psychiatrists acknowledge they have no idea what they might be. The explanation for this gap is a simple one: Scientists haven't extensively studied the effects of drugs on kids.

According to Stanford's Chang, many parents aren't willing to let anyone experiment on their children, especially because traditional double-blind studies would prevent them from knowing if their kids are taking real drugs or placebos.

"It's certainly possible that these drugs could help, but we just don't have the data to make a definitive statement about it, nor do we know much about the safety or impact on growth and development that one always needs to know when prescribing drugs to children," said Luby, the Washington University child psychiatrist.

Researchers are launching more studies of mental illness in children, but experts say research into antidepressants remains in the future. For now, child psychiatrists must continue to cross their fingers.

Some might say psychiatrists who treat adults are taking similar gambles. Drugs like Prozac have only been around for a few years, and their long-term effects -- say, over 20 or 30 years of use -- aren't known. Scientists aren't even totally sure how the drugs combat depression, anxiety and other disorders. It seems clear that they affect the brain's levels of a chemical called serotonin, but "no one really understands the chain of events," Chang said.

If the drugs do harbor unknown risks, the developing brains of children could be in danger. But psychiatrists and parents point out that the alternative, in many cases, is to abandon mentally ill children to their illnesses.

Consider the story of Kayla Heckman, a 10-year-old girl who lives in Pennsylvania and was profiled in a documentary about selective mutism. She went on Prozac at age 6 to treat a debilitating case of shyness that kept her virtually mum during kindergarten classes.

Small doses of the drug changed everything, recalled Kayla's mother, Sherry Heckman, who is studying to be a social worker. "I started seeing changes in her body language, in her tension. I began to see her becoming more relaxed."

Now, Kayla has been off Prozac for two years and is doing well. "I have no regrets whatsoever with making that choice," her mother said. "I feel that I personally gave my daughter a chance to have a life she wouldn't have had any other way, had we not used the medication. To me, it was a lifesaver for her."

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