LOS ANGELES — Sixty years ago, jamming an ice pick through the eye socket and striking it against the brain was a popular treatment for mental illness.
However, frontal lobotomies, electroconvulsive therapy and insulin shock therapy fell out of favor in the 1950s with the advent of psychiatric medications.
Now, half a century later, health care professionals are still fine tuning their methods.
About one in five American children and adolescents has a mental illness, according to the U.S. Surgeon General. Treatment options for the mentally ill include medications, therapies or a combination of both, but the mental health community is still in the early stages of developing treatments for children, who are often left with inadequate help.
Children's youth and undeveloped bodies slow medical testing while difficulty in diagnosing children has stunted treatment plans.
In Nebraska, about one in 20 children under 17 has a mental illness, but two-thirds are not getting the help or treatment they need, according to Project Relate, a public service campaign that joins mental health service providers, advocacy groups and non-profit organizations in Nebraska.
The State Mental Health Agency's expenditures in 2001 totaled more than $86.5 million, which breaks down to about $50 per person.
Where primary and preventive health care is favored, especially for the poor and uninsured, mentally ill patients may be missing out.
Of the children in the U.S. with mental illness, 62 percent have anxiety disorders, 49 percent have disruptive disorders, 30 percent have mood disorders and 10 percent have substance abuse disorders, according to a 1996 report from the Surgeon General; some of these children have more than one disorder.
The type of illness strongly dictates treatment plans.
"We know that cognitive-behavioral therapy and biofeedback is very, very, very good for anxiety disorders and even panic disorders," said Herbert Schreier, a psychiatrist at the Children's Hospital and Research Center Oakland in Oakland, Calif. "For bipolar disorders, obviously, not so good."
Biofeedback uses blood pressure, heart rate and other bodily functions to reveal and make patients aware of unconscious physical activities so the patient can learn to control them.
Cognitive-behavioral therapy is one of the principal treatments in the modern school of thought. It's a combination method that teaches patients to retrain their thinking by recognizing and redirecting certain thoughts.
Some of the applications of this kind of therapy include exposure therapy for people with anxiety disorders or having children play out the decision between healthy and unhealthy decisions in a video game.
"Cognitive-behavioral therapy is probably one of the treatments of choice – with medication – for adults and kids," said Randall Hagar, director of government relations for the California Psychiatric Association.
Slowly but surelY
Across the board, though, the mental health community is still in the early stages of developing treatments for children.
"The studies that demonstrate what to do in any of these cases are coming out, but they're coming out very slowly," Schreier said.
A significant obstacle in developing children's treatment is a lack of testing for child-appropriate doses of many medications. Before the Pediatric Research Equity Act of 2003, the Food and Drug Administration didn't have authority to require proof of drugs' safety and effectiveness.
In the years since the legislation, testing still lags because of a fear of experimenting on children.
Mental health medications fall into four categories: antipsychotic, antimanic, antidepressant and antianxiety. In a list of 29 mental health medications, more than half were approved only for ages 10 and older.
The majority of medications approved for children younger than 10 were stimulant medications for Attention Deficit Disorder and Attention Deficit Hyperactive Disorder.
"It will always be slower to get prescriptions for kids," Hagar said. "What has developed in place of a body of research is ... expert consensus."
When there's no FDA-approved child dose for a mental health medication, experts in the field discuss their own experiences with various drugs and doses and develop guidelines, called off-label prescriptions.
However, the process isn't as accurate as testing, and health care providers are not required to follow the guidelines.
"The big-deal issue arises when you think about age," Schreier said. "(The ADD medication) Ritalin is suggested not to start until you're 6 years old, but that's only because the drug companies only did their studies down to that (age)."
But a lack of testing alone doesn't mean medication would not be beneficial or shouldn't be used for a child, he said.
"You have a 3-year-old kid in preschools – and we have many of them – getting thrown out of preschool because they're so aggressive, hitting a kid with a chair, and you say we need to wait three years," Schreier said.
"Some people say 3-year-olds are all active," he continued. "Well, yeah, they're more active than 10-year-olds, perhaps, or a 15-year-old, but the fact is (if) you can distinguish an ADD kid ... it's crazy, then, to wait."
The medication debate
Some people hesitate to use drugs for fear of unnecessarily medicating or over-medicating their children. Unneeded medication can result from misdiagnosis or drugs' tempting simplicity.
"It's a lot easier to take a pill than sit through therapy," said Rusty Selix, the executive director and legislative representative for the Mental Health Association in California.
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