About 5 percent of children become clinically depressed at some point during the transition to adulthood. Depression is a burden both for the adolescents and their families and carries a number of risks, including teen suicide. Results of a major clinical study, funded by the National Institute of Mental Health (NIMH), appear in the October 2007 Archives of General Psychiatry.

The study concludes that combining antidepressant medication and cognitive behavioral therapy is the fastest and safest way to treat depression. Medication alone can be quick and easy, but may elevate the risk of suicide even as it is improving depression.

Cognitive behavioral therapy alone can be very effective, but on average the teens stay depressed longer before improvement.

Combining the two delivers the fastest results, without increased suicide risk, and teaches teens the behavioral tools to handle future stresses. These results came from boys and girls 12 to 17 years old, from 13 different medical centers, and from a variety of ethnic and social backgrounds. The best treatment for an individual teen may depend on many factors, but for all teens I believe the option for both of these treatments should be readily available.

Too often medications aren’t considered and too often therapy isn’t adequately covered by payment systems. Now that an evidence-based approach to teen depression is gaining strength, perhaps more teens will get the support they need.

The TADS Team. The Treatment for Adolescents with Depression Study (TADS): Long-term Effectiveness and Safety Outcomes. Arch Gen Psychiatry. 2007;64:1132-1143.

At moments of stress, such as getting ready for bed or for school, some kids feel the need to touch certain objects, say certain words, or to wash and wash their hands. Some children have an overwhelming desire for sameness. For some, their thoughts keep returning to lurking fears, such as something bad is about to happen. When these thoughts or rituals get in the way of enjoying day-to-day life, this is called obsessive-compulsive disorder (OCD). Sometimes OCD starts following a strep throat infection, suggesting a physical cause.

About 1 in 200 kids in the United States are diagnosed with OCD, and most of these are treated with a medicine; some receive cognitive-behavior therapy (CBT). Researchers at the University of Pennsylvania and Duke University decided to evaluate what works better, 12 weeks of CBT, drug therapy alone, or a combination of the two. The important results appear in the October 27, 2004 Journal of the American Medical Association. The kids who did the best were the ones who got 12 weeks of CBT, either alone or with the drug in addition (with the edge going to the combination at one University, but not at the other). This suggests that, rather than most kids being treated with a drug, and some getting therapy, the norm should be for kids to get 12 weeks of cognitive-behavior therapy, and that some of them should also receive a medication. Even if the cause is physical, learning new ways to cope with stressful situations can be more important than medicines!

A recent study has changed my thinking about ADHD, and I hope it changes the way that all children with ADHD are evaluated and treated. And that parents are treated. Parents deserve better understanding and support than they traditionally get. Dr. Andrea Chronis and her team at the University of Maryland make a compelling argument that whenever children have ADHD, getting help for their parents should be thoughtfully undertaken.

ADHD tends to run in families. In the Maryland ADHD Program study of 214 children, the parents of children with ADHD were 24 times more likely to have ADHD themselves than were parents of children without ADHD. These results were published in the December 2003 Journal of the American Academy of Child and Adolescent Psychiatry. As is often the case, many kids in the study also had Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) in addition to their ADHD. Their parents had higher rates of depression and other psychological problems, including alcohol and other types of substance abuse.

Is this genetic? Or might it result from the increased stress of dealing with ADHD? Both are probably true to some extent. Significantly, all treatments for ADHD tend to be less effective when the parents have their own psychological issues. It makes sense that parent with ADHD might be less able to make needed environmental changes. Even medications, however, are less effective when the parents. problems are untreated. This has important implications.

Whether or not parents have symptoms of their own, they are likely to be under great stress. Dealing with a child with ADHD can be exhausting, frustrating, and embarrassing (as well as creative, energizing, and delightful). Listening to parents and offering practical support should start at the beginning of an ADHD evaluation and continue through the course of treatment. The treatment plan should be developed with this in mind.

‘Medications alone are not sufficient to treat ADHD,’ Dr. Chronis emphasized when we spoke about her study. ‘We need to look beyond the child to recognize and treat the parents’ issues,’ for their own sakes and for the sakes of the children. Dr. Chronis is the director of the Maryland ADHD Program.

When treating obesity in children, I know that success is most likely if the whole family eats healthier and spends more time being active . even if only one child is obese. It makes deep sense to me that family changes would also have the greatest impact in ADHD, even if parents don.t have psychological issues. If parents do have ADHD or are depressed, it makes sense that success in the children would be extremely difficult without helping everyone.

I hope I never look at a child with ADHD in isolation again.

About 69 percent of depressed children, aged 6 to 17, improved significantly while taking Zoloft for their depression, according to a study published in the August 27, 2003 JAMA, but data from the study suggests to me that another option may be an even better choice for some children. Zoloft is manufactured by Pfizer. I’m glad that Pfizer has funded a clinical trial on how the medication works in children. In this Pfizer-sponsored study, Zoloft was considered generally well tolerated. Each of the following side effects was seen in at least 5 percent of the children taking the medication, and at least twice as often as in the children in the study who only took placebo pills: insomnia, diarrhea, decreased appetite, vomiting, agitation, urinary incontinence, and purpura (bleeding into the skin or mucus membranes). Most of these side effects were considered mild or moderate by the researchers. Nine percent of those taking Zoloft in the study had to stop because of side effects. Children taking the medication tended to lose weight, while those taking placebo continued to grow during the study. The difference in weight change was about 1 pound per month between the two groups. There was no increase in suicidal behavior in those taking the Zoloft, unlike that found in some studies of children taking Paxilfor depression.

This study of Zoloft is important for two reasons. First, children do not respond to medicines the same way adults do. Even though children tend to have more side effects and less benefit than do adults with this medication, this study does demonstrate positive benefit in some children (again, unlike some studies of Paxil). There was a trend in the study suggesting that Zoloft becomes an even better choice at the upper end of the age range studied, with more benefit and fewer side effects.

But to me, what was most striking about the study was that fully 59 percent of depressed children taking the placebo pill had significant improvement in their depression and followed a very similar pattern of benefit to those taking the strong drug! At the beginning of the study, the children had an average CDSR-R depression score of about 64 points. Over the entire 10 weeks of the study, those taking the Zoloft had significant improvement – by an average of 22.84 points. Those taking the placebo also improved significantly, but clearly not quite as much – an average of 20.19 points. Depressed children deserve all the help they can get. It seems to me that identifying and addressing depression may be an even more important intervention than the modest extra benefit afforded by the prescription. Far too many depressed children suffer without this important help.