Parents should be careful not to expect too much from their children, but they shouldn't expect too little either. Children, even ones with a serious disorder like TS, have to make their way in the world, and that means learning to fit in and follow the rules. There are certain symptoms that a child with TS can't control, even when he is appropriately medicated, but there are others that can be reined in. Like any child, a youngster with TS must understand that there are limits. It's the parents' job to set and enforce these limits, to help a child to function in polite society. Allowing a child to behave badly does him no service whatsoever.

Out there in the real world people may not enjoy looking at facial tics or listening to throat-clearing, but those behaviors are tolerable in society. What people can't and won't tolerate is someone who shouts obscenities or touches everyone's food at the dinner table. A child must be told what will and will not be permitted. For example, a child who misbehaves in a restaurant should know that his actions have consequences.

"Look, this behavior is really unacceptable," a parent might say. "You have to stop arguing with us and cursing when we go out to a restaurant.

"Well, I have no control over it," the child might answer.

"Your mother and I think you can can control it. If you feel you are going to yell and can't control it, we think you should leave the table. If you can't control yourself, you won't be able to go out with us to dinner anymore." control it. If you feel you are going to yell and can't control it, we think you should leave the table. If you can't control yourself, you won't be able to go out with us to dinner anymore."

"But I can't help it."

"We think you can, and the doctor thinks so too. Here's an idea: if you feel the need to scream, excuse yourself from the dinner table and go wait in the bathroom until the feeling goes away."

I've spoken to parents who worry about punishing a child for behavior he can't control, and I sympathize with their concerns. But there's nothing punitive or even unreasonable about that exchange. A child is not being threatened with punishment because he can't stop blinking or sniffing. He's being asked to modify behavior that he can can control. By the way, this process of setting limits should be honored by the extended family, including close friends and doting grandparents. No one should be permitted to sabotage the parents' efforts. Everybody should know and abide by the rules. control. By the way, this process of setting limits should be honored by the extended family, including close friends and doting grandparents. No one should be permitted to sabotage the parents' efforts. Everybody should know and abide by the rules.

Psychotherapy is not part of the standard treatment package for Tourette syndrome, but parent counseling or family therapy can be extremely beneficial for all concerned as a family tries to invent ways to cope with a disturbing, sometimes all-absorbing brain disorder. Parents of kids with TS need all the education and support they can get, and many find it by joining parent support groups or patient support groups, such as the Tourette Syndrome a.s.sociation. The organization keeps its members up to date about the treatment of TS, publishes a regular newsletter, and sponsors various activities that bring together people whose lives are touched by TS. Once in a while they even arrange a movie screening. Their latest? Twitch and Shout Twitch and Shout, of course.

CHAPTER 14.

Major Depressive Disorder Until a month before I met her, Claire, 15 years old, had always been the life of the party. Attractive, bubbly, and smart, she made excellent grades, held down a job at a drugstore after school, and had an active social life, including a boyfriend. I first saw Claire just after the start of her junior year of high school. Her parents said that she hadn't really been herself since she returned from a summer away at camp. She'd been having trouble concentrating on her studies, she quit her job at the drugstore, and her boyfriend broke up with her. She'd been having a lot of trouble sleeping. Her parents said she was snappish and short with them and spent most of the day in her room. "Everything is an effort. I don't enjoy anything," Claire told me when we first met.

Charlie, also 15, was reading aloud in English cla.s.s one day, and right in the middle of A Separate Peace A Separate Peace he burst into tears. When the teacher took him to see the guidance counselor, Charlie was inconsolable, and his parents had to be called to pick him up. Everyone who knew the boy was baffled by what had happened. He seemed to have everything going for him-he was nice-looking, a talented musician, a good athlete, and a nearly straight-A student-but when he came to see me, he was sleeping all the time. For the past two months he'd been eating very little, and his weight was plummeting. He had stopped playing baseball. He said that he woke up every morning thinking that life wasn't worth living. he burst into tears. When the teacher took him to see the guidance counselor, Charlie was inconsolable, and his parents had to be called to pick him up. Everyone who knew the boy was baffled by what had happened. He seemed to have everything going for him-he was nice-looking, a talented musician, a good athlete, and a nearly straight-A student-but when he came to see me, he was sleeping all the time. For the past two months he'd been eating very little, and his weight was plummeting. He had stopped playing baseball. He said that he woke up every morning thinking that life wasn't worth living.

MOOD DISORDERS.

Until about 15 years ago-the year that Charlie and Claire were born-it was generally accepted that children couldn't be be depressed, not clinically at least. The thinking was that the egos of children were not sufficiently developed to be affected by mood disorders. Today we know better. There is irrefutable evidence that major depressive disorder, or MDD, does exist in children and adolescents. In prep.u.b.escent children it's quite rare, affecting only 1 to 2.5 percent of the population under the age of 12 and 2 to 8 percent of the population between the ages of 12 and 18. Among children it seems to affect boys and girls equally, but in the adolescent population females are more likely to have it. depressed, not clinically at least. The thinking was that the egos of children were not sufficiently developed to be affected by mood disorders. Today we know better. There is irrefutable evidence that major depressive disorder, or MDD, does exist in children and adolescents. In prep.u.b.escent children it's quite rare, affecting only 1 to 2.5 percent of the population under the age of 12 and 2 to 8 percent of the population between the ages of 12 and 18. Among children it seems to affect boys and girls equally, but in the adolescent population females are more likely to have it.

Depression is the most common brain disorder in America; each year some 8 to 14 million Americans are recognized as suffering from clinical depression. One survey found that 19 percent of all adolescents had experienced an episode of MDD.

"It's been raining all weekend. I'm so depressed."

"That movie was so so depressing." depressing."

"I had such a depressing day at work today."

"I can't believe the Yankees lost again. I'm incredibly depressed!"

We've all heard comments like those. Most of us have made them ourselves. Depression Depression is an overused word these days, describing our reaction to everything from a train crash to a failed souffle. Of course, true clinical depression-MDD-is a lot more serious than a bad day at the office. It's a serious mood disorder with very specific symptoms, and it requires prompt, active treatment. is an overused word these days, describing our reaction to everything from a train crash to a failed souffle. Of course, true clinical depression-MDD-is a lot more serious than a bad day at the office. It's a serious mood disorder with very specific symptoms, and it requires prompt, active treatment.

MDD may come and go, with occasional flare-ups; kids with MDD have their "ups and downs." For example, Charlie, described earlier in this chapter, had his first depressive episode back in the first grade. His mother says she knew there was something wrong, but she had no idea what it was. Then Charlie got better and stayed that way until fifth grade, when he went through a month-long period of being agitated and all but impossible to live with. That too pa.s.sed, and he was fine until that frightening incident in tenth-grade English cla.s.s, the one that led his parents to my office. MDD doesn't spring up overnight, although it may seem that way sometimes. Like a volcano, it simply lies dormant until some sort of crisis triggers the first episode.

Other children and adolescents suffer from dysthymia dysthymia, a milder, more chronic form of depression, which should be distinguished from MDD. If MDD is like a full-blown infection, dysthymia is like a chronic virus-with a low-grade fever, some aches and pains, perhaps a mild headache. Kids with dysthymia get the "downs," but they rarely experience any "ups." One child who fits this description perfectly is Dominick, 16 years old. To hear his mother tell it, Dominick is a child who never seemed to get any joy out of life. He was the best student in his cla.s.s and the star of the football team, but none of it seemed to make him happy. Getting an A on a test was incredibly important to him-he was completely focused and driven in his efforts-but when he got the A, there was no pleasure attached to the accomplishment. Dominick wasn't morose, but he had no zest for life. "He never cries, but I don't think I've ever seen him smile either," his mother said. Recent studies show that dysthymia may well be a stepping-stone to MDD. Dominick is a likely candidate for clinical depression.

THE SYMPTOMS.

Major depressive disorder in children and adolescents is characterized by at least two weeks of a nearly constant depressed mood severe enough to cause distress and dysfunction. (We look for the so-called depressed triad: depressed triad: feelings of hopelessness, helplessness, and worthlessness.) The two-week minimum requirement for symptoms rules out the many unpleasant events and situations that can and do cause people to be unhappy and even temporarily depressed, such as a divorce, a medical emergency, a family financial crisis, or any of a dozen other problems. (An important exception is bereavement. The period of mourning considered normal for a death in the family is two months.) If the depressed mood is not a result of MDD, it will wax and wane; it won't be predominant for two weeks. In addition to the two weeks of depression, a child or adolescent with MDD will have at least four of the following symptoms: inability to concentrate, irritability and anger, marked fatigue, feelings of worthlessness, sleep problems, appet.i.te disturbance, social withdrawal, restlessness, and decrease in libido. One final symptom of MDD that may be present is feelings of hopelessness, helplessness, and worthlessness.) The two-week minimum requirement for symptoms rules out the many unpleasant events and situations that can and do cause people to be unhappy and even temporarily depressed, such as a divorce, a medical emergency, a family financial crisis, or any of a dozen other problems. (An important exception is bereavement. The period of mourning considered normal for a death in the family is two months.) If the depressed mood is not a result of MDD, it will wax and wane; it won't be predominant for two weeks. In addition to the two weeks of depression, a child or adolescent with MDD will have at least four of the following symptoms: inability to concentrate, irritability and anger, marked fatigue, feelings of worthlessness, sleep problems, appet.i.te disturbance, social withdrawal, restlessness, and decrease in libido. One final symptom of MDD that may be present is anhedonia: anhedonia: the inability to experience pleasure. Most youngsters have had their symptoms much longer than two weeks by the time they receive professional help. the inability to experience pleasure. Most youngsters have had their symptoms much longer than two weeks by the time they receive professional help.

MDD manifests itself differently in children and adolescents. Very young children may not necessarily look or act sad, although some will have downcast eyes or a blank expression. In fact, many children with MDD will seem more oppositional than depressed. They'll be irritable and cranky; everything everything bothers these kids. Behavior disturbances such as hyperactivity, temper tantrums, and absence of normal play are not unusual. A small number of children, perhaps as many as a third, will have thoughts of suicide. They also often complain about various aches and pains,-headaches, stomachaches, even back troubles. Typically a depressed youngster will see his pediatrician or some other physician before finally making his way to a child and adolescent psychiatrist's office. bothers these kids. Behavior disturbances such as hyperactivity, temper tantrums, and absence of normal play are not unusual. A small number of children, perhaps as many as a third, will have thoughts of suicide. They also often complain about various aches and pains,-headaches, stomachaches, even back troubles. Typically a depressed youngster will see his pediatrician or some other physician before finally making his way to a child and adolescent psychiatrist's office.

In teenagers the symptoms of MDD tend to be a little different, more like those of depressed adults. Depressed mood, diminished ability to concentrate, sleep, and appet.i.te disturbance, sensitivity to rejection, a feeling of being weighed down, and thoughts of suicide are common symptoms. Depressed adults often undereat and undersleep; teenagers are more likely to overeat and oversleep. A lot of depressed adolescents sleep in the middle of the day, coming home from school and taking a nap. Then they wake up at seven or eight o'clock in the evening, grumpy and irritable. After having something to eat-probably not with their parents and the rest of the family-they're wide awake until three o'clock in the morning and have trouble waking up the next day for school. Sleep disturbance is a vicious circle.

Depressed teenagers often have an additional symptom: mood reactivity. mood reactivity. These youngsters are able to cheer up when they are in a positive interaction or environment. Chad, a 16-year-old boy I treated for MDD, was chronically irritable. He didn't eat much, showed no interest in television, and couldn't concentrate on his schoolwork. That was when he was home alone or with his family. When his friends came over, his mood would brighten; sometimes he seemed almost happy. His father was baffled and angry. "He must be doing this on purpose," he said. "How can he be so pleasant when his friends come and so miserable the rest of the time?" These youngsters are able to cheer up when they are in a positive interaction or environment. Chad, a 16-year-old boy I treated for MDD, was chronically irritable. He didn't eat much, showed no interest in television, and couldn't concentrate on his schoolwork. That was when he was home alone or with his family. When his friends came over, his mood would brighten; sometimes he seemed almost happy. His father was baffled and angry. "He must be doing this on purpose," he said. "How can he be so pleasant when his friends come and so miserable the rest of the time?"

Depressed teenagers may also be very sensitive to rejection and may have a tendency to be histrionic, with extreme reactions to real or imagined slights. One 16-year-old girl with MDD whose boyfriend broke a date with her went up on the roof of her house and threatened tojump off. She stayed up there for hours, feeling completely despondent. She told her mother and father that life wasn't worth living if her boyfriend didn't love her. The fact that he had canceled their date because he had to study for a test made no difference.

The irritability a.s.sociated with MDD can lead to very erratic, even violent behavior. A 14-year-old boy named Gerard was brought in to see me after pulling a knife on his father. Gerard had been having problems at school-skipping cla.s.ses on a regular basis and behaving badly when he did attend. On the days he didn't go to school, he would just lie in bed all day, mostly sleeping but occasionally watching television. He hardly ate at all. He had no social life, no friends. One evening his father lost patience with Gerard and told him he had to go to school or else, and Gerard became enraged. That's when he reached for the knife, after pounding on and then overturning the kitchen table. When I interviewed him, Gerard wasn't forthcoming about his symptoms at first except to say he was tired all the time. All he would tell me about the episode with the knife was: "My father made me mad."

THE DIAGNOSIS.

It is highly unlikely that anyone watching Gerard turn over that table and grab that kitchen knife would describe him as depressed. The word depressed depressed summons up images of a weepy, withdrawn child. By the same token, when a child or an adolescent does look unhappy or withdrawn or demonstrates any of the other symptoms a.s.sociated with clinical depression, there are many possible explanations besides MDD. Before making a diagnosis of major depressive disorder, a child and adolescent psychiatrist must take a detailed history by interviewing the child, the parents, and the teachers. Then he must systematically consider and rule out all the other possibilities, bearing in mind that co-occurent conditions are very common with MDD. summons up images of a weepy, withdrawn child. By the same token, when a child or an adolescent does look unhappy or withdrawn or demonstrates any of the other symptoms a.s.sociated with clinical depression, there are many possible explanations besides MDD. Before making a diagnosis of major depressive disorder, a child and adolescent psychiatrist must take a detailed history by interviewing the child, the parents, and the teachers. Then he must systematically consider and rule out all the other possibilities, bearing in mind that co-occurent conditions are very common with MDD.

It's not uncommon for kids with MDD also to have an anxiety disorder, especially separation anxiety disorder (discussed in Chapter 9 Chapter 9) and social phobia (Chapter 10). Studies have shown that nearly half of the children diagnosed with MDD will have an anxiety disorder as well. Leonard, a 16-year-old boy I treated for MDD, was originally diagnosed with social phobia. When I first met him, Leonard told me that he had been feeling unhappy for five years. The other kids think he's weird, and he's afraid to talk to people at school, he told me. He would like to have friends, but he doesn't know how. Leonard's mom and dad have their own theories. Dad says that the problem is that Leonard has always had low self-esteem. Mom says it all started because Leonard is the smallest kid in his cla.s.s, and that makes him feel inadequate. One thing I learned during that first visit was that lately Leonard has been having a lot of trouble sleeping. He's been suffering from both initial insomnia initial insomnia (trouble falling asleep) and (trouble falling asleep) and middle insomnia middle insomnia (waking up in the middle of the night). Both sleep disturbances are common symptoms of MDD. (waking up in the middle of the night). Both sleep disturbances are common symptoms of MDD.

Major depressive disorder may sometimes look a lot like attention deficit hyperactivity disorder too (see Chapter 7 Chapter 7). Not too long ago I saw a little eight-year-old boy who was sent to me by a neurologist because of his disruptive behavior at home. He behaved himself at school well enough, but after school he would bang on the walls of his bedroom until he made holes in them. Almost anything would set set him off. He was agitated and cranky all the time, and he had many physical complaints. Nothing gave him pleasure. When his parents didn't give him his way, he went ballistic. My eventual diagnosis was MDD. him off. He was agitated and cranky all the time, and he had many physical complaints. Nothing gave him pleasure. When his parents didn't give him his way, he went ballistic. My eventual diagnosis was MDD.

Yet another relative of MDD is CD: conduct disorder (Chapter 18). Jamie, a 16-year-old boy, came in because he was irritable, fresh, and always getting into trouble both at home and out in the world. He was terrific at sports and a very good artist, but his academic achievement left a lot to be desired. He frequently cut cla.s.ses and had lots of fights after school. A psychologist had given Jamie's parents the diagnosis of CD, and there was no question that Jamie had it. It turned out that he also had MDD. (Depressed kids are often regarded as oppositional because of their irritability.) It took me a few weeks to find out that Jamie was also feeling, in his words, empty. "I felt like nothing. I felt like: Why move? Why get out of my chair?" he told me. It's important to remember that teenagers Jamie's age, and particularly those considerably younger than Jamie, don't necessarily speak the language of MDD. They don't say they're depressed or blue or gloomy or morose or any of the many words an adult might choose. Empty Empty was the closest Jamie could get. was the closest Jamie could get.

Another disorder that must be ruled out is schizophrenia (see Chapter 16 Chapter 16). This can be a tricky business sometimes, because children and teenagers with MDD may have delusions and other psychotic symptoms. The key here is that the delusions and hallucinations are all mood congruent-consistent with the mood of the youngster-and, in their own way, logical. For instance, kids with MDD will be depressed because they think they're dying, or they may hear voices that criticize them. When I met Franklin, I was all but certain that he had schizophrenia. He had just dropped out of college, and he had all sorts of symptoms: obsessions, compulsions, anxieties, the works. He thought his eyes eyes were burning, so he had to look down at the floor all the time. He also constantly inspected his hair and his clothes. He told me he felt sad all the time, and he couldn't sleep. After a lifetime of accomplishments-he had good grades in high school, and he was a varsity basketball player-Franklin had zero confidence in his abilities. "I feel as if I've lost myself," he told me. "When I lie in bed, I have to keep checking to see if my heart is still beating. I'm sure I have a tumor in my chest." Franklin's delusions sounded like schizophrenia, but further investigation pointed toward MDD. were burning, so he had to look down at the floor all the time. He also constantly inspected his hair and his clothes. He told me he felt sad all the time, and he couldn't sleep. After a lifetime of accomplishments-he had good grades in high school, and he was a varsity basketball player-Franklin had zero confidence in his abilities. "I feel as if I've lost myself," he told me. "When I lie in bed, I have to keep checking to see if my heart is still beating. I'm sure I have a tumor in my chest." Franklin's delusions sounded like schizophrenia, but further investigation pointed toward MDD.

Chronic fatigue syndrome is another disguise in which major depressive disorder may appear. That's what everyone thought was wrong with 14-year-old Nellie, who came to see me after she had been sick for over a year. Nellie had always done well in school, but friends didn't come easily, even back in elementary school. The other kids teased her a little back then because she was so shy and awkward. By the seventh grade she had no friends to speak of, but no one really knew why. At the beginning of the ninth grade Nellie had mononucleosis, which basically put her out of commission for a couple of months. She was better by Christmas, but in February she had a relapse. She was tired all the time. In March her pediatrician diagnosed chronic fatigue syndrome and sent her to school with a note saying she should take a nap every afternoon.

Fatigue was just the beginning of Nellie's symptoms. Before that school year was over, her list of complaints was quite long. She couldn't concentrate; she cried all the time; and for the first time ever, she didn't make the honor roll. Her appet.i.te was terrible, and although she went to sleep every night at nine and got up at six, she woke up several times during the night. The, reason I didn't have the opportunity to see her-and diagnose her MDD-for nearly a year is that her parents and everyone else around her thought that all her new symptoms were simply an offshoot of her chronic fatigue syndrome. They thought Nellie was just tired from her illness and overwhelmed by the workload of a regular teenager.

In the process of making this very elusive diagnosis of major depressive disorder, the child and adolescent psychiatrist must eliminate one last disorder, the one most closely related to major depressive disorder: bipolar disorder. As will be explained in Chapter 15 Chapter 15, bipolar disorder combines depression and mania, a sustained "high." With major depressive disorder (occasionally referred to as unipolar disorder) there is depression but no mania.

The best way of diagnosing major depressive disorder in children and adolescents is to come face to face with the troubled child. The essence of the diagnosis for MDD is hearing the youngster's responses and getting a feel for his mood.

THE BRAIN CHEMISTRY.

When I was growing up, everybody thought that acne was caused by eating chocolate: if we ate chocolate, we'd get pimples. Of course, lots of kids ate chocolate and didn't get pimples. Some ate chocolate and got a few now and then. And then there were the poor kids who didn't eat any chocolate but had terrible skin anyway. Today we know that chocolate isn't the culprit; some people are just vulnerable to acne. Certain external factors may bring on acne and make it worse, to be sure, but the vulnerability has to be there first.

It's a lot like that with MDD. There are internal and external events that may bring on a depressive episode, but the vulnerability-in this case a neurochemical vulnerability-has to be there first. Demoralizing or tragic events don't make everyone depressed; some people are born invulnerable. Given sufficient stress, both physical and psychological, nearly everyone has some sort of physical reaction; asthma, high blood pressure, ulcers, colitis, migraines, and even cold sores can be brought on by stress. In some people it's the brain that's affected, and a depressive episode is the result. It's important to remember, however, that it wasn't the death in the family, the breakup with a boyfriend, or the five straight days of rain that caused the depression. The cause of MDD arises in the brain.

The chemistry of a child's brain is what determines his vulnerability to MDD. A child inherits brain chemistry from his parents, so, not surprisingly, depression runs in families. Children whose parents have MDD have a greater than average chance of having MDD themselves; the relatives of youngsters with MDD are more than twice as likely to have the disorder than the relatives of normal kids. Abnormal responses have been reported in depressed adolescents during challenge testing of their endocrine system. These tests are not diagnostic, but they lend support to a biological basis for MDD.

The neurotransmitters that improve our mood or keep it stable are dopamine, norepinephrine, and serotonin. Any imbalance in these three neurotransmitters may account for an onset of MDD, but it is generally thought that underactivity of either serotonin or norepinephrine is largely responsible. In addition to those neurotransmitters the brain also produces endorphins, the chemicals that give people satisfaction or a sense of joy. Both internal and external stressors can have a strong effect on all of the brain's chemical components. In an effort to "fix" what is causing their child pain, parents often spend too much time and effort trying to puzzle out what might have caused a child's depressive episode and not enough time and effort seeking treatment. To treat the disease, it's not necessary to know what causes depression. Saying, "Oh, his parents are getting a divorce. That's why he's depressed" is a typical response. MDD can't just be explained away. It can't be willed away either, although there are many people who would like to think so. "If she would just pull herself together" and "If she would just stop feeling sorry for herself" are typical reactions to depression in both children and adults. Years ago I met a woman who had MDD episodes after the birth of each of her children. For the first five kids she didn't seek help, and no one encouraged her to do so. She figured she just needed to pull herself out of it; seeing a psychiatrist was a sign of weakness. After the birth of her sixth child she ended up in the hospital, psychotically depressed. Even then she was reluctant to talk about her symptoms. She felt guilty and ashamed. "Having babies is the most natural thing in the world," she said. "What's wrong with me?"

THE TREATMENT.

The best treatment for MDD is a combination of pharmacotherapy (antidepressants), psychotherapy, and family intervention. The medications that are the most effective and most commonly prescribed for MDD are the SSRIs (selective serotonin reuptake inhibitors), especially Prozac but also Zoloft, Paxil, and Luvox. The side effects, which are mild and infrequent, are diarrhea, nausea, and sleeplessness. Parents and children are amazed at how fast the SSRIs work sometimes. The parents of a severely depressed 10-year-old girl for whom I had prescribed Prozac reported that her symptoms began to disappear in only three weeks.

Another group of antidepressants used in treating children and adolescents with MDD are TCAs (tricyclic antidepressants): Tofranil, Pamelor, Elavil, and Norpramin. These medicines take longer to work than the SSRIs; they require four to six weeks for a clinical response. The nuisance side effects of the TCAs are dry mouth, constipation, and drowsiness, but they may also have an effect on the cardiovascular system. Before the medication is started and before the dose is increased, a youngster should have his blood pressure and pulse measured and he should have an electrocardiogram. These medicines need to be monitored carefully, since an overdose can be lethal. There have been several reports of sudden death of children taking Norpramin, but there is no proof that the Norpramin caused the deaths. When a child's MDD is severe and other medications have not been effective, Norpramin may still be the answer. The nuisance side effects of Norpramin are minimal, and it does does work. work.

Also occasionally prescribed for MDD are the atypical antidepressants, especially Wellbutrin and Trazadone. Wellbutrin has been used in patients who have not responded to either the SSRIs or the TCAs. Side effects of Wellbutrin are agitation, restlessness, and irritability, but they are infrequent, and they nearly always disappear over time or with a lower dose. Trazadone is usually given in addition to another antidepressant. The most common side effects-sedation, increased blood pressure, dizziness, and nausea-are mild and transient. A rare but serious side effect of Trazadone is priapism, a prolonged erection without s.e.xual stimulation. For obvious reasons, Trazadone should not be prescribed for adolescent males.

A group of antidepressants that have been used in adolescents with MDD who have not responded to other antidepressants are the MAOIs (monamine oxidase inhibitors): Nardil, Parnate, and Marplan. Dietary restrictions are required with these medications. Foods that are rich in tyramine, such as aged cheese, beer, red wine, smoked fish, and aged meats, interact with MAOIs to produce a hypertensive reaction: severe headache, palpitations, neck stiffness, nausea, and sweating. Because of the difficulty of monitoring the diet of a child or adolescent, we usually stay away from the MAOIs.

Synthetic thyroid hormones have been used to increase the effectiveness of antidepressant medications, especially in adolescents with MDD who have responded partially or not at all to antidepressants. The hormones most frequently used are T3, Cytomel; and T4, Synthroid. The side effects are weight loss and nervousness, but they are unusual.

Parents whose children are taking medicine worry about a lot of things. When the child or teenager is being treated for MDD, we often hear parents voicing concern, even fear, that the child will become addicted to the drug. Some drugs that alleviate depression are are addictive-cocaine and speed are two of the best known-but these drugs are different from the medicines we prescribe. When the effects of cocaine and speed wear off, there is a "crash" and a strong desire for more of the drug. The antidepressants aren't like that. A child may well addictive-cocaine and speed are two of the best known-but these drugs are different from the medicines we prescribe. When the effects of cocaine and speed wear off, there is a "crash" and a strong desire for more of the drug. The antidepressants aren't like that. A child may well need need to take this medication in order to rid himself of the MDD symptoms that are causing distress and dysfunction, but he will not become addicted. to take this medication in order to rid himself of the MDD symptoms that are causing distress and dysfunction, but he will not become addicted.

An adolescent diagnosed with major depressive disorder may benefit from this medicine for a long time. Even with the medication, however, he may have an occasional relapse, usually brought on by stress. About 50 percent of all depressed children will have a second depressive episode within five years of the first.

The most significant problem a.s.sociated with prescribing medication for MDD is that kids often take themselves off the medication, even though the beneficial effects of the medicine are nearly always quite obvious. I prescribed Tofranil for Wesley, a 17-year-old boy who was almost completely dysfunctional when he came to see me. He didn't go to school or see friends. He barely left his bed. After a few weeks of the medication he was going to school every day and holding down a part-time job in his father's store. He didn't have any friends yet, and he still felt, in his own words, "lousy." He decided that the medicine wasn't doing him any good-he wasn't happy happy, after all-so he stopped taking it. Shortly after that Wesley took to his bed again, until we got him back on the medication.

Lynn, a 14-year-old girl I treated for MDD, had a long-standing love-hate relationship with her medication. A bright girl with normal intelligence, she had a strong family history of MDD. Her older brother had attempted suicide a year earlier, and she herself had seriously considered taking her own life. Lynn responded well to Prozac, and cognitive behavioral therapy with a psychologist was progressing nicely. She was, she told me, "feeling pretty good." The problem was that she didn't like the idea of taking medication even if it did make her feel better. Her mother wasn't happy about the medicine either and made no effort to disguise her feelings. Lynn was constantly asking to be taken off the medicine. "I'm feeling so much better now. I'm sure I'll be fine," she said. When I told her she needed more time with the medicine, she took herself off it anyway. Her depression got worse almost immediately; she stayed in bed all day, crying and overeating. Her thoughts of suicide returned. Even in her severely depressed state Lynn knew that she needed to start taking the medication again.

Parents will have to monitor a child's medication, but the more involved a child is in the treatment process, the better the results will be. A youngster who understands that something is wrong with him and accepts the fact that this little pill is helping him to feel better is more likely to thrive than one who is kept in the dark about what's going on or someone who is terribly resistant to the medication. Adolescents-Wesley and Lynn, for example-should be encouraged to take the initiative in their own treatment, especially since mothers and dads don't typically have a great deal of power or influence over them anyway.

I find that making an adolescent take responsibility for treating his own illness may serve as a kind of wake-up call. "Okay. Why don't you try yourself without medication for the next two weeks and we'll see how it goes?" I said to one of my teenage patients recently. "But I want you to call me next week and report in about your symptoms. And that means you. you. I don't want your mother to call me. And I don't want to have to call you. This is your job now. You have to tell me what's going on." With the right kid, that strategy can work miracles. I don't want your mother to call me. And I don't want to have to call you. This is your job now. You have to tell me what's going on." With the right kid, that strategy can work miracles.

Medication is an indispensable part of the treatment for MDD, but therapy, especially symptom-oriented therapy, also plays a vital part. Cognitive psychotherapy helps a child or adolescent to change the negative thinking that is symptomatic of MDD and work on improving his social skills so that he can make friends. Like children with social phobia, kids with MDD have to learn how to meet people and talk to them, and this requires preparation and rehearsal. Children with MDD have to learn how not not to be depressed, and that takes practice and informed instruction. Professionals can be an immense help. to be depressed, and that takes practice and informed instruction. Professionals can be an immense help.

A specific treatment program for MDD, called interpersonal psychotherapy (IPT), has been helpful in the treatment of adults with milder forms of MDD, and recently it has been used for adolescents as well. The 16-week program, which focuses on helping the adolescent understand his illness and exploring how it affects his interpersonal relationships, can be extremely helpful in combination with the right medication.

Family intervention is often very beneficial as well. It helps the child, the parents, and the rest of the family to understand the nature of MDD as well as the treatment process. Parent counseling may provide insights about making changes in the child's environment and resolving school and family problems that may have contributed to the depression in the first place.

Often regarded as a last resort, electroconvulsive therapy (ECT) has been effective in treating severely depressed adolescents who have been unresponsive to any other treatment. ECT induces a seizure in the patient while he is under anesthesia. A series of eight to twelve sessions is usually required. Although widely misunderstood and almost as widely maligned, ECT has been shown to be a safe procedure that can produce wonderful results with no long-term side effects.

Prompt treatment makes a big difference in the prognosis of this disorder. The earlier MDD is treated, the shorter and less severe any subsequent depressive episode is likely to be. Left untreated, MDD will get worse; the episodes will last longer and be much more serious.

PARENTING AND DEPRESSION.

"I can't remember a time when there wasn't something wrong with Aaron," recalled the mother of a teenager who was diagnosed with MDD nearly ten years earlier. "He has always been moody and irritable. When he was three years old, he'd get angry at us and stalk off and slam the door. He was hard on himself too. From the beginning my husband thought we should get some help, but I just couldn't face the idea that such a little boy could need a psychiatrist. By the time he was five, he was talking about death all the time. That's not something you expect in a small child. Everyone suspected that he was depressed. On his sixth birthday we took Aaron to see his first psychiatrist."

Aaron's mother is not alone in her reluctance to accept the fact that she has a clinically depressed child. Emotions run very high with this disorder, and it is the rare parent who doesn't react with strong feelings to the behavior of a child with MDD. Anger and frustration are especially common, since these kids are usually sullen and difficult to manage. Generally speaking, children with MDD are not very pleasant to be around, and it's not unusual to discover that their parents don't like them all that much. "I feel terrible about this, but I actually dislike my own daughter," said the father of a 10-year-old. I've heard that comment, or some variation thereof, dozens of times.

Teenagers with MDD can be particularly annoying to their parents because it seems that they often have enough energy to do certain things, such as go out with their friends, but not others, such as their homework. They're pleasant enough when they're in the outside world and save their sullenness and their lethargy for the folks at home. There are occasions too in which a child is unpleasant with one parent but not the other. As difficult as it is to manage sometimes, parents have to realize that the behavior of a child with MDD is not willful. He's not being impossible on purpose.

Most parents of kids diagnosed with MDD feel more than a little guilty too. After all, it is a parent's job to make his child happy. Being happy is a basic essential of life. If a kid is depressed, the thinking goes, it must mean that the mother and father are doing something wrong. None of this is true, of course, but even parents who know better sometimes consider themselves dismal failures. The feelings of parental guilt a.s.sociated with this disorder are very strong, particularly when a child tries to commit suicide. One of the many reasons we recommend parent counseling is that it helps parents understand that no one no one-not the parents, not the child-is to blame for this disease. There's no reason for a parent to feel guilt or shame.

Another way in which parent counseling can be useful is to help parents redefine and come to terms with their special role as the mother and father of a child with major depressive disorder. Being the parent of a child or adolescent with MDD isn't easy, to say the least. There are all sorts of unexpected questions that may arise, especially as a child moves through adolescence to adulthood.

"I never know how much slack to cut her," said the mother of a 15-year-old girl diagnosed with MDD. "I know I have a right to expect things from her, but it takes so much effort for her to do the easiest things. I don't want to ask her to do too much and put a lot of unnecessary pressure on her. On the other hand, I don't want to let her off the hook about everything just because she's sick." This mother makes an excellent point. Sooner or later her daughter will have to take her place out in the world, and it's her parents' job to prepare her for that day. Parent counseling will bring these issues out into the open.

Even when a teenager is diagnosed with MDD, parents have to learn to let go a little and encourage a child to be independent. Allowing a child to make his own decisions is difficult for any parent; when a child's decision-making abilities are impaired by major depressive disorder, it can be nearly impossible.

"I've always been a little overprotective; I admit it," said one mother. "My older daughter is 21 years old and perfectly normal, and I still interfere in her life too much. My 19-year-old is the one who's depressed, and I have to remind myself constantly not to take over her life. I'm tempted to ask her every day if she's taking her medication and to call the doctor to see if she's showing up for her appointments, but I don't. I know that would be wrong."

Yes, that would be wrong, but the impulse is perfectly understandable. Knowing when to get involved and when to step back and let it happen is a real skill for any parent. Here's how yet another mother, whose 22-year-old clinically depressed son has just moved into his own apartment for the first time, expresses the conflict: "Part of me wants to let him go completely-say, 'It's your life and your problem.' But then I think, 'Wait. If my son had a broken leg, I wouldn't just point to the stairs and wish him the best of luck getting to the top. I'd get him a crutch or let him lean on me. Together we'd work out a way for him to get to the second floor.'"

CHAPTER 15.

Bipolar Disorder/Manic Depressive Illness According to his parents, Leo, nearly 14 years old, had been perfectly normal until about a year before he came to my office for the first time. At the age of 13 the boy had been doing well in school, and he'd had a full social life as well, with plenty of friends and activities. But then things started to change. Leo became rambunctious and difficult to deal with. He was very sad at times, becoming tearful and even crying quite often, and his judgment was poorer than it used to be. He dyed his hair bright red and then streaked it with purple. Then he got himself a small tattoo. Mom and Dad thought it was a rebellious teenager phase at first. Then Leo's behavior became even more worrisome. He overslept often and virtually had to be forced to go to school. He complained of headaches, neck discomfort, and other a.s.sorted pains. He was totally enervated one day and so energetic the next that he claimed he didn't need sleep. Instead he'd stay up all night practicing the guitar. When I talked to Leo about his music, he told me, in the most matter-of-fact way, that he needed to practice. He was going to be a huge huge rock star. rock star.

For the last few months Molly had been talking to herself a great deal, but her mother figured that her daughter was just rehearsing for the school play. At 16, Molly was quite pa.s.sionate about acting. For the three weeks before I met Molly, the girl had been "blue," as her mother put it-withdrawn and isolated from her friends and family, unable to concentrate on her studies. Then, two days before Molly came to see me, she came out of her funk with a vengeance. She was yelling and screaming incoherently and talking nonstop even when no one was around. She would eat only when forced to do so and hardly slept at all. By the time I saw Molly-and checked her into the hospital for a short stay-she was out of control, talking incessantly (mostly about Madonna) and singing songs from The Sound of Music. The Sound of Music. Her first night in the hospital she took off all her clothes and danced in the bathroom. The nurses said that Molly appeared to be having the time of her life. Her first night in the hospital she took off all her clothes and danced in the bathroom. The nurses said that Molly appeared to be having the time of her life.

HIGHS AND LOWS.

Adolescents are moody. That's an indisputable fact, like the sun rising in the east. Parents of teenagers expect erratic behavior from their kids, and so they should. Adolescence is a time for change of all sorts, and hormones tell only part of the story. Kids also go through some important developmental stages at this point in their lives, the most significant of which are separating from Mom and Dad and coming to grips with their s.e.xuality. Normal, healthy teenagers will accomplish these tasks without too many casualties, although there will probably be some serious power struggles along the way. Rebellion and moodiness come with the territory.

The territory occupied by bipolar disorder-also called manic-depressive illness manic-depressive illness-is characterized by a very different, much more serious brand of moodiness. This disorder involves intense, persistent moods that are clearly different from and much more intense than the child's usual demeanor and are extremely inappropriate to the event and the environment. The mood swings must be severe enough to cause distress and dysfunction.

The word bipolar bipolar refers to the two poles of this very serious disease: mania and depression. ( refers to the two poles of this very serious disease: mania and depression. (Chapter 14 covered major depressive disorder, or covered major depressive disorder, or unipolar unipolar disorder.) A child with bipolar disorder will have had at least one episode of mania-or disorder.) A child with bipolar disorder will have had at least one episode of mania-or hypomania hypomania, a milder, less intense version of mania. The symptoms of mania are distractibility, irritability, grandiosity, racing thoughts, a decreased need for sleep, an increased speed of speech, poor judgment, increased risk-taking behavior, and a break in reality testing, usually characterized by delusions and hallucinations. An adolescent having a manic episode, which may last anywhere from several days to a few months, typically will feel hypers.e.xual and expansive, will have unrealistic expectations about his performance, and will make rash decisions and spend money recklessly. A 16-year-old girl I treated once took her mother's credit card and bought a plane ticket to Boston to see a rock concert. Another time she was caught shoplifting. "I'm a movie star," she told the security guard. "My agent will pay for this stuff."

"Having Rory around is like watching an episode of Lifestyles of the Rich and Famous" Lifestyles of the Rich and Famous" said a fed-up father of a 17-year-old boy in the middle of a manic episode. "He likes only the finest things-the best watches and the best luggage and the best clothing. One day he charged a $500 ski parka, a $300 pair of alligator shoes, and two Armani sweaters and had it all sent home by Federal Express. Of course, he put everything on said a fed-up father of a 17-year-old boy in the middle of a manic episode. "He likes only the finest things-the best watches and the best luggage and the best clothing. One day he charged a $500 ski parka, a $300 pair of alligator shoes, and two Armani sweaters and had it all sent home by Federal Express. Of course, he put everything on my my credit card." credit card."

To be diagnosed with bipolar disorder adolescents must also have had a depressive episode, which lasts anywhere from two weeks to several months. Its symptoms are loss of concentration, sleep disturbance, change in appet.i.te, fatigue or decreased energy, agitation, lethargy, a feeling of worthlessness, and an inability to experience pleasure.

The incidence of bipolar disorder in children and adolescents is not known. The lifetime risk of bipolar disorder is about 1 percent among the general population-affecting men and women just about equally-but it can be much higher in families in which other members have mood disorders. The condition is very rare in children under the age of 12, although there have been reports of bipolar disorder in children as young as four.

Bipolar disorder often starts in adolescence, but is not recognized and diagnosed until much later, when kids become older and display cla.s.sic adult symptoms. A survey conducted by the National Depressive and Manic-Depressive a.s.sociation found that 59 percent of those surveyed reported suffering their first symptoms of bipolar disorder during childhood or adolescence. The age of onset of bipolar disorder is most frequently between 15 and 19.

THE SYMPTOMS.

The distress and dysfunction a.s.sociated with bipolar disorder can vary greatly, depending on the severity of the illness and which of the two poles-mania or depression-is "in charge." When adolescents with bipolar disorder are in the depression stage of this condition, they're usually pretty miserable. (The elements of the "depressed triad" say it all: feelings of hopelessness, helplessness, and worthlessness.) Mania is something else again. "You don't know what you're missing, Doc," one of my patients told me, describing what it's like when he's manic. "There's really nothing like it. I feel great. I look handsome. I'm brilliant. There's nothing I can't do." Patients in a hypomanic phase are often productive and very pleased with themselves. As long as they are in that state, their heads are filled with ideas, and they have the energy to act on them.

Most of the kids eventually diagnosed with bipolar disorder come to my office complaining about depression. I've had only one patient who complained about mania, a shy, soft-spoken, extremely religious 16-year-old girl. She told me that what bothers her most about her illness is her conviction that she's better than everybody else. "I don't want to be better than everybody else. I don't want to feel this way. It's a sin," she told me.

Patients in the mixed state mixed state-described by some experts as being trapped between depression and mania but not quite in either one-are usually in a lot of pain. The combination of feeling sad and worthless and weighed down and, at the same time, having racing thoughts and delusions of grandeur is incredibly exhausting and upsetting to adults; it can be devastating to a child or an adolescent. Many of the patients I've treated say they feel out of control, all revved up but depressed and crying at the same time. It's in this mixed state that distress and dysfunction are often most severe.

One final term to address is rapid cycling. rapid cycling. Officially defined as four or more distinct mood episodes in one year, rapid cycling may involve even more abrupt and frequent mood swings: up one day and down the next sometimes. Rapid cycling is relatively rare, however. Only about 20 percent of all patients with bipolar disorder have it, and most of them experience it relatively late in the illness. It is much more typical to hear the cycle described the way the mother of one of my young patients put it: "She's not up and down, up and down, up and down. She's down and then she's normal. Then she has an episode where she's really up, and we worry about her doing something dangerous and foolish. Then there's a long period of time when things are okay again. Then she's down again." Officially defined as four or more distinct mood episodes in one year, rapid cycling may involve even more abrupt and frequent mood swings: up one day and down the next sometimes. Rapid cycling is relatively rare, however. Only about 20 percent of all patients with bipolar disorder have it, and most of them experience it relatively late in the illness. It is much more typical to hear the cycle described the way the mother of one of my young patients put it: "She's not up and down, up and down, up and down. She's down and then she's normal. Then she has an episode where she's really up, and we worry about her doing something dangerous and foolish. Then there's a long period of time when things are okay again. Then she's down again."

Bruce, who turned 15 just a few days before I first met him, was a cla.s.sic case of rapid cycling bipolar disorder. His parents said that Bruce had been having troubles for about three months. He was withdrawn and somewhat irritable, and his sleep/wake cycle was reversed; he was sleeping in the daytime and staying awake almost all night. He would go on sleeping binges, staying in bed for days on end, and then he wouldn't sleep for 48 to 60 hours straight. All night long he would sit at his computer, totally absorbed in the intricacies of the Internet and communicating with people all over the world. When he finally got bored with his computer bulletin boards, he turned to the Home Shopping Network and ordered hundreds of dollars worth of merchandise. When I talked to Bruce, he was sweating profusely and talking a mile a minute. The topic he liked most was himself. He couldn't decide whether he should be president of the United States or play center for the New York Knicks.

Benjamin, 15 years old when I started treating him, had a full-blown manic episode during the two weeks he was away at camp last summer. According to the camp counselors, Benjamin was withdrawn and almost morose when he arrived at the camp, but over the course of that first week he became increasingly euphoric and irritable. He would talk very fast, sometimes so fast that no one could make sense sense of what he was saying. As the week wore on, he stopped sleeping and started masturbating several times a day. He also began to spend large amounts of money on inconsequential items for himself and everybody else in the cabin. He found a Bible and read it all the time, sometimes aloud to his bunkmates. I later learned that Benjamin was reading the Bible for a specific reason: he thought that he'd been chosen by G.o.d for a special purpose. of what he was saying. As the week wore on, he stopped sleeping and started masturbating several times a day. He also began to spend large amounts of money on inconsequential items for himself and everybody else in the cabin. He found a Bible and read it all the time, sometimes aloud to his bunkmates. I later learned that Benjamin was reading the Bible for a specific reason: he thought that he'd been chosen by G.o.d for a special purpose.

The reason behind a symptom can often be instructive in identifying any disorder. Ann-Marie, a 16-year-old girl I treated quite recently, had a couple of symptoms with especially significant explanations. Her father brought her in because her teachers and the princ.i.p.al of her school told Ann-Marie's parents that something was seriously wrong with their daughter. "I've been going to these parent-teacher conferences ever since she was in kindergarten," he told me. "This is the first time I've ever heard any complaints." The teacher told the father that Ann-Marie had taken to getting up in the middle of cla.s.s, walking around the room, giggling, and talking back to the teacher. She was looking strange too, dirty and unkempt and often dressed in odd color combinations. Her handwriting, once so tidy and precise, had become very flamboyant. She refused to make eye contact, they said. Ann-Marie's parents told me that her behavior at home was a little strange too. She had been talking to herself, and she became terribly upset whenever the television was on. Every time anyone turned on the set, Ann-Marie would rush to switch it off.