HISTORY: New school, old problems
Mr. E, age 13, was diagnosed with Down syndrome at birth and has mild mental retardation and bilateral sensorineural hearing loss. His pediatrician referred him to our child and adolescent psychiatry clinic for regressed behavior, depression, and apparent psychotic symptoms. He was also having problems sleeping and had begun puberty 8 months earlier.
Five months before referral, Mr. E had graduated from a small elementary school, where he was fully mainstreamed, to a large junior high school, where he spent most of the school day in a functional skills class. About that time, Mr. E began exhibiting nocturnal and daytime enuresis, loss of previously mastered skills, intolerance of novelty and change, and separation difficulty. Although toilet trained at age 7, he started having “accidents” at home, school, and elsewhere. He was reluctant to dress himself, and he resisted going to school.
The youth also talked to himself often and appeared to respond to internal stimuli. He “relived” conversations aloud, described imaginary friends to family and teachers, and spoke to a stuffed dog called Goofy. He would sit and stare into space for up to a half-hour, appearing preoccupied. Family members said he had exhibited these behaviors in grade school but until now appeared to have “outgrown” them.
Once sociable, Mr. E had become increasingly moody, negativistic, and isolative. He spent hours alone in his room. His mother, with whom he was close, reported that he was often angry with her for no apparent reason.
With puberty, his mother noted, Mr. E had begun kissing other developmentally disabled children. He also masturbated, but at his parents’ urging he restricted this activity to his room.
On evaluation, Mr. E was pleasant and outgoing. He had the facial dysmorphia and stature typical of Down syndrome. He smiled often and interacted well, and he attended and adapted to transitions in conversation and activities. His speech was dysarthric (with hyperglossia) and telegraphic; he could speak only four- to five-word sentences.
Was Mr. E exhibiting an adjustment reaction, depression, or a normal developmental response to puberty? Do his psychotic symptoms signal onset of schizophrenia?
Dr. Krassner’s and Kraus’ observations
Because Down syndrome is the most common genetic cause of mental retardation—seen in approximately 1 in 1,000 live births1—pediatricians and child psychiatrists see this disorder fairly frequently.
Regression, a form of coping exhibited by many children, is extremely common in youths with Down syndrome2 and often has a definite—though sometimes unclear—precipitant. We felt Mr. E’s move from a highly responsive, familiar school environment to a far less responsive one that accentuated his differences contributed to many of his symptoms.
Psychosis is less common in Down syndrome than in other developmental disabilities.2 Schizophrenia may occur, but diagnosis is complicated by cognition impairments, test-taking skills, and—in Mr. E’s case—inability to describe disordered thoughts or hallucinations due to poor language skills.3
Self-talk is common in Down syndrome and might be mistaken for psychosis. Note that despite his chronologic age, Mr. E is developmentally a 6-year-old, and self-talk and imaginary friends are considered normal behaviors for a child that age. What’s more, the stress of changing schools may have further compromised his developmental skills.
Which antidepressants are safe for treating pediatric depression?
The FDA’s recent advisory about reports of increased suicidality in youths taking selective serotonin reuptake inhibitors (SSRIs) and other antidepressants for major depressive disorder during clinical trials has raised questions about using these agents in children and adolescents. Until more data become available, however, SSRIs remain the preferred drug therapy for pediatric depression.
- Based on our experience, we recommend citalopram, escitalopram, fluoxetine, and sertraline as first-line medications for pediatric depression because their side effects are relatively benign. The reported link between increased risk of suicidal ideation and behavior and use of paroxetine in pediatric patients has not been clearly established, so we cannot extrapolate that possible risk to other SSRIs.
- Newer antidepressants should be considered with caution in pediatric patients. Bupropion is contraindicated in patients with a history of seizures, bulimia, or anorexia. Mirtazapine is extremely sedating, with side effects such as weight gain and, in rare cases, agranulocytosis. Nefazodone comes with a “black box” warning for risk of liver toxicity. Trazodone is also sedating and carries a risk of priapism in boys.
- Older antidepressants, such as tricyclics, require extreme caution before prescribing to children and adolescents. Tricyclics, with their cardiac side effects, are not recommended for patients with Down syndrome, many of whom have cardiac pathology.
By contrast, depression is fairly common in Down syndrome, although it is much less prevalent in children than in adults with the developmental disorder.2