Guest Editorial
Reflections
on Special Education, 2004
By Harold S. Koplewicz, M.D.
This month's issue of Education Update is dedicated to special
education, which usually connotes images of students in wheelchairs
or with severe learning disabilities. However, the 10 million
children and adolescents in the United States who suffer from
a psychiatric disorder are rarely considered, yet these disorders
are also barriers to learning.
While most schools now recognize that Autism, Asperger's and
even Attention-Deficit/Hyperactivity Disorder (ADHD) impair
learning without effective intervention, students with ADHD
in particular are more likely to drop out of school and spiral
into a downward cycle involving substance abuse and incarceration.
But most do not realize that two million teenagers in the United
States suffer from depression. These are not simply spoiled,
demoralized or sullen teens; they have a medical condition
that affects their appetite, concentration, sleep and motivation.
Because of these symptoms, these students often have trouble
with school attendance and performance, and some try to medicate
themselves with alcohol, marijuana and other illicit substances.
Unfortunately, due
to the national shortage of child and adolescent psychiatrists
(under 7,400) and lack of health insurance parity, many teens
were receiving antidepressant medications from primary healthcare
physicians. While the overwhelming majority of children and
adolescents who took these medicines had only nuisance side-effects,
a small percentage developed agitation and disinhibition,
which sometimes led to self-destructive behaviors and suicidal
thoughts. In controlled studies of over 4,000 teenagers with
depression, not a single teenager committed suicide. But
in the general population, there have been tragic scattered
reports of suicides. This led to a new FDA “black box” warning
on all antidepressants, which will unfortunately lead to fewer
teens with depression getting the treatment they need.
It's important for us to note that
during the past decade, the suicide rate among teenagers, while still too
high, decreased by 30 percent. This welcome change coincided with the availability
and increased use of the new “SSRI” antidepressants.
The best evidence is that these antidepressants are not bad medications, but
there are tragic cases of bad practice of medicine. The diagnosis of depression
requires extensive training and takes time, but pediatricians are reimbursed
for about seven minutes of face-to-face contact with their patients. What we
need is not to restrict or eliminate the use of SSRIs, but to better educate
parents about how real depression is and that we have effective treatments,
but with limitations. More importantly, pediatricians and family practitioners
need to be systematically trained on how to evaluate this important medical
condition, how to initiate treatment, and how to monitor it effectively to
achieve optimal results.
Special education was conceived in order to overcome barriers that prevent
learning. We have come a long way, but we have to recognize that beyond ramps
for wheelchairs and programs for dyslexia, we must acknowledge that students
with psychiatric disorders as common and potentially lethal as depression need
health services in school as well. While students with depression do not need
a special curriculum, their teachers and parents have to be able to recognize
their suffering, and their doctors must be able to provide effective treatment
and careful monitoring while they are improving.#
Dr. Koplewicz is Founder and Director of the NYU Child Study Center and the Arnold
and Debbie Simon Professor of Child Psychiatry.
