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DECEMBER 2004

Guest Editorial
Reflections on Special Education, 2004
By Harold S. Koplewicz, M.D.

Steven Claikelson

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.

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