Children, Antipsychotics and Psychoanalysis

I fear our nation has lost its soul. We are drugging poor children into submission. Antipsychotics, powerful mind altering drugs with serious side effects, are being given with increasing frequency to very young children for explosive behavior. A recent study done by researchers at Columbia and Rutgers discovered the alarming statistic that children on Medicaid were four times more likely to be prescribed antipsychotics than children with private insurance. http://www.nytimes.com/2009/12/12/health/12medicaid.html

Prescribing of antipsychotics for two to five year olds has doubled in the past several years. Most worrisome is the finding that more than half of these children had received no mental health services. They did not have a mental health assessment or any treatment from a psychotherapist or psychiatrist. http://news.yahoo.com/s/hsn/20100105/hl_hsn/moretoddlersyoungchildrengivenantipsychotics

As an antidote to the heartache these findings cause me, I attended the recent National Meeting of the American Psychoanalytic Association. There I listened to discussions offered by leading researchers at the interface of neuroscience, developmental psychology and behavioral genetics. This research offers a different paradigm from that presented by the pharmaceutical industry. Rather than describing these children as “explosive” they are understood as having difficulty with emotional regulation. Young children learn to regulate emotions in relationships. When people who care for a child can think about his experience of the world, when they can help him to contain intense emotions without becoming overwhelmed themselves, that child learns to regulate strong feelings and manage himself in a complex social environment. This research is shedding new light on the nature/nurture debate, and the question of how much a child’s innate qualities affect the problems he is experiencing. A child may be born with a genetic vulnerability for difficulty regulating emotions. Responsive parenting, however, may alter the actual expression of these genes, and even change the chemistry and structure of the brain.

I understand why we are so quick to turn to drugs. Parents feel overwhelmed. The combination of a temperamentally difficult infant and a parent who does not have support of extended family or even a spouse is particularly challenging. Parents naturally seek help from their pediatrician. Because of pressures from a complex health insurance industry, primary care clinicians must see patients in 10-15 minute slots in order to maintain a viable practice. Mental health resources are severely limited. Parents are pressured by teachers, whose classrooms are disrupted by these children. Pediatricians, parents and teachers are bombarded by intense marketing efforts of the pharmaceutical industry. Antipsychotics offer the promise of a quick easy fix.

The psychoanalytic community offers high quality research into effective interventions. On an individual level, there is the model of parent-infant psychotherapy. A therapist works with the parent and child together with the aim supporting the parent in her efforts to think about their child’s inner world. Reflective parenting programs such as the Yale-based Minding the Baby program work toward the same goal with groups of parents, many of whom are poor and have suffered abuse. Both types of interventions have demonstrated positive impact on child development.

As a pediatrician and advanced scholar with the Berkshire Psychoanalytic Institute I have had the privilege to be part of the psychoanalytic community while practicing pediatrics in a small town. I have applied the ideas derived from contemporary developmental theory in my practice with remarkably positive results. When parents can themselves be heard, it helps them to think about their child. This experience often results in immediate improvement in behavior. As parents feel greater competence, a positive cycle of interaction is set in place. The rapidly moving train of development can get back on track.

Compared to the roar of the pharmaceutical industry, the voice of the psychoanalytic community is barely a whisper. Add to this fact a seriously undervalued system of primary care and mental health care, and it is no wonder that we turn to drugs. Our current health care system does not support interventions that value relationships.
Perhaps it was necessary for us to get to such a terrible place. I am confident that no one wants to be part of a culture that drugs its poor children into submission. I hope that we can use this time of health care reform to rethink our priorities. If we are going to invest in our nation’s children, primary care, preventive health care and mental health care should be at the top of the list.