Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary developmental science can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Thursday, April 8, 2010

Psychotropic Meds for Preschoolers? Think Again.

The most recent issue of Child and Adolescent Psychopharmacology News is devoted to this controversial subject. The author, Joan Luby, MD, provides a fair and thorough overview of the complexities of the issue. For example, she writes:
Several factors in the current health care system, including structures now in place that provide reimbursement for medication treatment at far higher rates than for psychotherapy, lack of sufficient age-appropriate psychotherapeutic resources in many communities, and impediments and burdens to families that prevent them from obtaining more intensive psychotherapeutic care are all important factors in contributing to inappropriate use of psychotropic agents. Further, over use of pharmacological agents as sedatives should not be used as rationale for thwarting needed research, but should rather be addressed in the pursuit of high quality and appropriate mental health care for children.

But then she goes on to say, in the section of her piece entitled, " Balancing Risk and Urgency to Help: Clinicians on the Front Line,":
In circumstances where no other services are available(lack of transportation, lack of a caregiver with capacity to pursue therapy, no clinicians available with appropriate expertise) and symptoms are severe and impairing, pharmacological agents may be necessary as a first line agent in a young child.

As one of those clinicians "on the front lines" I find this suggestion unacceptable. Certainly there may be cases of severe mental illness in very young children which warrant treatment with psychopharmacological agents. But if such a young child had a brain tumor, parents and clinicians would find the means to get the child appropriate comprehensive treatment by a specialist. Such an illness would not be treated by clinicians "on the front lines." Last year in the Boston Globe I published a column entitled Backed into a Treatment Corner which speaks to just this dilemma.

After just having addressed the problem of use of psychopharmacological agents as sedatives, Dr. Luby has gone on to advocate for just that, essentially saying "if their is no other option, give drugs." As long as we continue to accept this second class citizen status of childhood mental illness, it is unlikely that significant progress will be made towards, in her words, "high quality and appropriate mental health care for children."

The article does address alternatives to psychopharmacology, but states, "the availability of empirically proven psychosocial therapies is insufficient to meet the need." This is where our efforts should be going. Here is one potentially fruitful route of investigation.

Longitudinal studies that follow children from infancy through adulthood have demonstrated a clear connection between a parent’s capacity to reflect on her child’s experience and secure attachment. Secure attachment relationships facilitate the capacity for emotional regulation. Emotional regulation in turn leads to resourceful thinking, social adaptation and overall mental health.

Selma Fraiberg was among the first to describe an intervention that aims to support a parent’s efforts to understand her child’s experience in her classic paper Ghosts in the Nursery. Subsequently, the fields of parent- infant and parent-child psychotherapy have expanded upon these ideas. Minding the Baby at Yale is one example of a reflective parenting program. Short Term Mentalization and Relational Therapy is a form of family therapy that specifically aims to facilitate a parent’s capacity to reflect on her child’s experience.

These interventions are currently used mostly by specialized infant mental health clinicians. I have been able to use this type of intervention in the setting of primary care pediatrics with significant results. In fact, by virtue of the longstanding relationship of trust that many parents have with their pediatrician, the primary care setting is ideally suited to make use of this model of intervention. Perhaps if we put as much energy into investigating these therapeutic techniques, and teaching them to clinicians on the front lines, as we do in discussing and promoting use of psychotropic medication, we would make a safer and more lasting impact on children's mental health.

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