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.

Tuesday, December 14, 2010

Rising SSI benefits for young children and marketing of atypical antipsychotics: a possible link

A legacy of unintended side effects, a powerful piece of investigative reporting in Sunday's Boston Globe, offers a view of the desperation of poverty. Parents speak to reporter Patricia Wen of seeking diagnoses and psychiatric medication for their young children in order to receive SSI(Supplemental Security Income)benefits. In order to qualify for SSI a child must have a recognized disability. In 1990 8% of children qualified because of mental, learning or behavioral issues. In 2009, that number had jumped nationwide to 53 percent. Wen writes:

In New England, the numbers are even higher — 63 percent of children qualify for SSI based on such mental disabilities. That is the highest percentage for any region in the country. And here and across the nation, the SSI trend line is up, with children under 5 the fastest-growing group. Once diagnosed, these children often bring in close to half their family’s income.
There are many alarming issues raised by this piece, and Ms. Wen is brave to tackle the subject, given that questioning benefits for troubled children is likely not to be a popular position among Globe readers.

One particular statistic jumped out at me. Wen outlines the historical shift in the program, from its inception in 1972, to the spike in mental disability cases following a legal ruling in favor of a boy whose disability payments had been cut off, through the identified abuses of the system in the 1990's followed by cracking down by federal law makers. Wen writes:

The children’s SSI disability rolls instantly shrunk — but the decline would be short-lived. Families and clinicians began to adjust to the new rules, which emphasized extensive medical records for any claimed disability. From 1997 to 2007, the number of children who qualified under behavioral, mental, and learning disorders more than tripled from 180,000 to 562,000.
What else happened in exactly that time period of significance for children's mental health? In June of 2001 I took a course sponsored by Harvard Medical School on Major Psychiatric Illnesses in Children and Adolescents. I attended a lecture given by Janet Wosniak entitled "Juvenile Bipolar Disorder: An Overlooked Condition in Treatment Resistant Depressed Children."

Little did any of us at the lecture know at the time that, largely as a result of Dr Wosniak her close colleague Joseph Biederman's ideas, we would over the next nine years see a 4000 percent increase in diagnosis of this "overlooked condition." These children were described as irritable with prolonged, aggressive temper outbursts that she called "affect storms." Some children were as young as 3 and over 60% were under age 12. In a previous blog post on the subject I wrote;
So here we have a perfect storm. A new disease with no clearly identified treatment. A new drug. Between 2000 and 2010 six atypical antipsychotics, Clozaril, Seroquel, Zyprexa, Risperdol, Abilify and Geodon were approved for treatment of pediatric bipolar disorder. The number of prescriptions for atypical antipsychotics for children and adolescents doubled to 4.4 million between 2003 and 2006. Prescribing of antipsychotics for two to five year olds has doubled in the past several years. Atypical antipsychotics are among the most profitable class of drugs in the United States.
I can't help but wonder if these events- rapid increase in SSI benefits for children under five for a mental health disability, and the rapid rise in diagnosis of bipolar disorder in young children in parallel with the explosion of development and marketing of atypical antipsychotics, are closely linked.

We urgently need a different paradigm for understanding emotional and behavioral problems in young children from that offered by the pharmaceutical industry. Money needs to be redirected to supporting parents in their ability to be physically and emotionally present with their very young children at times of most rapid brain development. Many interventions, such as Yale's Minding the Baby program, have been successful in setting children on a healthy path of development even in the context of significant economic and psychosocial risk. A wealth of high quality research is showing that children learn to regulate emotions in the context of relationships, and that this learning takes place at the level of gene expression and biochemistry of the brain.

Wen writes, "This abrupt climb in cases is a sign, some researchers say, that the SSI program has veered far from its original purpose." Aid for children with true disabilities, whether physical or mental, is extremely important, and the take home message should not be that the program is a bad one. Rather this piece demonstrates with disturbing clarity how much we need to intervene early to support parents and their young children, before they get to such a point of desperation that they are willing to label a child as disabled in order to survive.

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