Pediatricians Prescribing Psychiatric Medication: A Dose of Reality

Recently I attended a meeting of a working group of the Massachusetts Chapter of the American Academy of
Pediatrics(MCAAP) The task of this working group, a subgroup of the MCAAP task force on mental health care in pediatrics, was to address the need for collaboration between pediatricians and mental health professionals in caring for children. At the meeting individuals described different models.

One pediatrician, a man who has been in practice for over 30 years in a large group with 15 pediatricians and 10 nurse practitioners, was invited to present his model, held up as an example of an innovative and workable model. This is what he said.

First, clinicians went in groups of 4 to attend conferences run by Joseph Biederman, who, this doctor stated, "runs one of the best research programs in the country." (This is the same Biederman recently found guilty of violating conflict of interest rules in accepting, and not reporting, millions of dollars from the pharmaceutical companies that make psychiatric medication- see previous post.) Then a child psychiatrist, a close colleague of Biederman"s, started bi-weekly phone consultation with the group as a whole.

Now, this pediatrician said with pride, the clinicians in his practice are comfortable " treating 80% of ADHD, anxiety and depression." They were hiring a social worker, whose job it would be not to do therapy, but rather to "make sure patients are taking their medications and refilling prescriptions."

In other words, mental health care, at least for this doctor and his large group, is equivalent to prescribing psychiatric medication.

This practice is paid by Blue Cross Blue Shield under the new model of AQC(alternative quality care) global budget. If the practice overspends they pay the insurance company and if they underspend they split the profit. In addition, if they practice "quality care" as defined by the insurance company, they receive more money. One measure of quality is follow up every four month for ADHD and compliance with psychiatric medication.

Another pediatrician offered an alternative model of collaborative care. She described a close personal relationship with a psychologist, who was also at the meeting. She described how, through confidential voicemail and email, they spoke frequently about their most challenging patients, working closely to provide care, and in doing so keeping a number of patients out of the hospital.

Until this point, I had been silent, taking this all in, trying to find some solid ground to stand on. In a sense the people who presented these two models were speaking completely different languages, one in which mental health care equals medication and another in which mental health care equals providing a holding environment through relationships. I volunteered that providing a setting in which mental health professionals and pediatricians in a community could develop relationships, such as a monthly collaborative case conference, might be the best model. Fortunately the leader of the group was intrigued by this idea as a model to implement and study.

Unfortunately this point of view is at risk of being overpowered, under the influence of the pharmaceutical and health insurance industries, by the first doctor's model. Our best hope for fighting this trend, I believe, lies in maintaining a focus on prevention, and on promotion of healthy social -emotional development in early childhood through relationship based interventions. I will continue to focus my efforts, as I have written about at length on this blog, both on working with young children and their families and teaching pediatricians about the world of research and knowledge coming from the discipline of infant mental health.

I left the meeting feeling a combination of horrified and hopeful, but certainly energized to forge ahead, even if at times it really feels like swimming against the tide!

The Antidepressant Debate: A Pediatrician's View

In 2002, when I was practicing general pediatrics, I was called to our local emergency room to see a teenager who had attempted suicide by ingesting a variety of pills. She was a patient of a pediatrician who did not have admitting privileges at our hospital, so I did not have a prior relationship with her. After she had been medically stabilized, I took a detailed history.

She was an athlete and top student who had been struggling under the pressure of college applications when her pediatrician, several weeks before this incident, had placed her on the antidepressant paxil. Both the girl and her mother described behavior that was totally different from her usual self. She had gone out drinking with kids who she hardly knew. She was impulsive and agitated. I was alarmed by this sudden change in behavior, so alarmed that I ordered a CT scan to be sure that her symptoms were not caused by a brain tumor.

I now understand that she was experiencing a side effect of paxil. While there had been growing evidence that these drugs had the potential to cause suicidal ideation and behavior, as is well documented in Side Effects: A Prosecutor, a Whistleblower, and a Bestselling Antidepressant on Trial by Alison Bass, it was not until 2004 that the "black box " warning describing the risk of suicidality in pediatric patients was instituted. in 2002 I was unaware of these findings, and had in fact prescribed these medications to a number of teenagers in a way that in retrospect seems cavalier and risky.

In today's New York Times Sunday Dialogue Seeking a Path Through Depression's Landscape there is minimal mention of children. Marcia Angell, in her letter in response to Warren Procci's letter (which was written in response to last Sunday's op ed In Defense of Antidepressants) states:

Many have devastating side effects, especially in children and when used long term. Studies generally show that the benefits are small.

I follow these discussions with interest, but I believe the problems of psychiatric medication use in children is of a different magnitude. It is not simply a question of the relative merits of psychotherapy or medication, or of the potentially serious side effects. Rather it is a question of what is not done when psychiatric medication is used to treat symptoms in children.

Last summer I attended a wonderful course entitled "Keeping The Brain in Mind." Teacher Francine Lapides referred to psychotherapists as "neuroarchitects." In the course of a long-term trusting relationship with a patient, one in which a therapist is attuned to the patient's experience, often in a way that the patient's own parents were not, the brain may actually change. This kind of a relationship can change the way a person manages and responds to stress. The patient may learn, at the level of biochemistry of the brain, to think about feelings and regulate and manage difficult experiences.

Listening to this material as a pediatrician, I thought about parents as the original neuroarchitects. When a child is struggling, whether with sadness, anxiety or explosive behavior, supporting parents efforts to understand and manage their child's experience can offer parents the opportunity to help their child in safe and meaningful ways. This is not to say that the problem is the parent's fault. But when parents themselves have the chance to tell their story in a supportive non-judgmental environment, I have found that this fortifies them to be present with their child in a way that helps the child manage his or her particular vulnerabilities. This kind of emotional presence with a troubled child is very hard work, and parents need the time and space to be heard.

In a sense, psychiatric drugs can deprive parents of this opportunity. Drugs place the problem squarely in the child. In my pediatric practice, I meet with parents and bill under the child's name. It is not therapy for the parents or the child, but rather support for the relationship. Certainly many excellent child therapists work with parents in this way. But when symptoms are treated with medication, it may be difficult to find the motivation to do this hard work. Thus the opportunity to use the loving caregiving relationship to help a child learn to manage his or her own feelings may be lost.

Without this opportunity, I wonder how many of these children will end up ten, twenty or thirty years from now telling a therapist about how their parents didn't understand what they were feeling. This missed opportunity is, in my opinion, a potentially tragic side effect of prescribing psychiatric drugs to young children.

Beyond Biederman and Antipsychotics for Young Children

In the blogging world there is a lot of understandable outrage about this issue (though surprisingly little in the press-nothing in the New York times and one holiday weekend piece in the Boston Globe.) There is outrage both about the finding that Biederman and his colleagues had, in fact, failed to disclose enormous consulting fees from the pharmaceutical companies, and that the punishment was fairly mild, considering that as a result of his work huge numbers of young children were placed on atypical antipsychotics, powerful mind-altering drugs with serious side effects. In addition, there seems to be quite a bit of evidence that Biederman and his colleagues were actually working in collaboration with the pharmaceutical companies to promote both these drugs and the diagnosis of bipolar disorder in children. This issue is thoroughly covered on a blog called Boring Old Man.

Reading about this subject causes me a great deal of agitation as well. But outrage is not enough. The questions that need to be answered are one: how did we allow this to happen? And two, what path can we take as an alternative to this misguided one? Without addressing these questions the outrage simply causes hypertension.

Yesterday morning I was feeling rising agitation as I delved into this selection of blog posts, when fortunately my 10 AM patient arrived. I think her story offers some answer to these questions. As always, I will change details to protect privacy while maintaining the essence of the story.

3-year-old Anna was adopted by her parents, John and Diane, about 4 months prior to this, our second visit. At our fist visit, I met for an hour with her parents. Anna had experienced significant loss and physical trauma in her early years and had been adopted out of foster care after a number of different placements. When she first came home with John and Diane, she had little language, but now after just 4 months in many ways she was thriving. But both both parents were being undone by her almost daily severe explosive tantrums. Their marriage was severely strained as they fought over how to manage these outbursts. had called me in desperation one day to say that she needed to come in sooner, despite the fact that our appointment was only two days away.

After I listened for about 45 minutes, while they told me the story of what they knew of Anna's previous life, as well as about their lives and how they came to adopt, I asked for them to describe to me in detail what these tantrums looked like. At some seemingly minor frustration, Anna would first clench her fists in frustration. When her parents intervened, this would escalate to uncontrollable kicking, biting and spitting. Diane described feeling full of anger when her otherwise sweet child behaved in this way, and John insisted that Anna needed to "learn to listen to them." Sometimes they would give her a time out, sending her to her room, or threatening to take away some beloved toy. Or they would ignore her, letting her run around. With either approach the episode ended when she eventually simply collapsed from exhaustion.

Just before our visit I had been reading the work of psychiatrist Bruce Perry, who I referred to in my previous blog post, who has written some wonderful handouts about the effects of early trauma on brain development and behavior. I had his model in my mind when Diane said to me, "Its as if she's in survival mode."

"I think you're exactly right," I said to them. "When Anna acts like this, the thinking parts of her brain are not working. In many ways she's like a helpless infant, able to use only the more primitive parts of her brain. She needs you to help her manage and contain her feelings. At that moment, likely in some way because of her earlier trauma, she is unable to do it herself." Then I said "You need to be your most generous just at the time when you feel the most angry."

Diane and John were quiet for a moment as they thought this over. For some reason, perhaps because they had a quiet time together to tell their story. they really took this idea in. In fact Diane repeated the phrase a few times, nodding in thoughtful understanding. Our time was up, and we scheduled a follow up appointment the next week, when I would meet Anna. This was the appointment following my blog reading session.

Anna gave me a charming smile as she came into the room and began to explore the toys. We all sat on the floor and I watched her easy interaction with her Mom and Dad. Then after a while we spoke about our previous visit. Diane said, " I thought about that a lot- we need to be most generous when we feel most angry." She described observing Anna begin to escalate and saying softly,"do you need a hug?" Diane described how this would sometimes cause Anna to pause, kind of stunned out of the direction she was taking. Both John and Diane were learning how to identify, and thus avoid, some of the things that triggered her meltdowns, both by diverting her attention and giving her more love and attention at these vulnerable moments.

We all acknowledged that this kind of thoughtful attention was very hard work, and that clearly they had a long and challenging road ahead. But both parents were fortified, and had an idea of what they were working towards. We planned to meet again in a few weeks.

So what does this story have to say about the Biederman issue? First of all, parents are desperate when they are struggling with a child in this way. When a clinician sees such a family, he feels that desperation and of course wants to help. The combined forces of the health insurance industry, with poor reimbursement for mental health care and thus lack of access to quality care, aggressive marketing by the pharmaceutical industry and cultural expectation of a quick fix together with this Biederman et al fiasco, allowed the "bipolar" diagnosis and atypical antipsychotics to, in a sense, fill a void. As I state in the last chapter of my forthcoming book Keeping Your Child in Mind,

Infant mental health services, unfortunately, are not well covered by third-party payers and are not marketed as widely as prescription drugs. And as we have seen, they require hard work and do not offer the “quick fix” of medication. As such, they are less available as a form of intervention for struggling young children and families.

Yet it is just the discipline of infant mental health, as exemplified by the work of Dr. Perry and others I have written about over the past year, that offers the answer to the second question: what is an alternative path to that offered by Biederman and colleagues? That same morning of the blog reading and this visit, I had been communicating with colleagues about developing a new program that integrates care among obstetricians, pediatricians and psychiatrists to address perinatal emotional complications. It has been well established that explosive behavior problems in children are often associated with postpartum depression. It is this kind of preventive work that offers a meaningful alternative approach.

Now that it has, I hope, been clearly established that this explosion of "bipolar disorder" diagnosis and antipsychotic use in young children was the wrong path, we need to move on. We need to fully invest in making the changes necessary to out health care system to enable us to go down a different path towards meaningful help for these struggling families and children.

Achieving Emotional Regulation: Using the Body to Help the Brain

I recently heard a great story from a parent in my behavioral pediatrics practice. Their son was very active and had a hard time settling down to learn, and so, before an early morning tutoring session, a very resourceful teacher suggested he ride a scooter down the empty halls to the room where a group of kids with reading difficulties met. To make it fair, the teacher allowed all of the students in the group to ride scooters to class. The kids lay on their stomachs and used their arms to propel them down the long hall. Interestingly, not only this boy, but all of the kids in the class began to do better!

One of the best weekends of the Infant-Parent Mental Health Post-Graduate Certificate Program which I have been attending and writing about over the past year, was with child psychiatrist Bruce Perry. He spoke of the importance of what he referred to as "rapid alternating movements' in achieving emotional regulation. Dr. Perry's ideas grew out of his frustration with the traditional model of psychiatric care, where children who have experienced significant trauma are expected to sit and talk with a therapist about their experience( and of course are also medicated.) HIs model of intervention is based on knowledge of brain development and is termed the "Neurosequential Model of Therapeutics.'

While it is not my intention to describe the model in detail, one of the main messages, which has relevance not only to traumatized children, is that in order to think, learn and process experience, one must first feel calm. A range of activities can achieve this calm. Dr. Perry does therapy sessions with very troubled children while going on walks. Horseback riding, martial arts, drumming and dance are other activities that can serve to achieve this kind of calm. A group of fellows from the program got to try out the theory. After a long, very stimulating (and also somewhat dysregulating) day of learning with Dr. Perry, we went ice skating. Not only was it a lot of fun, but it worked wonders in helping us to process the experience.

Often when kids are struggling in school, teachers express concern that they are "over-scheduled." But if extracurricular activities are carefully planned and well thought out, they can be considered an essential part of treatment. It is best to have some kind of a calming activity interspersed with homework, tutoring or therapy. These can be tailored to a child's particular talents and interests. Many know the story that Michael Phelps struggled terribly with ADHD. Swimming can be a very regulating activity, but some kids with learning and behavior problems also have sensory processing difficulties and can't stand to have their head under water. Clearly swimming isn't the right choice for them.

The more children I see with a range of "behavior problems," the more I recognize the importance of using the body to help the brain. Occupational therapy for young children can accomplish this goal. But as children get older, and can learn to express their feelings, parents can help them identify what works for them. This same boy on the scooter, several years later, learned to recognize that when he was feeling overwhelmed, going down to the basement to play his drums helped him to regroup. This kind of awareness, both of mind and body, can serve kids well not only in childhood, but over the course of a lifetime as they learn to adapt to their particular vulnerabilities.

Value Primary Care Clinicians, Not Psychiatric Drugs for Children

As I sat down to write this blog post, I was torn between two stories. One, in yesterday's Boston Globe Harvard Doctors Punished Over Pay, refers to the child psychiatrists who advocate for atypical antipsychotics for children and who received, but did not report, large sums of money from the drug companies that make these medications. The article stated:

Concluding a three-year investigation, Massachusetts General Hospital and Harvard Medical School sanctioned renowned child psychiatrist Dr. Joseph Biederman and two colleagues after finding they violated conflict of interest rule.

The other was last weeks pair of stories about the government's plan to essentially spy on primary care clinicians. The original New York Times article U.S. Plans Stealth Survey on Access to Doctors stated

Alarmed by a shortage of primary care doctors, Obama administration officials are recruiting a team of “mystery shoppers” to pose as patients, call doctors’ offices and request appointments to see how difficult it is for people to get care when they need it.

Two days later, the Times ran another story entitled Administration Halts Survey of Making Doctors Visits describing how the Obama administration had "shelved plans" for the survey.

I decided to address them both, as I see them as linked. They both speak to the value this country places on individuals listening to and understanding each other.

Prescribing powerful mind-altering drugs to preschoolers with emotional and behavioral problems is the antithesis of listening, both to children and to parents. As I have observed frequently both on this blog and in my forthcoming book, Keeping Your Child in Mind

Being understood by a person we love is one of our most powerful yearnings, for adults and children alike. The need for understanding is part of what makes us human. When our feelings are validated, we know that we’re not alone. For a young child, this understanding helps develop his mind and sense of himself. When the people who care for him can reflect back his experience, he learns to recognize and manage his emotions, think more clearly, and adapt to his complex social world

Yet the combined forces of the health insurance industry and pharmaceutical industry have led to a situation in which listening to desperate parents who are struggling with their troubled children often is translated into prescribing a drug (one with very serious side effects) to control their behavior. A March 2009 Times article Drug Makers Told Studies Would Aid It, Papers Say refers to the same psychiatrist now found two years later to have violated conflict of interest rules.

The psychiatrist, Dr. Joseph Biederman, outlined plans to test Johnson & Johnson’s drugs in presentations to company executives. One slide referred to a proposed trial in preschool children of risperidone, an antipsychotic drug made by the drug company. The trial, the slide stated, “will support the safety and effectiveness of risperidone in this age group."

Primary care clinicians, in conjunction with mental health clinicians, have the opportunity in relationships with families over time, to support parents efforts to promote their children's healthy emotional development. Parents themselves need to be heard and understood. They may be struggling with financial stress, a strained marriage or single parenthood, conflicted relationships with their own parents as well as a temperamentally challenging and inflexible child. In my book I place these two paradigms, effective listening, and prescribing psychiatric drugs, side by side.

Those who advocate use of medication in young children with a range of behavior problems argue that stress hurts the brain and that these medications can protect the brain from this stress. When children and parents feel out of control, when there is sleep deprivation and explosive behavior, both parents and children experience a great deal of stress. It is not surprising that giving a powerful drug that acts on the brain would calm a child down.

But medication is not the only way to reduce stress. As I describe in chapter two, being understood by people who love you also reduces stress at the level of brain biochemistry. Reducing stress and changing the brain in this way is hard work. It requires sustained effort and a lot of support for parents. But the changes are safe and may last a lifetime.

Much as I am an ardent supporter of President Obama, the proposed, "spying" on primary care clinicians to evaluate the primary care shortage has me concerned that he doesn't fully understand what good primary care clinicians do.

Effective listening is very hard work. A good primary care clinician values and nurtures relationships with families over time. She holds the health and well being of the family, supporting and guiding them through the myriad of challenges both emotional and physical that come their way. She spends hours on the phone, both with insurance companies, advocating for coverage for procedures and medications that require"prior authorization," as well as with patients and their worried family members.

I know that President Obama values, and is a master of, this kind of effective listening. I hope that he applies these listening skills to the primary care clinicians, and listen to their stories. Perhaps then the administration will come up with a policy to address the shortage of primary care clinicians (sure to worsen as millions join the ranks of the insured) that, unlike the spying plan, makes sense.