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.