Over-reliance on Psychiatric Medication in Children: A Pediatrician's View

This weekend I was scheduled to speak at a conference in LA sponsored by the International Society for Ethical Psychology and Psychiatry entitled "Alternatives to Biological Psychiatry." Unfortunately, due to a family emergency, I was unable to attend. As I had already prepared my talk, I decided to translate it into a blog post.

Recent studies predict that treatment of mental illness and mood disorders will soon makeup 30-40% of a pediatrician’s office practice. A study that appeared in the journal Pediatrics revealed that 8% of pediatricians felt they had adequate training in prescribing antidepressants, 16% felt comfortable prescribing them, but 72% actually did. The cover of the October 2011 issue of Pediatric Annals reads: "Assessment of Pediatric Mental Health:Primary care providers are now on the front lines in the diagnosis of mental health issues". While this over-reliance on medication in children has complex social and political roots, the fact is that pediatricians are the ones putting prescriptions into parent's hands.

There are a number of realities of pediatric practice that have led to this situation. Clinicians in most communities are faced with severe shortage of quality mental health care services. The health insurance industry contributes to this poor access, as low reimbursement and complex administrative rules are disincentives for therapists to participate in these plans. In addition, primary care clinicians are under intense time pressures. Again the health insurance industry plays a role, as in order to maintain a staff to manage multiple insurances, clinicians must see more and more patients in less and less time. In addition, there is often great pressure from teachers, parents and other clinicians to prescribe medication. And last, the
AAP endorses the biological model of psychiatry, as evidenced by the recent recommendation to extend diagnosis of ADHD down to age 4. Prescribing psychiatric medication to young children is a common endpoint of all of these factors.

The growing discipline known as Infant Mental Health offers a different paradigm. Research at the interface of neuroscience, epigenetics and developmental psychology offers both a different way to understand the emotional and behavior problems of young children, as well as a different model of intervenion. While in pediatrics the term infant refers to the first year, this discipline addresses the 0-5 age group.

While it is not my intention to cover this topic in depth, there are some key concepts. First, it is infant-parent mental health, and interventions always involve working with parent and child together. Second, symptoms (or behaviors) have meaning and come from somewhere. And third, the developmental trajectory of any individual child is a result of a complex interplay of genes and environment.

This model is best illustrated with an example. Following my recent appearance on the Diane Rehm Show, I received many emails from parents describing their experiences. One mother gave me permission to use her story, provided she could not be identified. I have selected out key aspects of the detailed story she sent me to illustrate how these principles can be applied to help young children and their families. I have divided her experience into obstacles to care and paths to success.

Obstacles to care:
Dysregulated from birth, with severe colic and poor sleep.
Pediatricians did not recognize signs early
Structured preschool setting “stressed him out”
Frustrated teachers diagnosed ADHD
Previously happy boy now crying all the time
Parents depressed, marriage severely strained

Paths to success:
Parents discovered Stanley Greenspan’s book Overcoming ADHD
Recognize difficulties as problem of self-regulation
Adjust environment and alter expectations without using label
Play-based preschool
Occupational therapy to address sensory processing challenges, with parents in attendance
Minimize media exposure
Calm, happy child, happy parents
Excels at chess, top of his class

So how can we help more children and families find this path to success? Changes need to be made at a policy level, including improving access to primary care and mental health care, calling attention to impact of pharmaceutical industry, and addressing problems in the health insurance industry, perhaps with a single payer system. The second front is through education of professional who work with young children about the growing body of knowledge coming out of the discipline of infant mental health, and its application to their work. This includes primary care providers, mental health clinicians, teachers and child care workers

A wonderful piece in the November 2009 issue of Atlantic entitled The Science of Success describes the "orchid hypothesis." Children with genetic vulnerabilities, like many of these children who are dysregulated from birth and have multiple sensory processing challenges, who grow up in an environment where they are misunderstood, "bad behavior" is punished, or "symptoms" are medicated away, may develop more serious forms of mental illness. On the other hand, in an environment that helps them to make sense of and manage their experience, as the parents of this child above did, they can grow up to be society’s most creative, successful, and happy people.

I conclude with a number of quotes from Ralph Waldo Emerson, who my daughter is currently studying in high school.

Whoso would be a man [woman] must be a non-conformist
For non-conformity the world whips you with displeasure
Nothing can bring you peace but yourself. Nothing can bring you peace but the triumph of principle.
This time, like all times, is a very good one, if we but know what to do with it.

Learning from parents-a most important education

Recently I had an "aha" moment of sorts. I was speaking to a group at the Pacella Parent Child Center in New York. I was explaining the path that had led me to write my book, Keeping Your Child in Mind. I was telling the group how in 2006, when my own kids were both school age, I stopped doing primary care and began doing exclusively behavioral pediatrics. I was still working within a general pediatrics practice. The major change was that I started scheduling all my patients for 50 minute visits. Where previously an "ADHD evaluation" had been, at most, one 50 minute visit, and many visits for behavior problems only 30 minutes in length, I began insisting on a minimum of two 50 minute visits for any behavior problem, preferably the first with parents alone.

Many practitioners might now dismiss what I am about to say, insisting that this is not a financially viable plan. But the fact is that I have been reimbursed for these visits on average $150. It is possible for a practice to have one or two clinicians devote several 50 minutes a week to addressing "behavior problems," especially given the potential gain. As I describe in my book, when parents are simply given advice about "what to do" both clinician and parent often experience failure. In contrast, giving a parent time and space to be heard often results in dramatic improvements in behavior.

With this change in my practice, I began to listen more carefully to my patients, specifically to parents. I heard stories of struggles with infertility, newborns who were difficult to soothe from day one, parents who struggled with depression when their children were infants, among many other things. But I also learned about what made things better. Once parents were given the time and space to tell their story, they came up with many resourceful solutions to address their children's difficulties.

Certainly the ideas I have developed over the years come in large part from studying contemporary research from leaders in the field of child development. I am a graduate of the Scholar's program of the Berkshire Psychoanalytic Institute and of the UMass Boston Infant-Parent Mental Health Post-Graduate Certificate Program. But perhaps my most important education has been in carefully listening to the experience of parents.

Last week I had the privilege to be on the Diane Rehm Show speaking about the new guidelines from the American Academy of Pediatrics extending age of diagnosis of ADHD down to age four. To sum up the position I presented on the hour- long show, I advised using caution before prescribing medications to kids under six. I advocated for early intervention, even in infancy when problems of self regulation can present. I argued for validating parent's experience without using a major psychiatric diagnosis, and for recognizing the meaning of behavior rather than focusing exclusively on symptoms.

A mother who had listened to the show emailed me, thanking me for being "the voice of reason." She shared in detail her experience with her now six-year-old child. She described terrible struggles for the first five years until she and her husband discovered Stanley Greenspan's book about ADHD (his ideas and approach are very similar to mine) and everything "clicked." They took matters into their own hands in advocating for their son, who is now thriving. There were many details in her story- both the obstacles to help and the elements of the path to success.

Recently I have seen myself referred to in the media as a "child mental health expert." I appreciate this description, as it affords an opportunity for recognition of this important perspective that my infant mental health colleagues and I bring to the conversation. But reading what this mother wrote reminded me again that parents are always the experts with their child, and that there is still much that I can learn.

Diagnosing ADHD Under Age 6: A Mistaken Idea

Once again ADHD is in the news. At the American Academy of Pediatrics National Conference and Exhibition this weekend in Boston, the new guidelines for diagnosis and treatment of ADHD were unveiled with much fanfare. The most significant change is that the AAP now endorses diagnosing the disorder from age 4-18, a change from the previous guidelines which recommended diagnosis from age 6-12. I take no issue with extending the age of diagnosis upward. But the new recommendation to extend the diagnosis down to age 4 is very worrisome.

As I describe in a previous post, what is now called ADHD is a constellation of symptoms that represent problems of regulation of behavior, attention and emotions. These problems have complex causes. There may be a biological vulnerabilities, which often have a genetic component. Often there are associated sensory processing problems. Family conflict, including parent-child conflict as well as marital conflict, is clearly associated with problems of self regulation. Sleep and eating problems often occur within the context of family conflict and can exacerbate problems of self-regulation.

Children who are struggling in a variety of ways are scheduled in pediatric practices for an "ADHD evaluation." The question asked is: "Do symptoms meet diagnostic criteria?" The more appropriate question should be "What is the experience of this particular child and what can we do to set things in a better direction?" By invoking the label of ADHD, thinking may stop. Curiosity about the meaning of behavior ends. However, years of longitudinal research, as I describe in my book, Keeping Your Child in Mind, has shown that children develop the capacity for empathy, flexible thinking and emotional regulation when parents respond to the meaning of behavior rather than simply the behavior itself.

A press release regarding the new guidelines describes the recommendations for children under 6 as follows.

According to the AAP guidelines, in preschool children (ages 4 and 5) with ADHD, doctors should first try behavioral interventions, such as group or individual parent training in behavior management techniques. Methylphenidate may be considered for preschool children with moderate to severe symptoms who do not see significant improvement after behavior therapy, starting with a lower dose.

Certainly children with problems of self-regulation are struggling, and they absolutely should receive treatment. But receiving a diagnosis of ADHD should not be the only route to receiving treatment, particularly if that treatment consist primarily of "parent training" "behavior management" or medication. There are a whole range of other interventions that can be very helpful to these struggling children and families. These include parent-child psychotherapy and occupational therapy that aim specifically to improve a child's capacity for self-regulation. Getting a label should not be a prerequisite for getting help.

Addressing "comorbidities" does not solve the problem. What this means is simply adding more letters to the child's diagnosis such as ODD (oppositional defiant disorder) CD(conduct disorder) that represent meaningless descriptions of symptoms without any consideration of underlying cause. In my experience, almost all children who have the diagnosis of ADHD are oppositional and defiant. But there are as many variations to the causes of this behavior as there are families.

Under age six children can get the greatest benefit from alternative interventions. This is the time when the brain is most plastic. Changing relationships can change the brain. In addition there are not, or at least should not be, the academic concerns that begin in first grade. Once kids begin to fall behind academically it can affect their self-esteem, and so the pressures to treat with medication increase.

A study done last year showed that kids who are the youngest in their class are 60 percent more likely to be diagnosed with ADHD than kids who are the oldest. There is a wide range of maturity rate. A four or five-year- old who is among the youngest in the class is at particular risk for being diagnosed with ADHD for what is in fact a normal developmental variation.

Recent reports show a dramatic rise in both diagnosis of ADHD and prescribing of stimulant medication for ADHD. We can be sure that with the implementation of these new guidelines, this trend will continue.

What is infant mental health? A case of a hitting toddler

In a few weeks I will launch a new program in the Boston area (more information to follow when the details are ironed out) where I will see children under the age of five. The working name is "Early Childhood Social-Emotional Health" program (ECSH) It is an infant mental health program, drawing on the explosion of knowledge coming out of this growing discipline. I had the privilege of learning about the most current research first-hand from leaders in the field in an excellent a yearlong program at UMass Boston: The Infant-Parent Mental Health Post-Graduate Certificate Program.

There are two major problems with the term "infant mental health." First of all, it implies that there is such a thing as infant mental illness, which is, in my opinion, not the case. Second, when say that I am a pediatrician who treats behavior problems in children under age five, most people are puzzled. I tell them that I give parents space and time to reflect, and to be curious about the meaning of behavior, with the aim of getting development back on a healthy path. Still the blank look. I have found that the best way to explain it is through stories, as I do in my book Keeping Your Child in Mind. As always, I protect privacy by changing identifying details.

"She always hits! I don't know what's wrong with her!" Jane despaired at the start of her visit with me. She came with her three-month-old son, who slept in his carrier. She was horrified that her 18-month-old daughter Callie (who did not come to this visit, so Jane and I could talk freely) was behaving this way. She and her husband never hit. She couldn't understand where this behavior came from. The worst time, she said, was when she was trying to nurse the baby. Callie would try to climb up on her, and when told to get down she would hit her mother, the baby or both. Jane felt tense and angry. Her husband worked long hours and she was alone with the two kids most of the day. "What can I do to make her stop?" she asked.

This is not an uncommon occurrence. I frequently hear parents describe "visions of Columbine" when they see aggressive behavior in their toddlers. Rather than jumping right in with what to do, I took some time to listen to Jane's story. She told me of a difficult pregnancy and how hard it had been when she was alone much of the time when Callie was an infant.

Then she began to talk about her own family. Her father was an alcoholic who was verbally and sometimes physically abusive to her mother. There was constant yelling. She told me that she "hated aggression." When she saw Callie hitting she had an immediate physical sensation of stress. Jane just wanted her to stop.

We began to wonder together about why Callie might be hitting. Jane described how close she and Callie had been before the baby was born. With her husband gone much of the time she rarely had time alone with Callie anymore. "Perhaps she misses me," Jane said. She was surprised when I suggested that while clearly hitting was not acceptable, aggression in a toddler could be seen as a healthy thing. It was not the same as adult aggression, which carried a whole host of complex meanings. We might reframe Callie's behavior as claiming what she felt was her rightful place. We talked about how toddlers are asserting their emerging sense of self . Yet they recognize that they are in fact powerless in many situations. "Wow!" Jane exclaimed. "I feel that way sometimes, but I have words to express my feelings!"

We talked very little about what to do. I was careful to frame the issue of her childhood trauma and its relation to the current situation. This history did not mean that Callie's hitting was her "fault." Rather Jane needed to move her issues out of the way so she could see the situation from Callie's perspective. I was confident that she would then know what to do.

Sure enough, when she returned two weeks later, this time with Callie, the hitting had almost completely resolved. "I give her a bottle," Jane said. She had thought that she was "supposed to" get rid of the bottle by a year. But when the baby was born, Callie had become interested in the bottle again. So the three of them now sat quietly while Jane nursed the baby. Callie would drink an ounce or two and then lose interest in the bottle. She would play at her mother's feet until Jane was finished nursing.

Callie was a delightful little girl who played quietly while Jane and I spoke. Then we got to see the essence of toddlerhood in action. Callie went to her mother's purse and said "passie." Jane explained to me that as with the bottle, Callie had a renewed interest in the pacifier. "I decided to just let her have it." Jane rummaged in her bag and pulled it out, handing it to Callie, who took it, looked it over and gave it back. She returned to her play. A few minutes later she again said, "passie. " Again her mother gave it to her, and again she gave it back. This, I said, is the ambivalence of toddlerhood. Part of her wants to be a baby, but she also wants to grow up and be a big girl. Jane, by being respectful of Callie's perspective, was enabling her to sort this through naturally, Had Jane refused to let her have the pacifier, it is likely that, as an assertion of her wish to control the situation, Callie would have insisted on having it, and a battle would have ensued. She might have started using the pacifier again.

Jane, through her natural intuition about her daughter, figured out what to do. I simply offered her the space and time to think and to be heard. I hope that this small intervention has set the whole family on a different path. The baby now can nurse in peace. Jane is less worried that there is something wrong with Callie, who is in turn free to express her emerging self. For a young family, a little reflection goes a long way.

ADHD: The role of diet and sleep

I recently had a guest post published on the CNN news blog, The Charts, entitled Calming your child's ADHD symptoms. The subject clearly needs a fresh look, given the startling statistic from a recent CDC report that diagnosis of ADHD was up by 29% from 2000 to 2009, and evidence that medication use for ADHD increased at an average yearly rate of 3.4% from 1996 to 2008.

In a nutshell, I describe ADHD as a problem of regulation of emotion, behavior and attention. I offer three points of approach. The first is to address family relationships. This is because children learn self-regulation in context of relationships with primary caregivers, and family conflict is clearly associated with increased risk for ADHD. Second, I recommend involving kids in activities that promote self-regulation including, but not limited to, horseback riding, swimming, martial arts and drumming. And last I recommend careful use of medication when a child's symptoms interfere with learning and social relationships.

A number of people commented that I had not addressed the issues of diet or sleep, both of which have been associated with symptoms of inattention and hyperactivity. I gave some careful thought to why I had not included these issues among the top three. The reason is that, in my experience, problems around sleep and diet are usually embedded in problems in relationships (the major exception is obstructive sleep apnea, a sometimes overlooked condition that can cause of hyperactivity in children. This topic is well covered in a recent post by an ENT specialist on the blog KevinMD.)

For example, I took care of one teenage girl with symptoms of inattention who met diagnostic criteria for ADHD. I learned that up until her thirteenth birthday, her mother lay in bed with her every night until she fell asleep. Then on the day of her birthday, her mother decided that her daughter was too old for this habit, and abruptly stopped, insisting that she fall asleep on her own. Not surprisingly, her brain and body had no idea how to fall asleep independently, so she was staying up until two or three o'clock every morning, sneaking her laptop into bed with her.

Many children with a range of behavior problems crave sweets. Parents describe constant battles around food choices. It is likely that these problems have complex causes: sweets may be used to reduce stress, and food is a place where children can exert absolute control by simply closing their mouths.

Certainly it is important for growth, development, and learning that children eat a healthy diet. Ideally they should have three meals a day with sufficient fresh fruits, vegetables, and protein and a minimum of processed foods. However, if all attention in management of ADHD is focused on diet, to the exclusion of relationships, then the intervention is off the mark. In addition, evidence for more specific food restrictions, such as dairy, wheat or food dyes, is more anecdotal, and some of these diets can be quite restrictive.

Similarly, getting enough sleep is essential to healthy brain function and regulation of behavior, emotions and attention. But, with the exception of obstructive sleep apnea, most sleep problems develop in the context of relationships. In my work with the teenager I describe above, we needed to understand what about family relationships, between mother and father as well as between mother and daughter, led to this problematic situation. Only then could we could begin to solve the "sleep problem." Many children I see with a diagnosis of ADHD have been engaging in battles with their parents for years around sleep, but almost always in the setting of a range of conflicts within the family.

My answer to those who question the omission of sleep and diet from my discussion of ADHD is that yes, these issues are important. In my CNN piece I describe inattention, impulsivity and hyperactivity as symptoms, and urge parents and clinicians who treat ADHD to not simply treat symptoms, but rather to address the underlying cause. Similarly, problems with sleep and diet are often symptoms of problems in relationships. Many parents describe being overwhelmed by the volume of information coming at them about this complex entity known as ADHD. I believe both parents and professional would do well to be open to a variety of ideas while maintaining a focus on supporting relationships and repairing disruptions in relationships.

Prevention and Primary Care

One main objective of the Affordable Care Act, or health care reform, is to focus on prevention. This has been translated into requiring insurance companies to cover annual physicals and a variety of screening tests. Of course primary prevention is done in the setting of primary care. Unfortunately the government is, in a sense, working against itself because of the current system for determining reimbursement for medical services. Pauline Chen documents this well in her recent piece in the New York Times: How One Small Group Sets Doctors' Pay She writes:

Why are there so many medical specialists in a time when we need more primary care doctors? Meet the RUC, a committee of 29 men and women who play a critical role in dividing the Medicare pie.

She describes the close connection between the RUC and the Centers for Medicare and Medicaid Services, or C.M.S.

First, C.M.S. historically has approved 90 percent or more of the recommendations from the RUC. Second, while the RUC makes its recommendations based on an anonymous two-thirds majority vote, about 80 percent of those voting to begin with — accounting for 23 of the 29 seats — are physicians representing professional societies. Third, almost all of those physicians are specialists (currently only five RUC members are doctors from primary care fields).

Prevention happens through the relationships that develop over time in the primary care setting. Consider this story from my pediatric practice( details, as always, have been changed to protect privacy) Six year old Kevin’s mom, Robin, was upset about his constant fighting with his younger sister. I had taken care of both children since they were infants.

Robin was distraught over Kevin's need to always have everything first, and his demands were escalating. They were having increasing difficulty getting out of the house in the morning. I saw them for 2 fifty-minute visits. The first involved the whole family and we talked about some common approaches to managing behavior. I was struck by Mom’s level of distress, which seemed out of proportion to this fairly typical sibling rivalry. Towards the end of the second visit, when Mom was alone with Kevin, she quietly began to cry. I looked puzzled. She told me of the horrible accident that had taken the life of her older brother when she was a child. Her family never spoke about it. That trauma came flooding back now that she had two children of her own. She recognized that she had to mourn this loss in order to be present with her children in the way she wanted to be.

This was 10 years ago. Recently I ran into Kevin. He is now a talented musician as well as an excellent student. I saw him in town with his arm around a girl. He gave me a big smile and a friendly "hello." Of course I can't say what path his life would have taken had this trauma of his mother's not been addressed. But I suspect that it had a role in freeing him to develop into the person he is today.

Prevention can only happen in a meaningful way if the value of primary care is recognized. This involves not only monetary value. Certainly with the burden of loan repayment, financial issues are paramount in determining what field doctors-in-training chose to go in to. But in addition we as a society need to recognize that listening, particularly listening that occurs in the context of a relationship that develops over time, is an important form of treatment. Prevention is not only about screening tests.