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.

Friday, June 28, 2013

The made-up reality of psychiatry's new DSM 5

A member of the American Psychoanalytic Association posted the following on an internal email list, and I am reproducing it with permission. It captures the kind of circular reasoning behind the current paradigm of psychiatry as represented by DSM 5. As in "we define the disease by these symptoms, therefore if you have these symptoms, you have the disease."
The following two questions were published in a recent (June 8) issue of Psychiatric News and also distributed by APA in an email message, apparently as part of a PR quiz program to popularize the DSM-5.  However, I'm posting them here to convey an idea of what many of us feel has gone wrong in American Psychiatry in the last decades.  Each of these clinical vignettes describes a patient with some kind of mental disorder.  Each vignette ends with a quiz question. Fair enough.

However, I have changed to UPPER CASE some words in the two questions to which I'd like to call your attention.  Note in both cases, the question is phrased in such a way that the task is to decide which of the listed DSM-5 entities CAUSED the patient's symptoms and clinical "picture" described in the vignette.  However, the real task is to try to guess which set of symptoms listed in the DSM-5 most closely matches the patient's symptoms.
Framing the questions as they are indicates a mind set that these DSM-5 "disorders" are "real" things which are somehow present in the patient (like a bacteria) and which then CAUSE the patient's symptoms.  In actual fact, because there are no such entities other than in the DSM-5's attempt to classify the myriad variations of human mental disorders into convenient slots, the actual meaning of psychiatric diagnoses in the current state of our knowledge is being turned on its head in the minds of contemporary (biologically based) psychiatric thinking. As you know, in the DSM-5 all "disorders" supposedly reflect an "underlying psychobiological dysfunction" which then leads to the conclusion that all one has to do is to discern the biological mechanism underlying the disorder, find the right pill, and voila!  Cured! What a great doctor!  What a great specialty!!
He then quotes the two quiz cases.
 A 65-year-old woman reports being housebound despite feeling physically healthy. She reports falling while shopping several years ago; although she sustained no injuries, the situation was so distressing to her that she becomes extremely nervous when she has to leave her house unaccompanied. She has no children and few friends. She is very distressed by the fact that she has few opportunities to venture outside her home. Which of the following disorders BEST ACCOUNTS FOR her disability?
a) specific phobia*situational subtype
b) social anxiety disorder
c) posttraumatic stress disorder
d) agoraphobia
e) adjustment disorder
 A 35-year-old man is in danger of losing his job; the job requires frequent long-range traveling, and for the past year he has avoided flying. Two years prior, he traveled on a particularly turbulent flight, and although he was not in any real danger, he was convinced that the pilot minimized the risk and that the plane almost crashed. He flew again one month later, and although he experienced a smooth flight, the anticipation of turbulence was so distressing that he experienced a panic attack during the flight. He has not flown since. Which of the following disorders IS THE MOST LIKELY CAUSE of his anxiety?
a) agoraphobia
b) acute stress disorder
c) specific phobia*situational type
d) social anxiety disorder
e) panic disorder
He references a commentary in the very same issue of Psychiatry News entitled New Evidence Said to Challenge Psychiatry's Basic Paradigms that calls attention to the lost state of the discipline.
Psychiatry is at a crossroads, according to Patrick Bracken, M.D., Ph.D., clinical director of the West Cork Mental Health Service in Ireland, at APA’s annual meeting in San Francisco in May.
“Accumulating evidence challenges the current paradigm underlying psychiatric thinking and practice,” said Bracken. The problem lies deeper than just “too many drugs....”
Psychiatry is not like cardiology, he said. The mind is not simply another organ of the body, but encompasses relationships, values, and meaning.
Clearly a new paradigm is needed.  

Wednesday, June 12, 2013

Too many psychiatric diagnoses for children: an epidemic of labels

Allen Frances, professor of child psychiatry at Duke University and chair of the DSM IV(Diagnostic and Statistical Manual of Mental Disorders) task force hit the nail on the head in a recent commentary "Why So Many Epidemics of Childhood Mental Disorders?" in the Journal of Developmental and Behavioral Pediatrics. Because he makes his argument so clearly and persuasively (and the full article is only available to those who subscribe to the journal) I will quote it at length.

Since the publication of DSM-IV in 1994, the rates of 3 mental disorders have skyrocketed: attention deficit disorder (ADD) tripled, autism increased by 20-fold, and childhood bipolar disorder by 40-fold. It is no accident that diagnostic inflation has focused on the mental disorders of children and teenagers. These are inherently difficult to diagnose accurately because youngsters have a short track record; are in developmental flux that makes presentations transient and unstable; are sensitive to family, peer, and school stresses; and may be using drugs. If ever diagnosis should be conservative, it should be in kids. Instead, we have experienced an unprecedented diagnostic exuberance encouraged in part by DSM-IV, but mostly stimulated by the powerful external forces of drug company marketing and the close coupling of school services to a diagnosis of mental disorder.
He gives the example of ADHD, describing how the revisions to DSM IV had anticipated a jump in diagnoses in girls with the additon of an "inattentive" subtype. But in fact there was an unexpected tripling of ADHD rates and parallel increase in use of psychiatric medication. He writes:

Three years after DSM-IV was published, drug companies introduced new and expensive on-patent drugs that provided the incentive and resources for an aggressive marketing campaign to psychiatrists, pediatricians, and family doctors. Simultaneously, successful drug company lobbying gave them unrestricted freedom to advertise directly to consumers. Parents and teachers were inundated with the message that ADD was terribly underdiagnosed and easily treated with a pill. Sales of ADD drugs ballooned to an astounding $7 billion.
He then moves on to bipolar disorder:

Childhood bipolar disorder is an even more chilling case. DSM-IV had wisely rejected a proposal that there be a separate and much looser definition of bipolar disorder in children. The argument for inclusion rested on the unreplicated findings of just 1 (albeit very influential) research group suggesting that kids present a developmentally different prodromal form of bipolar disorder characterized by ambient irritability, impulsivity, and temper outbursts, rather than the typical cyclical mood swings of adults. Rejection by DSM-IV did not stop charismatic thought leaders (who were heavily financed by drug companies) from spreading the gospel of childhood bipolar disorder. The 40-fold increase in rates was accompanied by an increase in antipsychotic spending up to $18.2 billion in 2011. These drugs frequently cause massive weight gain in children. The overuse of antipsychotics in kids was not deterred by the fact that childhood obesity is an important risk factor for diabetes and heart disease. Drug companies have received billion dollar fines for off-label marketing to kids, but these pale in comparison to the enormous revenues. Of note, the inappropriate use of antipsychotics is most pronounced among children who are economically disadvantaged.
He then accurately depicts the link between the rise in diagnoses of autism with the fact that a diagnosis is needed for a child to receive appropriate services:
The introduction of Asperger's by DSM-IV was expected to result in a 3- to 4-fold increase rates of autism. Severe classic autism had an unmistakable presentation with rates lower than 1 per 2000. Asperger's blends imperceptibly into normal eccentricity, and the rates of autism are now reported at 1 per 88 in the United States and 1 in 38 in Korea. Theories connecting the increase in prevalence to vaccination have been discredited. Instead, the rates have grown so rapidly because a diagnosis of autism is required to allow a child access to greatly enhanced school services. About half the youngsters who now receive the diagnosis do not really meet the DSM-IV criteria when these are carefully applied. And follow-up studies finding that half the kids no longer meet criteria also confirm that diagnostic inflation is rampant. Eligibility for school services should be decoupled from an unreliable clinical diagnosis and instead be based on educational need. 
The challenge, and Frances does acknowledge this fact, is to avoid over-diagnosis while at the same time not undertreating those who need help. Most of the children who receive these labels, and their families, are struggling in significant ways. They do need help,  and sometimes lots of it. The issue is inextricably linked with the need to "name" the problem, a need comes in part from both clinicians and parents, who may feel more of a sense of control if what they are struggling with has a name, and also insurance companies who require a diagnosis for reimbursement of services.

Psychiatric diagnoses in children, by definition, place the problem squarely in the child, when in fact it is almost always more complex than this. Genetic vulnerability and environment both have an important role to play. A recent article in the Archives of Diseases of Childhood; Poverty, Maltreatment and Attention Deficit Hyperactivity Disorder offers insight in to this complexity:
This paper hypothesises that the population of children receiving a clinical diagnosis of ADHD is aetiologically heterogeneous: that within this population, there is a group for whom the development of ADHD is largely genetically driven, and another who have a 'phenocopy' of ADHD as a result of very adverse early childhood experiences, with the prevalence of this phenocopy being heavily skewed towards populations living with poverty and violence. A third group will have a high genetic risk and have been exposed to violence.
The key phrase here is "aetiologically heterogeneous." Psychiatric labels, be it "ADHD" "bipolar disorder" or "autism," are artificial constructs that provide a false sense of simplicity.  When I see a child and family in consultation, the aim of the work is to take the time to listen to the story and understand where, and it may be in several places, the "problem" actually lies. In order to help these children and families in a meaningful way, we need to be able to, in the words of one of my mentors Ed Tronick, "embrace complexity."

Sunday, June 2, 2013

Pediatricians and prevention of toxic stress

The Harvard Center on the Developing Child has produced a new video: Building Adult Capabilities to Improve Child Outcomes: A Theory of Change. The video wisely identifies the need to support the adults in a child's life in order to promote long-term health, both physical and emotional. It points to the abundance of scientific evidence showing the need for providing safe and secure relationships in early childhood to reach these goals. Exposure to stress in the absence of such safe, secure relationships is termed "toxic stress."

As pediatricians have regular contact with young children and their families, the need to translate this research in to the clinical setting of pediatric practice is clear. The American Academy of Pediatrics (AAP) has embraced this task. The 2013 AAP national conference titled Early Brain and Child Development: Building Brains, Building Futures, will present the science of early childhood.

In addition, concurrent with the release of the above video are a number of publications addressing the need to integrate the research in to practice. One article, Listening to the Baby's Brain to Reduce Toxic Stress: Changing the Pediatric Check Up to Reduce Toxic Stress  describes new interventions.
Purposeful Parenting materials, for example, emphasize “face time” with infants, a type of “serve and return” interaction fundamental to the wiring of the brain: When an infant smiles, the caregiver should smile back—and should do so repeatedly throughout the day. When infants learn early on that smiling, then cooing, then words, are the best way to get attention, they keep using those strategies. But if face time fails to occur frequently enough, infants may learn less healthy ways—such as crying or whining—to get the attention or support they crave. The lack of something as simple as face time can lead to more infant stress and less healthy ways to cope with stress in the future.
This recommendation appears to draw on the powerful research of Ed Tronick showing the distress caused to an infant when a caregiver presents an unresponsive "still-face." His research has shown that when a caregiver is attuned with an infant in 30% of interactions, and if the remaining misattunements are recognized and repaired, the child develops a positive affective core-  an ability to experience joy and connection.

Given these findings, the AAP recommendation is a good one. But most caregivers intuitively provide this attunement without needing anyone to tell them what to do. They naturally experience what D. W. Winnicot termed "primary maternal preoccupation," acting as what he called the "ordinary devoted mother." When they do not, simply telling them to smile at their baby will likely be ineffective. This is where the link to the video comes in. To "build adult capacities" in this situation, there needs to be an opportunity to listen to that parent, who may be struggling with postpartum depression, may be socially isolated, or may herself have been abused.

Fortunately the AAP model also looks at the larger context. The director of Developmental and Behavioral Pediatrics at Yale University is quoted:
In order to make these changes, Weitzman says, pediatricians will need broad systemic changes to support them, including better medical training, payment systems, treatment options, and help to coordinate care.
What is needed is space and time to listen. That includes listening to the pediatricians who are themselves under tremendous pressures. This need is addressed my book Keeping Your Child in Mind, whose  second chapter  is titled "Strengthening the Secure Base: Listening to Parents." The book demonstrates this idea of supporting adults with the aim of supporting children, showing what this approach looks like from infancy to adolescence, as seen from the front lines of pediatric practice. It concludes:
 If those who care for children and families on the front lines have the time to develop these relationships, if there is a strong system of mental health care to support families who are struggling and a medical education system that encourages clinicians to listen to parents’ stories, we will be well on our way. The image comes to mind of a set of Russian dolls. When the health care system allows the primary care clinician time to listen to the whole of parents’ experience and to support their inherent wisdom and intuition, parents are enabled to be fully present with their child. In other words, the system holds the clinician, who holds the parents, who hold the children.