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.

Sunday, May 22, 2016

Antidepressants for Girls: Are We Putting Future Mothers in an Untenable Position? (When There are Alternatives)

A significant unintended consequence of over-reliance on psychiatric medication for children was brought to light in a recent study  showing that children exposed to SSRIs (selective serotonin re-uptake inhibitors- a class of psychiatric medication used to treat anxiety and depression) during pregnancy were diagnosed with depression by age 14 at more than four times the rate of children whose mothers were diagnosed with a psychiatric disorder but did not take the medication. This study follows on the heels of another showing an increase in risk of autism in children whose mothers took SSRI’s during the second and third trimester of pregnancy.
Such reports are usually met, appropriately, with an outpouring of reassurances from clinicians who take care of pregnant women, who need to protect their emotional wellbeing in whatever way they can.
From my perspective as a pediatrician specializing in early childhood mental health our attention must be on prevention. Our culture is quick to medicate young girls without thought to the increasingly well-recognized slow and difficult process of withdrawal from SSRI's. With multiple studies like those cited above producing a cloud of uncertainty, and limited data on the long-term developmental outcome for a fetus exposed to SSRI’s in utero, we are knowingly putting future mothers in an untenable position.
In addition, recent alarming reports of a tripling of the suicide rate for girls age 10-14, in the context of rapidly rising rates of prescribing of SSRI's suggest that this approach is failing.
There is another way. Extensive evidence reveals that when parents listen for the meaning of a child’s behavior, they support development of emotional regulation, social adaptation, and overall mental health.
In contrast, when the standard of care is to name and then eliminate problematic behavior, often with a pill, listening is devalued both culturally and monetarily.
A question from a review course offered by the American Academy of Pediatrics (AAP) exemplifies this standard. Presenting a case of a 7-year-old girl with separation anxiety since preschool, bedtime resistance, and frequent tantrums, we are asked to choose the correct treatment. We are told that parents are divorced, she is an only child, and at her father’s house she expresses fear that something would happen to her mother.
While cognitive behavioral therapy to “work on skills to manage her distress” is the “correct” answer, an SSRI is recommended as a second line of treatment.
An explosion of research at the interface of developmental psychology, neuroscience and genetics shows us that rather than labeling behavior and seeking to “manage” or eliminate it, the road to healing lies in listening with curiosity to discover meaning.
Did this young girl observe conflict, perhaps even violence, between her parents in the years preceding their divorce? Is there a family history of anxiety, suggesting a genetic vulnerability? Does she have sensory processing challenges that cause her to be overwhelmed in a stimulating classroom? Some combination of all these factors might exist. Only when we know the story can we find the path to healing.
In my practice, eight-year-old Sophie, diagnosed with anxiety disorder by her previous pediatrician, came to refill a prescription for Prozac. After several hour-long appointments, some with her alone and some with her mother Linda, I learned that, like the child in the vignette, she had divorced parents. During every-other weekend visits with her father Mark, he drank heavily. Quick to explode in rage, he frequently verbally humiliated Sophie and her mother. The primary problem needing treatment was his alcoholism. Sophie's behavior represented an adaptive response to a frightening situation.
Parents share this kind of information only when they feel safe. Safety comes when we offer time and space for nonjudgmental listening. When parents can make sense of their child’s behavior, they are in an ideal position to support that child, helping to name feelings, identify provocative situations, and develop strategies to manage these challenges.
Another vignette offers a view of both the problem and the solution.
Beth, mother of 3-month-old Logan, a patient in my behavioral pediatrics practice, could have been the girl from the AAP vignette 15 years later. She struggled with feelings of anxiety. Attempts to stop SSRI’s, which she had taken on and off for years, were unsuccessful. Despite reassurances from many doctors, she was plagued by guilt over the possible effects on her baby, who was now “colicky” and not gaining weight.
I worked with the family, drawing on an evidence-based treatment known as child-parent psychotherapy. We sat on the floor, with Logan’s father, Peter, joining in. Logan began to gain weight in parallel with his mother’s improved emotional state.  My aim was simply to listen, and to support Logan’s parents in reflecting on the meaning of his behavior. By six months he was thriving. Beth’s anxiety abated and she was able to come off the SSRI. 
Over-reliance on psychiatric medication in children has negative impact on this generation and the next. The unknown effect of psychiatric medication on the developing fetus is but one unintended consequence. As I describe in my new book The Silenced Child: From Labels, Medications, and Quick-Fix Solutions to Listening, Growth, and Lifelong Resilience we silence communication and miss opportunities for prevention. In contrast, when we offer space and time for listening to parents, starting in the earliest weeks of life, we have the opportunity to set development on a healthy path.

1 comment:

  1. The vast majority of the children and teens who get antidepressants these days for "depression" do not actually meet DSM criteria for major depressive disorder. Clinicians who presribe them, if they say anything about it at all, label the family situation as "WNL." What that really means is not "within normal limits" but "we never looked."

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