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.

Monday, April 18, 2016

Mind-Altering Drugs and the Toddler

When statistics regarding the significant rise in prescribing of antidepressant and antipsychotic medication  for children under age 2 made its way into a New York Times article, the outpouring of comments revealed an understandable outrage. World-renowned child development researcher Ed Tronick, who was quoted in the article, accurately summed things up with his comment, "it's just nuts."   Efforts were made to figure out where blame for this clearly unacceptable situation lies. Is it big Pharma? Is it the doctors who write the prescriptions? Is it teachers who pressure doctors to medicate? Or perhaps parents who beg doctors for help?
Interestingly my colleagues and I from Tronick's InfantParent Mental Health Post Graduate Certificate program were at the time having a conversation about the non-productive, and possibly destructive notion of assigning blame. When people feel blamed they become defensive and shut down. They stop listening.
In Tronick's program, individuals from a wide range of disciplines come together to learn about current research in supporting healthy development of the brains and minds of our youngest members of society. We learn the tremendous value of listening with curiosity. This kind of listening promotes development of emotional regulation, social adaptation, and overall mental health. 
Fellows who participate in this program - there are now going on five generations of the Boston-based program and many more from its California-based counterpart- are all well versed in the wealth of evidence-based treatments, other than psychiatric medication, available to help struggling young children and their families. We all look hopefully to the day when these treatments are the standard of care.
The reasons these prescriptions are written for very young children are far-reaching and complex. Explanation requires space well beyond a comment on an article, or even a blog post. In my new book The Silenced Child: From Labels, Medications, and Quick-Fix Solutions to Listening, Growth, and Lifelong Resilience I offer evidence that listening grows healthy brains and minds. I call attention to the convergence of social forces that have let medication replace listening.
It is likely that each individual clinician who writes a prescription for an antidepressant or antipsychotic for a child under 2, while certainly misguided, is sincerely interested in helping that child. Parents often feel overwhelmed and desperate to help their children. Accepting a prescription makes sense in the absence of other options.
Aggressive marketing by the pharmaceutical industry, along with publication in medical journals of research funded by drug companies, has a role to play. A powerful health insurance industry that does not reimburse for time spent listening contributes to the problem. The complexity of the health insurance industry including, for example, enormous effort needed to obtain "prior authorization" for a range of treatments, restricts the amount of time primary care clinicians can spend listening. The shortage of qualified mental health professionals who offer this kind of listening is intimately intertwined with our condoning of medication as the primary treatment, without protecting time for listening. 

The prevailing medical model of disease and the DSM system- the status quo in mental health care- work against listening. This system looks to name a problem and then eliminate it, without opportunity to discover its cause. It places the "problem" squarely in the child, without consideration of the relational and social context. Due to factors in the medical education system, most psychiatrists and primary care doctors who prescribe these medications are not aware of the rapidly expanding research and knowledge in the discipline of infant mental health. 
Forces in the early childhood education system put tremendous pressures on teachers. They may be faced with classes of 20-30 children, and have minimal training or support in working with children with problems of behavioral and emotional regulation. Preserving safety of the classroom is a legitimate priority, and one of the reasons teachers recommend medication. 

Behavior is a form of communication. Medication can silence that communication. Until we place a renewed value on protecting time for listening, we will continue to see an increase in this kind of prescribing. In effect we will be silencing the voices of the youngest members of our society.