Psychotropic Meds for Preschoolers? Think Again.

The most recent issue of Child and Adolescent Psychopharmacology News is devoted to this controversial subject. The author, Joan Luby, MD, provides a fair and thorough overview of the complexities of the issue. For example, she writes:

Several factors in the current health care system, including structures now in place that provide reimbursement for medication treatment at far higher rates than for psychotherapy, lack of sufficient age-appropriate psychotherapeutic resources in many communities, and impediments and burdens to families that prevent them from obtaining more intensive psychotherapeutic care are all important factors in contributing to inappropriate use of psychotropic agents. Further, over use of pharmacological agents as sedatives should not be used as rationale for thwarting needed research, but should rather be addressed in the pursuit of high quality and appropriate mental health care for children.

But then she goes on to say, in the section of her piece entitled, " Balancing Risk and Urgency to Help: Clinicians on the Front Line,":

In circumstances where no other services are available(lack of transportation, lack of a caregiver with capacity to pursue therapy, no clinicians available with appropriate expertise) and symptoms are severe and impairing, pharmacological agents may be necessary as a first line agent in a young child.

As one of those clinicians "on the front lines" I find this suggestion unacceptable. Certainly there may be cases of severe mental illness in very young children which warrant treatment with psychopharmacological agents. But if such a young child had a brain tumor, parents and clinicians would find the means to get the child appropriate comprehensive treatment by a specialist. Such an illness would not be treated by clinicians "on the front lines." Last year in the Boston Globe I published a column entitled Backed into a Treatment Corner which speaks to just this dilemma.

After just having addressed the problem of use of psychopharmacological agents as sedatives, Dr. Luby has gone on to advocate for just that, essentially saying "if their is no other option, give drugs." As long as we continue to accept this second class citizen status of childhood mental illness, it is unlikely that significant progress will be made towards, in her words, "high quality and appropriate mental health care for children."

The article does address alternatives to psychopharmacology, but states, "the availability of empirically proven psychosocial therapies is insufficient to meet the need." This is where our efforts should be going. Here is one potentially fruitful route of investigation.

Longitudinal studies that follow children from infancy through adulthood have demonstrated a clear connection between a parent’s capacity to reflect on her child’s experience and secure attachment. Secure attachment relationships facilitate the capacity for emotional regulation. Emotional regulation in turn leads to resourceful thinking, social adaptation and overall mental health.

Selma Fraiberg was among the first to describe an intervention that aims to support a parent’s efforts to understand her child’s experience in her classic paper Ghosts in the Nursery. Subsequently, the fields of parent- infant and parent-child psychotherapy have expanded upon these ideas. Minding the Baby at Yale is one example of a reflective parenting program. Short Term Mentalization and Relational Therapy is a form of family therapy that specifically aims to facilitate a parent’s capacity to reflect on her child’s experience.

These interventions are currently used mostly by specialized infant mental health clinicians. I have been able to use this type of intervention in the setting of primary care pediatrics with significant results. In fact, by virtue of the longstanding relationship of trust that many parents have with their pediatrician, the primary care setting is ideally suited to make use of this model of intervention. Perhaps if we put as much energy into investigating these therapeutic techniques, and teaching them to clinicians on the front lines, as we do in discussing and promoting use of psychotropic medication, we would make a safer and more lasting impact on children's mental health.

Teaching Young Pediatricians to Wonder

Last week, I again had the privilege of teaching pediatricians in training. These students were very bright, challenging and asked excellent questions. They all agreed about the limit of the pediatric model of "giving advice." One resident, who had young children of her own, spoke of new mothers using blogs for emotional support. Many of these mothers speak less than kindly about their pediatricians, who they perceive as "not getting it" and telling them "what to do." We agreed that being given advice could be disempowering and that many parenting books, full of advice, actually make parents feel worse.

My seminar's aim was to teach them about the application of contemporary ideas about child development into their practice of pediatrics. This research shows that when parents can think about the meaning of their child's behavior, rather than respond just to the behavior itself, they facilitate their child's healthy emotional development. I shared with them an example from my practice to show how they could support parents in this task.

3 year old Mary had prolonged tantrums at bedtime and was up several times a night. Her parents told me that they would hold the door shut while Mary screamed and threw herself at the door in increasing agitation. Finally after an hour or so of this, one parent would go in to lie down with Mary because she was so agitated, and then she would fall asleep.

My students found the story disturbing, as it was obvious to them that this experience would be frightening for Mary. But I asked them to resist the impulse to give advice about how to manage bedtime and instead asked them to wonder, why were her parents, bright loving people, doing this?

I showed them a slide from a recent lecture by leading researchers in developmental psychology, Peter Fonagy and Mary Target. The slide showed how when people are stressed, their ability to reflect on another person's experience significantly decreased.

Rather than give these parents advice about how to manage this sleep problem, my task was to listen to their story, support them and even perhaps uncover the source of this stress. In doing so I might be able to help them think about what was happening from Mary's perspective.

Because we had a full 50 minute visit, and they began to feel comfortable with me, they did eventually share what was going on. They spoke of a terrible upheaval in Dad's family business and significant financial stress. They realized that Mary was likely responding to the huge amount of tension in the household. she was struggling to engage her increasingly emotionally distant parents. They understood that Mary was experiencing a kind of separation anxiety,and was looking for reassurance. Her anxiety came out most intensely at bedtime, which naturally precedes a long period of separation.

I gave these parents minimal advice about what to do. Instead, I helped them to understand a different way to be with Mary at bedtime. Within a few weeks her sleep problem resolved. My wondering about the meaning of their behavior led them to wonder about the meaning of Mary's behavior.


One of the residents asked me "what do I say?" Residents are taught "what to do" and then tell their patients "what to do." I hope that I conveyed to them that is not about what to say. Its about being present, open and emotionally available. Its about wondering. If they begin to wonder why parents behave the way they do with their children, they will be able to support parent's efforts to wonder about the meaning of a child's behavior.

I realize it's a big leap. One resident in the group was doing a rotation in the neonatal intensive care unit . When treating a critically ill newborn, knowing "what to do" is appropriate. I am asking him to use his brain in a completely different way.

Practicing primary care can be a deeply rewarding experience if we use our relationship with families in the way I have described. But it is not easy. One must be able to switch from a "what to do" mode when dealing with a sick child, to a wondering mode when working with behavior problems, which can make up as much as 40% of primary care visits.

However, if we can do this, we are in an ideal position to promote the healthy emotional development of the next generation. When seen from this perspective, primary care clinicians should be the highest, not the lowest, both paid and valued providers in our health care system.

My Shrinking "ADHD" Practice

I consider my most successful cases to be the ones that do not seem me any more. Not that they are "better", but they and their families have come to realize the full complexity of the problems they are struggling with, and are getting appropriate help.

I inherited my "ADHD practice" from another pediatrician. He was wonderful man, a larger than life, toss babies in the air pediatrician with a hearty laugh. He never had an unkind word to say about anyone. He had retired from general pediatrics and was only seeing "ADHD patients," when he died suddenly in a tragic accident. His patients were devastated. I had recently started my own behavioral pediatrics practice, and his practice, where I had worked previously, asked if I would return and take over his "ADHD patients." Out of loyalty to him, I agreed.

I learned that he was seeing his 170 or so patients once every three to six months for a 30 minute visit. This was pretty much the standard of care in pediatrics. But I felt that if I were going to prescribe a mind altering drug to these children, I wanted to learn what was going on in their lives. I particularly tried to open things up when kids were doing poorly. I didn't focus on adjusting the dose of medication when they were failing in school, but explored other possible reasons for their academic struggles. This meant uncovering some pretty difficult problems, including complex family conflict. Some families got angry and left. "We thought you just weighed and measured Johnny and then refilled the prescription."

But a few families welcomed this chance to talk. I encouraged one mother(details have been changed to protect privacy) to meet with me alone because at our visits with her 12 year old daughter, Kaitlin, she would speak so harshly and critically that it made me uncomfortable. "She's just lazy, " she would say. "She's always been impossible." When we met alone, she described a deeply troubled relationship with Kaitlyn since she was an infant. Kaitlin had been on medication for ADHD since she was 9, but her mother revealed to me that she had always questioned the diagnosis, saying, "its more complicated than that."

We worked together for a year. I met with them for a 60 minute visit every three months. I would ask about the medication, while also talking about other aspects of Kaitlin's life. I started to meet for half the visit with Kaitlin alone. It each visit I suggested that talking with someone on a more regular basis would probably be helpful, but they did not follow through. Finally, at the end of one session Mom said to me, "Kaitlyn feels that she would like to talk with a therapist." I referred them to a wonderful colleague who fortunately took their insurance and had time.

It proved to be a great match. Kaitlin has now been in therapy for 2 years. Recently my colleague and I met for lunch. She filled me in. Kaitlin is off her medication. While she does need extra help, she is doing well in school. She is developing a strong sense of herself. She has many friends and interests. Perhaps most importantly, her mother, who also meets regularly with my colleague, is happy and very proud of her daughter.

Some of my patients have what I refer to as "straightforward ADHD." They likely have a neurobiologically based difficulty with focusing and attention. Stimulant medication allows them to learn. There are no other issues. If I can get all of my patients to receive the help they need, as I did with Kaitlin, my practice would consist of only these children. It would be a fraction of the size it is now.

Drugs for Children May Silence Stories

In the Academy Award winning film, Precious, the main character’s transformation comes about largely through her ability to tell the story of her trauma, specifically in the form of writing. In this endeavor she is encouraged by a loving teacher. In the book History Beyond Trauma, two French psychoanalysts argue that symptoms their patients exhibit represent the horrors of war that are not spoken of, sometimes for generations. The patient is relieved of his symptoms when the stories of trauma are finally told, usually in the setting of the relationship between patient and analyst.

These works brought to mind a referral I recently received in my pediatric practice to prescribe medication for a seven year old child. The details have been changed to protect privacy. The psychological testing report read, “Given these findings relative to attention and working memory, it would be prudent for _____’s parents to share these testing results with their pediatrician regarding a medication trial aimed at mitigating his difficulties with self-regulation and attentional control."

Two years earlier I had seen Sam’s parents, Rebecca and John, for a consultation. Rebecca was feeling overwhelmed. Sam would get over-stimulated in groups of people. He was becoming increasingly oppositional. They had adopted Sam after taking him in as a foster child when he was three. Prior to this, he had lived with his mother, who was an actively drinking alcoholic. She had physically and emotionally abused him, saying frequently that she wished she’d never had him. His father was in prison and had never been involved in his life.

Rebecca and John wanted some advice about what to do to manage Sam’s challenging behavior. I began at that visit to introduce the idea that early trauma can have a significant effect on children’s behavior. My thinking was guided by important research by Miriam Steele. She and her colleagues studied children who had all suffered serious adversity, including neglect and both physical and sexual abuse. What was it, she and her colleagues wanted to know, that led to a positive relationship between an adoptive parent and child?

They found that one key factor was the adoptive parent’s ability to think about the child’s behavior as related to their life story. When parents did think about the meaning of their child’s behavior in relation to this story, they were more likely to describe joy and pleasure in the relationship. This is where I wanted to bring Rebecca and John.

While I did offer some of the advice they were looking for, I also recommended that they engage in therapy for the whole family. I acknowledged that raising a child with a history like Sam’s could be extraordinarily difficult. Even with all the love, safety and security they were giving him, teaching him how to trust and to regulate his feelings, things children usually learn in the first years of life, would be a big challenge for all of them.

They did not come for a follow up visit, and did not follow through on my recommendation. Why they did not I am not sure. I do know that there is a severe shortage of quality mental health care in our community. I also learned that Rebecca was suffering from significant depression. Thinking about what happened to Sam in his early life, and facing the enormity of the task of raising a traumatized child might have been too much for her.

I did not hear from the family until I received the report suggesting I prescribe medication. Stimulant medication will likely be of help to Sam in the short term. Many children who have been traumatized feel much calmer on medication. It may even help them to learn. The problem comes when medication is used instead of, rather than in addition to therapy. Alleviating symptoms with medication often decreases motivation to do this difficult but important work.

Precious, in the context of a caring relationship with her teacher, was able to tell of her experience. The patients with history of war trauma similarly have this chance in the relationship with their therapist. Medicating Sam will be a Bandaid. It may fix his problematic behavior in school. But underneath will be an open wound that will only begin to heal when he has the opportunity not only to tell his story, but to have his story heard.

Who Listens to the Doctor? Part 2

Doctors are trained to solve problems and to fix things. For much of what we do, this is an appropriate and helpful strategy. But for primary care doctors on the front lines with developing children and families, another strategy is needed. In a previous post, I wrote about an experience I had teaching young doctors in training. One intern proclaimed to another at the beginning of my talk that she would sleep through it. Instead, she was an active participant when she saw it was an opportunity to unburden herself of a difficult and painful interaction with the mother of a young boy.

This discussion I had with those young doctors made me think of a wonderful book by a Hungarian psychoanalyst, Michael Balint, called The Doctor,his Patient and the Illness. Following World War II, general practitioners in England found that much of their medical practice was consumed by addressing complex psychological problems. Out of this phenomenon there grew a research seminar to study psychological issues as they present in general medical practice. These later became know as “Balint Groups”, and consisted of a group of primary care doctors and a psychiatrist who facilitated the discussion. In the introduction to this book, in which Balint describes in detail the proceedings of his seminar, he writes:

The first topic chosen for discussion at one of these seminars happened to be the drugs usually prescribed by practitioners. The discussion quickly revealed- certainly not for the first time in the history of medicine-that by far the most frequently used drug in general practice was the doctor himself, i.e. that it was not only the bottle of medicine or the box of pills that mattered, but the way the doctor gave them to his patient-in fact, the whole atmosphere in which the drug was given and taken.

This seemed to us at the time a very elevating discovery, and we all felt very proud and important about it. The seminar, however, soon went on to discover that no pharmacology of this important drug exists yet. To put this discovery in terms familiar to doctors, no guidance whatever is contained in any textbook as to the dosage in which the doctor should prescribe himself, in what form, how frequently, what his curative and maintenance dose should be, and so on….in fact, the paucity of information about this most frequently used drug is appalling and frightening.

Balint groups are now part of many family practice training programs in the United States. The idea is similar to Balint’s original concern, namely to address directly the way in which a doctor, as a person with a relationship with a patient, is a critical part of the treatment. Offering oneself in this way can take its toll, particularly if a doctor is very good at it. The groups provide an opportunity to address not only the treatment of the patient, but also what it is like for the doctor when many troubled people unburden themselves of their deepest feelings. In many training programs for mental health professionals there are opportunities to talk with others about these experiences, in a sense allowing the clinician to unburden him or herself and therefore be open to listening to his or her patients. But for primary care doctors such an experience is the exception, not the rule.

As health care reform moves forward, finding a way to attract doctors in training to primary care will be critical. Appropriate financial compensation is essential. Understanding and respecting the "doctor as drug" concept is equally important in building a system that promotes a model of prevention.

What I Learned From Eli

Yesterday my 11 year old son ate his first oyster. "I slurped it down," he said."It was chewy and tasted of lemon." I asked him if it was OK for me to write a blog post about him. "Sure," he replied. He is proud of his role as my teacher.

For the first seven or so years of his life, after breast milk and baby food, Eli ate only three things- bagels with cream cheese, pasta with pesto and chicken nuggets. My mother-in-law, though not one to judge me, looked askance when we arrived at her house with our own Tupperware containers of food for him.

Once I read that picky eaters have more taste buds than the average person. I believe that must be true. It always seemed to us that things just tasted more to Eli. It wasn't that he was being oppositional or controlling. He simply could not eat other foods. Similarly, he couldn't stand loud noises. Once, on a family outing to hear fireworks, he and I had to go back to the car and watch from the muffled safety inside. Now Eli is an accomplished musician who plays guitar and saxophone.

Things were not easy for him or us in those early years. But amidst all the advice and worry, one wise very good friend said to me, "Be careful." I understood this to mean that we should not be pushed into doing things that did not feel right to us. That we needed to hang in there with him. So we did.

He still has his moments. The second oyster made him gag, and he declared, "I'm never eating another oyster for the rest of my life." But he ate one. And for him that was quite an accomplishment.

Letter in NY Times refutes Warner's book

OK- Just one more. Here is a letter published in today's New York Times Science section. The 150 word limit helped me present a clear and concise argument!


To the Editor:

Re “Doing an About-Face on ‘Overmedicated’ Children” (Books, Feb. 23): The myth of the overmedicated child is no myth. The morning of the day Judith Warner’s book came out, in my pediatric practice I saw three children for refills of their medication for ADHD. One’s mother was an actively drinking alcoholic. Another’s father had recently been deported. A third told me of chaotic scenes of yelling among siblings and parents.

None of these issues were being addressed. Our culture’s condoning of use of medication to treat complex problems merges with parental resistance and lack of access to quality therapy to create this situation. Certainly medication may protect the brain. But being understood by the people who love you can also protect the brain. Over-reliance on medication leads our culture to shirk responsibility for listening to both parents and children.

Claudia M. Gold, M.D.

Great Barrington, Mass.