Continuing Medical Education (CME) Cost and Over-Reliance on Psychiatric Drugs for Children: A Possible Link

On the day I began to formulate the idea for this piece, I received an email announcing a continuing medical education (CME) course in psychiatry. Number one on the list of course objectives was: "Implement recent developments in psychopharmacology in clinical practice." I was mulling over the issue of CME after having been recently informed that offering CME credits for the intensive program in Infant-Parent Mental Health at University of Massachusetts Boston in which I am a fellow might be prohibitively expensive. In contrast, my colleagues in psychology, social work, and counseling will be able to get CEU’s (continuing education units).

There are four MDs in my group of 25(three pediatricians and one psychiatrist.) For us CME is necessary for maintaining professional licensing as well as obtaining hospital admitting privileges and being credentialed with insurance companies. Staying up-to-date with important new research and knowledge is certainly an essential part of practicing medicine. Yet given the already massive time pressures on physicians, MD's are unlikely to take a course that does not offer CME credit. We are a distinct minority.

Not having any knowledge about this subject, I did some research. Apparently the cost of offering CME is regulated by an organization called the Accreditation Council for Continuing Medical Education (ACCME.) If a person or organization wants to offer CME for a course, they must apply to the ACCME. According to their website the cost for "pre-application"(I'm not sure what that is) is $1000. The initial accreditation fee is $7,500 and the annual fee is $3,000. The reaccreditation fee is also $7,500. The International Association for Continuing Education and Training(IACET) in contrast, charges an application fee of $450 and an overall fee of $2,300 for CEU accreditation.

In the Infant-Parent Mental Health Post-Graduate Certificate Program(IPMHPCP), in ten intensive three-day weekends over the course of a year, we learn from leading researchers and clinicians from a range of disciplines about how early relationships shape the brain and influence healthy emotional development. The same program is run in Napa, California. The program’s website states:

“The IPMHPCP goals are to prepare individual professionals who:
Are highly skilled and invested in infant-parent work;
Have an integrated understanding of infant-parent relationships, regulatory, and social-emotional/mental health concepts and theories;
Have an understanding of the major theorists, researchers, and clinicians in the area of social-emotional development, infant-parent mental health, and infant-caregiver relationships;
Are invested in an interdisciplinary approach to promotion, prevention, screening, assessment, treatment, monitoring, and policy development; and,
Are able, within their scope of practice, to provide promotion, prevention, screening, assessment, treatment, and monitoring of children age 0-5, their parents and other caregivers.”

How very relevant is this work both to pediatricians who see families early and often, and to child psychiatrists who treat young children. Yet if this program is unable to provide CME it is less likely that these disciplines will have access to this important information.

Instead pediatricians and psychiatrists learn primarily about how drugs shape the brain. I recently attended a full day CME course on “Child Psychiatry in Primary Care.” While we learned a great deal about medication, including the use of atypical antipsychotics for explosive behavior in young children, there was not one mention of the word "relationship."

In contrast, a pediatrician colleague of mine took a course last week given by leading childhood trauma researcher Bessel van der Kolk, (who I refer to in my two previous posts.) He offers a different model for understanding explosive behavior that is very much tied relationships, and he is critical of over-relaince on psychiatric medication. My colleague found the course extremely helpful and relevant, but CME was not offered.

I do not know why CME credits are so much more expensive than CEUs. But I do wonder if this system, which seems to have a good deal of control over who knows what, contributes to how we understand and treat emotional problems in young children.

I have no doubt that the IPMHPCP has left me well qualified to do the work I do, namely treat a range of behavior issues in young children within the setting of a pediatric practice. I have sought out the kind of educational opportunities I believe have most relevance for this kind of work. When it comes time to renew my license, I can only hope that the Board of Registration in Medicine will recognize this fact.

Helping a Traumatized Child: A Hopeful Follow-Up

I live in a small town, so I often have the opportunity to get follow-up on the children I cared for in my previous job. Walking down the street this morning I heard a voice call out "Hi Dr.Gold!!" I turned to see the mother of a child I had seen for a number of years. Similar to the child I described in the previous post, this child had experienced significant trauma in her early years. To protect privacy I will not go into detail. This family had come to me for medication for ADHD. While the child clearly met diagnostic criteria, and ADHD medication helped her to stay in school and not fail completely, it was obvious from the start that she needed more intensive help than I could offer. Yet her parents resisted. There were many reasons for this, ranging from transportation issues to a wish not to address some very painful subjects.

My leaving that practice actually forced the issue. The only person who would prescribe medication was a psychiatrist in a nearby town. She has a practice policy that anyone on medication must be in therapy.

When I run into families I know in public, I am hesitant to talk about our work in order to protect their privacy. But this mother seemed positively joyful, so I was moved to ask, How's Jane? (not her real name) ""She's thriving!" was her response. "We have her in therapy and she's on some new medications. I don't know why I resisted for so long!!"

This morning I also received an email from a pediatrician colleague bemoaning the fact that so many pediatricians have become simply drug prescribers. She asked: "Can we wipe the slate clean and start again? - maybe by listening and telling the stories over and over again; perhaps. Slow and steady." I like this cautious optimism, and believe strongly that it is the only way. We cannot give up on these kids!!

Preserve Important Childhood Trauma Treatment Program

In a powerful recent New York Times op ed, Post-Traumatic Childhood, leading trauma researcher Bessel van der Kolk writes about the possible of loss of funding for the National Child Traumatic Stress Network, an organization developed in 2001 to evaluate and develop treatments for traumatized children nationwide. He writes:


Most traumatized children now do not even receive a proper mental health assessment. Moreover, hundreds of thousands of them are numbed by powerful drugs that help control their "bad behavior," but that don't deal with the imprint of terror and helplessness on their minds and brains. Drugs can sedate, but they do not help children deal with trauma - in fact, they may prevent recovery by interfering with learning and the formation of relationships, essential preconditions for becoming functioning adults.

This paragraph brought to mind a particularly distressing case from my previous job as a behavioral pediatrician in a busy small town practice. This eight year old boy(details have been changed to protect privacy) had recently moved to a new foster home in my town and his foster parents brought him to see me to prescribe medication for attention deficit hyperactivity disorder(ADHD), which had been diagnosed by a psychiatrist in another town about 40 minutes away.

This little boy had not only been physically and sexually abused starting at a very young age, but he had been removed from another foster home where he had allegedly sexually assaulted another young child. He was impulsive and distracted in school, symptoms which, according to his new foster mother, were helped by his medication. She wanted me to prescribe the medication because the trip to the psychiatrist was too long. At the time I saw him, he was receiving no other treatment besides monthly visits to the psychiatrist for his medication.

When I resisted, saying in as gentle a way as possible that his problems needed much more intensive intervention than I could offer as a pediatrician, his foster mother was indignant. "But his psychiatrist said I should come to you. It's only to refill the medication, and I just can't drive that far." When I called the psychiatrist, horrified to learn that she had endorsed this plan, she reluctantly agreed to continue seeing the patient, but made it clear that she felt I was just making this foster mother's life more difficult.

I don't know if I made things any better for this boy by insisting that he at least be treated by a trained mental health professional. I spoke with the psychiatrist about the need for more intensive help, but given the lack of resources and lack of motivation, both on the part of the foster mother and psychiatrist, this probably didn't happen. Yet I felt that I could not collude with the system in sedating away this child's symptoms rather than addressing the underlying trauma, the "imprint of terror and helplessness" so eloquently and dramatically described by Dr. van der Kolk.

Soon after this incident I left that job. I had begun to feel increasingly uncomfortable prescribing medication to children in this way. The standard of care for ADHD treatment, where similarly traumatized children are often treated by pediatricians who prescribe medication at visits every 3 months, did not seem right. Instead I am writing to call attention to the problem, as well as developing, within a pediatric practice, an infant mental health program that focuses on prevention.

Many others in the areas of childhood trauma research, as well as the growing discipline of infant mental health, are speaking out about the need for changes in the way we treat these most vulnerable members of our society. I hope that our combined voices will be sufficient to call attention to the problem, and reverse the proposed 70 percent reduction in funding for the National Child Traumatic Stress Network.

Supporting Successful Communication Between Parent and Child

Recently, at the UMass Boston Infant Parent Mental Health Post Graduate Certificate Program in which I have been participating for the past year, we heard a wonderful talk by Carole Gammer, a family therapist who lives in Paris, France. She has written a book entitled, The Child's Voice in Family Therapy. Among the more remarkable things about her presentation was that she spoke to us in English while showing video tapes of observed therapy sessions conducted in French and German.

In one case, a young single mother who struggled with serious depression was having constant battles with her five year old daughter. In a way typical of many families I see, she asked Dr. Gammer "what to do to make her listen." Dr. Gammer works with child and parent together in a very focal way to help develop more healthy ways of relating. I found her work similar to mine but rather than have parents tell their story, she has parent and child act it out with puppets. In the segment she showed us, she asked them to act out a typical morning. It was remarkable that despite the fact that they were being observed by psychology students, both became absorbed in the play and really showed what it was like. The mother made repeated demands of her daughter-get out of be, get dressed-which her daughter did not do. The mother finally ended up threatening to abandon her child if she did not get up and get ready for school. It left us thinking that it was no wonder the child also had severe separation anxiety.

Then Dr. Gammer did her intervention, which involved selecting one very specific interaction to work on. The one they chose was eating breakfast. After some discussion with Dr. Gammer, the mother offered a couple of choices and she and her daughter eventually agreed on cornflakes. It was the first moment of successful communication between mother and child. By chance, Dr. Gammer stopped the video at this point to answer some questions, so we got a good long look. The mother had up until this point looked very tense and angry, but in this moment of cooperation her body seemed to relax. She was smiling, and her pleasure at her success was evident. Her daughter looked directly at her, smiling at her as she agreed, "OK, cornflakes( a word that is shared by all three languages!)

This was a lovely example of supporting parents by helping them" be" with a child rather than telling them "what to do." When things are out of control as was the case for this mother-daughter pair, both parent and child are angry and sad, yet they are longing to connect. I have found that meaningful change happens in my behavioral pediatrics practice when we share these powerful moments of re-connection. One can imagine that the levels of stress hormones in this mother, likely at a constant high level as she battles with her child over every little thing, decreased in that instant. In turn, the same probably happened for her daughter.

It is only a tiny moment, but at least they both know what is possible and what to work for. This focal intervention, along with others like it in the context of the supportive, non-judgemental relationship Dr. Gammer has with this family, is likely to transform the unhealthy dance of mutual dysregulation, in which these two have been engaged, into one of mutual regulation, as they accumulate successes like the one we saw in this video. In my opinion, while it is clearly more work, this is a far better approach than giving a parent advice about "what to do."

National Children's Mental Health Awareness Day

My posts have been less frequent as I am down to the wire with the final proofreading of my forthcoming book, Keeping Your Child in Mind, which will be available on August 30th. However I did not want this day to go unacknowledged, so I will reference and quote from the bulletin Promoting Resilience in Young Children created for the occasion by the State of Massachusetts, which includes multiple resources.

The future prosperity of our nation depends on the healthy growth, development and school success of each and every one of our young children. Yet, it is estimated that one quarter of the children in our state are at risk for “toxic” or emotionally costly stress caused by domestic violence, child abuse/neglect, family substance abuse and parental depression (Boston Thrive in Five research review, 2009)1. Young children can also be strongly affected by a range of issues such as a death in the family, a car accident, or long- term separation from a parent.
Because young children’s brains are still developing, trauma and stress can have long-term effects on the developing architecture of their brains. Without supports to promote resilience as they grow, children may take with them the effects of traumatic events, and be more likely to experience problems with substance abuse, depression, and stress management.
A strong relationship with a caring adult who responds sensitively to a child is the first line of defense in protecting against stress or trauma. Due to their own stressors, sometimes a parent or caregiver may need to support to help children cope appropriately.

1 National Scientific Council on the Developing Child, 2005 ibid

Why is this Post Different From All Other Posts?

My son's bar mitzvah is this September (yes-two weeks after my book comes out!!) and so despite the fact that we are not a particularly observant family, we found ourselves at Shabbat services on Saturday morning of Passover. The Rabbi has members of the congregation take turns reading parts of the service. By total random chance, it was my turn to read when we got to the translation of the day's Torah portion. And this is what I read:

A God, compassionate and gracious, slow to anger, abounding in kindness and faithfulness, extending kindness to the thousandth generation, forgiving iniquity, transgression, and sins. Yet He does not remit all punishment, but visits the iniquity of parents upon children and children's children, upon the third and fourth generations.

So there it is in the Torah, what in the world of child development is referred to as "intergenerational transmission of trauma," or "intergenerational transmission of attachment." This can take many forms. Parents who have been abused are more likely, without adequate help, to abuse their own children. Most parents I see in my office who are struggling with their child’s challenging behavior tell me some variation of the statement "Í don’t want to do to Charlie what my parents did to me.” Yet they are horrified to find that they are in fact behaving in exactly the same way as their parents. They find themselves distracted and emotionally unavailable, or explosive and full of rage. In the book History Beyond Trauma two French psychoanalysts describe how psychiatric symptoms can represent trauma of war that has not been expressed, sometimes for generations.

"So why is this in the Torah?" the Rabbi asked. One member of the congregation said that it was about taking responsibility for your behavior as a parent. I thought this was a good answer. When this question of how parents behavior affects their children comes up, it is often heard as blaming parents for their children's problems. In the first chapter of my book I have a section entitled "Guilt, Blame and Responsibility" (also a previous blog post of the same title) because I think is is important to address this problem up front. When people feel blamed, they may become defensive and shut down. Here's an excerpt

Guilt and blame are negative words, and responsibility is a positive one. People generally feel good about themselves when they take responsibility for their lives. They feel empowered. But taking on the responsibility for raising a child in a meaningful and effective way is not an easy task. In the setting of
fragmented families, financial stress or a parental history of abuse or neglect, it is especially difficult. Add to this a child with a challenging temperament, and the responsibility can easily feel overwhelming.

As I've said many times before, supporting parents in this essential task of raising the next generation is critical. The flip side of recognizing our society's responsibility to support parents is for parents to recognize their responsibility for facilitating their child's healthy development. For what its worth, the Torah seems to support this point of view.

A Beautiful Parenting Moment at the Local Coffee Shop

It was a peaceful Saturday morning at Fuel, a local coffee shop in Great Barrington. People sat quietly murmuring with friends over coffee and muffins, or intently working at their laptops. I was doing the final edits for my forthcoming book Keeping Your Child in Mind, when I looked up to see a small boy of about two years tottering down the narrow aisle holding a plate with an enormous cinnamon bun almost the size of his head. His father followed close behind and they sat down at a table right next to me. The boy was proudly surveying his prize when his father innocently reached over and asked "May I share?" Instantaneously the peace was shattered."NO!!! MINE!!! NO SHARE!!!" His father made a hasty retreat but it was too late. The boy quickly descended into an all out tantrum despite his father's attempts to soothe him.

His mother, who had been at the cash register, rushed back to try to help. While she joined the efforts to quiet his screams, now transformed into sobs of “no share!”, she and the boy’s father looked to be deciding whether to abandon their outing or try to repair the situation. Fuel is a friendly place, and the other customers, including myself, smiled at them knowingly. This, together with a gradual decline in the intensity of their son's crying, seemed to lead to a decision to stay. His mother sat with him while his father went to finish the transaction at the register. He returned with breakfast for the grown-ups and after a bit more time, the boy's crying slowed to a quiet whimper. Calm once again descended, and the three of them were quietly eating their breakfast when the boy took a piece of his cinnamon roll, reached across the table to his father and said, “Share?”

Mine is a favorite word of most toddlers. This word doesn’t represent greed, but rather the toddler’s great joy in his newly emerging sense of self. Certainly limits must be set, and a toddler must learn over time that everything is not in fact, "mine." Just how to impart this sense of limits while at the same time facilitating a healthy sense of self is one of the great challenges of being a parent of a toddler. Sometimes a child might feel particularly vulnerable, such as when he is hungry or tired, and can collapse in the face of a parent who shatters the illusion of his omnipotence. I imagine this was the case with this little boy and his cinnamon bun.

His parents, clearly attuned to the emotional state of their child despite the pressure of a public scene, sensed that this was not a moment to set a limit. He had his two-year-old reason for feeling that sole possession of this prize was essential. They were all rewarded by a happy repair of the disrupted morning. And with their respect for his autonomy, he was able to take in the idea of sharing, though for the time being, he needed to share at his own initiative.

This was a tiny moment, yet full of such richness and complexity. Strung together, such moments, when parents respond to the meaning of a child's behavior rather than simply the behavior itself, serve to set a child on a path of healthy emotional development.