What is children's mental health care?

 Patricia Wen's front page story Children's Access to Mental Health Care is Growing, in which she describes the "co-location" of mental health care services in pediatric practices, brought me back to the summer of 2011 when I attended a meeting of a working group of the Massachusetts Chapter of the American Academy of 
Pediatrics (MCAAP.) The task of this working group, a subgroup of the MCAAP task force on mental health care in pediatrics, was to address the need for collaboration between pediatricians and mental health professionals in caring for children. At the meeting individuals described different models.



One pediatrician, a man who has been in practice for over 30 years in a large group with 15 pediatricians and 10 nurse practitioners, was invited to present his model, held up as an example of an innovative and workable model. This is what he said. 



First, clinicians went in groups of 4 to attend conferences run by a prominent MGH child psychiatrist. Then another child psychiatrist started bi-weekly phone consultation with the group as a whole. 



Now, this pediatrician said with pride, the clinicians in his practice are comfortable " treating 80% of ADHD, anxiety and depression." They were hiring a social worker, whose job it would be not to do therapy, but rather to "make sure patients are taking their medications and refilling prescriptions." 



In other words, mental health care, at least for this doctor and his large group, is equivalent to prescribing psychiatric medication.



This practice is paid by Blue Cross Blue Shield under the model of AQC(alternative quality care) global budget. If the practice overspends they pay the insurance company and if they underspend they split the profit. In addition, if they practice "quality care" as defined by the insurance company, they receive more money. One measure of quality is follow up every four month for ADHD and compliance with psychiatric medication.



Another pediatrician offered an alternative model of collaborative care. She described a close personal relationship with a psychologist, who was also at the meeting. She described how, through confidential voicemail and email, they spoke frequently about their most challenging patients, working closely to provide care, and in doing so keeping a number of patients out of the hospital.



 In a sense the people who presented these two models were speaking completely different languages, one in which mental health care equals medication and another in which mental health care equals providing a "holding environment" through relationships. Unfortunately the second model is at risk of being overpowered, under the influence of the pharmaceutical and health insurance industries, by the first model. 

Our best hope for fighting this trend, I believe, lies in maintaining a focus on prevention- on promotion of healthy social-emotional development in early childhood through relationship-based interventions. 

In the Early Childhood Social Emotional Health Program at Newton-Wellesley Hospital I collaborate closely with pediatricians who refer infants, toddlers and preschoolers. I work with children with a range of issues including, but not limited to colic, sleep problems, separation anxiety and explosive behavior. I work with parents and child together. Another program, Project Climb at Colorado Children's Hospital, described in the article  Providing Perinatal Mental Health Care in Pediatric Primary Care integrates infant mental health services in to primary care.

This is a role that primary care clinicians can and should embrace. In a previous post I wrote about a proposed model of including a professional who is experienced with working with parents and infants together in every primary care practice. This person could work with parent-infant pairs when parents are struggling with postpartum depression or anxiety, and/or an infant is fussy/colicky, or in other ways "dysregulated."   

 Research at the interface of developmental psychology, neuroscience and genetics offers extensive evidence that supporting early parent-child relationships is an essential part of promoting healthy  emotional development.

This important aspect of children's mental health care was not mentioned in Wen's article. Instead, the focus was on treatment of "ADHD" and other DSM diagnoses in collaboration with MCPAP- the Massachusetts Child Psychiatry Access Project- whose role Wen describes: 

The Massachusetts Child Psychiatry Access Project provides a hotline for pediatricians to call for consultations with psychiatrists, especially for help with the complexities of prescribing psychotropic drugs. 

The co-location model described in Wen's article is an excellent one. Pediatricians have relationships with children and families that are invaluable. They are important collaborators with mental health professionals.  Parents and young children can be found frequently in a primary care office.  However, any conversation about "co-location" of children's mental health care is lopsided and incomplete without a discussion of preventive care focused on infancy and early childhood. 

  

Ode to joy: moments of parent-child connection

A friend and colleague recently asked if I thought joy was an emotion or a state. Without pause, I responded that it was a way of being fully present.

Early the next morning I was at Starbucks writing to another colleague about a case from my pediatrics practice for a book we are writing about parenting. I was describing a scene with a mother and 4-month-old son.  He had been a very challenging newborn who cried all the time, and she had struggled with postpartum depression. In my office they gazed adoringly at each other with huge smiles of delight.  I wrote, "There was pure joy in their relationship."

I glanced up from my writing to see yet another scene. A father was calmly telling his two-year-old daughter that she needed to hold his hand when they crossed the street. He was negotiating his coffee and her juice while she repeatedly wriggled away. "I can carry you or you can hold my hand, " he said. No go. She reached out to him for an instant, but again dodged his reaching hand. "Big girls hold hands crossing the street." It seemed this would work as she again reached out, but again changed her mind. Then somehow very gracefully he switched his beverages and offered his other hand. "Do you want to hold this one?" This was the magic needed. It seemed as if she had to have some say before she would temporarily relinquish her growing independence.  I watched this big tall daddy and his little girl walk across the street hand-in-hand. Another moment of joy, both for them and for me.

Interestingly, the day before another colleague had invited me to speak at a conference for early childhood professionals about the "magic of the moment" in our work supporting early parent-child relationships.

The dictionary definition of joy actually describes it as either an emotion or a state. But for me the word captures not only a state, but a state of connection, with another person, with nature, or, to quote a famous book title, "Life, the Universe and Everything."

All of these experiences served as a reminder to keep the focus, in my work with families and young children, and in my life in general, on striving for these moments of joy, of meaningful connection. These tiny moments all strung together lead to, borrowing two other words from the title of that upcoming conference, resilience and peace. 

Connecting the dots to discover the cause of "ADHD"

A reader of my previous post asked how I "connect the dots" from supporting newborns and parents to "ADHD" treatment. He states that, "trying to figure out the cause will not help any kid today." This comment motivated me to clarify what I mean by cause, as I think finding out the cause will help every kid today.

What I mean by "finding out the cause" is to give parents the space and time to tell their story, to make sense of their child's symptoms.  The aim is not to determine if the child has enough symptoms to meet diagnositic criteria for a DSM defined disorder, but rather to support  parents' efforts to find a coherent narrative. It involves starting with at least 1-2 full hour visits with both parents.  I put "ADHD" in quotes because by giving the symptoms a name, as in "ADHD evaluation" we narrow our thinking before we even start. Ideally we listen to the family's story with an open minded curiosity.

The story often starts with a fussy or colicky baby. Even before this, there may have been stress in pregnancy which is known to be associated with advanced motor development and behavioral dysregulation in the newborn. Postpartum depression and/or anxiety may have been present. Supporting a dysregulated baby is particularly challenging when a parent is affected by depression and/or anxiety. These babies often continue to have symptoms of dysregulation into the toddler and preschool years, with frequent tantrums, "not listening" or "explosive behavior." There is often a strong family history of "ADHD," substance abuse or other mental illnesses. This history is closely linked with current relationships. For example, if one parent has "ADHD," the child's behavior may be especially dysregulating for that parent. One parent who does not have "ADHD" may blame the other parent, resulting in marital discord. The child may have significant sensory processing challenges. The child may be developmentally immature and the youngest in a structured preschool program. Sleep disurbance on the part of both parent and child has a significant role to play in development of symptoms.  There are as many variations to this narrative as there are families. Clinicians also need to be attentive to the fact that child maltreatment is a rare cause of "ADHD"  that we do not want to miss, and must be considered.

 Once parents have the opportunity to make sense of their child's symptoms,  "what to do" follows naturally. Medication may, in a few cases, be indicated, particularly if a child's self esteem is suffering due to academic demands. But more often than not, the "what to do" is elsewhere. For example, a parent may need to do his own therapy to address troubled past relationships. A parent may take up yoga to manage the dysregulation her child's symptoms precipitate, so that she can remain calm in the face of his difficulties. Sleep disruptions are often part of the story and must be addressed. Marital counselling may be necessary. A good occupational therapist, who helps the family to manage the child's unique challenges in the context of relationships, can be invaluable.

Time, space and a nonjudgmental listener are essential first step in evaluation of any child with behavioral symptoms. The "why" must come before the "what." Then the "what to do"will follow naturally.

Evidence mounts that our current approach to "ADHD" is way off base

An NIH funded study published last week in the Lancet revealed that five major mental health disorders- ADHD, autism, bipolar disorder, depression and schizophrenia- share genetic roots. The authors state that their findings blur diagnostic categories. They write:

These results provide evidence relevant to the goal of moving beyond descriptive syndromes in psychiatry, and towards a nosology informed by disease cause.

Epigenetics, or the environmental influence on gene expression, must immediately be brought in to any discussion of these important findings. "Cause" is related to a complex interplay between genetic risk and environmental effects.

Another study on ADHD published this week points to the problems inherent using this oversimplified diagnostic category. The study, published in Pediatrics, showed that not only do symptoms of ADHD persist into adulthood in 30% of cases, but there is also a significant amount of "co-morbidity," including these alarming statistics:

The study also found the risk for suicide was nearly five times higher among those diagnosed with ADHD than in the comparison group, and nearly 3% of study participants were in jail when recruited for the adult portion of the study.

A review of the study published in USA today includes this telling line:

Symptoms[of ADHD] can be controlled by a combination of behavioral therapy and medication. 

Maybe the reason that so many people have such poor outcomes is that we are neglecting to understand the underlying cause of the problem and instead simply labeling and "managing" symptoms. These dismal long-term results, along with the similarly dismal results reported in the preschool ADHD study showing that 90 percent of children had signficant symptoms at 6 year follow up, state loud and clear that the way we approach what we are now calling "ADHD"  is not working. We need to do something dramatically different from the current standard of care.

What we are calling "ADHD" is a constellation of symptoms that represent problems with regulation of attention, behavior, and emotion. The term itself gives the illusion that we know the specific biological mechanism in the way that we know how lack of insulin causes diabetes. This is however, far from true.

As the first study I refer to indicates, we are just beginning to learn about the underlying biology of mental illness, and those findings suggest that "ADHD" may be an artificial construct.

My clinical experience tells me that these genes they have described may be functionally related to sensory processing.  Problems with sensory processing seem to be common to many diagnostic categories for mental illness that we currently use. However, children develop the capacity for self-regulation in the context of relationships. Identifying the problematic gene is only part of the answer. Understanding and addressing the environmental risk is the other.

If we consider the interplay of genetics and environment, then a third study published last week, this one also in Pediatrics, will point us in the direction of meaningful preventive intervention. This study identified the problem of postpartum anxiety, concluding that:

Postpartum state anxiety is a common, acute phenomenon during the maternity hospitalization that is associated with increased maternal health care utilization after discharge and reduced breastfeeding duration. 

Given what we already know about the risk of psychiatric disorders in children of parents struggling with depression,  these findings only increase the urgency of focusing our resources on supporting parent-infant pairs. We need to help set development in a healthy direction from the start.  Genetic vulnerabilities are present at birth, and if we devote maximum resources to supporting the environment, then we may significantly decrease the risk of those vulnerabilities manifesting as psychiatric illness.

What is psychoanalysis?

Five days a week on the couch may be a rarity, but in our quick-fix culture, where we are more inclined to "manage" behavior than to understand it, psychoanalytic thought is more important than ever. There is an ongoing discussion in the psychoanalytic community about professional standards. One person raised the question "What is psychoanalysis?" The answers in the ensuing conversation for the most part refer to on-the-couch long-term therapy, a valuable but marginalized form of treatment.

 As a non-psychoanalyst treating children and families in the "real world," I hope that the psychoanalytic community will keep an eye out (or both eyes out) for the goal of insuring that psychoanalytic ideas continue to be part of mainstream thinking. One colleague of mine refers to this approach as "psychoanalysis off the couch."

Towards that end, I was moved to compile a list of what I think are the most important psychoanalytic ideas (along with the person to whom the ideas are originally attributed.)

1) Symptoms have meaning

    Sigmund Freud

This meaning is often out of awareness, or "unconscious." This idea is particularly important in a culture where symptoms are managed with medication without effort to discover meaning. For example, the current issue of Child and Adolescent Psychopharmacology News has an article entitled "The Use of Pharmacological Agents to Treat Aggression: Is it Time to be Thinking about a Mechanism?" The author acknowledges the lack of evidence for efficacy of drug treatment, and suggests further exploration of the biochemical mechanism of action of the drugs.

Every young patient I see with aggressive behavior has a complex history. This may include biological vulnerabilities represented by sensitivity to sensory input, environmental stressors such as marital conflict or witnessed domestic violence, or even a history of abuse. The idea that we can address these problems simply by finding the drug that affects the pathway in the brain for aggressive behavior is, at this stage in our knowledge of neuroscience, pure fantasy. We can only address the symptom of aggressive behavior by understanding the underlying cause.

2) The holding environment

    D. W. Winnicott

The original holding environment is that provided by the primary caregiver, where the whole of a child's experience, including both loving and aggressive feelings, is tolerated and contained. In providing this holding environment, the caregiver helps the child to make sense of and manage his or her unique experience of the world.

In clinical work,  the holding environment is the setting;  a quiet space and time with a trusted person who accepts and contains difficult feelings. In my office at Newton-Wellesley Hospital's Early Childhood Social Emotional Health Program I have a special room for mothers and babies that has pastel rugs and soft chairs. It is quiet, private, and filled with light from a large window. One of my young clients called it a "feel better room." I think of it as a holding environment, where both mother and baby can feel safe, contained and understood.

3) All psychotherapy is about mourning

    Martin Cooperman

This does not necessarily mean a death, but may refer to a range of issues including troubled past relationship or even war trauma. I vividly recall  the first case that led me to understand my work in this way, and since then I have come to recognize that tissues are my most important piece of office equipment.

When I first began studying psychoanalytic thought as a  scholar with the Berkshire Psychoanalytic Institute, I was working with a five -year-old boy in my general pediatric practice whose intense sibling rivalry with his younger sister was a source of great stress for his mother.  His relentless need to be first was increasingly disruptive to the day, often making it difficult get out of the house. His mother knew me well, as I had taken care of both kids since infancy. At a full hour visit devoted to discussion of this issue, she suddenly became tearful.  She told me that her older brother had been killed when she was a young child. Her family had never mourned this loss and had simply tried to run away from it. The task of mourning her brother had in a sense been deposited in her son, and was now represented by his symptom. Once her feelings were put in their rightful place, the intense sibling rivalry subsided and returned to a normal level, which she was well able to manage on her own.

4) Disruption and repair

     Ed Tronick

Embedded in this construct is another important contribution of Winnicott's- the good-enough mother. I summarize both ideas in my book Keeping Your Child in Mind:

Research by psychologist Ed Tronick and his colleagues provides evidence that supports Winnicott’s idea that the good- enough mother, the mother who fails at times to be attuned to her child, facilitates her child’s healthy development. Tronick refers to moments of disruption, similar to Winnicott’s “failures of attunement.” Tronick and his colleagues videotaped minute-by-minute interactions between infants and their mothers. His research has demonstrated that these moments of disruption can actually enhance development of emotional regulation. Mismatches, when they are recognized and repaired, increase a child’s sense of mastery and confidence in his ability to cope with difficult feelings. The accumulated experience gained from dealing with and repairing multiple mismatches, or disruptions, become part of the infant’s way of relating to other people.

Puting all four ideas together, it is important to recognize that behavior has meaning, and that to discover that meaning, which is often linked to loss and/or trauma, there needs to be a holding environment.  Things will inevitably go wrong in relationships, but if people can reflect on what went wrong and repair the disruption, they will have the opportunity to grow through the process, and will likely end up in a better place.

Preschool ADHD, preterm babies, and T. Berry Brazelton

There are two important studies published in the latest issue of the Journal of the American Academy of Child and Adolescent Psychiatry. First, the PATS (preschool attention deficit/hyperactivity disorder treatment study) showed that at 6 year follow-up the treatment, consisting of medication and/or behavior management, was not working. Ninety percent of children continued to experience symptoms 6 years after diagnosis and ongoing treatment. This is because the current standard of care does not look at the cause of the symptoms, as I have written about repeatedly on this blog and in my book Keeping Your Child in Mind. Here is an example of  a story from a previous post.

Tears ran down Elena’s cheeks as she described being so overwhelmed and full of rage that she forcefully held her fully clothed 4-year-old son, James, under the shower when he wouldn’t go to bed. Later in the same 50-minute visit she revealed that she had suffered years of physical and emotional abuse as a child. As is typical of visits to my behavioral pediatrics practice, she had brought James because he was “defiant.” “Something must be wrong with him,” was followed by, “Tell me what to do to make him listen.” James’ preschool teachers, who were having trouble managing his behavior, had suggested that he might have attention deficit hyperactivity disorder (ADHD.) They recommended to Elena that medication be considered. They knew nothing of this history. My wish in listening to this story is not to judge, but rather to understand the experience of both mother and child.

As I elaborate in more detail in that post, this prescribing of medication to young children represents a prejudice against children. A colleague described it as a massive exercise in societal repression.   Hidden abuse is an extreme example. It may be simply that the classroom environment is not suited to the child's particular vulnerabilites. There are countless different stories in between. It is not surprising that without an opportunity to hear these stories, medication and behavior management would fail to alleviate symptoms.

Second,  less well-noticed but perhaps more important, is a study showing the link between late preterm birth, maternal depression and preschool psychiatric disorders. It showed that late preterm babies (34-36 weeks) were at increased risk for anxiety disorders at preschool age if their mothers had postpartum depression.

How fitting that T. Berry Brazelton is receiving the Presidential Citizen's Medal in coincidence with these studies. It is Brazelton who taught us to look at each baby's unique qualities and capacities for complex communication. In settings such as the ones described in that study, where both mother and baby are vulnerable, his  Neonatal Behavioral Assessment Scale, as modified to the NBO, has great relevance. Brazelton, in all his wealth of contributions, shows tremendous respect for both parents and children.

These two studies show that we need to invest resources in supporting mother-baby pairs from birth, and in listening to families with young children so that their stories can be heard.

Maybe Brazelton will tell this story to President Obama!!!

ADHD treatment gone wrong: when prescriptions replace listening

Now that the letters to the editor in response to the New York Times article Drowned in a Stream of Prescriptions have been published, I am going to take advantage of this blog to publish mine.

There is one glaring error in the generally well-researched and deeply disturbing article Drowned in a Stream of Prescriptions. In a record review of Richard’s treatment the reporters found none of  “the more conventional talk-based therapies that experts generally consider an important component of A.D.H.D. treatment.” If only this were true. Just last week, AAP Smartbriefs, a review of newsworthy events in pediatrics, offered this headline Non-Drug ADHD Treatments Don't Pan Out in Study. The “psychological treatments” the study refers to are cognitive and behavioral training and neurofeedback. Talk-based therapy isn't even mentioned.

What is noticeably absent in Richard’s treatment is not talking, but listening. In the age of the 10-minute med check, there is no room for listening. If Richard was truly a well functioning person until mid-college, was his primary diagnosis schizophrenia? Was there some kind of trauma? In a world where ADHD is so quickly diagnosed, there was no time given to fully hear his story. That time that might have saved his life.