Over-reliance on Psychiatric Medication in Children: A Pediatrician's View

This weekend I was scheduled to speak at a conference in LA sponsored by the International Society for Ethical Psychology and Psychiatry entitled "Alternatives to Biological Psychiatry." Unfortunately, due to a family emergency, I was unable to attend. As I had already prepared my talk, I decided to translate it into a blog post.

Recent studies predict that treatment of mental illness and mood disorders will soon makeup 30-40% of a pediatrician’s office practice. A study that appeared in the journal Pediatrics revealed that 8% of pediatricians felt they had adequate training in prescribing antidepressants, 16% felt comfortable prescribing them, but 72% actually did. The cover of the October 2011 issue of Pediatric Annals reads: "Assessment of Pediatric Mental Health:Primary care providers are now on the front lines in the diagnosis of mental health issues". While this over-reliance on medication in children has complex social and political roots, the fact is that pediatricians are the ones putting prescriptions into parent's hands.

There are a number of realities of pediatric practice that have led to this situation. Clinicians in most communities are faced with severe shortage of quality mental health care services. The health insurance industry contributes to this poor access, as low reimbursement and complex administrative rules are disincentives for therapists to participate in these plans. In addition, primary care clinicians are under intense time pressures. Again the health insurance industry plays a role, as in order to maintain a staff to manage multiple insurances, clinicians must see more and more patients in less and less time. In addition, there is often great pressure from teachers, parents and other clinicians to prescribe medication. And last, the
AAP endorses the biological model of psychiatry, as evidenced by the recent recommendation to extend diagnosis of ADHD down to age 4. Prescribing psychiatric medication to young children is a common endpoint of all of these factors.

The growing discipline known as Infant Mental Health offers a different paradigm. Research at the interface of neuroscience, epigenetics and developmental psychology offers both a different way to understand the emotional and behavior problems of young children, as well as a different model of intervenion. While in pediatrics the term infant refers to the first year, this discipline addresses the 0-5 age group.

While it is not my intention to cover this topic in depth, there are some key concepts. First, it is infant-parent mental health, and interventions always involve working with parent and child together. Second, symptoms (or behaviors) have meaning and come from somewhere. And third, the developmental trajectory of any individual child is a result of a complex interplay of genes and environment.

This model is best illustrated with an example. Following my recent appearance on the Diane Rehm Show, I received many emails from parents describing their experiences. One mother gave me permission to use her story, provided she could not be identified. I have selected out key aspects of the detailed story she sent me to illustrate how these principles can be applied to help young children and their families. I have divided her experience into obstacles to care and paths to success.

Obstacles to care:
Dysregulated from birth, with severe colic and poor sleep.
Pediatricians did not recognize signs early
Structured preschool setting “stressed him out”
Frustrated teachers diagnosed ADHD
Previously happy boy now crying all the time
Parents depressed, marriage severely strained

Paths to success:
Parents discovered Stanley Greenspan’s book Overcoming ADHD
Recognize difficulties as problem of self-regulation
Adjust environment and alter expectations without using label
Play-based preschool
Occupational therapy to address sensory processing challenges, with parents in attendance
Minimize media exposure
Calm, happy child, happy parents
Excels at chess, top of his class

So how can we help more children and families find this path to success? Changes need to be made at a policy level, including improving access to primary care and mental health care, calling attention to impact of pharmaceutical industry, and addressing problems in the health insurance industry, perhaps with a single payer system. The second front is through education of professional who work with young children about the growing body of knowledge coming out of the discipline of infant mental health, and its application to their work. This includes primary care providers, mental health clinicians, teachers and child care workers

A wonderful piece in the November 2009 issue of Atlantic entitled The Science of Success describes the "orchid hypothesis." Children with genetic vulnerabilities, like many of these children who are dysregulated from birth and have multiple sensory processing challenges, who grow up in an environment where they are misunderstood, "bad behavior" is punished, or "symptoms" are medicated away, may develop more serious forms of mental illness. On the other hand, in an environment that helps them to make sense of and manage their experience, as the parents of this child above did, they can grow up to be society’s most creative, successful, and happy people.

I conclude with a number of quotes from Ralph Waldo Emerson, who my daughter is currently studying in high school.

Whoso would be a man [woman] must be a non-conformist
For non-conformity the world whips you with displeasure
Nothing can bring you peace but yourself. Nothing can bring you peace but the triumph of principle.
This time, like all times, is a very good one, if we but know what to do with it.