To MA Gubernatorial Candidates on Mental Health: What About Children?

At last night's MSPP ( Massachusetts School for Professional Psychology) sponsored Gubernatorial Forum on Mental Health there was much talk among all of the candidates about how devoting resources to mental health care is a wise investment. But there was virtually not one mention of prevention in the form of children's mental health care. This was striking, as Nobel prize winning economist James Heckman has offered extensive evidence of how devoting resources to prevention in early childhood leads to decreased long-term costs of physical and mental health care.

Investing in early childhood also leads to decreased spending on prisons, a topic all of the candidates addressed in terms of decreasing the number of people in prison for non-violent crimes and first time drug offenses. They all correctly identified the high rate of mental illness in prison and the need to offer treatment, particularly substance abuse treatment.

The whole night I was thinking, "what about the children?" This might have been due to the format, and the fact that moderator Tom Ashbrook did not ask a single question about children.
I was struck by the contrast between this discussion and last week's American Academy of Pediatrics sponsored symposium on Child Health, Resilience and Toxic Stress.

All the best science of our time, in the form of research at the interface of neuroscience, genetics and developmental psychology, tells us that to invest in prevention means to invest in parents and children.

I was disappointed by Martha Coakley in a sense towing the NIMH party line, whose great shortcomings I describe in a previous post, by saying that mental illness is like any physical illness, such as diabetes. I am one hundred percent in favor of parity for mental health care, and decreasing the stigma of mental illness. But the only way to achieve this parity is to recognize that mental illness is not like diabetes.

Resilience and emotional wellbeing develop in the context of relationships. To both prevent and treat mental illness the focus of intervention needs to be on relationships. What makes us human is our historical and relational context. We need to value space and time to listen to each other.

The most important point of the evening, that was made in some form by all three democratic candidates, is that reimbursement for mental health care needs to increase significantly. When we place value, both cultural and monetary, on taking the time to listen, whether to parents of young children, teens struggling with substance abuse, or adults with a range of diagnostic labels, then we will be making meaningful steps not only towards mental health care parity, but also towards promotion of health and resilience.

Should pediatrics and child psychiatry marry for the sake of the children?

There is an interesting exchange of letters in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry between a prominent pediatrician and two psychiatrists regarding an article that recently appeared entitled "Is There a Child Psychiatrist in the House?" The pediatrician, William Carey, argues that pediatricians are well trained to manage such things as colic, sleep disturbances, toilet training and temper tantrums, perhaps more so than child psychiatrists. The authors of the original article reply that they are puzzled that Carey sees anything in the original article that threatens the role of the primary care clinician, and agree wholeheartedly with the proposed marriage.  Carey quotes a prominent British pediatrician, probably Winnicott, saying "many years ago" that "pediatrics and psychiatry have been living together long enough and its time we got married, if only for the sake of the children."

Here I would like to point out that Winnicott, a pediatrician turned psychoanalyst, practiced in a time before the explosion of psychiatric medications, and when psychoanalytic thought heavily influenced the practice of psychiatry. If that were still the case, I would agree with this marriage. However, in our current climate of mental health care, where the 15 minute "med check" is the most common type of visit, I think both fields would do well not to marry each other, but rather to marry the growing field of infant parent mental health.

I trained in both general and developmental and behavioral pediatrics, and work in a department of child psychiatry.  I know that for the most part neither discipline is exposed to the explosion of research and knowledge coming out of this new discipline, at the interface of neuroscience, genetics and developmental psychology. This knowledge has great bearing on preventive mental health care.

Here is a case in point. Prior to my own education in this new field, that came in part from my studies as a scholar with the Berkshire Psychoanalytic Institute and in part from a superb post-graduate training in infant parent mental health at U Mass Boston, I would not have known how to work effectively with mother-baby pairs in the setting of maternal mental illness.

Three-month-old Jenna sleeps peacefully in her mother’s lap. The cards seem stacked against her. Cara at 17 is struggling to finish high school. She has been diagnosed in the past with depression and anxiety, but currently is receiving no treatment. Her primary care doctor, who referred her to me, has been prescribing an anti-anxiety medication as a temporizing measure. Cara has been playing phone tag for over a month with the therapist at the community mental health center, whom she needs to see in order to get an appointment with a psychiatrist.

Cara is scheduled as my patient in my behavioral pediatric practice. I put anxiety as the diagnosis on the billing form. But in truth the aim of my work with this mother-infant pair is to protect her daughter’s developing brain from the well-documented ill effects of maternal mental illness on child development.

Cara talks in a rambling manner about a range of subjects- her older sister at 20 pregnant with her second child, but neglectful of the first, her father who abandoned the family when she was two. She is particularly focused on her difficult relationship with Jenna’s father, Ed. She tells of his drug use, his neediness and his difficulty accepting his role as father.

An infant’s brain makes as many as 1.8 million neural connections per second. The way in which these connections are formed is highly influenced by human relationships. As Cara responds to Jenna’s face and voice, is attuned with her rhythms and needs, both physical and emotional, she is literally growing her brain.

Important research has shown that when a mother can think about her baby’s mind and attribute meaning to his behavior, she helps him to develop a secure sense of himself and of his relationship with her. This security helps him to regulate himself in the face of difficult emotions. As he grows older he will have the capacity to think clearly and flexibly and manage himself in a complex social environment.

When I work with mother-baby pairs like Cara and Jenna, I focus on one simple thing. I listen to these mothers with the aim of helping them to reflect on their baby’s experience of the world and the meaning of their behavior. It never ceases to amaze me that with this singular focus, meaningful communication happens even in what appears to be chaotic and dismal circumstances.

As I listen to Cara’s rambling story, I know I need to help her start thinking about how all of this affects her relationship with Jenna. I use a technique I learned from leading researcher and clinician Peter Fonagy to help a person who is stuck in this kind of non-reflective thinking. I hold up my two hands. “Wait," I say. “I want you to help me understand how you think these problems with Ed connect with your relationship with Jenna.”

She pauses for a moment and then begins to cry. “When Jenna is so needy of me, it makes me think she’s just like her father, and I get so mad. Then I feel terrible for getting angry at her.” It’s a remarkable insight. But she isn’t done. She looks down at Jenna. “See how relaxed she is when I am calm. But when I get upset, she starts to cry.” Then she tells me of a time when she felt about to lose control, but somehow had managed to make Jenna laugh. “We were having a conversation,” she says joyfully, “even though she doesn’t say any words!”

After a year of visits like this every one to two months, despite having grown up in a quite chaotic environment, Jenna is a bright, curious well-regulated toddler. The research from infant-parent mental health clearly supports devoting this kind of time and attention early on to parent-child relationships as a model of preventive mental health care.

However, in order for a marriage between the two disciplines and infant-parent mental health to be successful, both need to divorce the current climate of health care where, under the influence of a powerful health insurance industry, there is no time for listening.

NYT on mental illness, talk therapy, drugs: what about children?

Last week there was an invitation to dialogue in the New York Times on this subject.  In today's Times there is a fascinating array of responses, but none addresses the issue as it relates to children, for whom there has been an exponential rise in prescribing of psychiatric medication in the last decade. Here is the letter I sent in.

We live in a culture of advice and quick fixes. Increasingly, understanding of human experience is reduced to lists of symptoms, diagnosis and medication. There is less curiosity, less careful listening to one another.

Talk therapy, which perhaps should be called “listening therapy,” offers space and time to create a meaningful narrative, including an opportunity to experience feelings of grief and loss.

This is particularly important in work with children. When symptoms are medicated away, the opportunity to tell stories that give meaning to behavior may be lost. Research has shown that a child’s knowledge of family narrative, both the ups and downs, is highly correlated with self- esteem, resilience and mental health. Giving a parents an opportunity to tell their story to a nonjudgmental listener, to integrate their own narrative,  is critical to treatment of childhood “behavior problems.”

I am not advocating for talk therapy for children. Rather, in order to help children who are struggling with a range of "behavior problems," it is essential to listen to their parents, to give them an opportunity to reflect on the meaning of behavior. The behavior is a symptom, perhaps even an adaptive response, to the underlying problem. There is extensive evidence, that I describe in my book Keeping Your Child in Mind, that when parents reflect on the meaning of behavior in this way, they have the opportunity to promote healthy development at the level of gene expression and structure and biochemistry of the brain.

In my practice, where I see children under the age of five, parents typically present with concerns like, "he never listens" or "she is defiant." But as we take the time to think about how the problem developed, meaningful shifts in understanding occur. For example, parents may recognize the way a child's behavior pushes their buttons because of their own history of abuse. Or serious marital conflict, that often has zeroed in on the child's behavior, comes to the fore.  Or the impact of an easygoing sibling may be recognized. Tantrums and meltdowns at birthday parties may be understood in the context of a child's longstanding difficulty with processing sensory input.

Creating this narrative, this story that makes sense of the problem, may only be the beginning of the treatment. Intensive work with parent and child together, to address the way the child's behavior provokes the parent, is often indicated. Marital counselling, or even working with a couple who are not together, to help them work together to support their child may be necessary. Quality occupational therapy can be invaluable to help a child to feel calm in his body. Parents may benefit from things such as yoga to help them to calm their own reactions.

Here is where the trouble really starts. Quality clinicians who offer these services are in short supply. Insurance is often a huge obstacle. But, creating perhaps an even bigger obstacle, is the cultural norm of the "quick fix" approach of medicating symptoms, even in children as young as 5.  Not only must parents overcome these obstacles of finding a provider, making the time, allocating funds, as well as doing the important but often challenging emotional work of addressing these issues. They must go against pressure from teachers, relatives, friends and  health care providers.

I will continue to offer parents space and time to be heard, to create meaningful narrative, because I am confident that telling stories, and working through the feelings of grief and loss that often accompany them, is the path to meaningful connection and healthy emotional development.  It causes me great heartache when these efforts are thwarted by a system that works in opposition to this approach.

Psychiatric Medication For Children? Important New Book Gives Pause

Two things most stood out for me in Kaitlin Bell Barnett's new book Dosed: The Medication Generation Grows Up. The first is the stories of women struggling to get off of SSRI's (selective serotonin re-uptake inhibitors), started in early adolescence, when they decide to get pregnant. The second is Bell Barnett's review of the literature regarding sexual dysfunction as a side effect of SSRIs in adolescence.

The book as a whole has much to say that is very important. As I write in my blurb for the cover:

Dosed is a fascinating, well-researched, and very important book. After reading it, I hope that no parent, pediatrician or psychiatrist will give psychiatric medication to a child or adolescent without very careful consideration of the potential long-term consequences. Bell Barnett shows that these medications are often not a ‘quick fix,’ but rather have deep, lasting impact, not only on physical and emotional health, but also on a person’s core sense of self.

Bell Barnett is a journalist who was herself started on SSRIs as a teenager. Her book intertwines in depth interviews with people who were started on psychiatric medication in childhood and are now young adults, with a journalistic study of the history of psychiatric medication use in children. I could probably write several posts covering all the important issues she addresses, but have chosen to focus on these two.

I first learned of the emerging evidence that SSRIs may cause long term sexual dysfunction last fall when I attended a talk by Robert Whitaker, author of the controversial book about psychiatric illness and medication Anatomy of an Epidemic. I was so alarmed about this data that I wanted to immediately write a blog post about it. But shortly after that talk I received the galleys of Bell Barnett's book. I discovered that she has a through review of the rather scant literature on the subject along with some very poignant stories, so I decided to wait until her book came out. I recommend that anyone who is concerned about this issue (as anyone who takes or prescribes these drugs should be) read her book. The subject is covered in the chapter entitled "Side Effects." Here are a few sample quotes.

A comprehensive review of the literature conducted in 2004 found just one clinical trial that reported erectile dysfunction in a teenager; most clinical guidelines and reviews of SSRIs didn't mention sexual side effects at all.

This is pretty shocking since, as the authors of the study cited above noted, anywhere from 30-40 percent of adults experience some kind of SSRI induced problems with libido, arousal, or orgasm.

And this important point:

Despite the lack of formal studies involving young people, anecdotal evidence suggests that drugs causing decreased libido and sexual dysfunction do sometimes pose a real problem, psychologically and socially, both for teenagers who are in the process of developing a sexual identity and for young adults testing out long-term intimate relationships.

And this from Elizabeth, who started taking SSRIs in 9th grade:

I am not sure I can [over]state the extent to which it impacted things. I didn't grow up with a normal sex drive, and that was obviously due to a combination of factors, but being on and off antidepressants whose impact I really couldn't understand back when I didn't have any real understanding of my sex drive or sex in relationships to begin with means I basically went through adolescence without experiencing anything in that realm in a "normal' way.

There's more, but the bottom line is that this issue is not well studied and yet of major significance in adolescent development.

Bell-Barnett poignantly captures the challenges faced by her interviewees who were started on SSRIs in childhood and now want to have children. Aware of the potential effects on the developing fetus, they try to get off the medication, but rebound with debilitating symptoms of depression. SSRIs are one of the most common medications prescribed in pregnancy. Yet we really do not know what the effects are on the developing fetus. A policy statement put out by the American Academy of Pediatrics earlier this year points to evidence that SSRI use in the third trimester is linked to a constellation of neonatal signs and symptoms. We do know that maternal depression itself can have a negative impact on the developing fetus. So if a woman is already on SSRIs and develops symptoms of depression without them, it may be best to stay on them during pregnancy.

The take home point of Bell Barnett's book, however, is that this issue needs to be considered by parents and clinicians when girls are prescribed these medications in childhood and adolescence well before having children is on their minds. These medications have a great allure as they may very quickly resolve symptoms. But one thing that Bell Barnett makes clear, and that is also supported by the literature, is that getting off these medications is very difficult.

Certainly these children and teenager should get help if they are struggling with depression. But other forms of intervention, including psychodynamic psychotherapy combined with self-regulating activities such as yoga, offer an alternative to medication. There is a severe shortage of quality mental health services due in part to the influence of the health insurance industry. It is a complex issue that must be addressed at the level of health care policy.

Large-scale use of these medications has major life-long impact on identity and sense of self of the current generation, referred to as "Generation Rx." Considering the complex issue of SSRIs in pregnancy, there is also potential for significant impact on the next generation. The time to pay attention to this problem is now. Reading Bell Barnett's book is a good place to start.