Can we stem the rising tide of serious psychiatric illness in college?

Last week I "launched" my oldest off to college. As anticipated, it was an intense emotional experience full of joy, sadness, and many things in between. (I have to tip my hat to fellow Globe writer Beverly Beckham for her piece I was the sun, the kids were my planets that was very helpful. However, I might have written that my child was the sun, a burst of light in our household, and the experience of leaving her is like being temporarily knocked out of orbit as our family re-orients to life without her.)

The same week I received in the mail, in exchange for filling out a questionnaire about a study on diversion -use of ADHD medications by individuals for whom it was not prescribed- this pretty laminated poster of all the drugs currently available for treatment of ADHD.

Statistics indicate that serious mental health problems in the college community are growing at rapid rates. Some optimistically speculate that this is because of decreased stigma for getting care. But I wonder at the paradox of the parallel increase in availability of new psychiatric drugs- I counted 22 different formulations for ADHD medications on that poster- and the rise of serious mental health problems. Could it be that the drugs themselves are responsible for this increase? If the drugs were effective in childhood, shouldn't we see a significant decline in serious mental illness in college?

How would this work? Starting at a young age, rather than learning to manage stress in the context of supportive relationships, the symptoms are medicated away. The brain is actually wired in relationships, and in the absence of this kind of co-regulation of emotion, the areas of the brain responsible for emotional regulation do not develop properly. All forms of mental illness, including depression, anxiety and attention problems are essentially problems of emotional regulation. Then as the challenges of life increase in complexity, the medications often increase in strength and complexity. Children learn to be defined by their medication and are further estranged from a core sense of self. Add to that unknown side effects on the developing brain, and it is no wonder that there is a significant increase in serious mental illness by the time a child gets to college.

But what about that issue of decreased stigma? That also is likely true. At a superb talk given by a psychology professor at our child's orientation, we learned about the school's  "invisible safety net." It is made up of an elaborate interconnected system of students, faculty and mental health professionals to monitor the emotional well-being of the students. It is all about relationships and connection.

The very existence of this net reduces the stigma of emotional struggles. The fact that the school goes to the trouble to train such an elaborate system of care (sophomore advisors- or "SA's" the front line of this system, must apply in January of their freshman year, and they get several weeks of training prior to the start of the school year), conveys to both students and parents that it is normal and expected that people will struggle and need help.

I believe there is something to be learned from this "invisible safety net" model. If we as a country were to implement a model of preventive mental health care, we would have in place a net made up of primary care clinicians, early childhood educators, childcare workers, mental health care professionals, as well as others who come in contact with young children and families. There would be open and expected lines of communication. (At this college, if a parent calls with a concern about their child, within the hour there is a person making face-to-face contact with that student, even if it is just inviting them out for a slice of pizza- and that person is trained to recognize when it is necessary to call in a higher level of intervention.)

If such a net were there from infancy-including a system for identification and treatment of perinatal mental health problems- through adolescence, then maybe kids wouldn't need all those pretty little pills to take to college.

Women are Women where ever we birth

Taking stimulants for SATs: sadly we taught them that

As a general and behavioral pediatrician I admit that I have participated in many conversations that went something like this. In a child's presence a parent says: "He does well in his morning classes, but then his grades are down in the afternoon-can we use something longer acting?" Or, "She did so well at first, but now she's getting 70's. I think she needs a higher dose." These conversations occurred in the setting of a brief follow-up visit for ADHD. These visits might be spread as far apart as 3 to 6 months. What else happened in those months? There was neither the time nor the expectation to address that question in a meaningful way.

Is it any surprise, given that this form, length and frequency of visits for ADHD is the standard of care in pediatrics, that now there is an explosion of abuse of prescription stimulants in the high pressure setting of the college application process? A recent New York Times article Risky Rise of the Good-Grade Pill addressing this issue states:

The number of prescriptions for A.D.H.D. medications dispensed for young people ages 10 to 19 has risen 26 percent since 2007, to almost 21 million yearly, according to IMS Health, a health care information company — a number that experts estimate corresponds to more than two million individuals. But there is no reliable research on how many high school students take stimulants as a study aid. Doctors and teenagers from more than 15 schools across the nation with high academic standards estimated that the portion of students who do so ranges from 15 percent to 40 percent.

My daughter is a senior at one of these "high-pressure private schools" referred to in the article. She confirms these statistics, putting the number at about one third. A previous post, Meds for ADHD: They Work But is that the Right Question?, was inspired by conversation in which she asked me about the ethics of taking these drugs for the SATs. In that post I speak to the need to understand ADHD as a problem regulation of attention, emotion and behavior, and to focus on relationship-based interventions to promote self-regulation. It is the hyperfocus on medication to the exclusion of both understanding of the child's experience, and also other forms of intervention, that has led to this problem in the high school setting.

Relationship-rich interventions include such things as martial arts, music, and team sports (Michael Phelps had severe ADHD), activities that foster relationships and also promote self-regulation. Family systems are often severely strained when a child is struggling, and interventions aimed at supporting the family as a whole are very important. Careful examination of the school setting and accommodations to decrease over-stimulation are similarly necessary. But if the drug makes the symptom go away, there is no motivation to devote effort and resources to make these kinds of changes.

When I asked my daughter today if she had ever taken stimulants before a test she replied that she thought it was a silly idea. Her reason? "If you do well on stimulants it's not really you, and you will end up at a college where you will be miserable. Then you will need to keep taking the drugs." Such a wise child!

Now, why do we want to mainstream homebirth?

Obama, what we can do for health care