The ecology of the child: a post-modern view of pediatric mental health

1. The ecology of the child:a post-modern view of pediatric mental health scott shannon, md university of colorado

2. Agenda: • The brain • The science • The data • The problem • A solution

3. The Brain:

4. The magic of the child’s brain • The brain accounts for over 1/2 of the human genome • The brain quadruples in size after birth • Age 5: most adept at making interconnections • A infant needs to sleep over 20 hours per day based on the metabolic demands of the brain

5. The child’s neurons • At the peak of brain development over 250,000 neurons are created per minute • A child has twice your number of neurons • A single neuron may migrate a few centimeters: the equivalent of NY to California • A single neuron may have 10,000 connections

6. Plasticity • Early brain stimulation increases number of cerebral blood vessels by 80% • College grad has 40% more neural connections than HS dropout • Early stimulation vs. deprivation: 30 pts IQ • The vast majority of a child’s neurons are not prewired but respond to stimulation

7. Genomics • Patterns of gene expression under varying environmental conditions • The link between genotype and phenotype • How the environment alters our chemistry • Creates biochemical individuality

8. Genomics “ Genetic variations do not cause disease but rather influence a person’s susceptibility to environmental factors.” “Virtually all human diseases result from the interaction of genetic susceptibility and modifiable environmental factors.” CDC: The Office of Genetic and Disease Prevention, August, 2000

9. Epigenetics • Heritable changes in gene expression by other than shift in DNA sequence • More powerful and important for most mental and physical health issues • Swedish farmers • Agouti mice • Prostate Cancer- lifestyle intervention created almost 500 relevant metabolic pathway changes for tumor expression in 3 months Ornish, D PNAS 2008 . 105 (24) : 8369-74

10. Agouti mice • Furthermore, recent studies have demonstrated for the first time that heritable environmentally induced epigenetic modifications underlie reversible transgenerational alterations in phenotype. Jertle, R JAMA 2008. 299 (1) 1249-52

11. You

12. Community Culture Spirituality Friends Family Vocation Extended Family You Recreation Life Purpose Environment Nutrition Nature Pets

13. You You Community Culture Spirituality Friends Family Vocation Extended Family You Recreation Life Purpose Environment Nutrition Nature Pets You You

14. The Science

15. What is Ecology • From the Greek: oikos (household) • Coined in 1866 by German biologist Ernst Haeckel • Study of the relationships that interlink all things on earth • The relationship between an organism and its environment • “The web of life”

16. Ecology • De-emphasizes individual organisms • Emphasizes systems and networks • Study the whole, the pattern of interactions • In direct opposition to mechanistic thinking • Complex systems can only be understood in context

17. Integrated nesting hierarchies Each self-balancing All interdependent A change in any subsystem has the potential to significantly alter any other

18. The Ecology of the Child: Environmental Physical Mental Emotional Social Spiritual

19. The Data

20. What is happening now? • American children have the most psychiatric illness in the civilized world-WHO study • Childhood depression: epidemic in USA • Autism: 10x the rate of the 1980’s • ADHD: 250,000 in 1975 to 4,000,000 today • Pediatric office: Psychiatric labels: 3x in 25 years • Pediatric BPD: Rate of hospitalization up five fold-1996-2004. Rate of diagnosis up 40 FOLD in 10 years 2001/02 HBSC International Report: Young People's Health in ContextCurrie C. et al (eds.) 2004. Young People's Health in Context: international report from the HBSC 2001/02 survey. WHO Policy Series Blader, J and Carlson, G Biol Psychiatry: 2007: Feb 15 Moreno, C et al Archives of General Psychiatry, 64:1032-8 2007: September

21. Bipolar Disorder Explodes in Youth • Diagnosis of outpatient youth 1994-03 • Pediatric BPD increased 40 fold • Adult BPD increased 0.8 fold • 67% of Pediatric BPD: male • 68% of Adult BPD: female • ADHD: 32% vs 3% Moreno et al, Arch Gen Psych. 2007 Sept; 64 (9): 1032-1039

22. How are we responding • Use of psych meds in kids tripled in last 15 years • ADHD meds (0-5 yrs): up 369% 2000-2003 • Anti-depressants (0-5 yrs): up 21% in 3 yrs • Anti-psychotics up five fold in kids: 1993 to 2002 • Sleeping pills (10-18): up 85% in 3 yrs • US now consumes 80% of worlds stimulants • Only 20% of anti-psychotics for psychosis

23. Psychiatric Meds in kids • Inadequate data for efficacy outside of stimulants • Little science of long term safety • 1.6 million kids on 2 or more meds: no science • Few psych meds have FDA indication for kids • Neurological and hormonal impact mostly unknown

24. Atypical Antipsychotics in kids • 176 kids • 27% met criteria for metabolic syndrome • Only 2.9% in untreated youth • Study triggered by observation of sudden onset DM in youth on these medications Panagiotopoulos, D AACAP meeting October 2009 Hawaii

25. Unsupported use of AAPs in kids • Retrospective analysis of 11,700 kids on AAPs • Abilify: 77.1% of use unsupported • Olanzapine: 43.9% of use unsupported; 29.1% weak • Quietipine: 32.6% unsupported; 45.9% weak • Risperidone: 30.6% unsupported; 1.7% weak • Ziprasidone: 43.1% unsupported; 56.9% weak Pathak, P Psychiatric Services 2010 February

26. The science behind labels • The DSM • Reliability • Validity • Problems

27. Diagnostic and Statistical Manual • Created in 1950 DSM-I: 106 labels • Revised in 1968 DSM-II: 140 labels • Revised 1980 DSM-III: 206 labels • Revised 1994 DSM-IV: 370 labels • Homosexuality removed in 1973 by referendum of members

28. Reliability • Personal belief systems in psychiatry create idiosyncrasies and wide variation • Reliability is fair in academic settings with lengthy structured interviews • “However, the reliability of psychiatric diagnosis among practicing clinicians is still poor” • “The unreliability of psychiatric diagnosis has been and still is a major problem in psychiatry.” Abroraya et al, Psychiatry 2006, 3 (1): 41-50

29. Low Reliability • Large meta-analysis • 38 studies • 16,000 patients • Low correlation between clinical evaluations and standardized diagnostic interviews (SDIs) • K value: 0.27 overall (poor) Rettew, DC et al Int Methods Psych Res 2009, 18:169-184

30. ADHD: Illness or ??? • Triggers for ADHD: thyroid abnormality, iron deficiency, head injury, Fragile X, FAS, food additives, depression, Lead toxicity, PTSD, etc. • Final Common Pathway: think fever • Is fever an illness? • Fever responds to NSAIDs, but what are we treating? • ADHD symptoms: non-specific indication of CNS dysfunction

31. NIH Consensus Panel • Conclusion: “Unclear if ADHD is at the far end of the spectrum of normal behavior or if it reflects a qualitatively different behavioral syndrome.” • “ADHD symptoms have a CNS basis” • “Remarkable lack of research on the etiology or prevention of ADHD. We know little about this. ” • “We have no strategies for prevention of ADHD.” • “Can’t conclude that ADHD represents a disordered biological state” NIH Consensus Panel, JAACAP, 2000; 39:182-93.

32. Landmark Brain Imaging Study in ADHD • 446 kids with and without ADHD scanned repeatedly over years • 40,000 measures of cortical thickness • ADHD kids lag 3 yrs in cortical growth • ADHD: matures earlier in motor cortex • Brain imaging not ready for clinical use • No evidence of abnormality, only delay Shaw, P. National Academy of Science December 2007: (104) 49: 49-54

33. NIMH: Brain Imaging in ADHD • Delay most pronounced in frontal cortex

34. Do Stimulants Work? • MTA Study Follow-up • Raine Study Review • Oregon Study

35. MTA Follow-Up • Largest and most important study ever of ADHD • 14 month study of 436 kids • 6 and 8 year follow-up released. • No positive effect of medication treatment found • Only 30% of kids still met criteria for ADHD • Benefit lost by three years • Non-medicated children functioned as well as medicated children after eight years • Growth: “significantly decreased” Molina, BS et al J Am Acad Child Adol Psychiatry 2009 ; 48 (5):484-500

36. Long-term study of ADHD • Raine Study Review: tracked large population of children in western Australia over 9 years. • Harm: use of stimulants increased diastolic blood pressure by 10 pts. • Benefit: Use of stimulant medication increased risk of school failure by 950% • The results seem to indicate that there is little long-term benefit of stimulant medication in the core symptoms of ADHD. http://www.health.wa.gov.au/publications/documents/ MICADHD_Raine_ADHD_Study_report_022010.pdf

37. Oregon Study • Study commissioned by 15 US states to explore which ADHD medications were most effective and safest • 731 page report published by OHSU in 2005 • It analyzed “virtually every investigation ever done on ADHD drugs anywhere in the world” • No axe to grind, no commercial interest • Looked at 2,107 studies • 180 studies meet the highest criteria http://www.rx.wa.gov/documents/adhd_final_report1207.pdf

38. Oregon Study • Results: “analysis severely limited by lack of studies measuring functional or long term results” • Concluded: “good quality evidence on the use of drugs to affect outcomes relating to academic performance, risky behaviors, social achievements… is lacking” • Concluded: “No evidence of long-term safety of drugs used to treat ADHD in adolescents” • Concluded: Overall the body of evidence was of poor quality. http://www.rx.wa.gov/documents/adhd_final_report1207.pdf

39. The Problem

40. Clear pattern • More and more kids are exhibiting behavioral and emotional symptoms • We label • We medicate • We blame the child, we blame the brain • The science behind labeling and medicating children is weak • We are losing ground in the US

41. Why so many? • Multiple intersecting stressors • Progressive trend over the last twenty years • Little attempt to identify and alter triggers • Less supportive factors • More debilitating factors

42. Seven Ecological Disasters for Kids • Poor Nutrition/ SAD (standard American diet) • Maternal Depression • Poor fit with school and learning style • Child-Parent fit issues • Over-stimulation and lack of sleep • Obesity • Divorce

43. Maternal Depression If mom is depressed: kid has 4x risk of labeling • Father in home offers protection • Depression twice as common in childhood • 33% of kids with diagnosis remitted with mom • 17% of kids gained diagnosis if mom still ill • 23 year follow up as adults: more depression, pain, disability, psychiatric meds, avoidance and fewer friends Hammen, C Arch Gen Psychiatry 2003; 60: 253-258 Weissman, M JAMA 2006; 295 (12) : 1389-98

44. Overweight Children in US CDC

45. A solution

46. Our Call to Arms • As parents, educators, health care professionals we must take a stand • We must resist the pathologization of our youth • We must take action to improve the lives of children and stop blaming the child’s brain

47. Nutritional • Reduce intake of trans fats and hydrogenated oils: fried, margarine, junk • Enhance omega 3 EFAs:fish, game, nuts • Increase magnesium intake: soy, nuts, greens • Reduce sugar intake and glycemic load • Reduce or eliminate caffeine • Monitor and support protein intake • Supplementation is key

48. Environmental • Protect and support sleep time • Enhance sunlight exposure • Demand a clean environment: take political action. The Precautionary Principle • Pesticides and herbicides: avoid via organics • Monitor noise pollution • Air pollution: filters, negative ions, • Time in nature: biophilia, the green effect • EMF: How dangerous?? Headsets

49. Educational • Reduce size of schools: “SS Project” • Reduce pace and academic pressure • Incorporate affective education • NCLB: leave it behind • Broaden supported of learning styles beyond verb/analytic & mathematic • Decompression of early development

50. Cultural • Materialism must be confronted • We must build more spiritual depth • Reduce violence and aggression in our children’s lives: real and media driven • Acknowledge our competitive culture and manage it positively • Premature sexuality should be limited • We must limit pace and tempo • Families must develop an active lifestyle