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

1
The ecology of the childa 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 childs 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

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The childs 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

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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 childs 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 persons 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

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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

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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
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You
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Community
Culture
Spirituality
Friends
Family
Vocation
Extended Family
You
Recreation
Life Purpose
Environment
Nutrition
Nature
Pets
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You
You
Community
Culture
Spirituality
Friends
Family
Vocation
Extended Family
You
Recreation
Life Purpose
Environment
Nutrition
Nature
Pets
You
You
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The Science
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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

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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

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

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The Ecology of the Child

• Environmental
• Physical
• Mental
• Emotional
• Social
• Spiritual

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The Data
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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 1980s
• 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 Context?Currie 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,
  641032-8 2007 September

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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

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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

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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

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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

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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

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The science behind labels

• The DSM
• Reliability
• Validity
• Problems

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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

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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

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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, 18169-184

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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

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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.
• Cant conclude that ADHD represents a disordered
  biological state
• NIH Consensus Panel,
  JAACAP, 2000 39182-93.

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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

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NIMH Brain Imaging in ADHD

• Delay most pronounced in frontal cortex

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Do Stimulants Work?

• MTA Study Follow-up
• Raine Study Review
• Oregon Study

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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

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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/publica
  tions/documents/ MICADHD_Raine_ADHD_Study_report_
  022010.pdf

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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_report12
  07.pdf

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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_report12
  07.pdf

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The Problem
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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

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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

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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

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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

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Overweight Children in US CDC
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A solution
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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 childs brain

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Nutritional

• Reduce intake of trans fats and hydrogenated
  oils fried, margarine, junk
• Enhance omega 3 EFAsfish, 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

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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

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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

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Cultural

• Materialism must be confronted
• We must build more spiritual depth
• Reduce violence and aggression in our childrens
  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

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Trauma Find it, Treat it

• Frequent moves can be traumatic
• We need to recognize subtle forms of isolation
  and neglect
• Threats of violence and terrorism real to the
  child
• Sexual and physical abuse are more common than we
  think
• Violence in media is pervasive and damaging

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Relational

• Increase face time. Quantity is also important
• Schedules and kids how to balance?
• We must build more sense of community, more
  engaged adults
• Depressed moms MUST be treated
• Screen time should be limited

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What our kids really need

• Relational based life
• Engaged, emotionally sound parents
• Physical activity and fitness
• Proper sleep and relaxation
• Fit with parents acceptance and understanding
• Proper fit at school for learning style

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What our kids really need

• Limited screen time
• God time spirituality, sunlight and nature
• Proper nutrition and supplementation
• Success experiences find gifts and talents
• Sense of closeness to parents
• Clean environment
• A lack of violence

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The bottom line

• We must embrace an ecological view of the
  children, their behavior and their mental health.
• Every child exists in a web of life with a
  diverse and crucial interconnectedness
• Psychiatric symptoms are a call to examine the
  childs world

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References

• Bronfenbrenner, U (ed) Making Human Beings Human
  bioecological perspectives on human development
  Sage Publications Thousand Oaks, CA 2005.
• Capra, F The Web of Life Anchor NY, 1997
• Engel, G The need for a new medical model A
  challenge for biomedicine Science 1970 196
  129-139.
• Shannon, S Please Dont Label My Child
  Rodale NY, 2007.
• Shannon, S Handbook of Complementary and
  Alternative Therapies in Mental Health Academic
  Press San Diego, 2002.
• Storck, M and Vander Stoep, Fostering
  Ecological Perspectives in Child Psychiatry C/A
  Psy Clinics of NA 16 (2007) 133-63.
• Wilkinson, CB Human ecology and mental illness
  Am J Psychiatry 1982 139 (8) 985-90.

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Scott Shannon, MD

• Integrative Psychiatry
• Fort Collins, Colorado 80525
• 970.221-1106
• scottshannon_at_cowisp.net
• www.wholeness.com