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

Loading...

PPT – The ecology of the child: a post-modern view of pediatric mental health PowerPoint presentation | free to view - id: 74d96f-NWNmY



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

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

Description:

scott shannon, md university of colorado – PowerPoint PPT presentation

Number of Views:63
Avg rating:3.0/5.0
Slides: 58
Provided by: Tria662
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: 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 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

5
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

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 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

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 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

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, 18169-184

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

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/publica
    tions/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_report12
    07.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_report12
    07.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 childs brain

47
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

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 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

51
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

52
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

53
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

54
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

55
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

56
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.

57
Scott Shannon, MD
  • Integrative Psychiatry
  • Fort Collins, Colorado 80525
  • 970.221-1106
  • scottshannon_at_cowisp.net
  • www.wholeness.com
About PowerShow.com