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The ecology of the child: a post-modern view of pediatric mental health. scott shannon, md university of colorado. Agenda:. The brain The science The data The problem A solution. The Brain:. The magic of the child ’ s brain. The brain accounts for over 1/2 of the human genome

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

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

scott shannon, md

university of colorado


  • The brain

  • The science

  • The data

  • The problem

  • A solution

The magic of the child s brain
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

The child s neurons
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


  • 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


  • Patterns of gene expression under varying environmental conditions

  • The link between genotype and phenotype

  • How the environment alters our chemistry

  • Creates biochemical individuality


“ 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


  • 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

Agouti mice
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











Life Purpose

















Life Purpose







What is ecology
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”


  • 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

Integrated nesting hierarchies

Each self-balancing

All interdependent

A change in any subsystem has the potential to significantly alter any other

The ecology of the child
The Ecology of the Child:







What is happening now
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

Bipolar disorder explodes in youth
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

How are we responding
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

Psychiatric meds in kids
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

Atypical antipsychotics in kids
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

Unsupported use of aaps in kids
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

The science behind labels
The science behind labels

  • The DSM

  • Reliability

  • Validity

  • Problems

Diagnostic and statistical manual
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


  • 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

Low reliability
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

Adhd illness or
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

Nih consensus panel
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.

Landmark brain imaging study in adhd
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

Nimh brain imaging in adhd
NIMH: Brain Imaging in ADHD

  • Delay most pronounced in frontal cortex

Do stimulants work
Do Stimulants Work?

  • MTA Study Follow-up

  • Raine Study Review

  • Oregon Study

Mta follow up
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

Long term study of adhd
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. MICADHD_Raine_ADHD_Study_report_022010.pdf

Oregon study
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

Oregon study1
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.

Clear pattern
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

Why so many
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

Seven ecological disasters for kids
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

Maternal depression
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

Our call to arms
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


  • 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


  • 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


  • 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


  • 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

Trauma find it treat it
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


  • 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

What our kids really need
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

What our kids really need1
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

The bottom line
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 child’s world


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 Don’t 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.

Scott shannon md

Scott Shannon, MD

Integrative Psychiatry

Fort Collins, Colorado 80525


[email protected]