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


Agenda

Agenda:

  • The brain

  • The science

  • The data

  • The problem

  • A solution


The brain

The Brain:


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


Plasticity

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


Genomics

Genomics

  • Patterns of gene expression under varying environmental conditions

  • The link between genotype and phenotype

  • How the environment alters our chemistry

  • Creates biochemical individuality


Genomics1

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


Epigenetics

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


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


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

You


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

Community

Culture

Spirituality

Friends

Family

Vocation

Extended

Family

You

Recreation

Life Purpose

Environment

Nutrition

Nature

Pets


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

You

You

Community

Culture

Spirituality

Friends

Family

Vocation

Extended

Family

You

Recreation

Life Purpose

Environment

Nutrition

Nature

Pets

You

You


The science

The Science


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”


Ecology

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


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

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:

Environmental

Physical

Mental

Emotional

Social

Spiritual


The data

The Data


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


Reliability

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


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.

    http://www.health.wa.gov.au/publications/documents/ 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

    http://www.rx.wa.gov/documents/adhd_final_report1207.pdf


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.

    http://www.rx.wa.gov/documents/adhd_final_report1207.pdf


The problem

The Problem


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


Overweight children in us cdc

Overweight Children in US CDC


A solution

A solution


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


Nutritional

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


Environmental

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


Educational

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


Cultural

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


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


Relational

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


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


References

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 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

970.221-1106

[email protected]

www.wholeness.com


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