Rising SSI benefits for young children and marketing of atypical antipsychotics: a possible link

A legacy of unintended side effects, a powerful piece of investigative reporting in Sunday's Boston Globe, offers a view of the desperation of poverty. Parents speak to reporter Patricia Wen of seeking diagnoses and psychiatric medication for their young children in order to receive SSI(Supplemental Security Income)benefits. In order to qualify for SSI a child must have a recognized disability. In 1990 8% of children qualified because of mental, learning or behavioral issues. In 2009, that number had jumped nationwide to 53 percent. Wen writes:

In New England, the numbers are even higher — 63 percent of children qualify for SSI based on such mental disabilities. That is the highest percentage for any region in the country. And here and across the nation, the SSI trend line is up, with children under 5 the fastest-growing group. Once diagnosed, these children often bring in close to half their family’s income.

There are many alarming issues raised by this piece, and Ms. Wen is brave to tackle the subject, given that questioning benefits for troubled children is likely not to be a popular position among Globe readers.

One particular statistic jumped out at me. Wen outlines the historical shift in the program, from its inception in 1972, to the spike in mental disability cases following a legal ruling in favor of a boy whose disability payments had been cut off, through the identified abuses of the system in the 1990's followed by cracking down by federal law makers. Wen writes:

The children’s SSI disability rolls instantly shrunk — but the decline would be short-lived. Families and clinicians began to adjust to the new rules, which emphasized extensive medical records for any claimed disability. From 1997 to 2007, the number of children who qualified under behavioral, mental, and learning disorders more than tripled from 180,000 to 562,000.

What else happened in exactly that time period of significance for children's mental health? In June of 2001 I took a course sponsored by Harvard Medical School on Major Psychiatric Illnesses in Children and Adolescents. I attended a lecture given by Janet Wosniak entitled "Juvenile Bipolar Disorder: An Overlooked Condition in Treatment Resistant Depressed Children."

Little did any of us at the lecture know at the time that, largely as a result of Dr Wosniak her close colleague Joseph Biederman's ideas, we would over the next nine years see a 4000 percent increase in diagnosis of this "overlooked condition." These children were described as irritable with prolonged, aggressive temper outbursts that she called "affect storms." Some children were as young as 3 and over 60% were under age 12. In a previous blog post on the subject I wrote;

So here we have a perfect storm. A new disease with no clearly identified treatment. A new drug. Between 2000 and 2010 six atypical antipsychotics, Clozaril, Seroquel, Zyprexa, Risperdol, Abilify and Geodon were approved for treatment of pediatric bipolar disorder. The number of prescriptions for atypical antipsychotics for children and adolescents doubled to 4.4 million between 2003 and 2006. Prescribing of antipsychotics for two to five year olds has doubled in the past several years. Atypical antipsychotics are among the most profitable class of drugs in the United States.

I can't help but wonder if these events- rapid increase in SSI benefits for children under five for a mental health disability, and the rapid rise in diagnosis of bipolar disorder in young children in parallel with the explosion of development and marketing of atypical antipsychotics, are closely linked.

We urgently need a different paradigm for understanding emotional and behavioral problems in young children from that offered by the pharmaceutical industry. Money needs to be redirected to supporting parents in their ability to be physically and emotionally present with their very young children at times of most rapid brain development. Many interventions, such as Yale's Minding the Baby program, have been successful in setting children on a healthy path of development even in the context of significant economic and psychosocial risk. A wealth of high quality research is showing that children learn to regulate emotions in the context of relationships, and that this learning takes place at the level of gene expression and biochemistry of the brain.

Wen writes, "This abrupt climb in cases is a sign, some researchers say, that the SSI program has veered far from its original purpose." Aid for children with true disabilities, whether physical or mental, is extremely important, and the take home message should not be that the program is a bad one. Rather this piece demonstrates with disturbing clarity how much we need to intervene early to support parents and their young children, before they get to such a point of desperation that they are willing to label a child as disabled in order to survive.

How Parents and Children Regulate(and Dysregulate) Each Other

When parents and children come to see me in my behavioral pediatric practice, they are angry, disconnected and sad. In moments of explosive behavior, both parent and child feel terribly out of control. My aim it to help them reconnect and in doing so, to calm down and find pleasure again in their relationship.

Recently I saw a 4 year old boy,David, whose mother, Alice, described him as "explosive." She told of a typical scene- a request to get ready for bed was met with a firm "no," and soon mother and child were head to head in battle. An hour later, David was kicking and screaming on the floor and Alice was crying, horrified at herself for having threatened to hit him.

Rather than launching right in to "what to do" I took some time to listen to Alice's story while David played on the floor. Many things emerged, but most striking was the fact that the family had moved three times in the past year after David's father,Ron, lost his business, leaving the family in financial ruin. Ron had been severely depressed, but according to Alice, they were settled now and he had a good job. When I commented that it sounded like a very stressful year, she immediately responded with," Yes, but we didn't let it affect David."

From my position, this clearly seemed impossible. Such an experience is inevitably stressful for a four year old child. But for some reason, Alice, who was an intelligent woman, did not see it. Perhaps she felt so much guilt, or even shame, about what had happened to her family that could not let herself recognize this truth.

I saw my task at that moment as helping Alice to understand David's experience, to recognize that his increasingly frequent battles for control were likely in part due to feeling things were out of control for whole past year. But I needed help Alice recognize this without increasing her guilt and shame. It was a difficult and sensitive procedure.

When I saw them two weeks later, the explosive episodes had significantly decreased. Alice told me that his behavior no longer seemed so bewildering to her. Rather than getting angry, she listened to him, yet set more firm limits. She was delighted with the results and felt proud of her ability to regain a sense of joy and stability in her relationship with her son.

In recent blog posts, I have written about my experience as a fellow with the Infant Parent Mental Health Post Graduate Certificate Program at U Mass Boston, which is lead by Ed Tronick. At our first weekend Dr. Tronick, who is perhaps best known for developing the still face paradigm, talked to us about his mutual regulation model. In a paper we read for that weekend, Dr. Tronick writes:

"The MRM(mutual regulation model) stipulates that caregivers/mothers and infants/children are linked subsystems of a dyadic system and each component, infant and caregiver/mother, regulate disorganization and its costs by a bidirectional process of behavioral signaling and receiving."

The still face paradigm, in which a mother interacts face to face with her infant as she usually would, then for a two minute period presents a completely still face, followed by a reunion episode of resumed face to face interaction, in Dr. Tronick's words "demonstrates the costliness of an experimental disruption of the mutual regulatory process...as it serves as a model for the stress inherent in normal interactions." Dr. Tronick's model is compelling and very complex. I admit that while I was fascinated, I had a difficult time connecting this construct with the daily interactions I have with children and families in my office.That is until my "aha" moment this week.

I have recently been in contact with another leading researcher in the field, Arietta Slade. She has written extensively about what is referred to as parental reflective functioning. This is also described as "holding a child's mind in mind."It essentially refers to a parent's capacity to reflect on the meaning of her child's behavior. Slade, along with other researchers, has shown how enhancing a parent's capacity for reflective functioning is associated with many positive outcomes for a child's emotional development, including flexibility, cognitive resourcesfulness and the ability to manage complex social situation. I have been heavily influence by her work in my practice, and have written about the concept of holding a child in mind on this blog and in my forthcoming book.

In this "aha" moment, I suddenly understood that when things go well in my office, it is not only because a parent increases her capacity for reflective functioning. Supporting her in her efforts to her to reflect upon the meaning of her child's behavior is simply the point of entry. Once the child feels understood, or held in mind, he becomes calm. As I have written about elsewhere on this blog,it is likely that this change is on a neurobiological basis, occurring at the level of the structures of the brain that produce stress hormones. When a child is calm, a mother begins to feel better about herself. In fact, often a child's out of control behavior itself produces a feeling of shame in a parent. When parent and child are more in control, this sense of shame decreases. In turn, when a parent feels less shame, and less stress, she can think more clearly. She is better able to reflect on the meaning of her child's behavior. In turn a child feels even more calm and in control. Voila! Mutual Regulation! This is where we aim to be.

The Pharmaceutical Industry, Psychiatric Drugs and Primary Care

An article last week in the New York Times, entitled Drug makers wrote book under 2 doctors names reported on a book that was written by two psychiatrists for an audience of primary care clinicians. The book, whose aim was to teach these clinicians about how to treat psychiatric disorders, was in fact ghostwritten by the drug company then known as SmithKline Beecham.

Robert Whitaker, author of Anatomy of an Epidemic, comments on his blog in a post entitled Ghostwritten book hints at much larger problem He offers a larger context, stating that

In fact, this ghostwriting revelation simply hints at a much larger, pervasive problem, which is that financial bias profoundly affects the authorship of psychiatric textbooks at every turn. And it is quite easy to document that this is so.

Most concerning to me, as a pediatrician, was a comment on Mr. Whitaker's blog from an MD who states

The Amer. Acad Child and Adolescent Psychiatry Psychopharm conference this November seemed to me to reflect commercial bias in a level I found unsettling -given that AACAP has long been a refuge where quality of care has tended to come first.

Last week, I wrote in a blog post about the possible influence of the pharmaceutical industry on the recommendations child psychiatrists give to primary care clinicians. I describe a supposedly successful program that aims to increase access to mental health care. The program in fact simply supports primary care clinicians in prescribing psychiatric medication to children.

The New York Times article, Whitaker's post, and the comment on it all confirm my fears of the heavy influence of the pharmaceutical industry on how psychiatry is guiding primary care clinicians in treatment of of psychiatric problems, in both adults and children.

An alternative paradigm is urgently needed. A primary care clinician has a long standing relationship with a family than can be put to great use in addressing mental health problems in a preventive model. With the enormous financial influence of the pharmaceutical industry moving the ship of mental health care in one direction, getting it to move in a different direction will take an enormous effort. Add to this a cultural expectation of a quick fix, and this seems an almost impossible task. But when it comes to supporting children's healthy emotional development, I believe we have no choice but to make the effort to change direction.