Saturday, January 17, 2009

Goldilocks and mental health: What is just right?

An article in today's Milford Post raises an interesting point, although oversteps a significant boundary in making the point.  Jacob Azerrad, a clinical psychologist from Lexington, questions the need to use medications, especially powerful medications like the atypical antipsychotics, in young children with behavioral problems.  He is correct to say that the second generation of antipsychotics is not as risk-free as initially advertised.  This week's New England Journal of Medicine points out that there is an association between use of atyptical antipsychotics and sudden cardiac death;  users were about twice as likely as non-users to undergo sudden cardiac death, although they weren't looking specifically at children.  I think that he is also correct  to say that many parents "over-medicalize" behavioral issues that are really just part of normal development.  That, in fact, is the job of the pediatric and behavioral health specialist, to reassure parents that a lot of the rambunctious behavior of two year olds is just that and doesn't require medication.
On the other hand, bipolar disorder and other serious emotional disturbances do exist in the world, and the parents of teens and young adults who really do have these problems will tell you that they perceived a qualitative difference in their behaviors as early as age 2.  I am really not sure that I could have perceived that difference in a diagnostic sense at that time, but I am willing to believe that the brain can have problems in both hardware and software at a young age, and that parents know more than I do about their own kids.  So, given that I don't want to "overtreat", how do I not "underdiagnose"?  I don't think that it is an easy thing to do.   I often feel like Goldilocks confronting the porridge, looking for the balance that is "just right". 
Because of that, I am a bit reluctant to cast aspersions on those who try, especially in difficult cases like that of Rebecca Riley, the young girl who died of a clonidine overdose last year.  The child clearly had major behavioral issues;  she may or may not have merited the diagnose of bipolar disorder, but she was clearly a challenging case that resulted in the worst possible outcome.  And yet, she had lots of care:  DSS, a psychiatrist, counselors, day care folks and parents were all wrestling with her demons along with her.  I know that the system failed her;  I am not at all certain which part of the system did so.   I suspect that the key in her case might have been better communication within the team; but I recognize that absent more information, I really don't know. 
It is on this dilemma that our task remains:  how do we build a system that respects the perspective of families, is based on the science of child development as we currently understand it, and appropriately uses the tools at hand to help the families and children?  It ain't easy.

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