Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary research in child development can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Friday, November 26, 2010

Understanding Behavioral Epigenetics vs Increasing Access to Psychiatric Drugs for Children

These two topics could be two different blogs posts, but I decided to put them together because, in considering the larger question of where we invest our resources in promoting children's mental health, the two are subjects are linked. The first fills me with excitement and optimism, the second with despair.

My blog posts have been less frequent because I have been hard at work, under the guidance of the brilliant behavioral geneticist David Reiss, revising the section of my book that covers the critically important topic of epigenetics. Knowledge in this discipline is exploding, and he generously offered me the most up to date references. I am eager to see how this complex information translates for a general audience. Any comments to that effect will be much appreciated.

Epigenetics puts a whole new spin on the “nature vs. nurture” debate, which has historically viewed genes and environment as separate independent factors in determining the course of an individual’s development. Rare genetic disorders that result from a single change in the gene sequence have strengthened this misconception that one’s genetic makeup inevitably determines one’s future. Epigenetics refers to changes in DNA structure which alter gene expression, and hence individual characteristics, that do not involve changes to the sequence of DNA. According to leading researcher Michael Meaney, behavioral epigenetics specifically refers to the way environment, or life experience, influences gene expression and subsequent behavior and development.

The significance of this research for parenting is that that a child may be born with a particular gene for some problematic trait. But the effects of that gene on behavior will vary according to the environment. If parents do not respond negatively to difficult behavior, the effects of that gene may be altered and the problematic behavior may not occur. Conversely, negative response to challenging behavior will lead to expression of behavior associated with the problematic gene. These genes directly affect the development of the structure and biochemistry brain.

(For those readers who interpret this material as blaming parents when things go wrong, I refer you to an earlier blog post Guilt, Blame and Responsibility)

The importance of family environment on moderating genetic influence have been demonstrated widely in infants, children and adolescents. One particularly striking example is research on the (S) or short allele of the serotonin transporter gene . This gene is associated with stress responsivity and also with structure and function of the amygdala and medial prefrontal cortex, brain structures which are critical in emotional regulation. A person may have the short allele, but its expression, or its effect on behavior, is strongly affected by life experience. For example a person with the short allele has an increased risk of depression if he experiences stressful life events. Frances Champagne, a major figure in the field, writes in her paper, How social experiences influence the brain
Although these examples of interactions between genotypes and early environment are striking, we are only starting to fully appreciate the complex interplay between genetic backgrounds, social environments and brain development. Indeed, it is likely that such interactions[between genes and environment} will be found to be common and significant in development of most behavioral phenotypes[individual characteristics].


While hard at work wrapping my mind around these important research findings, I received, in AAP smartbriefs, a daily email about pediatric related news stories, an item about a recently published study in Pediatrics about a Massachusetts based program designed to improve access to child psychiatry services, known as MCPAP. Internal Medicine News sums up the study as follows;
A state-funded initiative to offer free mental health consultations to pediatric primary care physicians increased the proportion of pediatricians who said they were able to meet the needs of their psychiatric patients from 8% to 63% in 3.5 years.
Translation: Primary care doctors significantly increased their prescribing of psychiatric medication to children. In my opinion, this is not a statistic to be proud of. From 2005 to 2010 I was part a pediatric practice receiving the services of the MCPAP program. In May 2009 I heard Barry Sarvet, the lead author on the current study, speak at the 5th Annual Child Psychiatry in Primary Care Conference. At this conference he clearly and unequivocally supported the prescribing of psychoactive medication by pediatricians to young children, including atypical antipsychotics. Granted, this prescribing is under the guidance of a MCPAP psychiatrist. Some of these children are seen for a one time consultation, but in many cases the psychiatrist simply speaks with the pediatrician on the telephone.

In March of 2009 I wrote an op ed for the Boston Globe entitled Backed into a Treatment Corner. In the article I describe two very troubled patients for whom who I felt forced into prescribing psychiatric medication. I made the analogy to expecting a primary care clinican to treat a brain tumor.The article made no mention of the MCPAP program. It was widely praised, and many of the letters to the editor spoke to the importance of exposing this widespread problem. A few days after it was published,however, I received a call from Dr. Sarvet. He was furious. Apparently he had gotten in trouble with the powers that be that provide funding for MCPAP. My piece apparently made them look bad. I found this interesting, because in fact one of the patients was from New York State and thus not under the jurisdiction of MCPAP. Yet Dr. Sarvet experienced my piece as a condemnation of his program. When I explained that this had been far from my intention in writing the piece, his response was,"Well, its too late to take it back."

Certainly MCPAP was successful in accomplishing what it set out to do. My individual experience was that the participating psychiatrists were very helpful. They responded to my questions, which almost exclusively were about prescribing medication to older children with a diagnosis of ADHD, in a timely manner. But read the fine print in the current Pediatrics article:

FINANCIAL DISCLOSURE: Dr Prince serves as a consultant to
Astra-Zeneca, is a member of the speakers bureau for McNeil
Pharmaceutical, and has received a speaker’s honorarium from
Shire, and Dr Bostic serves as a consultant to Forest
Laboratories and GlaxoSmithKline; the other authors have
indicated they have no financial relationships relevant to this
article to disclose.
I can't help but wonder if all of the MCPAP psychiatrists have at some point in their career,if not specifically in relation to this article, had significant associations with the pharmaceutical companies who profit from prescribing of psychiatric medication to children. Has this relationship affected their recommendations regarding prescribing practices? I am hard pressed to believe that it has not.

So how to fit these two seemingly disparate topics together? Rather than channelling money into programs that increase use of psychiatric medication for young children, wouldn't it make more sense to turn our attention to prevention, and to supporting families in promoting children's healthy emotional development? If the research in epigenetics is showing that with such interventions we might actually impact on gene expression, and in turn grow and development of the brain, this seems a far better path to pursue than changing young developing brains with powerful psychiatric medications.

If health care providers on the front lines have the time to develop relationships with young families, if there is a strong system of mental health care to support families who are struggling, and a medical education system that supports clinicians in their efforts to listen to parent’s stories, we will be well on our way. The image comes to mind of a set of Russian dolls. The highly valued primary care clinician, reimbursed by the health care system, listening to the whole of parent’s experience, can help bring out their basic wisdom and inherent intuition. Then we as a society could be said to be holding all children in mind.

1 comment:

  1. Loved this article. I,too, have been interested in the role of behavioral epigenetics and manifestation in childhood behaviors. I am a recent grad of University of Southern Maine's Graduate School of Nursing. I received my MSN and am taking the certification exam to become a Family Psychiatric Mental Health Nurse Practitioner. My graduate clinical project/paper was on the necessity of early identification and treatment of adverse childhood events, as identified in the ACE study by Felitti et al and the role of behavioral epigenetics. It was affirming to my efforts to read your blog and know my efforts are being put in the right direction.Lorinda MacDonald-Portland,Maine

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