December 11, Dear Colleagues:

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1 AAP Headquarters 141 Northwest Point Blvd Elk Grove Village, IL Phone: 847/ Fax: 847/ Reply to Department of Federal Affairs Homer Building, Suite 400 N th St NW Washington, DC Phone: 202/ Fax: 202/ kids1st@aap.org Executive Committee President James M. Perrin, MD, FAAP President-Elect Sandra G. Hassink, MD, FAAP Immediate Past President Thomas K. McInerny, MD, FAAP Executive Director/CEO Errol R. Alden, MD, FAAP Board of Directors District I Carole E. Allen, MD, FAAP Arlington, MA District II Danielle Laraque, MD, FAAP Brooklyn, NY District III David I. Bromberg, MD, FAAP Frederick, MD District IV Jane M. Foy, MD, FAAP Winston Salem, NC District V Marilyn J. Bull, MD, FAAP Indianapolis, IN District VI Pamela K. Shaw, MD, FAAP Kansas City, KS District VII Anthony D. Johnson, MD, FAAP Little Rock, AR District VIII Kyle Yasuda, MD, FAAP Seattle, WA District IX Stuart A. Cohen, MD, MPH, FAAP San Diego, CA District X Sara H. Goza, MD, FAAP Fayetteville, GA December 11, 2014 National Institute of Mental Health Science Writing, Press, and Dissemination Branch 6001 Executive Boulevard, Room 6200, MSC 9663 Bethesda, MD Dear Colleagues: On behalf of the American Academy of Pediatrics (AAP), a non-profit organization of 62,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults, we welcome this opportunity to comment on the National Institute of Mental Health s (NIMH) draft Strategic Plan for (draft Plan). To begin, AAP commends NIMH for the comprehensive and ambitious scope of the draft Plan. We applaud you for your commitment to generate research that will greatly impact and transform mental health care, an important, but often forgotten segment of the American health care system. As pediatricians, we note the impact of mental health conditions on children and adolescents. In fact, nearly 1 in 5 children in the U.S. suffers from a diagnosable mental disorder, but only 20 to 25 percent of affected children receive treatment. There are countless more children who face mental and behavioral impairments that do not meet the criteria for a diagnosis whose needs are not being met by the current system. Although we are largely supportive of the Strategic Objectives (SOs) laid out in the report, we would like to comment on several aspects of the draft Plan as you work to finalize the document. Use of the terms mental illness and illness The AAP is concerned with the broad use of the term mental illness throughout the draft Plan. We would suggest using the term mental disorders instead, as this would be a more inclusive term, especially for those who have cognitive or behavioral disorders, like Autism Spectrum Disorder (ASD). There are numerous instances throughout the draft Plan where ASD would be excluded by use of the term mental illness. For example, on page 5, in the second paragraph, the report refers to the increasing prevalence of autism, and states that, [the increase] revealed the need for a deeper understanding of mental illnesses and their treatments. The AAP does not agree that ASD should be considered to be an illness. In another example, on page 4, the report states, Full implementation of these

2 Strategies, will, we hope, transform the diagnosis treatment, and prevention of these devastating illnesses. In most cases, developmental disabilities and behavioral disorders are not curable, unless there is a specific metabolic or acute cause. We suggest, instead, using the term devastating disorders. Strategic Objectives As mentioned earlier, AAP is largely supportive of the goals of the Strategic Objectives. However, we would like to share brief thoughts on each of the four objectives. In regard to Strategic Objective 1: Define the Biological Basis of Complex Behavior, AAP agrees with the goal but would suggest changing this to be Bases. It is unlikely that complex behavior has only one cause, and pluralizing the word more accurately reflects the complex nature of behavior. With regard to Strategic Objective 2: Chart Mental Illness Trajectories to Determine When, Where, and How to Intervene, AAP agrees with this objective and believes it is totally appropriate to discuss trajectories and evolution of symptoms (core and associated) to determine when, where, and how to intervene. This objective is of particular importance to the AAP. As noted in the draft, most mental illnesses emerge during the first two decades of life, therefore, childhood is our best opportunity to intervene and promote healthy development. NIMH s commitment to focusing on the early, pre-symptomatic phase of a mental illness is critical, as this may provide the best opportunity to treat or even prevent mental health disorders and improve lives. For Strategic Objective 3: Strive for Prevention and Cures, we agree with the objective but also feel the focus seems to be on treatment of mental illnesses, but not disabilities or the comorbid conditions associated with conditions like ASD. In most instances, developmental and behavioral disorders are not cureable unless there is a specific metabolic or acute cause. In Strategic Objective 4: Strengthen the Public Health Impact of NIMH-supported Research, we applaud the goal but again suggest that the draft Plan orient this objective towards disability and disorders, and not just mental illness. Toxic Stress In the section of the draft Plan titled Highlight: Beautiful Convolutions on page 27, authors note, Researchers are working to understand the early maturation of the brain, and how disruptions in development in early life contribute to later illness. The AAP supports efforts within the draft Plan and at NIMH to prioritize the identification of the childhood antecedents of adult mental illness as a focus area. AAP feels strongly that NIMH must invest more in research on the impact of toxic stress in early childhood and its impact on brain developments and lifelong mental health.

3 Toxic stress results when there is strong, excessive, and/or prolonged adversity that occurs in childhood without the buffer of stable, supportive relationships with caring adults. 1 Toxic stress can be caused by many factors including exposure to violence, abuse, or neglect; a caregiver s incapacity due to physical or mental illness or substance abuse; or economic hardship and adversity. However, positive parenting and nurturing emerging social, emotional, and language skills buffers toxic stress and builds resilience by promoting healthy, adaptive coping skills. Toxic stress affects brain architecture and functioning, altering gene expression and disrupting children s healthy brain development. This disruption may have significant and lifelong implications for health, learning, behavior, and adult functioning. As adults, children who have experienced toxic stress are more likely to suffer from physical, mental, and emotional health issues including emotional, behavioral, and interpersonal problems. The economic and personal toll of toxic stress on individuals, communities, and the nation as a whole is staggering. At the AAP s Symposium on Child Health, Resilience, & Toxic Stress held this June, many speakers highlighted the need for greater federal investment in preventing toxic stress and promoting healthy, resilient children. Given the emerging data on how early exposure to adversity can impair long-term health and development, AAP urges NIMH to pay particular attention to toxic stress in their strategic objectives. Although this exciting research tells us much about early brain and child development the needs of developing children, more investment is needed to further understand the neuroscience, molecular biology, and genomics behind the foundations of health in order to strengthen development in the prenatal and early childhood periods, and ultimately improve both physical and mental health in adulthood. Preemptive Medicine and Early Intervention In the paragraph titled Transforming the Trajectory of Mental Illnesses through Preemptive Medicine on page 10, AAP agrees that it is important for intervening with serious mental illness (psychosis, suicide), as the draft rightly points out, but we also think it is important to emphasize earlier diagnosis and treatment for persons with developmental disabilities like ASD. When ASD is identified and treated early, there is an opportunity to change the developmental trajectory as well as the chance to change the development of serious comorbid conditions for individuals with ASD. Evidence-Based Treatment On page 6, the strategic plan makes mention of an armamentarium of evidence-based treatments that exist in mental health care, and states that the challenge lies in optimizing these treatments. Unfortunately, for ASD, there are not enough existing treatments. The challenge lies within examining currently used treatments and determining if there is evidence that they are indeed working before we optimize them. 1 American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics. Technical Report: The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. 2012; 129(1):

4 Environmental Factors The AAP also suggests better defining what is meant by environmental factors on page 1, and other factors such as the environment, experience, etc. on page 18. We propose including intervention research and other ecological impacts in the family, school, community, state, and government. Additionally, the AAP would recommend NIMH direct resources toward research on toxins that may affect the brain development of young children both while in utero and during early childhood. Children are not little adults. They have unique physiologic, behavioral, and developmental differences that amplify their exposure to environmental chemicals. Because children are smaller than adults, their surface area to body mass ratio is greater. Children eat more food and drink more water per unit of body weight than do adults. The respiratory minute ventilation inspired air per unit time adjusting for weight is greater in young children than in adults. 2 As children grow and mature, their bodies may be especially vulnerable to certain chemical exposures during critical windows of development. For example, infants may be exposed to contaminants in water used in formula preparation and chemicals that may leech from bottles used during feeding. Toddlers engage in normal mouthing behaviors where they put foreign objects into their mouths that may expose them to dangerous toxins. Children of all ages spend more time on the floor or ground than do adults and come into more contact with contaminants on these surfaces. 3 Not only do children have more opportunities to be exposed to environmental chemicals, extensive evidence supports a causal relationship between prenatal and childhood exposure to environmental chemicals and a variety of health effects in the fetus and the child. A substantial proportion of chemicals are known to have a wide range of adverse and mostly irreversible -- effects on child health. As such, we encourage NIMH to include greater details in Strategic Objective 1 and to ensure that any focus on environmental and biological factors altering genetic risk for mental disorders have a specific focus on young children both while in utero and during early childhood. In conclusion, we would like to again thank you for providing this opportunity to comment on the National Institute of Mental Health s (NIMH) draft Strategic Plan for AAP commends NIMH for the comprehensive and ambitious scope of the draft Plan, and we hope you consider our suggestions as ones that could strengthen the final Strategic Plan. If you have any questions about our comments, please feel free to contact Tamar Haro in our Washington, DC office at (202) American Academy of Pediatrics, Council on Environmental Health. Pediatric Environmental Health, 3rd Edition American Academy of Pediatrics, Council on Environmental Health. Policy Statement: Chemical-Management Policy: Prioritizing Children s Health. Pediatrics. 2011; 127(5):

5 Sincerely, James M. Perrin, MD, FAAP President JMP/mrc