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 developmental science 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.

Saturday, October 3, 2015

Can Mental Health Care be Freed From the Medical Model of Disease?

I recently ran in to a colleague, an experienced psychotherapist, who marveled at my ability to "get out from under the medical model of disease." I have been fortunate to work with colleagues in the growing field of infant mental health who come from a range of disciplines. They bring model of strength and resilience, rather than a disease model, to treatment of emotional and behavioral problems of early childhood. 

Younger psychiatrists trained in the age of biological psychiatry have grown up in a professional family with a language of disorders. This language has likely shaped the way they think. It is embedded in their brains in a way similar to the language we grow up with in our homes. As such it may not be easy to change.  But the abundance of evidence at the interface of developmental psychology, neuroscience and genetics suggests that the path to healing lies in listening for the meaning of behavior, not in simply naming disorders and eliminating symptoms. The biological model of disease reifies the DSM (Diagnostic and Statistical Manual of Mental Disorders) diagnoses, when in fact they simply are descriptions of behaviors, or "symptoms," that tend to go together. 

This point was brought home for me when I taught a class on early childhood mental health to a group of child psychiatry fellows at a well-respected Boston teaching hospital. I was presenting the work of child psychiatrist Bruce Perry.  His neurosequential model of therapeutics (NMT,) that guides treatment based on an understanding of brain development, grew out of his frustration treating children with trauma histories according to the medical model. He recognized this approach was failing.   After presenting his alternative model in detail, I described a case of a 7-year-old boy with a complex history of early developmental trauma who was impulsive and getting in to dangerous situations.  I turned to the group of fellows and asked how they might treat this family. The first response was, "I would see if he met diagnostic criteria for depression and consider an SSRI." 

In another example,  I had a conversation with a young psychiatrist about our work with mothers who are struggling in the postpartum period. We agreed that there is a broad range of factors contributing to these struggles. There is the cultural context, with many mothers experiencing social isolation and unrealistic expectations of rapid return to pre-pregnancy functioning. The transition to parenthood under normal circumstances involves massive biological and psychological shifts. Relationships between partners are dramatically altered, and when both partners struggle alone, the sense of social isolation is magnified. And then there is the baby, a new person with unique qualities that may make this transition more challenging, for whom parents are now completely responsible.  I suggested that we think of the term "postpartum depression (PPD)" as an umbrella term that encompasses all of these factors. I wondered if the biological model of disease, that placed the problem squarely in the mother, might be limiting our approach. She replied, "but any good therapist would look at all these things when treating PPD." 

This way of thinking is exactly the problem I was trying to point out. When we speak of postpartum depression as a complication of pregnancy "just like diabetes" we reify the "disorder."  We need to listen for the full complexity of a new mother's experience before we label her with a psychiatric disorder. If, for example, the baby was premature and has difficulty with feeding, we can find meaning in the mother's struggles that lead us to treat the mother and baby together. Or if the father is feeling depressed and abandoned, the treatment might be a father-baby group. Or a mother who is in a new neighborhood with little social support and a spouse who works long hours might need a mother-baby group and an opportunity to go to the gym. I wonder if we really needed to label  a mother with a "disease" in order to engage this kind of support. 

A third example of this reification comes from a child psychiatrist in a blog post about the new DSM 5 diagnosis "Avoidant/Restrictive Food Intake disorder."  He wondered if this represented a "real problem" or over-pathologizing a normal behavior. There is a third option not mentioned anywhere in his article. Eating is a relationship-based behavior with often complex meaning. In my forthcoming book I have numerous cases of picky eaters whose behavior was a communication of distress related not only to sensory issues but also to troubled family dynamics that were only uncovered with space and time for listening. 

In our current system of health care, diagnostic categories are necessary for insurance to cover treatment. In all of these circumstances I describe above, treatment is definitely needed. It is important not to fall in to the trap that if it is not a "disorder," it is "normal" and therefore families don't need help. I use the generic "adjustment reaction" to avoid this trap and still work within the system. When it comes to working with young children and families, this "disease" vs. "normal" is an inaccurate and potentially dangerous dichotomy.

I am hopeful that the explosion of knowledge of the developmental science of early childhood is making its way in to mainstream mental health care. This is in part due to the Adverse Childhood Experience study that shows the long-term impact on both physical and mental health of early childhood experiences.  I hope it will be possible for all mental health professionals to learn a new language, not of diagnosing disease and eliminating symptoms, but of listening with the aim of promoting growth, healing, and resilience.

Thursday, September 10, 2015

Screening for Mental Health Disorders: A Double Edged Sword?

Recent calls for screening for a range of mental health problems point to an important recognition of the need to identify and address emotional suffering. Such screening offers an opportunity to decrease the stigma and shame that often accompany emotional pain.

A powerful new documentary The Dark Side of the Full Moon calls attention to the under-recognition and under-treatment of postpartum depression. In one scene, a mother refers to resistance from doctors who lack resources to address positive screens as "ridiculous." She is correct, if the alternative to screening is to look the other way in the face of women who are suffering.

But she is highlighting a real dilemma. For the value of screening lies in being able to listen to, and offer healing for, the diverse range of struggles of individuals and families that fall under the umbrella of postpartum depression, or other DSM defined mental illness.

Recently a colleague spoke of her distress at the lack of care available in her clinic where large numbers of women struggled terribly in the early weeks and months of motherhood. “At least a doctor gets them started on a medication, but it’s a long wait for an appointment with a therapist.”
 In a primary care practice, for a teenage who screens positive for depression, medication may similarly be the only option. 

 When a person feels alone and overwhelmed, whether a socially isolated sleep-deprived mom with a fussy baby, a parent at a loss in the face of an out-of-control preschooler who disrupts the whole family, or a teen struggling to make sense of a new explosion of feelings that accompany this stage of separation and identify formation, an hour of listening, particularly with someone with whom we have a longstanding trusting relationship, can have great healing power. 

Decades of longitudinal research in developmental psychology  offer evidence that when people who are important to us listen for the meaning of behavior rather than responding to the behavior itself, we develop the capacity for empathy, flexible thinking, emotional regulation and resilience. 

Connectedness regulates our physiology and protects against the harmful effects of stress. Charles Darwin, in a work less well known but equally significant to the Origin of Species, addresses the evolution of the capacity to express emotion. He identifies the highly intricate system of facial muscles, and similarly complex systems of muscle modulating tone and rhythm, or prosody, of voice that exist only in humans. These biologically based capacities indicate that emotional engagement is central to our evolutionary success.

This week the US Preventive Services Task Force (USPSTF) called for universal screening of depression in teens. A recent New York Times article addressed the controversy surrounding screening for autism. This summer the USPSTF made a similar call for screening for depression in pregnant and postpartum women.

Screening is an essential first step in alleviating emotional suffering. However, universal screening for mental health disorders, in the absence of opportunity to listen to the full complexity of the experience of a child and family, may lead to massive increases in prescribing of psychiatric medication.  Medication may have an important role to play, and may at times be lifesaving. However, as I argue in my forthcoming book, prescribing of medication in the absence of protected space and time for listening may actually interfere in development.

These recommendations for screening can be understood as a well-intentioned effort to bring attention to the troubled state of mental health care in our society.  But as we move forward to address the vast scope of problems that we will uncover, we need to think very carefully. The value of listening cannot be underestimated.

Monday, August 24, 2015

Autism, Anxiety, or Neither: A Tale of Two Boys

The subject of autism is so highly fraught, a well-respected child development researcher told me,  that she might need to be the only one in her field to never address the issue. A recent study showing that the likelihood of a child receiving a diagnosis depends on the center conducting the evaluation highlights the complexity of the problem.  For his PhD thesis, Phech Colatat at MIT Sloan School of Business Management reviewed records from three clinics established specifically for autism spectrum diagnosis.   At two centers the rate was around 35% while at a third the rate was 65%. The MIT news release about the study states: 

Those rates persisted over time, even when Colatat filtered for race, environmental factors, and parents’ education. 

But then comes what may be the most interesting finding: 

"...when doctors moved from one clinic to another, their rates of diagnosis immediately changed to match that of the clinic as a whole."

Colatat, based on extensive interviews and observations within the clinics, develops a theory for this phenomenon: imprinting. The article continues:

He conducted dozens of interviews with the clinicians to get a sense of how they had learned to diagnose autism. What he heard was the same few names again and again. At one clinic, a consultant from a nearby university had served as an intellectual mentor to the staff. She had impressed upon them how subtle the signs of autism can be, and as a result, they tended to give out the diagnosis more readily. At another, the clinic’s first director instilled the belief that autism can look like a lot of other conditions, which caused staff to be more conservative. These charismatic individuals made an impression that lasted.

Most striking about this study is the subjective nature of the diagnostic process. Once the purpose of the evaluation is to answer the question, "Does he or does he not have autism?" the possibility of exploration of the complexity of a child's experience is already limited. 

Referring to a recent trend to reframe the symptoms of autism as anxiety disorder, one pediatrician colleague described a kind of "aha" moment, saying excitedly, "Now I see that many of those kids diagnosed with autism really have anxiety disorder!" But both diagnostic labels may be similarly limiting. 

For both Charlie and Max, family outings often dissolved into screaming meltdowns. Both developed rituals of lining up toys, and could recite whole segments of Disney movie dialogue as they insisted on seeing the same film over and over again. Getting wet in a lake, hearing fireworks at a fair, being in a crowd, even of close family members, precipitated scenes of disaster. Teachers at their preschool had raised the question of autism.

Charlie's mother, Elena, had struggled her whole life with anxiety. His father Peter came from a family where discipline was strict, often shaming. He became overwhelmed with rage both at his wife, whom he blamed for his sensitive son's behavior, and at Charlie. Elena felt she had to protect Charlie from his father. Peter clearly favored Charlie's older brother, who he described as "laid back" and "easygoing." This tense family dynamic persisted for years as Charlie's challenging behaviors steadily escalated. Finally at the age of 8 he was referred to a center for autism and received a diagnosis. He entered the special education system as his behavior problems worsened.

Max's family took another route. They got a lot of support for themselves, from family members and from his mother Angela's own therapist, to make sense of Max's "quirks." They worked hard to help him manage what he experienced as onslaught of sensory stimulation. Angela, too, struggled with anxiety and sensory sensitivities, as did multiple family members. But her husband Mark, unlike Peter, came from a warm and loving family. Max's parents found a balance of limit setting and accommodation to his unique qualities. He discovered a love for both drumming and dance and excelled in both. By the time he was in high school, while his quirky behavior persisted, he recognized his challenges and found ways to manage them. He had a number of close friends and excelled academically. 

The need to find something "wrong" with a child may preclude meaningful help. Both these boys, and their families, needed time and space to be heard and understood. Our current system of DSM diagnosis, without this protected space time and space to listen, may bypass this search for understanding.

At the end of the article on Colotat’s research, the author raises the question of how we “get at the truth.” The term"autism" covers such a wide range of experience as to include both adults who advocate for themselves and individuals who cannot communicate at all. There is no “truth” for the diagnosis of autism, or for that matter any other DSM based  "mental disorder," all of which are based on subjective assessment of behavior or "symptoms."

The truth lies in our humanity, in the complex interplay between biology and environment. It lies in the stories we tell and the meaning we make of our experience. The search for the truth lies in protecting space and time to listen to those stories, in all their richness and complexity.

Monday, August 3, 2015

Is Listening a Science or an Art?

According to pediatrician turned psychoanalyst D.W. Winnicott, the "true self" in its original form develops when the mother meets the infant's "spontaneous gesture." She sees the baby as himself, without projecting her own expectations, fears, or needs. But as Winnicott identified, the mother is not perfect. Inevitably she fails in this process. Sometimes the failures are small; disruptions can easily be repaired. The true self continues to take shape and grow.  But more significant disruptions may occur.  Postpartum depression, a highly dysregulated baby, her own unresolved conflicts and losses, among other things, may obstruct a mother's view to her child's true self. That child may become an adult in search of his true self.

Winnicott understood this search on a profound level. He saw it in its original form in his work as a pediatrician with mothers and their babies. Then he saw it again, when his adult patients in analysis "regressed to dependence." They used him to discover, or re-discover, their own true self. Winnicott was able to support this process with his full presence, using the predictable space and time of the therapy session to provide a "holding environment" analogous to that offered by the mother in infancy. 

Psychoanalysis is sometimes described as the "talking cure." One might more accurately call it the "listening cure." In infancy the mother reflects the baby's experience, holds him with her body, her words, the sound of her voice. She helps him to give words to his feelings. When our emotions get the better of us, we have lost this ability to give words to feelings. When a therapist listens to our words, mirroring our experience in a way that echoes that original experience of being seen and understood, we can discover, or re-discover, that true self, that either never fully formed or got lost along the way. 

At the recent International Psychoanalytic Association Congress in Boston, a speaker at a panel on Winnicott (whose collected works will be published by Oxford University Press in 2016) addressed Winnicott's use of language. At the time he was developing his unique contributions to our understanding of human experience, adherence to Freud's original discoveries was considered paramount. Freud had developed his own language to describe his discoveries, and in part in an effort to make the field "scientific" there was pressure to use that same language. But Winnicott resisted. 

Using his own words was integral to his theories. By using his own language to describe his highly personal experience, he stayed true to himself. Thus it is the very lack of adherence to Freud's language that gives power to his ideas. But as Professor Scarfone articulated at this presentation, the ideas themselves are perhaps most true to Freud's discoveries. 

 We take its existence so much for granted, that we may forget that Freud's greatest original discovery was the unconscious. The unconscious is that part of the mind made up of feelings, thoughts, and memories that are out of our awareness but exert influence on our conscious thoughts and behaviors. The "talking cure" or "listening cure" connects those thoughts and feelings, which may maintain a grip on us in unhealthy and maladaptive ways, to conscious thoughts and words. When a therapist listens to a patient, she to performs a kind of mirroring function.  She parallels that original experience of connecting thoughts and feelings with words, when the mother recognizes the infant's true self. She offers the patient space and time to say what he means, to connect words with feelings, and so make the unconscious conscious.  In other words, she gives the patient the space and time to discover his true self.  

In the current age of "evidence-based" medicine, I question the necessity of scientific evidence of the healing power of listening.  For Winnicott, the search for the true self precludes a common language; thus it is in a sense by definition unscientific. Attempts to design controlled studies inevitably call for a common language, and for a reduction of human experience to quantifiable measures. When I offer space and time to listen parents whose children are struggling with a range of "behavior problems, I always hear a story that gives meaning to the behavior.  The stories themselves are the evidence. 

When I read Winnicott, I have the calming, centering experience of recognition and understanding. I feel that if he were here today he would "get" what I find troubling about this age of "evidence-based" medicine. Listening to parents and children,  facilitating development of a child's true self, is by definition unscientific. It is creative and original. Creativity emerges in the "play space" of the therapy setting. Telling of the story is itself a creative act. As Winnicott writes in Playing and Reality:
It is in playing and only in playing that the individual child or adult is able to be creative and to use the whole personality, and it is only in being creative that the individual discovers the self. 
In conclusion, I playfully offer an articulation of the connection between language and the true self from another creative thinker, Dr. Seuss:

          I meant what I said and I said what I meant
         An elephant's faithful one-hundred percent                          
                                                Dr Seuss, Horton Hatches the Egg

Sunday, June 28, 2015

First in Gun Violence, Last in Paid Maternity Leave: Is There A Link?

In his remarks in the wake of the Charleston shootings, President Obama said, "At some point, we as a country will have to reckon with the fact that this type of mass violence does not happen in other advanced countries." 

When reading a recent article about Dylann Roof's early life history, I immediately thought of the Center for Disease Control (CDC) study on adverse childhood experiences (ACE.)   A massive long-term study, it provides extensive evidence that exposure to adverse childhood experiences, including not only frank abuse, but also such things as neglect, domestic violence, divorce, parental mental illness and substance abuse, dramatically increases the risk of a wide range of health problems both mental and physical. The study is located on the CDC website under a section entitled "Division of Violence Prevention."

 While I only know what I read in the paper, it seems that Roof had a very difficult childhood, with possible exposure to domestic violence. His step grandmother suggests that his parents may not have been available, either physically or emotionally, to care for him. She also indicates that he developed obsessive-compulsive behavior as a young child. In my experience with many young children with similar symptoms, this behavior often represents a solution to a problem, a way to manage overwhelming anxiety and emotional distress. 

Who was listening to this young child and family when things began to unravel? Who took the time to understand the source of his increasingly troubled behavior? Is it possible that he was drawn to the white supremacist group as a way of finding a family? Was it a place where he could be heard when no one was listening?

The United States is the only industrialized nation in the world without government supported paid maternity leave. This statistic reflects a lack of value of parents and young children. In stark contrast, in Finland, every new parent receives a “baby box” filled with clothes, diapers and other assorted baby needs. When the box is empty, it often serves as the baby’s first bed. While the items themselves are useful, the meaning of this box is of greater significance. It says “our society places value on new parents and babies.” Could there be link between the amount of violence in our country, in contrast to other developed countries, and the lack of support for young children and families?

Certainly the conversation about racism, and why such groups even exist, is critical. But going back to Roof's childhood may lead to the answer to the question President Obama raised. As the CDC wisely recognizes, supporting young children and families, and devoting resources early, before these adverse experiences can exert their harmful effects on the body, brain and mind, goes  under the heading of "prevention of violence." Paid parental leave, and with it a shift towards valuing young children and families, may be a necessary first step.