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.

Monday, October 31, 2016

New AAP Sleep Guidelines, The Baby Box, and Questions Raised

In a tweet about the new sleep guidelines recently released by the American Academy of Pediatrics, a wise colleague in Scotland Suzanne Zeedyk asked, "How do we support parents without terrifying them?"

The evidence for "back to sleep" recommendations issued in the early 1990's was unequivocal; following the guidelines the rate of SIDS (sudden infant death syndrome) plummeted a dramatic 50%.   However, following the initial decline, the rate of SIDS has plateaued, leading the AAP to revisit sleep recommendations.

In a thorough document the AAP references the evidence for its  extensive (19 items) list of recommendations. There are two recommendations that I wish to explore in detail.

 It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface designed for infants, ideally for the first year of life, but at least for the first 6 months.

Communities around the world are taking the lead of Finland, where the Baby Box has been issued to all families on the birth of a baby for over 75 years, a practice that led to a dramatic decrease in infant mortality, and is now embedded in a societal support for parents and children that extends well beyond the newborn period.  In my community in Western Massachusetts, Berkshire Baby Box is launching among the first countywide distributions of the box in the United States.

The box fits seamlessly with the new recommendations. With the firm mattress, fitted sheets and portability, the box allows families to follow these recommendations with ease. 

As a specialist in infant mental health, I well recognize the central role of sleep, both for parent and child, in healthy development. I work with many families where infants'  frequent night waking exacerbates parental depression and marital conflict, two factors known to have negative long-term effects on both mental and physical health. In these families, teaching a baby to sleep independently has been a lifesaver. 

In many American families both parents work and lack extended family for support. In such situations the natural frequent night waking of a baby who relies on a parent to fall asleep can place extreme stress on a family, negatively impacting relationships between parents and with older siblings. 

As I have written in all of my books, teaching independent sleep should never be done under the age of 4 months, the age at which most infants acquire the developmental capacity to self-soothe. However, I am concerned that the AAP recommendations, taken out of context, for a baby to sleep in the parents’ room for 6-12 months, will complicate these situations significantly. This issue is intimately intertwined with the second recommendation I wish to address:

Keep soft objects and loose bedding away from the infant’s sleep area to reduce the risk of SIDS, suffocation, entrapment, and strangulation.

My concern here is with the "soft objects."

In 1953, D.W. Winnicott published his paper Transitional Objects and Transitional Phenomena in which he described, from his perspective as both pediatrician and psychoanalyst,  the significance of what many parents term  "lovey," or that particular soft object that has a seemingly magical power to comfort a young child. When my children were 4 months old, I bought them each a pair of puffalumps. These small soft lightweight animals immediately took on the role of transitional objects, comforting both children through many a challenge over the years, even making their way to college with my daughter. I learned that Fisher Price made a new line of large ones (the original were 8"-10") in 2006 that were subsequently discontinued. This is unfortunate in my view. When I speak with new parents, I recommend that when an infant turns 4 months, they introduce a small soft toy that does not pose any suffocation risk, that can serve as this transitional object. I recommend getting two so that one at a time can go in the wash, and in case one is lost.

This object is intimately intertwined with the issue not only of separate sleeping but also the way our culture places value on separateness and independence, a view that is in many ways unique to western culture. We value our children's independence and self-reliance. Sleeping independently is often the first of many such transitions in a typical American child's life. The transitional object can play a very important role in this process.

It may be that a change in this view is indicated. Perhaps we would find, as these recommendations are put in place, if they go together with national distribution of baby boxes, and the full range of government support given to families in countries like Finland, we would continue to see a decline in SIDS.

But the risk is that without attention to the social and cultural realities of raising children in a country that does not offer paid parental leave, does not invest in quality child care, and in general does not significantly support parents or children, these recommendations may leave parents in a difficult or even untenable bind.

The guidelines clearly ask that pediatricians to fall in line.

Health care professionals, staff in newborn nurseries and NICUs, and childcare providers should endorse and model the SIDS risk-reduction recommendations from birth

The guidelines do state: "Health care providers are encouraged to have open and nonjudgmental conversations with families about their sleep practices." However, the above recommendation makes me uneasy about what I hope is thoughtful questioning.  My anxiety, perhaps a mirror image of parental anxiety, leads me to add: Babies are to be put to sleep on their back. Smoking and bed sharing, as well as co-sleeping on a couch, are unequivocally to be avoided.

I feel pressure to have certainty on the subject.  I wonder if most parents and professionals feel the same pressure. Perhaps this wish for certainty is an inherent part of parental love. As I write in my recent book, The Silenced Child:

"When we become parents, we have the opportunity to open our hearts to a love unlike any other. But in opening ourselves to this love, we become vulnerable to loss. Loss is an inevitable part of parenting. That simple step of putting a baby to bed for the first time in his own room is full of poignancy. It is the first of many losses as our children grow up. The first day of kindergarten, going off to college, and all the many small steps toward becoming a separate, independent individual are mixed with ambivalence and loss for both parent and child. And though the idea is mostly out of our conscious awareness, in becoming parents we make ourselves vulnerable to an unlikely but real possibility of unbearable loss." 

Perhaps the 19 guidelines help to empower us, to assuage our feelings of helplessness in the face of this unthinkable possibility. 

Sleep is central to our emotional and physical well being. It represents complex issues around separation and independence that are inextricably linked with social and cultural support of parents and children.  I am hopeful that as these guidelines are implemented, we make room for discussion of these important and profound questions. They have bearing on the future of our children, and of our society as a whole.



Monday, October 3, 2016

Listening to Parents and Babies: A Perspective on Colic

Recently I had the pleasure of spending the day with Nadia Bruschweiler-Stern, pediatrician, psychoanalyst and director of the Brazelton Centre of Switzerland, where she uses the Neonatal Behavioral Assessment Scale (NBAS) in her clinical work with infants and parents. 

T. Berry Brazelton, renowned pediatrician and recipient of Obama's Presidential Citizens Medal in 2012, developed the NBAS when he observed that all children come into the world with their own unique set of strengths and vulnerabilities. The NBAS has proved to be a valuable way to identify the child’s contribution to the parent-child relationship from birth.

Bruschweiler- Stern was visiting to the Austen Riggs Center (where I have been appointed as a consultant in Human Development) for presentations to the fellows, staff and the larger community.

While there were many wonderful aspects to her visit, a highlight came in the car ride from New York, where we had been together at a gathering of innovators in the field of infant-parent mental health, to the Berkshires. She told the following story. 

She had attended a presentation of on colic for an audience of pediatricians and nurse midwives. Presenters described the medical causes and treatments of colic; one then suggested that when a mother is distressed by her infant's crying she should be sent for psychotherapy. I told Nadia I would have been hypertensive listening to this; she described a similar experience of her hair standing on end. She imagined these nurse midwives going back to their practices and referring all these moms for therapy. She felt she had to do something.

After working to calm her pounding heart, she raised her hand and shared something like the following. "When a baby cries, he communicates distress. When a mother cannot soothe him, she experiences anxiety. Her distress may make it harder to read the baby's signals.  This mutual exchange is a normal process and does not represent a disorder either on the part of the infant or the mother." She told us that the pediatricians were dismissive, but the midwives, who knew what she was saying was true. all flocked to her. 

This simple vignette captured the complexity of a large body of research, much of it subsumed under the Mutual Regulation Model. It also offered an example of engaging (at least part of) audience in nonthreatening way to accept an alternative model that does not pathologize either the mother or the baby.

When we take time to listen and make sense of the experience of both infant and parent, rather than figuring out what is "wrong" with either, we help them to connect in ways that are helpful rather than harmful. Or in the language of developmental psychology, we help move them from mutual dysregulation to mutual regulation. 

In her afternoon presentation, Dr. Bruschweiler-Stern offered examples of this process, showing powerful videos of using the Neonatal Behavioral Assessment Scale to support connections among mothers, fathers and infants following the birth of a baby. 

These were vulnerable families, with a range of struggles with loss, depression, and stressed relationships. By taking time to listen to the baby with the parents and understand his or her unique capacities for communication, she was able to address these vulnerabilities right from the start, helping to set these babies on a healthy developmental path.


Saturday, August 13, 2016

The Allure (and Danger) of Certainty: A Developmental View

“You don’t know who you can trust, but to survive you need to be connected to the social world. So you align yourself with the worst possible people.” Peter Fonagy, researcher, psychoanalyst, and Chief Executive of the Anna Freud Centre in London, spoke these words at the conclusion of a masterful presentation of the developmental origins of our ability to function in a complex social environment.

Rather than focus on the cause of disease, he led his audience, a range of professionals working to support early parent-child relationships, through decades of research at the interface of neuroscience, genetics and developmental psychology to an understanding of what defines emotional health.

Connection to others is central to our humanity. It regulates our physiology and protects against the harmful effects of stress. Its absence, the profound aloneness that accompanies difficulty in communicating with others, is the common factor underlying all forms of mental distress.

The foundations of connection are laid in early childhood, when caregivers respond to us as individuals with motivations and desires. Rather than simply controlling our behavior, they listen to us and reflect on the meaning of our communication. This process, referred as mentalization, or in more common language, being held in mind, exploded into the world of developmental psychology and neuroscience research after Fonagy and colleagues identified its significance in the early 1990’s.

But how does this early childhood experience of being held in mind help us to be connected in a social world? The next wave of research has demonstrated that the answer lies in what he terms “epistemic trust.” Epistemic means “of or relating to knowledge.” He defines the concept as “an individual’s willingness to consider new knowledge from another person as trustworthy, generalizable, and relevant.”

In other words, the way we acquire new knowledge about others and our social world is intimately intertwined with how we are listened to as a developing child. Children learn, from the cues a trusted caregiver offers, to whom they should listen, and what is important for them to learn.

An elegant series of experiments by Elizabeth Meins and colleagues demonstrates that the quality of early relationships is intimately tied with the development of epistemic trust.  A secure early relationship makes us more discerning about whom to trust, while instilling confidence to reject others’ views when these are inconsistent with the facts.

Stress and adversity are ubiquitous. Adversity becomes “trauma” when it is compounded by a sense that one’s mind is alone.

In an environment characterized by paucity of mentalization, epistemic mistrust, or hypervigilence, along with a sense of social isolation, develops. An individual then faces what Fonagy terms an “epistemic dilemma, “ characterized by cycling between hypervigilence and excessive credulity.

For a person facing this dilemma, a leader who speaks with absolute certainty, leaving no doubt that he or she is the one to whom we should listen, has power to protect against the emotionally intolerable experience of being alone. In this state, feelings can override facts.

 This developmental model helps to make sense of our current political situation.  In a democracy, when a large population feels fundamentally disconnected and unheard, filled with mistrust yet also vulnerable to emotionally driven messages, it makes all of us vulnerable. 

Fonagy, who aims to use his research to inform of social policy, is making broad inroads across the ocean in England. Kate Middleton, the Duchess of Cambridge, is now Royal Patron of the Anna 
Freud Centre which, with a handful of other mental health charities is joining with Princes William and Harry to change the discourse on mental health with their campaign Heads Together.

An article on her first foray into the public eye following the birth of Charlotte when she visited the Centre states:
 “Mental health experts hope the integrated approach with joint lessons for children and their parents will be replicated around Britain, as the Government prepares to invest £1.25 billion over five years to tackle the problems affecting around one million young people, often as a result of family breakdown, abuse, illness, and bereavement.”

In the United States we have been failing terribly in this respect. We are one of two developed countries without government supported parental leave. Childcare workers are among the lowest paid, with little support or training in child development. We have an epidemic of expulsion from preschool. Primary care clinicians are more likely to diagnose psychiatric disorders in young children than to take time to listen, as I describe in my new book The Silenced Child.

Fonagy’s brilliant body of research, together with all the best science of our time, tells us that we must invest in childhood, when the brain is making as many as 700 new connections per second. By supporting listening and connection between young children and their caregivers, we promote healthy development of the next generation. With the leadership that recognizes the value of this new science, we will have an opportunity to apply contemporary research and knowledge, setting our children and our country on a healthy path.