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, March 14, 2015

ADHD and Early Death: What is the Link?

Alarming headlines, based on a recent study, declare that diagnosis with ADHD doubles the risk of early death. Psychiatrist Stephen Faraone, commenting on the original study published in the Lancet, concludes that: “for clinicians early diagnosis and treatment should become the rule rather than the exception.” This conclusion represents a false assumption that the deaths occurred in cases that were not treated. 

The large cohort study in Denmark, that looked at records of 2 million individuals, identified over 32,000 who had been diagnosed with ADHD and then calculated the “all cause mortality rate.” There is no data available about whether or not they were treated. As ADHD is commonly treated with stimulant medication, it is unlikely that all of these cases were untreated. It is more likely that many, if not most, were treated with medication. If that were the case, the conclusion could be the exact opposite- namely that diagnosis and treatment with stimulant medication is associated with increased risk of early death. In that case, careful re-assessment of  the way we conceptualize and treat problems of attention would be in order.

If diagnosis and treatment with stimulants is associated with increased risk of early death, how would we make sense of this finding? The following story offers an example.

Max, whose life was cut short at 17, alone behind the wheel of his car with a blood alcohol level of well over .08, had been treated for many years for ADHD. I met his mother, Sally, when she was taking a long hard look at her son’s history and trying to make sense of his descent in to substance abuse with this tragic demise.

Max was the youngest of three. Where his two older sisters excelled in school, he was “flighty.” Even as young as three, the rest of the family would get frustrated with him when he got easily distracted when asked to do a simple task like put on his shoes. In a busy household, there was a lot of negative attention directed at Max.
But in this time of careful and at times agonizing reflection, Sally acknowledged that Max had been very curious and creative as well. He “noticed everything.” At age 5 he was uncharacteristically quiet and attentive at a classical music concert, surprising his parents by identifying the individual instruments. But in a family of high academic achievers, when in first grade he lagged behind in learning to read, they took him to the pediatrician, who diagnosed inattentive ADHD and put him on stimulant medication.
Her doctors had seen it as a straightforward problem, no different from food allergies or diabetes. Max “had “ ADHD so they gave him medication to treat it. The medication did have a remarkable effect on his ability to focus, from the first dose. But as the demands of school increased, the visits to the doctor consisted of changing dosages and formulations.
Sally’s heart ached as she recalled visits to the pediatrician where she spoke openly in front of Max about him as “unmotivated” or even “lazy.” Sally wondered if the exclusive focus on Max’s dose of medication and his ability to get his homework done- they had added and evening dose when he got in to middle school and the academic challenges increased- had distracted them from seeing Max’s true nature. In a soft voice that belied cries of agony, she wondered if the firm, demanding parenting style that had been so effective with their first two, was perhaps not ideal for Max.
Once she felt comfortable telling me her story, other relevant information emerged. When Max, an unplanned third child, was young, Sally had struggled with postpartum depression. During those early years she had not been able to give this active, sensitive toddler the attention he needed. In contrast, the two older girls had been a source of help and support. Her time and attention gravitated naturally to them. When Max was evaluated for ADHD by her pediatrician, this part of the story, a difficult chapter they all wished to forget, never came up. Now Sally wondered if Max’s “problem behavior” had been at least in part, an effort to connect, to get his mother’s attention. She had heard people speak of ADHD as a deficit not of the child’s ability to pay attention, but of the parents’ attention to their child.
She had been doing her best for Max. But perhaps she, the rest of the family, as well as the doctors who had treated Max, hadn’t really been listening to Max. The focus of visits to the doctor became almost exclusively on the dose of medication and his academic performance.

As his older sisters continued to thrive, Max attempted to distinguish himself through sports, an effort that was sadly derailed when in 11th grade he suffered a significant knee injury. His grades plummeted. Still the focus was on finding the correct regimen of ADHD medication.

Reluctantly Sally shared with me a longstanding family history of substance abuse. She suspected that this knee injury was “the beginning of the end.” Max began drinking, though, in keeping with the family tradition, he was able to keep this fact well hidden from his parents.

While medication may have a role to play, when individuals are diagnosed with ADHD and treated with medication in a system of care that does not offer space and time to listen to the story, to discover meaning in behavior, underlying problems are not addressed.

Perhaps the true association between diagnosis with ADHD and early death can be found in another large study, a long -term collaborative study sponsored by the Center for Disease Control, the Adverse Childhood Experiences or ACES study. This study offers extensive evidence of a high correlation between adverse childhood experiences (ACES) and a range of negative long-term health outcomes, including early death. ACES include not only abuse and neglect but also the more ubiquitous problems of parental mental illness, substance abuse and divorce.

What we call ADHD is a collection of symptoms of that represents problems of regulation of attention, behavior, and emotion. A biological vulnerability may be part of that story. But it is usually not the whole story.

The appropriate conclusion from this study, seen in light of Max’s story and the ACES study, should be that starting from an early age, space and time to tell the story is essential. The risk lies in diagnosing and medicating without understanding the whole story. In a safe, non-judgmental environment, when families have an opportunity be heard, to appreciate the often-complex meaning in a child’s behavior, as Sally was sadly doing after Max’s death, the path to healing becomes clear.

Friday, February 13, 2015

The Place of Love in Child Therapy

4-year-old Ella climbed on to the couch, into Susan’s lap, wrapping her arms tightly around her mother as Susan lovingly stroked her hair. They sat together in quiet loving embrace before beginning to pick up the toys, as the hour-long visit was coming to an end.

Weeks earlier Susan had wept in my office in anger and frustration. “She never listens,” preceded descriptions of explosive scenes where Ella kicked her mother, and Susan, in a haze of agitation, grabbed her daughter by the shoulders and shook her. At this visit, while Ella played quietly on the floor, Susan described a scene when Ella had told her mother, “I get so sad when you yell at me.” Susan now spoke, both to me and to her daughter, about how they were both having a hard time. Susan understood that just as she was feeling out-of-control in those moments, Ella was similarly stressed, and needed help from her mother in managing her intense feelings. This new understanding led to the moment of loving connection.

At the end of her graphic memoir, Are You My Mother?, Alison Bechdel describes a scene from a well-known case of psychoanalyst D.W.Winnicott., The Piggle. Winnicott sits on the floor with his little patient, Gabrielle, with whom he had worked for almost three years, starting when she was two. “I know you are really shy, “Winnicott says, ”and what you really want to tell me is that you love me.” He writes, “She was very positive in her gesture of assent."

Bechdel, in her last session with her own therapist, who during the course of their years of work together had gotten analytic training, has a similar experience. Her therapist says, “A lot of what we’ve done here has to do with love.” And then, “I know that you love me.” Bechdel sits quietly for a frame, and then says, “I … I do. I love you.”

Ours is a culture of advice. When parents come to me with their young children, they implore me to “tell me what to do.”  Recently I was interviewed on the radio by a child psychiatrist at a well-known New York teaching hospital. He told me that he had written a manual of “parent training” that offers “behavioral tools.” He claimed that when parents struggle with their child’s behavior it is because they “haven’t been taught” and they “don’t know what to do.”

I told him that I begged to disagree. Instead, I adhere to the wisdom of Winnicott, who wrote, “ No theory is acceptable that does not allow for the fact that mothers have always performed this essential function well enough.” As with Susan and Ella, problems occur when parents, for a range of reasons, sometimes including a child’s innate temperament, are stressed, and lose touch with their natural intuition.

Classical psychoanalytic theory supported work with an analyst alone with the child, even as young as two. Contemporary developmental science, with abundant evidence showing that the brain grows in relationships, offers a different perspective. While much of the conceptual framework of a discipline known as infant mental health is founded in psychoanalytic thinking, with the relationship
 being central to growth and healing, it offers a different model of treatment.

In the case of the Piggle,  her mother stayed home, a train ride away, with her new baby while Gabrielle traveled with her father to meet with Winnicott. In contrast, this relatively new and growing discipline of infant mental health supports working with parent and child together. While the brain can change in relationships throughout the lifespan, working with parent and child in the earliest years of life offers the greatest opportunity for change, as the brain is most rapidly growing.

In adult therapy, expressions of love, by the patient for the therapist, can be transformative and healing. But the aim is different when working with young children. As with Susan and Ella, the aim is not for the patient to express love for the therapist, but rather for the child and parent to be re-connected in love.

As Valentine’s Day approaches, I think of the deep transformative feelings of love that occurred during the visit with Ella and her mother.  It occurs to me that the work I do, along with my colleagues in the field of infant mental health, is neither parent training nor classic psychoanalysis. It is about facilitating, in the words of Simon and Garfunkel, a mother and child reunion.

Monday, February 2, 2015

Vaccination, Parenting, and the Specter of Unbearable Loss

As the measles outbreak gathers worrisome steam in parallel to the explosion of passionate rants both pro and anti-vaccination, I find myself wondering; what is this really about? Rather than get bogged down in the myriad of issues on either side- though at the outset I will say that as a pediatrician I unequivocally recommend vaccination- I will aim to look at the bigger picture.

Is this issue really about trying to have control in a situation where we as parents do not have control? Is it an effort to deny the fact that when we become parents, we make ourselves vulnerable to the unlikely but real possibility of unbearable loss?

The intensity of the rage, strikingly evident in a blog post by a cardiologist opposing vaccination, makes me wonder if this is really all about something else. Perhaps beneath all the vitriol is really fear of loss. 

As a culture, we are not good at dealing with loss.  The myriad of baby monitoring devices exploding on to the market, offer a kind of illusion of control, are an example of this phenomenon. Putting a baby to sleep on his back will do more to insure his safety than any commercial monitoring device, none of which are indicated for medical reasons. 

The defining of grief as an illness offers yet another example. The latest version of the DSM eliminated what is called the "bereavement exclusion." What this translates to clinically is that if a person has depressive symptoms for over two weeks following a loss, he can be diagnosed with major depressive disorder. 

In contrast to this cultural denial of loss, Buddhism embraces suffering and loss as a normal part of living. Buddhist Thich Nhat Hahn writes
If there is someone capable of sitting calmly and listening with his or her heart for one hour, the other person will feel great relief from his suffering. If you suffer so much and no one has been able to listen to your suffering, your suffering will remain there. But if someone is able to listen to you and understand you, you will feel relief after one hour of being together…. That is called compassionate listening. 
I wonder if the mess we are in is in part due to our devaluing of space and time for listening, for holding through pain and loss. 

There is deep fear on the part of parents on both sides of the vaccine argument. Those against vaccination fear harm by the vaccine. Those in favor fear for their child's exposure to disease.

Science is clearly on the side of vaccination. Measles is a highly contagious illness. Before vaccination became widespread in the early 1960’s, hundreds died every year from the disease. There is massive scientific evidence discrediting the claim that MMR vaccine causes autism. Yet here we are, on the cusp of what may prove to be a major public health crisis.

Could making space for loss have averted this crisis? Loss is an inevitable part of parenting- when we put our child to bed in his own crib for the first time, when he gets on the bus to go to Kindergarten, when he gets his license and takes that first drive on his own out the driveway. If as parents we felt safe enough, held enough, to acknowledge this idea, would we let go of a desperate need for control in a situation where we really don’t have control?

If so, perhaps we could recognize that vaccination is not about our individual child. It is about being a responsible citizen.

Thursday, January 8, 2015

Preschool Depression and Pathological Guilt: A Call for Listening

 Research by Dr Joan Luby at Washington University, whom one might call the mother of preschool depression, exemplifies the illness model of biological psychiatry. While Luby and her group do advocate for interventions that support parent-child relationships as a form of prevention, the danger of this model is its absence of opportunity for listening, for discovering meaning in behavior.
She and her research team have evidence of brain differences in children with behaviors that fall under the  category of Major Depressive Disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM). A recently published study showed that at age 6, children who had received a diagnosis of preschool depression had smaller volumes of a structure called the insula than children who did not have this diagnosis. Furthermore, children who exhibit what they call “pathological guilt” were more likely to have a smaller volume of the insula. Their conclusions are twofold. One is that the insula is implicated as a “biomarker” for major depression. The second is that helping children to “manage” symptoms of “pathological guilt” might offer a path to prevention.
This interpretation sounds alarm bells for me. As there is a pharmacologic treatment for depression, I hope to sound these bells before the DSM defined preschool depression goes the way of ADHD, with children being medicated in the absence of space and time to listen to the story, to understand behavior not as a symptom of a "disorder," but as a form of communication.
4-year-old Isabel’s parents, Martin and Andrea, were distraught that she often described herself as “bad, “even on occasion saying, “I hate myself.” She quickly accepted blame when something went wrong. With time and space to feel safe in my office, they told me the following story. When Martin misbehaved as a child, he was made to sit for hours on the bottom step of the basement stairs, his father berating him for being, “an embarrassment to the family.” He shared vivid memories, accompanied by deep feelings of shame and humiliation, of being grabbed by the ear and dragged away from family gatherings to this spot. Now a father himself, with no other model for discipline, he found himself repeating the same pattern with his own daughter. “What’s wrong with you?” he would shout. Her frequent meltdowns, the reason for the visit with me, precipitated not only yelling and commands to “go to your room” but also such expressions as, “why can’t you be more like your brother?”
Isabel, temperamentally more like her mother than her father, was very sensitive and easily disorganized, a quality she displayed since birth, in contrast to her “easy” baby brother. Both parents acknowledged deep conflict over discipline.  Andrea grew up in a home that, in contrast to Martin’s, had little discipline. “But,” she said, “I was  “good girl” so it wasn’t problem. Now Martin frequently blamed her for Isabel’s behavior, leading to an atmosphere of tension in the home, aggravated by the chronic sleep deprivation accompanying the arrival of a new baby.
I wonder if what Luby and colleagues are calling “ “pathological guilt” is actually shame.  Guilt can be a normal and healthy emotional experience. "I'm guilty" can also mean, “I’m responsible.” Shame, in contrast is pathological, and is associated with both depression and anxiety in childhood and adulthood. But without  opportunity to hear the story, it is impossible to know. Knowing this story, we can understand it as a kind of intergenerational transmission of shame. Perhaps if this pattern were to continue in Isabel’s family, a brain scan in a few years might show that Isabel has a smaller insula than her brother. 

Prevention does not lie in teaching Isabel to “manage her guilt.” This approach represents a devaluing of listening, a devaluing of the healing power of human connection, a direct result of the DSM illness model that places the problem squarely in the child. Supporting parent child relationships makes sense when it is not about "managing behavior," but rather listening and discovering meaning.

Once Martin had an opportunity to identify the source of his behavior in his own history, he could change his behavior with his daughter. He felt heard and understood, and so was better able to listen to his daughter, recognize what pediatrician/psychoanalyst D.W. Winnicott termed her “true self.” both parents could adopt a model of discipline suited to her unique qualities. Andrea and Martin saw how their own conflict, even when they tried to keep it from their children, affected the level of tension in the home. In the normal frenzy of activity that occurs in a household with a new baby, they had no time or space to reflect on these problems. 

The greatest risk of the model of biological psychiatry is failure to protect space and time for listening.  Listening is a kind of bridge between neuroscience and psychology. Without opportunity for listening, by diagnosing preschool age children with major depression we may leave many  standing alone on the shore, with no way over to the other side to growth, healing and resilience.