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.

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. 

Friday, June 12, 2015

Teen Bipolar Disorder and the Abnormal Brain: What Does the New Research Mean?

Two glaring omissions stand out in the recent widely publicized Yale study, titled in the Yale News  "Adolescent Brains Develop differently in Bipolar Disorder." Using MRI to compare a group of teens with the diagnosis of bipolar disorder according to DSM criteria with a group that did not have this disorder, they found volume decrease in the area of the brain cortex known to be involved in emotional regulation. 

The first omission is any mention of the possible effects of medication. While the newsletter does not even mention medication, the study itself does say that the teens carrying the bipolar were on medication but that "medication was not systematically studied." The long-term effects of psychiatric medication are unknown. A  study in the Archives of General Psychiatry suggested that one of group of drugs, the atypical antipsychotics, which are often used to treat bipolar disorder, may themselves be linked to decreased brain volume. 

But perhaps the more glaring omission is anything about the early history, or life story, of these teenagers. 

Elegant and compelling research by Harvard psychiatrist Martin Teicher and colleagues demonstrates that mental illness in the setting of what they term “maltreatment” is a very different entity, in terms of course of illness, response to stress, brain structure and gene expression, than the same DSM named “disorders” in the absence of these experiences.

Maltreatment is broadly defined as being “characterized by sustained or repeated exposure to events that usually involve a betrayal of trust.” 

It includes not only physical and sexual abuse, but also emotional abuse, including exposure to domestic violence, humiliation and shaming, as well as emotional and physical neglect. The incidence of childhood maltreatment ranges from about 14% in one-year prevalence to 42% in retrospective reviews covering the full 18 years of childhood.

The way maltreatment is defined has great significance in the way we think about the connection between childhood experiences and adult mental illness. The word “trauma” itself may convey a kind of “not me” response, but when the term is defined in this way, we see that these experiences are, in fact, ubiquitous.

This research shows that it is meaningless to talk about mental health disorders, as defined by the DSM system, without knowledge of this early life experience.

But perhaps more importantly, the language we use has great implication for treatment. The Yale study authors recognize that the brain is “plastic” so prevention is possible. But without recognizing the role of early life experience in development of the brain abnormalities, the treatment might very well end up being a drug.  Broadening our understanding of the cause of the brain abnormalities, as Teicher’s work demonstrates,  shows that true prevention lies in supporting young families, and intervening early in families where children are at risk for experiencing maltreatment.

Teicher recommends starting with the way we name these disorders:

We propose using the term ecophenotype to delineate these psychiatric conditions. We specifically recommend, as a first step, adding the specifier “with maltreatment history” or “with early life stress” to the disorders discussed here so that these populations can be studied separately or stratified within samples. This will lead to a richer understanding of differences in clinical presentation, genetic underpinnings, biological correlates, treatment response, and outcomes.

The Yale study, tellingly published in the journal “Biological Psychiatry” gives the impression that these “disorders” are biological in the way that, to use a frequent comparison, diabetes is. This view is a disservice to our humanity; to the way our lives have meaning because of our relationships with others and the stories we tell. The first and critical step in prevention of “bipolar disorder” is to recognize that these stories exist, and to make space and time to hear them.

Thursday, May 28, 2015

Is There a Role for Literature in "Evidence-Based" Medicine?

A recent article cast a long shadow over the highly touted concept of "evidenced-based" medicine, when a professor of ethics delineated multiple transgressions in research in the University of Minnesota's department of psychiatry. In another example, a colleague who questioned the way the data has been manipulated in favor of the popular "Triple P" parenting program, upon publishing a large study that did not support these findings, experienced professional repercussions. Complex relationships between the academic world and the pharmaceutical industry are well recognized. 

Certainly there exists a wealth of high-quality research that is not subject to this kind of corruption, and has an important role to play. But a hefty dose of caution is called for. Where else might we look for evidence to guide our practice of medicine? 

In my behavioral pediatrics practice, when we have time, we inevitably find that behind every "behavior problem" there is a story that makes sense of, or gives meaning to, the problem. In my forthcoming book (Da Capo, Spring 2016) about the need to protect space and time for listening in order to promote growth, healing and resilience, I offer these stories as a form of evidence. 

Literature, another form of storytelling, can offer a kind of evidence. In my book, I refer to one of most famous quotes from To Kill A Mockingbird, when Atticus tell his daughter Scout, "You never really understand a person until you consider things from his point of view, until you climb in his skin and walk around in it."  I now understand this as a description of an essential of human characteristic, namely the ability to reflect on the meaning of another person's behavior The enduring power of Harper Lee's book speaks to the significance of listening, of taking time to put ourselves in another person's skin.

In a section of my book titled “Listening for Loss,” I expanding upon the way loss, as in the case of infertility, pregnancy loss, loss of a child, and even loss in a previous generation, particularly when it has been unacknowledged and unmourned, can exert significant effects on subsequent relationships. I describe how the specter of unbearable loss is an inevitable, if usually unspoken, part of becoming a parent.

I recently discovered a beautiful, if exquisitely painful, expression of this idea in Hanya Yanagihara’s novel, A Little Life.

You have never known fear until you have a child, and maybe that is what tricks us into thinking it is more magnificent, because the fear itself is more magnificent. Every day, your first thought is not “I love him" but “How is he?” The world, overnight, rearranges itself into an obstacle course of terrors. I would hold him in my arms and wait to cross the street and would think how absurd it was that my child, that any child, could expect to survive this life. It seemed as improbable as the survival of one of those late-spring butterflies-you know, those little white ones-I sometimes saw wobbling through the air, always just millimeters away from smacking itself against a windshield.
I suspect this passage will resonate with many, if not most parents, to varying degrees, in large part according to their own life experience with loss. For me this is evidence that loss is part of parenting, and when things go wrong, when children have "problem behavior" we must protect space and time to listen for loss.

One young woman for many years had been treated for ADHD for her distracted and impulsive behavior. Only when she experienced a significant decline in his mental health did the story come to light that she had a brother who was stillborn about a year before her birth. Her mother had suffered prolonged severe depression in the face of this loss, which was never acknowledged or spoken about.

Perhaps we need a healthy combination of all three. High quality research, together with stories, both from our patients and from literature,  can help guide us to "best practice" of medicine.

Monday, May 18, 2015

How Does Infant Mental Health Inform Psychoanalysis?

Distancing from interpretation, when the analyst explains back to the patient the meaning of her words as he understands them, was a common theme at three recent psychoanalytic presentations. At one, a leading psychoanalyst explained how rather than interpret a patient's words, he seeks "clarification." A second spoke of how he too steers away from interpretation, aiming instead to "get out of the way" and let the patient come to his own understanding, to,  echoing the words of D.W. Winnicott, become himself.  A third similarly tried to distance him from this classical analytic concept, describing instead an attention to the "field of characters" that inhabit the patients thoughts. 

As I sat in the audience of these lectures, I found myself trying to retro-fit what I had learned in the past few years of immersion in infant mental health -or what I prefer to describe as the developmental science of early childhood- to the classical psychoanalytic theory I was exposed to as a scholar with the Berkshire Psychoanalytic Institute. 

When a recent talk I gave about my infant mental health informed treatment of a 2-year-old boy prompted a psychoanalyst colleague to ask, "what about the unconscious?" it all came together in a kind of "aha" moment. 

Psychoanalysis, originally called the "talking cure" is sometimes described as an effort to make the unconscious conscious. The idea that we have feelings that are out of awareness but yet influence our current relationships and behavior is so integral to our understanding of ourselves that it is hard to imagine that we did not always think this way. Yet the "unconscious" was in fact Freud's revolutionary discovery. 

In infancy and early childhood we have the original experience of connecting feelings with thoughts and words.  The analytic relationship thus in a sense seeks to recreate that original experience.  That is not to say that the analyst is the "better parent." Rather, by offering similar kind of holding environment, the analyst helps the patient to discover, or re-discover, that capacity. We can become calm, creative, flexible and develop healthy relationships- or as Freud said "to work and to love" -when we are able to think about and give words to our feelings. 

The mother (or primary caregiver) originally fulfills this function by containing the infant's experience, not only with words but also with her body, her voice, her presence.  In toddlerhood the actual words take on more significance. As a mother labels her child’s feelings with words, the child develops the capacity to think about and give words to feelings.

However, when the mother is not able to hold the child in this way, feelings remain unconnected to thoughts or words. They remain unlabeled and confused. Or one could say, they remain unconscious.

There are many reasons why a mother has trouble with this holding, containing, meaning-making function. She may be depressed. She may have experienced loss- as in infertility and pregnancy loss- and/or in her own childhood.  A baby may be particularly dysregulated, making this containing function particularly challenging. As a mother feels inadequate to the task, she may then slide in to depression, especially in the context of the severe sleep deprivation that accompanies a dysregulated baby.

When I treat a parent-child pair, I have the opportunity to support- in real time- this capacity to give words and thoughts to feelings, make meaning of experience, or, as I describe in my first book, to hold a child in mind. The transformative effects, for both parent and child, are often dramatic. 

In order to support a mother’s efforts to think about her baby’s mind, it is not necessary to analyze her, a process that may be helpful but can take a long time. As soon as a mother feels recognized and understood, she begins to be more present with her baby.  The baby becomes better regulated, in turn improving a mother's sense of self-esteem and decreasing feelings of shame. These changes, in turn, positively affect the mother’s ability to hold her baby in mind, further facilitating the baby's capacity for emotional regulation and development of a healthy sense of self. This process is described by Ed Tronick as the mutual regulation model.

Without this kind of holding, this kind of giving voice to feelings, a young child will have only a bodily awareness of stress without being able to connect thoughts and words to the experience. When there are no words connected to feelings, the experience continues to exert influence, living both in the unconscious mind and in the body. As such it maintains a grip on an individual's behavior and relationships. 

The analytic process then, in making the unconscious conscious, in a sense recreates this early experience of being held, recognized and understood in such a way as to connect feelings with thoughts and words. Rather than being hijacked by these feelings that are out of awareness, an analytic patient develops the ability to pause, to think about a feeling rather than unconsciously act it out.  

As I listen to these senior analysts wrestle with the question of how to capture the therapeutic effects of the psychoanalytic process, I see how the discipline infant mental health, where the work is done in real time with infants and parents, adds an important dimension to this exploration.