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 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.


Friday, June 17, 2016

Autism and Neuroscience Research: A Public Health Perspective

I vividly recall the emotional pain of a new mother in my pediatric practice many years ago as she described the stress she experienced bringing her infant son to meet her colleagues in her office. He screamed inconsolably the entire time. She was similarly unable to take him to social events, observing with deep envy the easy social interaction of other parents with their children. The low level depression she had struggled with much of her life returned in full force. Her son was later diagnosed with autism. 
Many parents of children subsequently diagnosed with autism describe this agonizing absence of the easy give-and-take they observe between other parents and their infants. A recent article,  An Integrative Model of Autism Spectrum Disorder by psychoanalyst William Singletary explores the latest research in neuroscience, genetics, and developmental psychology showing how this stressful experience of disconnection, while originally attributable to neurobiological vulnerabilities in the infant, itself plays a significant role in development of the disorder.  
It makes sense that my little patient too was stressed, but had limited ways of communicating his distress. Just as his mother was stressed and even depressed by the lack of intimacy with her child, so was this little boy likely stressed by the difficulty connecting. Evidence suggests that this disconnect may be at least in part due to variations in brain pathways responsible for sensory processing. Research shows that the stress of the disconnect itself may continue to exert a negative effect on the developing brain. 
Whenever we enter in to the realm of the infant-parent relationship in discussion of autism, there is a risk of echoes of the devastating "refrigerator mother" theory that placed blame for the disorder squarely on the mother. Research into the genetic and neurobiological underpinnings of autism offers evidence of the fallacy of this theory.  
Singletary identifies the significance of the relationship in a way that is healing rather than blaming.  Evidence of the brain's neuroplasticity shows us that by focusing on supporting the relationship, thus decreasing the stressful experience of lack of connection on the part of both parent and child, we may help to prevent progression and even reverse the genetic and structural brain abnormalities.
 The article addresses in depth a number of evidence-based treatments of autism that support parent-child relationship in this way, including the Early Start Denver ModelSingletary also offers case material from his psychoanalytic practice, explaining that his intensive treatment offers insight into the inner emotional life of the child with autism.  He finds evidence of the stress these children experience from the social isolation that results from their biological vulnerabilities. 
Reading his article, I found myself thinking about that mother and son so many years ago in my pediatric practice, and what I might have been able to do to help them.  Another article about a program in a pediatric practice in the Bronx offers an answer.
What if we had the opportunity to support all stressed parents and infants in the early weeks and months of life, when the brain is most plastic? The central issue is the absence of connection, made all the more painful with the cultural expectation that this should be a time of bliss and joy. Autism is but one cause of this loss of connection. 
The Bronx program integrates the Healthy Steps model in to a pediatric practice. When a pediatrician identifies a stressed parent-child pair, she asks her colleague down the hall to come and meet the family. A recent news article about the program describes a case of a young mother struggling with her two-year-old daughter around eating. The pediatrician, in her 15-minute visit, identifies the problem: 
It’s time to bring in an expert of childhood mental health. So Castalnuovo brings in Rahil Briggs, the child psychologist and introduces her personally to this family. It’s what’s called a “warm hand off” and makes it more likely they will actually see someone instead of disappearing down the rabbit hole of outside referrals.
A wide range of troubling behaviors that we see in young children are both cause and result of stressed relationships. When these issues can be addressed early we support healthy development of the rapidly growing brain.
If I had known what I know now, and had such a person in my office (thanks in part to the UMass Boston Infant-Parent Mental Health program I could now be that person), I might have said to that young mother, "I see that you are really struggling. I wonder if it might be helpful to take some time to make sense of this problem. My colleague down the the hall knows all about helping young children and their parents. Let me introduce you to her."
Would I have been able to change this course of that family's life? I don't know. But all the best science of our time suggests that the answer might be yes. 
The Healthy Steps model is not specifically about identification and treatment of autism. But it is one example of taking a broad public health approach to supporting early parent-child relationships.
If we are going to make a dent in the exponential rise in autism and other so-called mental health disorders in children, such a public health perspective is necessary. As I describe in my new book,The Silenced Child: From Labels, Medications, and Quick-Fix Solutions to Listening, Growth, and Lifelong Resilience, we need to look broadly at the way our culture supports, and fails to support, parents and children.  Paid parental leave programs and fostering a culture of postpartum care that recognizes the normal disorganization of the transition to parenthood are other examples of initiatives that offer opportunity to change the situation in significant ways. 
When we support these early relationships, intervening in situations of stress before things begin to derail, we have the opportunity to set development on a healthy path-at the level of behavior, genes and brains- for all children.