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 research in child development 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.

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. 

Monday, December 29, 2014

Traumatized Kids Who Were Drugged Offer Lessons for Mental Health Care

Extensive use of psychiatric medication for children in foster care offers a striking example of childism,  or societal prejudice against children.  A powerful five part film “Drugging Our Kids  by Dai Sugano and Karen De Sa documents this issue in a thorough and dramatic way, using interviews with young adults who were in the foster care system, some from as early as 2 years of age. They were  labeled with every psychiatric diagnosis under the sun, when really what they were suffering from was trauma and loss. After experiencing physical, sexual and emotional abuse, they were on multiple psychiatric medications for many years. With the help of a range of individuals who saw through the haze of drug effects to who they really were, those interviewed for the documentary were able to get off all medications.   In a segment entitled “Treatment for a Broken Heart is Not Another Medication,” child psychiatrist David Arendondo says, “The first line treatment not another medication. It is to understand, to listen to the child, to ask, ‘what’s going on, why are you sad in this way?’”

The film offers an even-handed approach, acknowledging that psychiatric medication can help children access other form of therapy, and in certain circumstances be lifesaving. But, they point out, most often that is not the way these medications are used. Many kids in foster care are on multiple powerful medications as their primary treatment, with new ones added whenever there is an escalation in “problem behavior.” Arendondo points to the fact that we do not know the long-term effects of these medications on the developing brain. But at the very least, large quantities of medication “blunt the developmental process.”

Many clinicians interviewed for the documentary describe how psychiatric medications are used as  “chemical restraint” to control a child’s behavior. Another way to describe this phenomenon is a silencing of children. Angry, out-of-control behavior is a form of communication. It says, “ I have never learned to manage my feelings. I have never been held in a loving and safe relationship.” Medication silences that communication.

The film points to the critical role of relationships and creativity in healing. DAnthony, a child in the foster care system whose development took a different path in large part through a relationship with a volunteer,  describes the role of music in his life. “Music keeps me out of trouble. I take anger and make music.” Anna Johnson, a health policy analyst interviewed for the piece, speaks of the therapeutic value of forms of self-expression like music, dance and yoga. She describes “creativity as therapy” helping children to process trauma and connect with others who may have had similar experiences. DAnthony's words exemplify this idea; “Music is about being better, being somebody.” 
The children in these stories have experienced Trauma with a capital "T." However, many children who are similarly diagnosed with psychiatric illness and medicated with psychiatric drugs have trauma in their history.  The CDC sponsored ACES Study offers extensive evidence that a range adverse childhood experiences including not only frank abuse and neglect, but also parental mental illness,  separation and divorce, substance abuse, and domestic violence are highly associated with a range of negative outcomes in both physical and mental health. 

These cumulative experiences are a kind of trauma with a small "t," more ubiquitous than frank physical and sexual abuse.   When we diagnose and medicate, without offering time and space for listening to stories, for healing through human connection and creativity, we are doing something quite similar to what was done to these foster care children, but in a more subtle and pervasive way. 
There is urgency to the problem of medicating children in foster care.  Many of these kids are on large numbers and high doses of medication that are interfering with the course of their development. However, the mental health care system urgently needs to be fixed not only for these most vulnerable kids, but also for the huge numbers of kids experiencing trauma with a small "t." Time for listening, time for creativity, time for meaningful human connection needs to be not optional, not an extra, but rather the cornerstone of our mental health care system.