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, February 6, 2016

Child Death and Child Protection: Rethinking the 'Intact Families vs. Safe Children' Split

A spate of tragic cases involving the Department of Children and Families (DCF) in Massachusetts recently led Governor Baker to call for “tilting the balance” from keeping families intact to keeping children safe. But as Elizabeth Young-Breuhl argues in her brilliant book Childism:Confronting Prejudice Against Children, published shortly after her untimely death in 2011, a child protection model supporting this dichotomy was misguided from the start.

Young-Bruehl writes: “Since CPS (child protective services) was created as a rescue service—a child saving service—not a family service supporting child development generally and helping parents, greater efficiency in prosecuting parents was achieved but not greater understanding of them, educating of them, or working with them therapeutically to prevent child abuse.”

Young-Bruehl describes the “discovery” of child abuse by pediatrician Henry Kempe in the 1960s. Kempe coined the term “battered child syndrome” based on his observation of children coming to the emergency room with unexplained injuries. Young-Bruehl observes that it was, from the start, not a disease of the abuser but of the child. She writes, “the name thus from the start took attention away from abusers and their motivations; and it implied that children could be helped without their abusers being helped.”
The field of child protection grew out of this “discovery.” Young-Breuhl describes in her book “Kempe had launched one of the swiftest transitions from identification of a social problem to legislation in America’s history . . .. The states all increased their vigilance by establishing or strengthening Child Protective Services (CPS) departments.”
But from the start, the system was not founded in an understanding of child development. 
A number of years ago I had the opportunity to speak to a group of lawyers at a symposium entitled “Child Protection in the 21st century.” The West Virginia Law School student who invited me wisely observed that those in the legal profession are often in a position to decide what is "in the best interest of the child" with little substantive understanding of what exactly is in the best interest of the child.  He invited me to share my knowledge as an expert in early childhood mental health.

 One of my co-presenters was a delightful judge from central West Virginia who has been doing child protection work for over 20 years. He openly admitted to his lack of knowledge on the subject of contemporary child development research.

Young-Breuhl, in her use of the word “motivations” ties her ideas in directly with explosion of research in the field of early childhood mental health offering evidence that children develop in a healthy way when people who care for them listen with curiosity for the motivations and intentions of behavior. When we offer non-judgmental listening to parents, when we are interested not in what they did wrong but in understanding their motivations, we support their efforts to listen to children, in turn supporting healthy development of families.

One solution lies in an innovative program developed by the non-profit Zero to Three: Safe Babies Court Teams Project. Judges, child welfare staff, attorneys, service providers, and other community leaders work together, enhancing their knowledge of child development while aiming to transform the experiences of children in the child welfare system.

Identifying the central role of listening to parents, they articulate an aim to “recognize the overwhelming odds confronting parents, [and] honor the parents’ personal journey.”

Every year I have the privilege of teaching the first class of Springfield College of Social Work Child and Adolescent Program. The majority of students are social workers on the front lines of the child protection system. I am struck by both the curiosity and openness of the students, and the number of extraordinarily difficult circumstances they find themselves in. They feel empowered and encouraged by the idea that listening, being fully present with parents who themselves have experienced significant trauma, can be a critical initial step in setting families on a different path.

But it is impossible to expect these overworked and underpaid DCF workers to listen in this way if they themselves are not heard and supported. The image comes to mind of a set of Russian dolls. When the legal system listens to the front-line professionals, they in turn listen to the parents, who in turn listen to the children.

Friday, January 22, 2016

Riding a Wave of Grief: A Life Lesson

(The following story was told to me by a friend; details have been changed to protect privacy.)

An early winter snowstorm left Janet with an unexpected whole day alone with her 17-year-old daughter Ally. As was typical for the pair, they spent the morning in comfortable separateness. Janet took advantage of the opportunity to catch up on paperwork, while Ally stayed in her room working on college applications. In Janet's view her relationship with her daughter had been close, but now that Ally was immersed in a zillion activities and life with her friends, the intimate talks had, in a way that Janet felt was appropriate, fallen off. She missed the closeness, but respected her daughter's need to have some space, especially given her imminent departure for college.

They met in the kitchen mid-day and chatted over lunch, deciding that when they had each done a bit more work, they would take some time to go through clothes in Ally's closet to weed out things she no longer wore.

An hour or so later Janet knocked on her daughter's door. Not hearing a response, she opened the door to find Ally's back to her, with her head in her closet. "Is this an OK time?" she asked. Ally nodded her head, but did not answer. When Janet approached, Ally turned her head towards a small pile of clothes in the middle of the room.  Janet saw that she was silently crying. Alarmed, she asked, "What's wrong?" but Ally simply shook her head, seemingly unable to speak. Janet was mystified, as just a short while before everything had been fine. She began to guess. "Did someone say something to you?" Ally shook her head. "Did something happen?" Again no. Janet saw her daughter's lower lip quivering, just as it had when as a little girl. Reaching out her arms to hold her, she saw Ally gesture towards her computer where she had been working on her applications. "Is it college?" "Are you feeling sad about leaving?" Finally, sensing that her mother would not give up, Ally managed to eek out, "It's a song." But more questions led nowhere as Ally seemed unable to talk any more. Finally she told her mother she wanted to be alone. "OK, " Janet said. "I'll check on you in a bit."

Still facing a pile of work, as well as dinner to be made, Janet put it all aside. After a half hour she returned to Ally's room, where Ally somewhat reluctantly agreed to accept her mother's help with the closet. She seemed to have calmed down, and while she was still subdued, the tears had stopped. As they became involved in the task of sorting through clothes, sharing memories associated with various items, Ally seemed to return to herself.

After making dinner Janet returned to check in with Ally, letting her know that as the snow had stopped she was going out to a meeting. As she went to get ready, Ally followed her to her room, saying, "OK, I'm calm enough now that I can tell you."

At this point on the verge of being late for her meeting, Janet followed Ally into her room and sat on the bed. Again the lower lip quivered. After they sat together in a period of silence, softly Ally said, "Everyone dies in the summer," followed by a pause and then, "That's the song lyrics." Now Ally was freely crying as Janet too felt tears well in her eyes. Sobs shook Ally's body as she relaxed in to her mother's arms.

"Everyone dies in the summer." That previous summer, a boy Ally had briefly dated was killed in a car accident. He was in college so they hadn't seen each other for some time. There was a lot of communal mourning, with parties and bonfires to celebrate his life. Despite encouragement, Ally had shared little of her feelings around the event with her parents. Janet had been worried at the time about how Ally was dealing with the death, but then as the school year began and things got busy, her concern had faded to the background.

But here it was, close to half a year later. Janet sat with Ally while her sobs slowed to a soft cry and eventually subsided. Janet decided to skip her meeting. The rest of the family came home and they all had dinner together. Now able to talk about what had happened, Ally expressed surprise that the song lyrics could have had such an effect on her.

Later in the evening Janet noticed that Ally was again in her room. Still worried about her daughter's emotional state, she went to check on her. "What are you doing? " she asked after finding Ally again at her computer. "I'm writing a poem." Once this wave of grief had a chance to move through and then pass, Janet observed in her daughter a kind of ease and freedom, accompanied by a burst of creativity.

As she relived this whole encounter in her mind, Janet found herself flooded with gratitude. Grateful to be present with her daughter in that moment. Grateful that Ally could let herself feel the sadness while still in the safety of her home. Ally now knew in her mind and in her body the value of moving through grief to healing and growth.  For Janet, hope now mixed with the sadness as she contemplated her own impending loss, as her daughter prepared to take her first steps out in the world on her own.

Thursday, December 17, 2015

The Wisdom of the Ordinary Devoted Mother

 As both a pediatrician and psychoanalyst, D.W. Winnicott had a unique view of human development. In his pediatric practice, he was immersed in the lives of developing infants and parents. (As the mother was usually the primary caregiver at the time he was practicing, he writes primarily of the mother-baby relationship.) In his psychoanalytic practice where his patients, in his words "regressed to dependence," he had a kind of mothering experience with an adult person who could communicate with both body and verbal language. 

In preparation for teaching a course on early childhood mental health at William James College starting in January, I have had the pleasure of reconnecting with the profound wisdom of his writings. While Winnicott wrote extensively for both a general and a professional audience, I discovered, on careful re-reading of his essay for a general audience entitled "The Ordinary Devoted Mother" that it contains a vast wealth of ideas. In fact, if I had to assign only one paper for the entire course, this could be it. 

He begins in his delightfully humble way by saying that he had no wish to tell mothers what to do because, " To start with, I didn't know." Like his American counterpart Benjamin Spock, he acknowledges the mother as the expert with respect to her child.

Identifying how his approach is sometimes misinterpreted as blaming mothers, he calls attention to an inherent conflict. He writes:

"But is it not natural that if this thing called devotion is really important, then its absence or relative failure in this area should have consequences that are untoward?"

Later in the essay he returns to the problem of blame, but first points out that this ordinary devotion is contingent on the mother herself being cared for. 

“I think that by the time the baby is ripe for birth the mother, if properly cared for herself by her man or the welfare state or both, is ready for an experience in which she knows extremely well what are the baby's needs."

Had he been writing today he would likely call attention the profound implication of our failure to support for mothers in the postpartum period, as represented by the absence of government sponsored paid parental leave. We are uniquely lacking in a culture of postpartum care, as I describe in detail in a previous post.

Next Winnicott introduces another central concept of his, referred to in other works as "the holding environment." He identifies the profound nature of the care a mother offers:

"You will understand I am not simply referring to her being able to know whether the baby is hungry or not, and all that sort of thing; I am referring to innumerable subtle things, things that only my friend the poet could put into words. For my part, I am contented with the word hold, and to extend its meaning to cover all that a mother is and does at this time."

He then goes on to speak of what in his other writings he refers to as the "good-enough mother." He describes how a mother in a healthy way fails to adapt completely to her baby's needs, in parallel with his growing ability to manage frustration. 

"In time the baby begins to need the mother to fail to adapt-this failure being also a graduated process that cannot be learned from books. It would be irksome for a human child to go on experiencing omnipotence when the apparatus has arrived which can cope with frustration and relative environmental failures. There is much satisfaction to be got from anger that does not go over into despair."

This concept has been supported in the research of developmental psychologist Ed Tronick who has shown that these very disruptions, along with their subsequent repair, give a developing child a positive sense of himself. 

Winnicott then returns to the idea of blame, wisely pointing out its close connection to the concept of guilt, an experience that comes naturally with the role of parent.
"Here I must go back to the idea of blame. It is necessary for us to be able to look at human growth and development, with all its complexities that are internal or personal to the child, and we must be able to say: here the ordinary devoted mother factor failed, without blaming anyone. For my part I have no interest in apportioning blame. Mothers and fathers blame themselves, but that is another matter, and indeed they blame themselves for almost anything."

He sticks with his conviction that we cannot shy away from calling attention to the importance of the mother-child relationship for fear of being accused of blaming parents.

"But I have one special reason why I feel we must be able to apportion etiological significance (not blame), and that is that in no other way can we recognize the positive value of the ordinary devoted mother factor- the vital necessity for every baby that someone should facilitate the earliest stages of the process of psychological growth, or psychosomatic growth, or shall I say the growth of the most immature and absolutely dependent human personality."

Contemporary research at the intersection of developmental psychology, neuroscience and genetics is revealing more every day of how early experience gets into the body and brain, and how disruptions in early relationships can lead to long-term problems of both physical and emotional health. Winnicott anticipates this knowledge when he writes:

"Psycho-somatic existence is an achievement, and although its basis is an inherited growth tendency, it cannot become a fact without the active participation of a human being who is holding and handling the baby. A breakdown in this area has to do with all the difficulties affecting bodily health which actually stem from uncertainty in personality structure. You will see the breakdown of these very early growth processes takes us immediately to the kind of symptomatology which we find in mental hospitals belongs initially to infant care."

He concludes with the following observation, which can serve as a kind of call to action for our  society to nurture and protect these earliest relationships. 

"It will be observed that though at first we were talking about very simple things, we were also talking about matters that have vital importance, matters that concern the laying down of the foundations of mental health. A great deal of course is done at later stages, but it is when the beginning is good that all that is done at later stages can take effect."

Friday, November 27, 2015

A Thanksgiving Tale of Loss, Love, and the Joy of Reconnection

(I have been fully absorbed in the editing of my soon-to-be released book The Silenced Child so have had less time for my blog. I hope readers will enjoy this little vignette exemplifying the power of relationships)

This Thanksgiving, while discussing great works of toddler literature such as Big Red Barn with the parents of my 2-year-old cousin, I was pleased to discover I still could recite many of the words from memory.  "Has he read Owl Babies?" I asked. When they said no, but that he loved owls, I offered to read it to him.  I immediately located the book on the shelf of my now 21-year-old daughter's bedroom among the classic board book with which I will never part.

He settled into his mother's lap, nestled against her 5-month pregnant belly. The noise of the adult chatter around us faded to the background as the three of us became fully absorbed in both the telling and listening to the story. Owl Babies, by Martin Waddell, is a classic tale of attachment, loss, and love.  Sister Sarah, brother Percy, and baby brother Bill are living happily in a tree with their owl mother. When one night they wake up to find her gone, they together find ways to manage their growing anxiety. "I think she's gone out hunting," practical Sarah suggests. To each stage of escalating worry, together with efforts to make sense of the situation, Bill repeats his refrain, "I want my mommy!"

The feelings of the story, and the memory of reading it to my own kids many years ago came back with intensity. I watched my little cousin, fully absorbed in rapt attention in the plight of the baby owls. While keeping the three of us together in the present moment of the drama by slowly and carefully reading every word, I looked both at his face and that of his mother. When Sarah suggests that all three siblings sit on one branch together, I thought simultaneously of my cousin's new sibling on the way, and how my now adult children support each other. When on the final page the mother returns with her reassuring "WHAT'S ALL THE FUSS?" I felt a flood of relief and joy along with my young audience.

While Sarah and Percy bravely deny that they had ever really been worried, Bill simply declares, "I love my mommy!" Both grown-ups had tears in our eyes, though I did not have the excuse my little cousin's mother offered of being "too pregnant for this." "May I read it again?" she asked. "Of course," I replied, and left them together to join the adult company.

Saturday, October 31, 2015

Does the DSM System Perpetuate the Stigma of Mental Illness?

In a recent conversation with a group of pediatrician colleagues, we bemoaned the lack of access to good therapy for our child patients and their families. One wisely observed that until we integrate mental health care into primary care , we will continue to have this problem. He went on to point out how the direct result of this lack of access to care is prescribing of medication to children without offering opportunity for listening and understanding. I agreed wholeheartedly, calling attention, as I do in my forthcoming book, to the way vast income disparity for professionals who offer this kind of listening has a big role to play in perpetuating this shortage of quality care.

But he went on to say that, as part of the solution, we should view DSM defined mental disorders as medical problems that are no different from any other medical problems.

Here I identified a paradox. On the one hand, we are calling for time and space for listening, for healing through human relationships that good therapy can offer. But the DSM 5 gives the illusion that mental health problems are, in the words of Andrew Solomon in his book The Noonday Demon, "single-effect illnesses." None of the named DSM disorders are known specific biological processes, but rather represent collections of "symptoms" or behaviors that tend to go together. 

I would argue that under the influence of the health insurance and pharmaceutical industries, DSM 5 is part of the problem, rather than the solution.   The DSM 5 can have the opposite effect of what we are calling for, because a single effect illness can be treated with a drug alone. By emphasizing the value of listening in healing, we are calling for recognition of the intricate interplay of biology and environment, and the complex relationship among brain, mind, feelings, and behavior. 

When we invoke the DSM 5 in this way, it is with well-meaning effort both to de-stigmatize mental illness and to obtain parity, or equal pay, for mental health care. But we may inadvertently be getting in our own way with this approach. When we compare, for example, depression and diabetes, we may in fact devalue the complexity of human experience. Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. Unlike the brain, the pancreas has no corresponding mind with thoughts and feelings. The pancreas does not love. It does not grieve, nor does it produce great literature.

A recent study identifying the important role of psychotherapy in treatment of schizophrenia, one that received great media attention, seemed to give an infusion of life to the notion that listening is healing. However, as psychoanalyst Todd Essig points out in his Forbes article on the subject, the stigma of talk therapy is prominent both in the media coverage and in the study itself. He writes:
Therefore, it was a big media surprise that people who suffer a psychotic illness benefit from the support and hope that comes from a therapeutic relationship with a knowledgeable, non-judgmental and empathic other. What’s tragic is we needed to spend millions of dollars on an NIMH study to re-discover this. It should have remained clinical common sense.
Before we look to the DSM, and rush to equate of “mental illness” with “physical illness” we as a culture must first and foremost return to a recognition of the healing power of human connection. We need to value -both culturally and monetarily- time spent listening. If this step does not come first, we may be sabotaging our own efforts.

In another conversation with a colleague who is a family practitioner, she spoke of the need for this kind of listening for all of her patients, including those who present with what is thought to be a purely “physical” illness. Underlying these symptoms is often complex emotional pain that can only be healed when we offer time to hear the full story.

Maybe what is called for is the mirror image of what my pediatrician colleague expressed. Perhaps rather than equating mental illness with physical illness, we need to recognize that all suffering has some emotional basis, and that relationships are central to all healing.

The DSM system may have some role to play. It offers clinicians opportunity to communicate, to know that they are talking about similar sets of behaviors. But in our current system of health care, without renewed value placed on listening, using it to equate physical and mental illness may serve only to stigmatize our humanity. 

Saturday, October 3, 2015

Can Mental Health Care be Freed From the Medical Model of Disease?

I recently ran in to a colleague, an experienced psychotherapist, who marveled at my ability to "get out from under the medical model of disease." I have been fortunate to work with colleagues in the growing field of infant mental health who come from a range of disciplines. They bring model of strength and resilience, rather than a disease model, to treatment of emotional and behavioral problems of early childhood. 

Younger psychiatrists trained in the age of biological psychiatry have grown up in a professional family with a language of disorders. This language has likely shaped the way they think. It is embedded in their brains in a way similar to the language we grow up with in our homes. As such it may not be easy to change.  But the abundance of evidence at the interface of developmental psychology, neuroscience and genetics suggests that the path to healing lies in listening for the meaning of behavior, not in simply naming disorders and eliminating symptoms. The biological model of disease reifies the DSM (Diagnostic and Statistical Manual of Mental Disorders) diagnoses, when in fact they simply are descriptions of behaviors, or "symptoms," that tend to go together. 

This point was brought home for me when I taught a class on early childhood mental health to a group of child psychiatry fellows at a well-respected Boston teaching hospital. I was presenting the work of child psychiatrist Bruce Perry.  His neurosequential model of therapeutics (NMT,) that guides treatment based on an understanding of brain development, grew out of his frustration treating children with trauma histories according to the medical model. He recognized this approach was failing.   After presenting his alternative model in detail, I described a case of a 7-year-old boy with a complex history of early developmental trauma who was impulsive and getting in to dangerous situations.  I turned to the group of fellows and asked how they might treat this family. The first response was, "I would see if he met diagnostic criteria for depression and consider an SSRI." 

In another example,  I had a conversation with a young psychiatrist about our work with mothers who are struggling in the postpartum period. We agreed that there is a broad range of factors contributing to these struggles. There is the cultural context, with many mothers experiencing social isolation and unrealistic expectations of rapid return to pre-pregnancy functioning. The transition to parenthood under normal circumstances involves massive biological and psychological shifts. Relationships between partners are dramatically altered, and when both partners struggle alone, the sense of social isolation is magnified. And then there is the baby, a new person with unique qualities that may make this transition more challenging, for whom parents are now completely responsible.  I suggested that we think of the term "postpartum depression (PPD)" as an umbrella term that encompasses all of these factors. I wondered if the biological model of disease, that placed the problem squarely in the mother, might be limiting our approach. She replied, "but any good therapist would look at all these things when treating PPD." 

This way of thinking is exactly the problem I was trying to point out. When we speak of postpartum depression as a complication of pregnancy "just like diabetes" we reify the "disorder."  We need to listen for the full complexity of a new mother's experience before we label her with a psychiatric disorder. If, for example, the baby was premature and has difficulty with feeding, we can find meaning in the mother's struggles that lead us to treat the mother and baby together. Or if the father is feeling depressed and abandoned, the treatment might be a father-baby group. Or a mother who is in a new neighborhood with little social support and a spouse who works long hours might need a mother-baby group and an opportunity to go to the gym. I wonder if we really needed to label  a mother with a "disease" in order to engage this kind of support. 

A third example of this reification comes from a child psychiatrist in a blog post about the new DSM 5 diagnosis "Avoidant/Restrictive Food Intake disorder."  He wondered if this represented a "real problem" or over-pathologizing a normal behavior. There is a third option not mentioned anywhere in his article. Eating is a relationship-based behavior with often complex meaning. In my forthcoming book I have numerous cases of picky eaters whose behavior was a communication of distress related not only to sensory issues but also to troubled family dynamics that were only uncovered with space and time for listening. 

In our current system of health care, diagnostic categories are necessary for insurance to cover treatment. In all of these circumstances I describe above, treatment is definitely needed. It is important not to fall in to the trap that if it is not a "disorder," it is "normal" and therefore families don't need help. I use the generic "adjustment reaction" to avoid this trap and still work within the system. When it comes to working with young children and families, this "disease" vs. "normal" is an inaccurate and potentially dangerous dichotomy.

I am hopeful that the explosion of knowledge of the developmental science of early childhood is making its way in to mainstream mental health care. This is in part due to the Adverse Childhood Experience study that shows the long-term impact on both physical and mental health of early childhood experiences.  I hope it will be possible for all mental health professionals to learn a new language, not of diagnosing disease and eliminating symptoms, but of listening with the aim of promoting growth, healing, and resilience.