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.

Tuesday, April 15, 2014

Antipsychotics for foster care kids with ADHD?

A recent study, one that received relatively scant media attention (compared with a concurrent New York Times piece about a new psychiatric diagnosis termed "sluggish cognitive tempo" that may be the "new ADHD") showed that antipsychotics are being prescribed to nearly one third of kids (age 2-17) in foster care who are diagnosed with attention deficit hyperactivity disorder (ADHD.)

This disturbing statistic brought to mind a common complaint I hear from parents about putting on shoes to go out of the house. A child will dawdle, ignoring multiple requests. The situation will escalate to the point where the parent becomes increasingly angry and frustrated, and the child descends in to an all out tantrum.

This kind of scene likely plays out in some form in every household with a young child. It can be useful to keep in mind as we aim to understand why a child who is in foster care might exhibit behavior that calls for bringing out these pharmaceutical big guns.

While there is a range of reasons for a child to be in foster care, one can assume that there has at minimum been some experience of trauma and loss. This might include physical and/or emotional abuse.

Research in the field of developmental psychology and attachment offers a way to understand this situation. Young children inevitably have tantrums. It is a normal healthy part of development. But if a caregiver herself has a history of trauma, her child's behavior may, as they say, "push her buttons." She may become flooded with stress in the face of her child's acting out. Unable to think clearly, she may respond with behavior that is either frightened or frightening. She may either become overwhelmed with rage, or shut down emotionally. In the language of psychology this is termed "dissociation." For the child, it is as if his caregiver suddenly isn't there. In this situation, the child learns to recognize his own emotional distress as a signal for abandonment.

Now put this same child in foster care and ask him to put his shoes on to go outside. What starts out as a "typical" parent-child interaction can quickly descend in to wildly uncontrollable behavior. I've heard parents who have adopted kids out of trauma say, "its like he's not even there." When the child was in this kind of situation with an abusing caregiver, he might, in a way that is in fact adaptive, responded to her dissociation with his own form of dissociation. Now he has learned that behavior. But out of context, in foster care with a non-abusing caregiver, it may look "crazy."

When this kind of "not listening" extends to other arenas, it may be reframed as "not paying attention."  This behavior often occurs together with the impulsivity. Impulsivity literally means to act without thinking. An inability to think in the face of strong emotions, as I describe in my book Keeping Your Child in Mind, can also be understood as part of the trauma, of not having been held in mind by caregivers early in development.  With problems of both inattention and impulsitivity the child may, according checklists commonly used to make the diagnosis, earn the ADHD label.

Perhaps this is how kids in foster care end up on antipsychotic medication for ADHD.

But by taking this path, we are essentially putting a muzzle on the child. The child's behavior is a form of communication. It says, "I have never learned how to manage myself in the face of life's inevitable frustrations." Rather than silence him with a powerful drug, that is well known to have serious side effects, we need to listen to that communication.

The first step is to recognize the meaning of the behavior. Once caregivers understand the "why" of the behavior, they can better support the child's efforts to regulate himself in the face of frustration. At first this might be in a very physical way. For example he might need to be held in a firm and loving embrace. Or he might need to run around the room. Or hit a punching bag. He might need a soft and gentle voice rather than a harsh and angry one. As a child gets older, regulating activities like dance, theater and martial arts can have a significant role to play. Once a child has developed the capacity to regulate his body in the face of distress, he can begin, perhaps in the setting of psychotherapy, to give words to his experience.

But if we simply silence him with medication, all of this opportunity for growth and healthy development may be lost.

Thursday, April 10, 2014

Autism: difference or disorder?

About 2 years ago, when the change in diagnostic criteria for Autism Spectrum Disorder proposed for DSM 5 was in the news, I wrote a blog post about the problem of giving children a diagnostic label in order to "get services covered" by insurance. An irate reader, himself a well know speaker and advocate for people with Autism and Asperger's, wrote a blog post in response, in which he said, "Dr.Gold simply does not understand that Autism is not a psychiatric disorder."

In the wake of the recent CDC statistics indicating that 1 in 68 children has autism, and the designation of April as autism awareness month, I have been thinking about this dilemma a great deal. For this young man and I were really exactly on the same page. Both of us were calling for a respect for and value of uniqueness and differentness.

This perspective was again beautifully articulated in a TED talk by Andrew Solomon, author of Far From the Tree. In an in-depth discussion of a range of entities including homosexuality, deafness, as well as autism, Solomon identifies the power of unconditional love in the context of complete acceptance of individual differences.

While I fundamentally agree with the perspective of these two men, my mind stumbles on these facts. The DSM 5 is the fifth version of the Diagnostic and Statistical Manual of Mental Disorders. The CDC is the Center for Disease Control. So much as we may want to think of autism as a celebration of individual differences, the prevailing view is that it is a disorder.

Solomon suggests that by hoping a child does not have autism, a parent is saying that she wishes this child did not exist and that she had a different child. I see the exact opposite. The parents I see who are in this position unconditionally love their child for who he is. They are motivated to make sense of his experience and give him space to grow in to himself.

While there is emerging evidence of the role genetic and neurobiological mechanisms in the behaviors collectively referred to as autism, it is not a know biological entity in the way, for example, diabetes is.

One little girl I worked with ran around in circles at preschool and repeated letters in nonsensical patterns. There was a strong family history of both anxiety and "quirky" behavior. She was easily overwhelmed by a range of sensory inputs.  Her mother would herself become overwhelmed in the face of her child's struggles as she recalled her own difficult childhood. Another little boy endlessly repeated whole scenes of dialogue from Disney movies. He ate only 3 different foods for the first 7 years of his life. His parents fought frequently about his challenging behavior, which usually caused it to escalate.

For both these children the diagnosis of autism was raised. But both sets of parents resisted. When they addressed the child's unique qualities as well as the environmental stresses that contributed to the problematic behavior, dramatic changes occurred. Both are now teenagers. The first is a talented actress, singer and musician. The second is a chef. Both have active and successful social lives. One view is that they "outgrew" autism. Another is that they were they given space and time to grow into themselves.

It the first five years of life there are major changes in the brain, changes that occur in the context of relationships.  We are now recognizing that changes occur not only in brain structure, but in genes and gene expression as well. It is a work in progress.

These children and families do benefit significantly from help. This may be in the form of a special preschool placement, occupational therapy, family therapy or other interventions that can set these children on a healthy path of development. In order to get these services, a diagnosis is often necessary. This is an example of the tail wagging the dog.

The massive rise in diagnosis of autism indicates that something is amiss. I wonder if that "something" is that in our fast-paced society we rarely take the time to listen to the story, to let meaning unfold. There is a need for an "answer." There is a lack of tolerance for uncertainty.

When a child is young, when his "true self" is emerging, supporting parents efforts to "hang in there" without the need to name, to label, to diagnose, may give these young children the best opportunity to transform what in early childhood may be challenges and vulnerabilities in to adaptive assets and strengths.

Thursday, March 27, 2014

Rising numbers of kids expelled from preschool and diagnosed with autism: are they linked?

Two alarming news items compete for attention. The first,  a New York Times editorial entitled Giving Up on Four-Year-Olds describes a recent report showing expulsion from preschool as a form of discipline occurring in increasing numbers. A second speaks to the new CDC statistics indicating that 1 in 68 children have autism, a change from 1 in 88 just 5 years ago.

Perhaps both represent a lack of value of space and time for listening, in particular for listening to children and parents. Elizabeth Young-Breuhl might refer to both phenomena as prejudice against children

Each child who is expelled from preschool has a story. Similarly, every child diagnosed with autism has a story. It takes time, and a safe non-judgmental environment to bring these stories to light and so make sense of a child's behavior.

There may be witnessed domestic violence. When  a child lives in fear, he may respond to the "threat" of a child standing too close to him in line by pushing him. A reprimanding voice may lead to escalation of stress and even the development of a "fight-flight reaction." Being sent to the principal's office leads to further disorganization. 

Sensory processing challenges are often prominent. A withdrawal from social interaction makes sense from the perspective of a child who is flooded and overwhelmed by a busy classroom. Crawling under a desk may not be something "wrong" but rather an adaptive response.
Increasingly structured school environments, with little room for variation and high student:teacher ratios may exacerbate both of these problems. 

However, once we have the opportunity to hear the story, what to do to help the child becomes clear. One boy whose behavior had escalated to the point where he was throwing things at the teacher felt calm if he could start the day with a few minutes buried under the plastic balls in the ball pit. Another who would run in circles much of the day discovered music. When she was invited to sing or play an instrument she could sit calmly with the other children. Another family recognized how the level of chaos in the home was particularly problematic given their son's vulnerabilities, and took steps to change that environment.

A recent New York Times article describes a wonderful school program, Head Start Trauma Smart, an example of an innovative program that takes time to listen to the story, make sense of a child's behavior and respond appropriately. In contrast, expelling children for "acting out" may result in a cascade of worsening behavior problems.

The massive rise in autism numbers may reflect a need to name a problem with certainty, rather than taking the time to let the story unfold, to let a child grow in to himself. Perhaps if parents, teachers and clinicians had the opportunity to get a child the help he needs without pressure to name the problem, the numbers would be much lower.

Clearly there are significant differences between these two issues. But an underlying theme emerges. 

Monday, March 24, 2014

Huge increase in ADHD diagnosis in young women a worrisome trend

"I know its my ADHD acting up," a mother of three young children recently said to me as an explanation for her inability to recall a particular piece of information. My observation, in the setting of my behavioral pediatrics practice, of increasing numbers of mothers of young children being diagnosed with ADHD is in keeping with a recent report from Express Scripts. This report, based on pharmacy claims data, showed a 53% rise in writing of prescriptions for ADHD in adults from 2008-2012, with "the largest gains seen in women age 26-34, climbing 85%."

A psychiatrist colleague of mine took this data at face value, saying that "ADHD is genetic" so with the rise in diagnosis in children, it makes perfect sense that there should be a parallel rise in diagnosis in adults. 

But there are big holes in this argument. Certainly problems of regulation of attention, behavior and emotion, that are all called "ADHD," have a familial component. But we are far from identifying a specific genetic cause. These qualities, both in children and adults, represent a complex interplay between genetic vulnerability and environmental effects.  

So how else might we explain this rise in writing of prescriptions for this group, many of whom are young mothers? In today's fast-paced society, parents of young children are often overextended and overwhelmed. In my practice many fathers work very long hours, leaving mothers alone to manage everything. In the absence of extended family this can be highly stressful. Physical activities such as yoga, running or even walking have a calming organizing effect on the brain, but often these mothers are unable to carve out time for themselves during the day. Sleep deprivation has a huge role to play. There is a well-established link between sleep deprivation and symptoms of distractibility, inattention, and hyperactivity. This may be an inevitable part of parenting young children. But often there are ways to improve sleep if parents have the opportunity to make sense of the situation and take the time to fix it. But often there is not this time, so families get stuck in a reactive mode, with a vicious cycle setting in as lack of sleep makes them increasingly less able to think clearly.

I have concerns about this trend of diagnosing and treating ADHD, particularly in this population of young mothers. If we label this behavior as a disorder and prescribe a pill, we are not placing responsibility (blame) squarely on the mother? Do we not have a responsibility as a society to care for mothers to support their efforts to care for the next generation? Will the motivation to find more creative solutions, such as flexible parental leave, and valuing of self-care (the airlines recognize this need in the instruction to adjust your own oxygen mask before your children's) be lost?

These medications are not without harmful effects. About a year ago, a young woman, not a mother but in this age group, wrote poignantly in the New York Times of her struggle with Adderall addiction that took hold in an environment of ever increasing demands for productivity.

I am probably not alone in wondering about an alternative explanation to that of my psychiatrist colleague. Clearly this trend is a boon for the pharmaceutical industry. Could it be that some very clever people in marketing saw an opportunity, and set about selling "Adult ADHD" to both a general and a professional audience? If so, they have certainly been very successful.

Monday, March 10, 2014

Take new smartphone use study with a hefty dose of empathy for parents

A new study documenting the ubiquitous use of smartphones by parents at fast food restaurants with their young children is getting a lot of media attention. From Time magazine there is this headline: " Don't Text While Parenting- It Will Make You Cranky." "Put Down that Cellphone" from NBC. "Parents on Smartphone Ignore Their Kids," from ABC News.

I doubt that anyone is surprised by the findings of this study. People everywhere are on their smartphones all the time. In the arena of parenting, it is important to call attention to the impact of this behavior. There is extensive evidence that face-to-face interaction is critical for healthy emotional development. Mealtime offers an important opportunity for this type of interaction, especially in today's fast-paced culture.

However, I worry about the parent blaming tone of these headlines. Rather than saying, "This is bad, don't do it," perhaps we should be curious about why parents are using smartphones in this way.

One answer lies the increasing recognition of the addictive nature of these devices. Everyone, not just parents in fast food restaurants, is using smartphones all the time. The other may lie in the fact that parents, especially parents of young children, often feel alone, stressed and overwhelmed. Putting these two together and the allure of the screen becomes understandable.

The American Academy of Pediatrics press release states:
The study raises several questions for future research, including ...what are the long-term effects on child development from caregivers who frequently become absorbed with a device while spending time with their children.
I think we already know the answer to this question. I wonder if another important question might read: "How do we support parents in being more fully present with their young children, given the combination of high stress and an easy available, socially acceptable addictive device?"

Friday, February 28, 2014

Legal marijuana, antidepressants, and the danger of not listening

 A popular blog post Why I Tried to Kill Myself at Penn is making its way around the college-age crowd. The author calls attention a high-stress a culture that does not value listening.
During my sophomore year at Penn, I tried to kill myself by swallowing a bottle of Wellbutrin. I spent 4 days in the hospital.
Penn’s response? – Sending some administrator to see me in the hospital (HUP). The first and only thing that she said was, “Are we going to make this an annual pattern?” because I had been hospitalized the year before. I said “No” and she gave me her business card.
After suicides, everyone laments, “Why didn’t they talk?” Often, we did. People just didn’t want to listen, because in the moment it was easier for everyone if you put on a smile and pretended to be okay.
A parent recently described calling the emergency student support services when she was worried about her son's emotional state during his first semester at college. After a five minute conversation, she was told by the person who responded to her call, " We can make an appointment with the psychiatrist to see if he needs medication."

I thought about these two stories when a study, a survey of 1,829 people being prescribed antidepressants, was released showing a much higher than expected rate of serious psychological side effects:
Over half of people aged 18 to 25 in the study reported suicidal feelings and in the total sample there were large percentages of people suffering from 'sexual difficulties' (62%) and 'feeling emotionally numb' (60%). Percentages for other effects included: 'feeling not like myself' (52%), 'reduction in positive feelings' (42%), 'caring less about others' (39%) and 'withdrawal effects' (55%). However, 82% reported that the drugs had helped alleviate their depression. 
Professor Read concluded: "While the biological side-effects of antidepressants, such as weight gain and nausea, are well documented, psychological and interpersonal issues have been largely ignored or denied. They appear to be alarmingly common."
Psychiatric medication side effects are a double-edged sword. The first, that receives the most, though as indicated by this study insufficient, attention is from the medication itself. But the second, and equally if not more serious, is the way prescribing of psychiatric medication becomes a replacement for listening.

What makes us human is our ability to empathize. Drawing from both Buddhism and psychoanalysis, the "presence of mind" of another person is responsible for therapeutic healing. "Being with," "bearing witness," are other phrases that describe this phenomenon. When we jump to a pill we run the risk of skipping this step. If the medication itself also has psychological side effects, it is not surprising that, in combination with feeling alone and unrecognized, a person might attempt suicide.

Psychiatric medication may be necessary when an individual is unable to function without it. Ideally such a determination is made in the setting of both psychotherapy and other self-regulating activities such as yoga or meditation. But that is not the way these medications are used. Because they can be so effective at eliminating distress in the short term, our fast-paced, quick-fix culture makes them very appealing, almost irresistible.

I decided to include the topic of legalization of marijuana in this post as a kind of cautionary tale. In California cannabis is commonly prescribed to treat anxiety. Psychiatric diagnoses and drug prescribing are often based on symptoms alone, as is well captured in this amusing though disturbing anecdote from a Psychology Today post by psychologist Jonathan Shendler:

During my first week as a psychiatry department faculty member, a fourth-year psychiatry resident—I will call her Gabrielle—staffed a case with me. She gave me some demographic information about her patient (38, White, female) and then proceeded to list the medications she was prescribing. The rest of our conversation went something like this:“What are we treating her for?” "Anxiety." "How do we understand her anxiety?"Gabrielle cocked her head to the side with a blank, non-comprehending look, as though I had spoken a foreign language. I rephrased the question.“What do you think is making your patient anxious?”She cocked her head to the other side. I rephrased again.“What is causing her anxiety?"
Gabrielle thought for a moment and then brightened. “She has Generalized Anxiety Disorder.”“Generalized anxiety disorder is not the cause of her anxiety,” I said. “That is the term we use to describe her anxiety. I am asking you to think about what is making your patient anxious.”She cocked her head again.“What is going on psychologically?”Psychologically?”
“Yes, psychologically.”There was a pause while Gabrielle processed the question. Finally she said, “I don’t think it’s psychological, I think it’s biological.”

As we are on the cusp of general legalization of marijuana (that I do not oppose) it becomes imperative that psychiatric medications not replace listening. It is essential that we protect time and space for being present, for curiosity, for empathy. Otherwise we are simply offering another way, and one that is not without side effects itself, to devalue the role of human relationships in healing.

Sunday, February 16, 2014

ADHD, bipolar disorder and the DSM: A need for uncertainty?

A recent article in the New Republic, provocatively titled “ADHD Does Not Exist,” starts out well enough. The author, a psychiatrist with “over 50 years experience” points to the fact that ADHD describes a collection of symptoms, rather than their underlying cause. Using stimulants to control these symptoms, he argues, is analogous to prescribing pain medication for cardiac chest pain rather than addressing the underlying circulatory problem.  But my antennae went up when he applied his views to a case, and concluded that his patient, a 12-year-old-boy, was misdiagnosed with ADHD, when in fact he had bipolar disorder. My level of alarm rose when he went on to describe his treatment:
In William’s case, the family agreed to try medication first without psychotherapy, to see what kind of impact the pharmaceutical treatment could have. The first medication we tried, an anti-seizure drug commonly prescribed for bipolar disorder, reduced the boy’s mood and behavioral symptoms dramatically but resulted in side effects including upset stomach and dizziness. We started William on lithium, and within two months we found a dosage that worked well for him, reducing his symptoms to very mild levels, with no significant side effects.
There is no mention of developmental history or family relationships. There is no exploration of the context in which these symptoms occur, and certainly no evidence that William’s experience being bounced from medication to medication is being considered.  Dr. Saul in essence replaces one treatment of symptoms without determining the underlying cause with another treatment of symptoms without addressing the underlying cause.

The author points to a strong family history of bipolar disorder to support his diagnosis. Statistics from the National Institute of Mental Health indicate that when a parent or sibling has bipolar disorder, a child is up to six times more likely to develop the illness.

But when it comes to an individual child and family, not only are statistics meaningless, but they may also preclude exploration of the underlying cause of the child’s symptoms. These symptoms are usually due to a complex interplay of biology and environment. Statistics do not speak to the effect of early intervention in decreasing the risk. 

Consider Jacob, a five-year-old boy I saw recently in my behavioral pediatrics practice. He was adopted, and two biological relatives had bipolar disorder. A pediatrician, his adoptive parents and a neurologist suspected that he too had the disorder. But with space and time to hear the story, the following emerged.

Jacob had been an easy baby. Then when he was about two, he experienced a number of significant losses. A foster child with whom he was very close was removed from the home because of behavior problems. Just weeks after his adoptive mother, Alice, learned she was pregnant, her sister died suddenly of a cerebral hemorrhage. Jacob’s maternal grandmother, in the face of the loss of her own daughter, threw herself in to caring for Jacob’s baby sister. 

Jacob’s mother wept in my office as she spoke of her own loss, not only of her sister, but also of her mother who withdrew in the face of her grief. Shortly after these events, Jacob’s behavior problems began in earnest. He became alternatively clingy and aggressive. When I saw the family, no one had slept through the night for a long time.

Jacob might very well have a biological vulnerability to emotional dysregulation inherited from his parents who carried the bipolar label. But multiple losses, subsequent disruptions in attachment relationships, sleep disruption, and other factors had significant roles to play in development of his symptoms. Had he, like William, been prescribed medication for his symptoms, this story, and the meaning of his behavior, would not have been heard. For every child I see in my practice, there is a story, often equally complex, behind the symptoms. 

Rather than offer time and space for the nuances, complexities and uncertainties of human behavior and relationships, the DSM (Diagnostic and Statistical Manual of Mental Disorders) paradigm, with its diagnoses of disorders based on symptoms, often followed by prescribing of medication, creates an aura of certainty, as in “you have X and the treatment is Y.” But there is virtually no evidence of any known biological processes corresponding to either ADHD or bipolar disorder (or any other DSM diagnoses, for that matter.) This certainty implied in the giving of a diagnosis and prescribing of medication has a kind of comfort, but also a real danger. There is no room for curiosity, for wonder, for not knowing.  Jacob’s behavior was a form of communication. Giving medication to control his behavior is in effect a silencing of that communication.

A recent New York Times article, “The Dangers of Certainty,” addresses this issue in a very different context. The author describes how he was profoundly influenced by the 1973 BBC documentary series, “The Ascent of Man,” hosted by Dr. Jacob Bronowski. The article describes an episode in which Bronowski discusses Heisenberg’s uncertainty principle.  
Dr. Bronowski’s 11th essay took him to the ancient university city of Göttingen in Germany, to explain the genesis of Werner Heisenberg’s uncertainty principle in the hugely creative milieu that surrounded the physicist Max Born in the 1920s. Dr. Bronowski insisted that the principle of uncertainty was a misnomer, because it gives the impression that in science (and outside of it) we are always uncertain. But this is wrong. Knowledge is precise, but that precision is confined within a certain toleration of uncertainty….Dr. Bronowski thought that the uncertainty principle should therefore be called the principle of tolerance. Pursuing knowledge means accepting uncertainty. ..In the everyday world, we do not just accept a lack of ultimate exactitude with a melancholic shrug, but we constantly employ such inexactitude in our relations with other people. Our relations with others also require a principle of tolerance. We encounter other people across a gray area of negotiation and approximation. Such is the business of listening and the back and forth of conversation and social interaction. 
As he eloquently put it, “Human knowledge is personal and responsible, an unending adventure at the edge of uncertainty.”The relationship between humans and nature and humans and other humans can take place only within a certain play of tolerance. Insisting on certainty, by contrast, leads ineluctably to arrogance and dogma based on ignorance.
The episode takes a dark turn when the scene shifts to Auschwitz, where many members of Bonowski’s family were murdered. The article’s author, a professor of philosophy at the New School, offers this interpretation:
The pursuit of scientific knowledge is as personal an act as lifting a paintbrush or writing a poem, and they are both profoundly human. If the human condition is defined by limitedness, then this is a glorious fact because it is a moral limitedness rooted in a faith in the power of the imagination, our sense of responsibility and our acceptance of our fallibility. We always have to acknowledge that we might be mistaken. When we forget that, then we forget ourselves and the worst can happen. 
I can already hear the shouts of outrage that I dare to compare mental health care with Nazism. Having grandparents who survived a concentration camp, I know well that this is a highly fraught subject. But of course that is not what I am doing. I am simply pointing to this article as a beautiful articulation of the value of uncertainty, especially in the context of understanding human behavior.