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, 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.

Sunday, May 22, 2016

Antidepressants for Girls: Are We Putting Future Mothers in an Untenable Position? (When There are Alternatives)

A significant unintended consequence of over-reliance on psychiatric medication for children was brought to light in a recent study  showing that children exposed to SSRIs (selective serotonin re-uptake inhibitors- a class of psychiatric medication used to treat anxiety and depression) during pregnancy were diagnosed with depression by age 14 at more than four times the rate of children whose mothers were diagnosed with a psychiatric disorder but did not take the medication. This study follows on the heels of another showing an increase in risk of autism in children whose mothers took SSRI’s during the second and third trimester of pregnancy.
Such reports are usually met, appropriately, with an outpouring of reassurances from clinicians who take care of pregnant women, who need to protect their emotional wellbeing in whatever way they can.
From my perspective as a pediatrician specializing in early childhood mental health our attention must be on prevention. Our culture is quick to medicate young girls without thought to the increasingly well-recognized slow and difficult process of withdrawal from SSRI's. With multiple studies like those cited above producing a cloud of uncertainty, and limited data on the long-term developmental outcome for a fetus exposed to SSRI’s in utero, we are knowingly putting future mothers in an untenable position.
In addition, recent alarming reports of a tripling of the suicide rate for girls age 10-14, in the context of rapidly rising rates of prescribing of SSRI's suggest that this approach is failing.
There is another way. Extensive evidence reveals that when parents listen for the meaning of a child’s behavior, they support development of emotional regulation, social adaptation, and overall mental health.
In contrast, when the standard of care is to name and then eliminate problematic behavior, often with a pill, listening is devalued both culturally and monetarily.
A question from a review course offered by the American Academy of Pediatrics (AAP) exemplifies this standard. Presenting a case of a 7-year-old girl with separation anxiety since preschool, bedtime resistance, and frequent tantrums, we are asked to choose the correct treatment. We are told that parents are divorced, she is an only child, and at her father’s house she expresses fear that something would happen to her mother.
While cognitive behavioral therapy to “work on skills to manage her distress” is the “correct” answer, an SSRI is recommended as a second line of treatment.
An explosion of research at the interface of developmental psychology, neuroscience and genetics shows us that rather than labeling behavior and seeking to “manage” or eliminate it, the road to healing lies in listening with curiosity to discover meaning.
Did this young girl observe conflict, perhaps even violence, between her parents in the years preceding their divorce? Is there a family history of anxiety, suggesting a genetic vulnerability? Does she have sensory processing challenges that cause her to be overwhelmed in a stimulating classroom? Some combination of all these factors might exist. Only when we know the story can we find the path to healing.
In my practice, eight-year-old Sophie, diagnosed with anxiety disorder by her previous pediatrician, came to refill a prescription for Prozac. After several hour-long appointments, some with her alone and some with her mother Linda, I learned that, like the child in the vignette, she had divorced parents. During every-other weekend visits with her father Mark, he drank heavily. Quick to explode in rage, he frequently verbally humiliated Sophie and her mother. The primary problem needing treatment was his alcoholism. Sophie's behavior represented an adaptive response to a frightening situation.
Parents share this kind of information only when they feel safe. Safety comes when we offer time and space for nonjudgmental listening. When parents can make sense of their child’s behavior, they are in an ideal position to support that child, helping to name feelings, identify provocative situations, and develop strategies to manage these challenges.
Another vignette offers a view of both the problem and the solution.
Beth, mother of 3-month-old Logan, a patient in my behavioral pediatrics practice, could have been the girl from the AAP vignette 15 years later. She struggled with feelings of anxiety. Attempts to stop SSRI’s, which she had taken on and off for years, were unsuccessful. Despite reassurances from many doctors, she was plagued by guilt over the possible effects on her baby, who was now “colicky” and not gaining weight.
I worked with the family, drawing on an evidence-based treatment known as child-parent psychotherapy. We sat on the floor, with Logan’s father, Peter, joining in. Logan began to gain weight in parallel with his mother’s improved emotional state.  My aim was simply to listen, and to support Logan’s parents in reflecting on the meaning of his behavior. By six months he was thriving. Beth’s anxiety abated and she was able to come off the SSRI. 
Over-reliance on psychiatric medication in children has negative impact on this generation and the next. The unknown effect of psychiatric medication on the developing fetus is but one unintended consequence. As I describe in my new book The Silenced Child: From Labels, Medications, and Quick-Fix Solutions to Listening, Growth, and Lifelong Resilience we silence communication and miss opportunities for prevention. In contrast, when we offer space and time for listening to parents, starting in the earliest weeks of life, we have the opportunity to set development on a healthy path.

Monday, April 18, 2016

Mind-Altering Drugs and the Toddler

When statistics regarding the significant rise in prescribing of antidepressant and antipsychotic medication  for children under age 2 made its way into a New York Times article, the outpouring of comments revealed an understandable outrage. World-renowned child development researcher Ed Tronick, who was quoted in the article, accurately summed things up with his comment, "it's just nuts."   Efforts were made to figure out where blame for this clearly unacceptable situation lies. Is it big Pharma? Is it the doctors who write the prescriptions? Is it teachers who pressure doctors to medicate? Or perhaps parents who beg doctors for help?
Interestingly my colleagues and I from Tronick's InfantParent Mental Health Post Graduate Certificate program were at the time having a conversation about the non-productive, and possibly destructive notion of assigning blame. When people feel blamed they become defensive and shut down. They stop listening.
In Tronick's program, individuals from a wide range of disciplines come together to learn about current research in supporting healthy development of the brains and minds of our youngest members of society. We learn the tremendous value of listening with curiosity. This kind of listening promotes development of emotional regulation, social adaptation, and overall mental health. 
Fellows who participate in this program - there are now going on five generations of the Boston-based program and many more from its California-based counterpart- are all well versed in the wealth of evidence-based treatments, other than psychiatric medication, available to help struggling young children and their families. We all look hopefully to the day when these treatments are the standard of care.
The reasons these prescriptions are written for very young children are far-reaching and complex. Explanation requires space well beyond a comment on an article, or even a blog post. In my new book The Silenced Child: From Labels, Medications, and Quick-Fix Solutions to Listening, Growth, and Lifelong Resilience I offer evidence that listening grows healthy brains and minds. I call attention to the convergence of social forces that have let medication replace listening.
It is likely that each individual clinician who writes a prescription for an antidepressant or antipsychotic for a child under 2, while certainly misguided, is sincerely interested in helping that child. Parents often feel overwhelmed and desperate to help their children. Accepting a prescription makes sense in the absence of other options.
Aggressive marketing by the pharmaceutical industry, along with publication in medical journals of research funded by drug companies, has a role to play. A powerful health insurance industry that does not reimburse for time spent listening contributes to the problem. The complexity of the health insurance industry including, for example, enormous effort needed to obtain "prior authorization" for a range of treatments, restricts the amount of time primary care clinicians can spend listening. The shortage of qualified mental health professionals who offer this kind of listening is intimately intertwined with our condoning of medication as the primary treatment, without protecting time for listening. 

The prevailing medical model of disease and the DSM system- the status quo in mental health care- work against listening. This system looks to name a problem and then eliminate it, without opportunity to discover its cause. It places the "problem" squarely in the child, without consideration of the relational and social context. Due to factors in the medical education system, most psychiatrists and primary care doctors who prescribe these medications are not aware of the rapidly expanding research and knowledge in the discipline of infant mental health. 
Forces in the early childhood education system put tremendous pressures on teachers. They may be faced with classes of 20-30 children, and have minimal training or support in working with children with problems of behavioral and emotional regulation. Preserving safety of the classroom is a legitimate priority, and one of the reasons teachers recommend medication. 

Behavior is a form of communication. Medication can silence that communication. Until we place a renewed value on protecting time for listening, we will continue to see an increase in this kind of prescribing. In effect we will be silencing the voices of the youngest members of our society.