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, July 25, 2014

How Yoga Informs Parenting: Value in Not Knowing

In yoga, a pose referred to by my teacher as "how wonderful" involves a lifting of the head and chest, and opening of the arms out to the side, with a bend in the elbows.

In her introductory words of wisdom to a class in which that pose was to be the theme of the day, she asked us, "Do you ever make up stories?" She shared that she may in response to a distracted expression from a friend think, "She's mad at me," or from her 3-year-old child who refuses to put on his shoes, "He's trying to drive me crazy!" She identified how this ability to try to make sense of other's behavior has evolutionary significance. It helps us navigate a complex social world- otherwise, she said, we would have no idea what was going on. But sometimes this kind of assuming of meaning, this making up stories, can get us in to trouble.

What if instead, we employ the open stance of  "I don't know?"-words she demonstrated fit perfectly with the pose of "how wonderful."

In my behavioral pediatric practice, I find parents often driven by a  need to know. "Is there something wrong with him?" they ask. There are tremendous pressures -from teachers, from family, from insurance companies, to name the problem. There is a kind of certainty in this approach, a kind of professional declaring of "I know whats wrong with you."

What if, rather than being guided by diagnostic instruments, that ask questions with the aim of getting an answer, we approach the situation with a stance of curiosity, of inquiry, of "not knowing."

I find if, in a way not dissimilar to the hour-long yoga class, I offer space and time to let the story unfold, we uncover complex meaning in "problem" behavior. There may be a number of relatives with similar traits, suggesting a genetic component. There may have been significant stresses in a family that, even with parents' best efforts to shield a child from the effects, have been noticed and absorbed. A child may have a range of sensory sensitivities that he can manage, but under the stress of separation, often at bedtime or in the process of getting out the door, these sensitivities are magnified. "Problem" behavior may be both cause of and result of family conflict between parents, among siblings, between generations.

There is courage in a stance of not knowing. In yoga, we trust our teacher to guide us in the backbends that evolve out of the "how wonderful/I don't know" pose. The work is hard.  She challenges us while taking care to protect us from harm.

Perhaps professionals who care for children with "behavior problems" -pediatricians, psychiatrists, teachers- could learn a lesson from my yoga teacher (support from the health care system that decided what is and is not "covered" would be essential to this kind of approach.) Rather than being guided by a need to make a "diagnosis," we would support parents in a safe, holding environment through a time of not knowing, on a journey to find the true meaning of behavior.

This kind of journey might not only serve to decrease the number of children receiving psychiatric diagnoses, but also help us to discover creative solutions. We would have the opportunity to uncover both weaknesses and strengths, and to support development of resilience.  In the words of pediatrician turned psychoanalyst D.W. Winnicott, we would be promoting development of a child's "true self."

How wonderful.

Tuesday, July 15, 2014

Why Depression is Not Like Diabetes

At the recent gubernatorial candidates forum on mental health, Martha Coakley repeated the oft-heard phrase that depression is like diabetes. Her motivation was good, the idea being to reduce the stigma of mental illness, and to offer "parity" or equal insurance coverage, for mental and physical illness. However, I am concerned that this phrase, and its companion, "ADHD is like diabetes," will, in fact, have the exact opposite effect.

A recent New York Times op ed, The Trouble with Brain Science, helped me to put my finger on what is troubling about these statements. Psychologist Gary Marcus identifies the need for a bridge between neuroscience and psychology that does not currently exist.

Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. The above analogies disregard the intimate intertwining of brain and mind. For the pancreas, there is no corresponding "mind" that exists in the realm of feelings and relationships.

While there is some emerging evidence of the brain structures involved in the collection of symptoms named by the DSM (Diagnostic and Statistical Manual of Mental Disorders,) there are no known biological processes corresponding to depression, ADHD or any other diagnosis in the DSM. There is, however, a wealth of new evidence showing how brain structure and function changes in relationships.

These collections of symptoms, intimately intertwined with feelings and relationships, are problems of behavioral and emotional regulation. The capacity for emotional regulation develops in relationships.  If DSM diagnoses can only be legitimized by comparing them to diabetes-and food allergies, as was recently done by the director of the NIMH (National Institute for Mental Health)- this comparison may increase, rather than decrease the stigma by de-valuing relationships and our basic human need for meaningful connection.

The primary treatment for diabetes is a drug. This analogy works if we accept that the primary treatment for mental illness is drugs. The pharmaceutical industry must be pleased with this approach.

But, in fact, the primary treatment for problems of emotional well-being is time. What is needed is time and space for listening, where individuals can have the opportunity to have their feelings recognized and understood. In this time and space, people can make sense of, and find meaning in, their experience.

A model that compares depression to diabetes is an illness model. It promotes a kind of "there is something wrong with you and I will fix it" approach.   It is not simply a question of "therapy vs. medication" as many "evidence based" research studies suggest. It is a question of a completely different model, a resilience model. Such a model, that values time and space for listening and being heard, seeks to help people re-connect with their most competent selves.

But we will only get there if we stop comparing depression to diabetes.

Thursday, July 3, 2014

Supporting Parent-Baby Pairs in the Wake of Infertility

A new study in Denmark demonstrated a 33% increased risk of a range of psychiatric disorders in children whose mothers were treated for infertility. The authors do not offer a cause, but postulate that the increased risk is related not to the treatments, but to the infertility itself.

These findings echo research showing increased risk of psychiatric problems in children whose mothers have struggled with perinatal emotional complications such as anxiety and depression.

How can we make sense of this?

Mental health, including the capacity for emotional regulation, empathy, resourceful thinking and resilience, develops in relationships. So the answer to this question lies in the way infertility impacts on parent-child relationships.

I recently came upon a beautiful expression in a work of literature that captures pediatrician D.W. Winnicott's concept of primary maternal preoccupation, that he identifies as central to a child's healthy emotional development.

The book is James Agee's A Death in the Family. In this early scene, the father is awakened during the night because his father is ill. As he dresses to leave the house, his wife, on her way downstairs to make him breakfast, whispers to him to bring his shoes in to the kitchen.

"He watched her disappear, wondering what in hell she meant by that, and was suddenly taken with a snort of silent amusement. She looked so deadly serious, about the shoes. God, the ten thousand little things every day that a woman kept thinking of, on account of children. Hardly even thinking, he thought to himself as he pulled on his other sock. Practically automatic. Like breathing."

The experience of infertility may get in the way of this breathing. Without appropriate support, a mother may feel that she is suffocating.

A mother, and also a father who, while not experiencing the physical assaults of infertility treatments, certainly shares in the emotional trauma, may come to the experience of parenthood with a range of significant vulnerabilities.

Anxiety over the well being of a new baby, no matter how much reassurance well meaning clinicians offer, may be unrelenting. In the face of repeated loss, as occurs in the process of infertility treatment, not only with every period, but sometimes with early pregnancy loss, may lead a parent to, in an adaptive effort to protect themselves from further loss, disengage emotionally. A parent may not fully surrender to the falling in love that accompanies the birth of a baby. And parents may be simply emotionally exhausted.

The baby also may have a role to play. There is evidence that stress in pregnancy, as is almost inevitable in a pregnancy that follows infertility treatments, is associated with what is termed "behavioral dysregulation" in the baby. That is, the baby may be more difficult to feed, may cry more or have irregular sleep patterns.

The good news is that, having identified infertility as a risk factor in development of mental illness, there is ample opportunity to set these vulnerable parent-baby pairs on a healthy path. One option is suggested in a recent article in the Atlantic, How Supportive Parenting Protects the Brain, where the possible role of the pediatrician is addressed.

What if every parent-baby pair, in the aftermath of infertility treatment, got some extra time and attention? An extra hour-long visit-with clinicians reimbursed for their time- to meet with parent and baby together, to listen to them both? Even better, as pediatricians have variable interest/expertise in this kind of work, have an infant mental health specialist, physically located in the pediatrician's office. The Newborn Behavioral Observation system is a wonderful tool for listening to parent and baby together in a way that sets development on a healthy path.

The idea is to normalize, rather than stigmatize.

This study might cause alarm for parents who are already stressed by the process of infertility treatment. I was alarmed myself by the statement by one of the study's authors that "this knowledge should be balanced against the physical and psychological benefits of pregnancy." To even entertain the idea of not getting pregnant because of this potential risk to the child is absurd, and feels almost punishing.

But if instead we use this study as further evidence of the value of protecting space and time to listen to parents and babies, then alarm could be transformed in to hope.

Thursday, June 26, 2014

To MA Gubernatorial Candidates on Mental Health: What About Children?

At last night's MSPP ( Massachusetts School for Professional Psychology) sponsored Gubernatorial Forum on Mental Health there was much talk among all of the candidates about how devoting resources to mental health care is a wise investment. But there was virtually not one mention of prevention in the form of children's mental health care. This was striking, as Nobel prize winning economist James Heckman has offered extensive evidence of how devoting resources to prevention in early childhood leads to decreased long-term costs of physical and mental health care.

Investing in early childhood also leads to decreased spending on prisons, a topic all of the candidates addressed in terms of decreasing the number of people in prison for non-violent crimes and first time drug offenses. They all correctly identified the high rate of mental illness in prison and the need to offer treatment, particularly substance abuse treatment.

The whole night I was thinking, "what about the children?" This might have been due to the format, and the fact that moderator Tom Ashbrook did not ask a single question about children.
I was struck by the contrast between this discussion and last week's American Academy of Pediatrics sponsored symposium on Child Health, Resilience and Toxic Stress.

All the best science of our time, in the form of research at the interface of neuroscience, genetics and developmental psychology, tells us that to invest in prevention means to invest in parents and children.

I was disappointed by Martha Coakley in a sense towing the NIMH party line, whose great shortcomings I describe in a previous post, by saying that mental illness is like any physical illness, such as diabetes. I am one hundred percent in favor of parity for mental health care, and decreasing the stigma of mental illness. But the only way to achieve this parity is to recognize that mental illness is not like diabetes.

Resilience and emotional wellbeing develop in the context of relationships. To both prevent and treat mental illness the focus of intervention needs to be on relationships. What makes us human is our historical and relational context. We need to value space and time to listen to each other.

The most important point of the evening, that was made in some form by all three democratic candidates, is that reimbursement for mental health care needs to increase significantly. When we place value, both cultural and monetary, on taking the time to listen, whether to parents of young children, teens struggling with substance abuse, or adults with a range of diagnostic labels, then we will be making meaningful steps not only towards mental health care parity, but also towards promotion of health and resilience.

Monday, June 23, 2014

ADHD at 4, Violent at 15: Are Lessons Learned?

When I write about lessons I have learned from my patients, I go to great lengths to protect their privacy by altering details and identifying information. However, as the Serpico family has so generously and bravely offered their story to the public in the New York Times, the details are available for all to see. And the story offers a very important lesson.

The focus of the article, Seeing Son's Violent Potential, But Finding Little Help or Hope is on the current situation- on how a well-insured, well-educated family is struggling to get help for their deeply troubled teenage son.

But the lesson comes early on, and is contained in this paragraph:
Lena and Robert Serpico knew something was not right before their son was in kindergarten. They had taken him and his younger brother in as foster children from a mother who used drugs, and they later adopted both. The older boy, whose name is not being published at the Serpicos’ request, was restless and impulsive from the beginning and got his first diagnosis at age 4: attention deficit hyperactivity disorder.
While the amount of time this boy lived with his biological mother is not stated, if he was the older of two brothers and they were placed in foster care together, it was at least nine months. The human infant is uniquely helpless in the early weeks and months of life. His brain develops the capacity for self-regulation when the people who care for him can be present and attuned. The brain undergoes its most rapid development in the first year. A caregiver who is using drugs will be impaired in her ability to offer this attunment, significantly impacting on that child's self-regulation capacity. Separation from a primary caregiver, no matter how impaired, is itself traumatic even for a very young child.

The good news is that the brain continues to grow and change rapidly in the first 5 years. There is ample opportunity to set things on a better path even in the face of early adversity. Several evidence based interventions, such as Child-Parent Psychotherapy, can help parents make sense of a child's behavior and so set development, at the level of brain structure and function, on a better path. When early childhood educators recognize the impact of early experience, as in the Head Start-Trauma Smart program, there is opportunity to support healthy development in the classroom.

But for this child, there is no indication of any significant intervention before age 4, despite the fact that he was "restless and impulsive from the beginning." There seems to be no link made between his early developmental experience and his difficulty with self-regulation. Though the article does not address this question, I wonder how much information his adoptive parents were given about the developmental effects of his early life experience. I wonder how much support they were given in the early years of foster care and then adoption.  Was there space and time to listen to them? By labeling his constellation of behaviors at age 4 as "ADHD" and prescribing medication, the path to finding meaning in his behavior was closed off.

Because stimulant medication is so effective at controlling behavior, his impulsively subsided in the elementary school years. But given his history, it is almost inevitable that without addressing the underlying cause for the behavioral and emotional dysregulation, with the onset of adolescence symptoms would resurface. While the short term goal of sitting still and paying attention in school was achieved, valuable time was lost.  His opportunity to communicate his need for help with self-regulation was silenced by medication.

He showed an affinity for guitar during those years of relative peace. Music,  martial arts, theater athletics, and a range of other activities, both through the activities themselves as well as the relationships formed, are other ways in which children can develop emotional, attentional and behavioral regulation.  With a diagnosis made and his symptoms effectively eliminated, motivation to pursue more creative, long lasting interventions, either in addition to or instead of medication, was likely not there.

What instead followed was a string of different diagnoses and medications, with what his parents describe as a terrifying downward spiral in mental health,  in parallel with a dramatic upward spiral of health care costs.

Virtually all of the comments on the article, over 800 as I write this, focus on the Serpico's struggles to get, and pay for, appropriate care for their teenage son. Certainly that is an important issue. Early intervention will be of no use to the Serpico family now. In fact, it might be quite painful to think of missed opportunities.

But the real value of this story lies in its cautionary nature. If it can be used to advocate for recognition of the impact of early development, and for investment in preventive intervention in the early years, their story could potentially help to save a lot of grief, suffering, and money.

Wednesday, June 18, 2014

Pediatric Leaders on Health and Resilience: Listen to Parents

"We need to actively engage parents before we jump to invest in pre-K for all," Jack Shonkoff, director of the Center on the Developing Child at Harvard University wisely proclaimed yesterday at the American Academy of Pediatrics (AAP) Symposium on Child Health, Resilience and Toxic Stress in Washington, DC. Promoting a "two generation approach,"  symposium speakers recognized that not only the child, but the parent-child relationship, is the concern of the pediatrician.

One of the speakers addressed the problem of "uncompensated time." This phrase hit the nail on the head. Time and space is the treatment. People need to feel safe to be able talk about what is important.  This includes both the clinician and the parent. When the pediatrician feels stressed by a waiting room full of patients that the current system of care demands he must see, he is not able to be present with a parent in the way that careful listening requires.

It  is like a set of Russian dolls. The society values the clinician's time, offering the opportunity to listen to the parent, who listens to the child. And as many at the symposium recognized, it is not just pediatricians, but also child care workers, teachers, home visitors and others who have the opportunity to support stressed parents. All policy needs to be focused on protecting space and time to listen. Listening is not high tech. But it is this space and time, where parents feel safe and valued, that we have the opportunity to grow healthy brains and minds.

Pediatrician and journalist Perri Klass gave a beautiful talk about Reach Out and Read, a national program that distributes books to parents in pediatrician's offices. She spoke honestly about the growing realization that benefits were not from larger vocabulary or "school readiness." Rather it was the act of reading, the gentle sound of the parent's voice, fully in the moment with the child, that was responsible for positive results.

One audience member asked a wise question about giving a book to a mother who has herself not been read to, and so does not have a model for this kind of intimate interaction. Klass responded that this is true of any advice or guidance we give to a parent. Her response leads back to the notion that rather than giving information, or teaching skills, first we need to listen, to be curious about the experience of the person we are with.

My first book, Keeping Your Child in Mind, whose second chapter is "Listening to Parents, Strengthening the Secure Base"  translates the explosion of contemporary research that Shonkoff referred to in his presentation. The book shows what this approach looks like for a range of everyday parenting concerns from newborn to teenage years.

While the symposium was occurring, a relevant headline,  A Case Study in Maternal Mental Illness, on New York Times front page, told the tragic story of a mother's struggles with her belief that she had caused her baby harm. This conviction eventually led to her jump from a building with her infant strapped to her chest. While one cannot fully understand the treatment she received by reading a newspaper article, it appears that there were multiple interventions along the way, all of which treated the mother and baby separately. Many pediatricians reassured the mother that there was "nothing wrong." Psychiatrists diagnosed depression and prescribed medication.

Knowing the research on the value of treating parent and child together, I can't help but wonder if time with an experienced clinician who could sit on the floor with both parent and baby, might have offered the opportunity to make sense of her suffering and so set the pair on a different path. In the abundance of advice, reassurance and diagnosing of illness, was there time and space for listening?

For when parents, who may be stressed and overwhelmed, feel heard, recognized and understood, they are better able to do the same for their child. When  parents listen to their child, are fully present with their child, they offer the opportunity build resilience and the capacity to manage adversity. It is not about giving information, or even about teaching skills. It is about supporting parents' efforts to connect with their most competent self.

Central to this view is the notion of the good-enough mother, a phrase coined by pediatrician turned psychoanalyst D.W. Winnicott, and demonstrated in the contemporary research of developmental psychologist Ed Tronick. The good-enough mother is not perfect. But it is her very imperfection that drives development forward in a healthy way. Parents make mistakes. It is through these mistakes, and their subsequent recognition and repair, that children learn to manage the inevitable challenges of life.

It was an inspiring symposium, but we may be making this more complicated than it needs to be. All the best science tells us that our single aim should be to protect time and space for listening to parents, and so to children. This is the road to health and resilience.

Sunday, June 8, 2014

Insel of NIMH Misses the Mark: Medication as Social Control

Tom Insel, director of the National Institute of Mental Health (NIMH,) in his recent blog post Are Children Overmedicated? seems to suggest that perhaps more psychiatric medication is in order. Comparing mental illness in children to food allergies, he dismisses the "usual" explanations given for the increase prescribing of medication.  In his view these explanations are; blaming psychiatrists who are too busy to provide therapy, parents who are too busy to provide a stable home environment, drug companies for marketing their products, and schools for lack of recess.  Concluding that perhaps the explanation for increase in prescribing of psychiatric medication to children is a greater number of children with serious psychiatric illness,  he shows a lack of recognition of the complexity of the situation. 

When a recent New York Times article, that Insel makes reference to, reported on the rise in prescribing of psychiatric medication for toddlers diagnosed with ADHD, with a disproportionate number coming from families of poverty, one clinician remarked that if this is an attempt to medicate social and economic issues, then we have a huge problem. He was on to something.

In conversations with pediatricians (the main prescribers of these medications) and child psychiatrists on the front lines, I find many in a reactive stance. When people feel overwhelmed, they go in to survival mode, with their immediate aim just to get through the day.  They find themselves prescribing medication because they have no other options.

From many I have heard some variation of this statement:  "In light of my inability to address the family dynamics and social-economic circumstances, all I have available is medications to help with the child’s symptoms. I see patients who come from unstable environments, where parents are themselves stressed and overwhelmed. I recognized that a child's “difficult,” “impulsive,” “oppositional” behavior is most often a communication about family, social, and economic stressors that are making a child's family less competent at caring for him. However, I lack the resources or the tools to do anything about these overwhelming issues. I hate that feeling of impotence.  So I use the only tool I have, medication. When I can bear to think about it, I recognized that medication is just shutting off the child's efforts to tell me something – in effect silencing his voice- and that I have become a force for social control."

When that child is in a school setting, with a high student-teacher ratio, perhaps also with teachers who have little experience working with kids from stressed family backgrounds who are struggling with emotional regulation, the pressure to control the child’s behavior increases significantly. It is not simply that schools have reduced unstructured time (though this is a problem as well.) Medication again becomes an agent of social control. Rather than devote the resources to address the underlying issues, we can use the medication, so effective in the short term, to silence the children.

Insel also does not address contemporary research demonstrating the developmental and relational nature of emotional and behavioral problems in children, well known within the discipline of infant mental health. Referring to "biomarkers" he seems to have an idea that one day we may be able to test for mental illness in children with a blood test or a brain scan.   The importance of safe, secure primary caregiving relationships in healthy emotional development is supported by an abundance of research in neuroscience, genetics, and developmental psychology, One cannot treat emotional and behavioral problems in children by treating only the child.

As knowledge about early childhood mental health makes its way in to mainstream health care, there have been calls for universal screening. But if we are using medication as an agent of social control, we need to be very careful not to put the cart before the horse. 

If we do not first have a health care system, and an education system, that has time and space to listen, to support parents, to appreciate the complex interplay of biological vulnerability and environmental stress, to understand the meaning of a child's behavior, what may happen is that the huge numbers of children who screen positive will have no meaningful, relationship-based treatment available (and the medication/talk therapy dichotomy is another oversimplification- there are multiple evidence-based interventions that support parent-child relationships.)  This together with universal preschool has the potential, unless there is significant change, to result in massive numbers of young children silenced by psychiatric medication.

I wonder if Dr. Insel is himself feeling overwhelmed. Perhaps he realizes that the increase in children with emotional and behavioral challenges, as well as medicating of these children, is a symptom of an enormous social problem. That problem is our society's undervaluing of children and parents, our failure to devote resources to support healthy growth and development, described by Elizabeth Young Breuhl as childism, or prejudice against children. He has good reason to feel overwhelmed with this realization, as it makes his task as director of the NIMH exponentially larger.