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, March 25, 2017

Did Mothers Save the Affordable Care Act?

In striking contrast to the happenings in the US congress on Thursday afternoon, Kate Middleton, future queen of England, spoke these words at London's Royal College of Obstetricians and Gynecologists on the occasion of a launch of educational films dealing with maternal mental health:
Nothing can really prepare you for you the sheer overwhelming experience of what it means to become a mother, It is full of complex emotions of joy, exhaustion, love and worry all mixed together. Your fundamental identity changes overnight. You go from thinking of yourself as primarily an individual, to suddenly being a mother, first and foremost.
Her normalization of the struggles of this transition, heightened by absence of the kind of support she acknowledges she, unlike many mothers, has in abundance, provided exactly what is needed to decrease stigma and shame. 

When after a tense day on Friday the House had to admit defeat and pull legislation to repeal the Affordable Care Act, it occurred to me that perhaps the late removal of 10 essential health benefits, including maternity and mental health care, done to appease the conservative Freedom Caucus, in fact contributed to the final demise of the American Health Care Act. 

Both maternity care and mental health care are exactly what we need in abundance to turn our country around. In his highly acclaimed book Hillbilly Elegy J.D. Vance comes to the conclusion that the problems afflicting the communities who feel unheard and unrecognized, and so voted in large numbers for President Trump, have their roots in Adverse Childhood Experiences

When parents feel heard and supported, they are available to be present with their children in a way that promotes healthy development, both physical and emotional. In contrast, when parents struggle- with things such as mental illness, substance abuse, marital conflict and domestic violence-it impacts upon their children's growing bodies and brains in ways that have long-term negative consequences. 

In my rural community in Western Massachusetts, we are bringing together clinicians who work with newborns and parents-including pediatricians, maternity nurses, early intervention specialists and home visitors- to insure that all babies and parents feel heard and supported from the moment of birth. An abundance of scientific evidence shows us that investment in the earliest days and weeks of life offers the greatest opportunity to promote development and prevent transmission of trauma to the next generation. 

I recognize that the politics are complicated. However, the idea that perhaps members of Congress, all of whom have mothers, could not bring themselves to vote against mothers in such an explicit way gives me hope. 

Perhaps we needed to come face-to-face with the importance of maternal and mental health care in a dramatic, high profile, and potentially dangerous way. Now that we are here, I am hopeful that momentum will move us forward to address this issue in ways that are broad and far-reaching. Kate Middleton, and her program Heads Together, serves as an excellent model.

Sunday, March 5, 2017

Rethinking Sensory Sensitivities: Why Music is Therapy

Towards the end of  our 2 day visit with neuroscientist Stephen Porges at the University of Massachusetts Boston Infant-Parent Mental Health program,  I asked about a young girl I treated a number of years ago with selective mutism.  Her parents described how during a large family gathering  she would shut down. But if they listened to classical music, she would join the gathering and begin to speak. This story, he replied, represents his theory in action.

In my 30 years practicing general and behavioral pediatrics and now specializing in early childhood mental health, I have increasingly come to recognize the central role of sensory processing in healthy emotional development. When I listen carefully to stories of parents, whether the child is 18 months, 5 years or even 17 years, with concerns ranging from a fussy baby, attention problems, behaviors associate with autism, anxiety, and explosive behavior, I invariably discover behaviors  suggestive of sensory processing sensitivities. A child could not ride in the car without screaming unless the same song was played over and over again. A visit to a butterfly museum ended in a meltdown as a child longed to have a butterfly land on his shirt but yet fell apart when it did. A newborn became completely disorganized and unable to feed when his father sneezed. These details I have collected over the years could fill several books.

Many have wondered about the central role of sensory processing in behaviors or "symptoms" we name as psychiatric disorders. Occupational therapy as a discipline has called for recognition of "Sensory Integration Disorder." Child psychiatrist Stanley Greenspan called attention to the way sensory  and affective experience are intimately intertwined.

In those two days, however, Stephen Porges fundamentally transformed my understanding of sensory processing and its role in emotional and behavioral disturbances.

The bones of the middle ear, it turns out, are a direct entry point, via the autonomic nervous system, to our social engagement system. He described how mammals are different from reptiles because two of these tiny bones are detached, allowing us to hear the low amplitude, high frequency sounds of the human voice.

Proper functioning of the middle ear muscles, along with the muscles of the face, particularly around the eyes, as well as the larynx that control intonation and prosody of voice, is essential for social engagement. When the way we take in sound is distorted, it disrupts the entire autonomic nervous system, interfering with this social engagement system.

Underlying this conceptualization is the Polyvagal Theory, founded on decades of detailed neurophysiology research. (The theory is very complex: I attempt to explain it more fully in my recently released book The Developmental Science of Early Childhood.)

Essentially Porges discovered that rather than the simple either-or of social engagement or fight flight, there is a third way that our body responds to the environment when we experience overwhelming threat. This response is under the influence of what he terms the "primitive vagus" and is closer in function to the reptilian brain.

When my patient with selective mutism listens to classical music, the sense of threat she is experiencing in the environment, that is paralyzing her social engagement system, subsides.

Porges has developed a model of treatment called The Safe and Sound Protocol, with body of evidence to support its efficacy in treating a range of difficulties. It is described as a "non-invasive intervention involves listening to music that has been processed specifically to retune the nervous system (regulating state) to introduce a sense of safety and the ability to socially engage."

Porges is calling on us to rethink static categories of "disorders" and rather to recognize the wide range of disturbances of emotion and behavior as distortions of the social engagement system via distortions in function of the autonomic nervous system. With this conceptualization, listening to music could be the primary treatment.

While Porges' theory and research resonate deeply with my clinical work, my profound understanding of his ideas actually comes from my son, who has given me permission to write about him. Sitting in a car in the parking lot with the windows closed while the rest of the family enjoyed fireworks, running in circles and not engaging with other children in preschool, gagging on foods other than the narrow range he could tolerate- these typical examples represent his early years. 

Unaware of Porges' theory, my son found his own treatment. In toy stores only the musical instruments interested him. At the age of 8 he took up the saxophone. His beautiful voice transformed to a deep bass in his adolescent years. Now in college, he performs regularly in two singing groups who are like second families.  Thriving academically,  his social engagement system is working. 

It is not often that someone comes along and profoundly alters the way we understand the world. In my view, Stephen Porges is one such person. 

Monday, January 16, 2017

Protesting Trump's Inauguration with Action: Baby Steps

While protests occur across the country in multiple forms around the inauguration, I will be ensconced at a 5-day Group Relations Conference. While perhaps what I write will come across as justification for my absence from these events, I see this activity as representing a protest of a different kind.

 I am attending the conference as part of my new job offering a range of supports in our local community for the parents of newborns aimed at fostering healthy relationships from the start of life.  

In these troubling times, in addition to gathering in large numbers to show our opposition to the many deeply concerning things our incoming president says and does, I hope that taking small steps every day to support human connection will promote positive change.  The following story from my behavioral pediatrics practice offers an example of one such baby step.

Bonnie's face, darkened by fatigue, communicated sadness bordering on despair. Living in poverty and alone in caring for her two-week-old daughter Jasmine after the baby's father abandoned them, she hobbled into my office, barely managing the weight of the sleeping infant bundled in her carrier. Bonnie slumped into a chair, unleashing a string of worries about her daughter's health and her precarious living situation. 

Referred to me by a wise colleague who saw the vulnerability in this pair, their needs seemed overwhelming as I sat quietly, thinking of how best to use our 50 minutes together. I suggested we see what Jasmine could tell us about herself. With Bonnie nodding her assent, I reached for my NBO toolkit.

Early in his work as a general pediatrician in the 1950s, T. Berry Brazelton, recipient of Obama's Presidential Citizen's Medal, observed the tremendous capacity of the newborn infant for complex communication. Research based on these observations led to development of the Neonatal Behavioral Assessment Scale (NBAS). The scale changed the way both child development experts and pediatricians understood babies. The Newborn Behavioral Observations System (NBO), a relationship-building tool that has as its core an opportunity for listening without judgment, is a clinical application of the NBAS developed by psychologist J. Kevin Nugent and colleagues. 
While Bonnie held the sleeping Jasmine in her arms, I performed what are referred to as the "habituation items" of the NBO. These examine a young infant's ability to protect sleep. When I shone a light in her face and she barely flinched, Bonnie proudly proclaimed, "She's a great sleeper."
Next we sat on the floor and, as Jasmine roused herself from a deep sleep, we described our observations about her movements. "She's so strong!" Bonnie exclaimed. Her mood shifted gradually as she saw how Jasmine supported her head while we held her in a sitting position, and then made rudimentary crawling movements when we placed her on her belly. (As always, I used this as an opportunity to counsel about having the baby sleep on her back.) 
By the time we moved on to the orienting items and observed how Jasmine turned to her mother's voice and followed a bright red ball, Bonnie was positively joyful. When she stood at the front desk to schedule a follow up appointment, her transformed mood seemed contagious as office staff and other waiting families admired Jasmine and shared in Bonnie's exuberance. 
The poverty, isolation, and stress plaguing this mother-baby pair remain. Addressing these problems will take both time and broad social change. But in light of the 700 new connections per second a newborn brain makes in the context of caregiving relationships, these 50 minutes could hold great significance.
I see this visit as a kind of metaphor. In parallel with large-scale vigilant attention to the actions of the incoming administration, we must also value taking even the smallest actions every day against forces of hate and intolerance, moving our world in the direction of love and human connection. 

Sunday, December 4, 2016

Can We Restore Empathy and Heal Our Country by Listening to Babies and Parents?

In his extraordinary new book Hillbilly Elegy, J.D. Vance generously offers his personal story to help us gain insight into why so many people in our country feel unheard and left out. When I was about two thirds of the way through the book, in conversation with my millennial daughter, I said that it seemed there was a kind of intergenerational transmission of trauma, with magnified effects in each successive generation who experienced domestic violence, substance abuse, and other forms of developmental disruption.

Thus I was surprised when later that day I got to the end of the book and found Vance came to a similar conclusion. He references the Adverse Childhood Experiences (ACE) study. I describe the study in my forthcoming book where I show how these experiences get into the body and brain (and how to help when they do.)
The ACE study provides abundant evidence of the long-term effects of early exposure to a range of negative experience, including not only abuse and neglect but also parental mental illness, substance abuse, divorce, and domestic violence.
The effects are far-reaching, with significant increase in not only mental and physical illness, but also teen pregnancy, incarceration and other social problems. Vance writes:
ACEs happen everywhere, in every community. But studies have shown that ACEs are far more common in my corner of the demographic world.
Referring to people’s wish for a “magical public policy solution,” Vance offers a number of suggestions about how to address this problem. While he feels that there is no one solution, he recognizes that the problem has its origin in homes and in families.

Coincidentally, the day before I finished the book I had participated in an extraordinary meeting via Zoom with researchers from all over the world who are studying the effects of the Newborn Behavioral Observations (NBO) System, which offers one possible solution. It is a brief intervention designed to listen to baby and parents together.

The first days after the birth of a baby, when both a mother and father’s brain are bathed in oxytocin, present an opportune moment for intervention. The newborn’s brain makes as many as 700 connections per second as he or she learns to adapt to the outside world. During this period new identities as parents take shape and relationships are transformed.

At the meeting I “met” a colleague from Australia, Susan Nicolson, who has succeeded in implementing this intervention at a hospital with 8,000 deliveries a year. In an article she describes this process. Prior to presenting their idea to the hospital board, they had conducted a small study with teen mothers using a brief intervention with elements of the NBO added to routine hospital maternity care. 

The study showed significant differences in the way these mothers interacted with their babies, with more positive engagement and joyful play. The intervention seemed to open their minds to being curious about their baby’s experience. This stance of curiosity has been demonstrated in extensive research to be associated with emotional regulation, flexible thinking, empathy, and overall mental health.

They shared their findings at the hospital board meeting. Nicolson writes:
With the consent of a small number of study participants, some video snippets of mother–infant interaction were shown to board members at that meeting. The videos of young mothers and their babies interacting with each other at home proved as much of a call to action as the study findings did. As one board member put it, “We don’t usually see what happens to families after we help them get through pregnancy and birth safely. I was so moved, I had to ring my mother and talk about it.”
Nicolson offers a public health perspective on her work, suggesting that universal integration of the NBO would support parent-infant relationships in a way similar to the World Health Organization/UNICEF-accredited “Baby-Friendly” hospitals support of breastfeeding.

A growing body of evidence from NBO research worldwide suggests that large scale implementation could have a significant impact on postpartum depression, parenting stress, and a range of other factors that have potential to derail healthy development.

In our small rural community in western MA, we plan to train a range of people who interface with infants and parents in the NBO, including maternity nurses, home visitors, pediatricians and early intervention workers. Our hope is to build a model that can be applied to rural communities throughout our country.

So how does this idea related to the problem Vance identifies? Broad swaths of our population do not feel heard. Our current political climate suggests that we are all having difficulty listening to each other. While clearly other supports would need to follow in its wake, starting all lives with 30 minutes of focused attention on listening might just be the thing that helps lead us on a path to healing. 


Monday, October 31, 2016

New AAP Sleep Guidelines, The Baby Box, and Questions Raised

In a tweet about the new sleep guidelines recently released by the American Academy of Pediatrics, a wise colleague in Scotland Suzanne Zeedyk asked, "How do we support parents without terrifying them?"

The evidence for "back to sleep" recommendations issued in the early 1990's was unequivocal; following the guidelines the rate of SIDS (sudden infant death syndrome) plummeted a dramatic 50%.   However, following the initial decline, the rate of SIDS has plateaued, leading the AAP to revisit sleep recommendations.

In a thorough document the AAP references the evidence for its  extensive (19 items) list of recommendations. There are two recommendations that I wish to explore in detail.

 It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface designed for infants, ideally for the first year of life, but at least for the first 6 months.

Communities around the world are taking the lead of Finland, where the Baby Box has been issued to all families on the birth of a baby for over 75 years, a practice that led to a dramatic decrease in infant mortality, and is now embedded in a societal support for parents and children that extends well beyond the newborn period.  In my community in Western Massachusetts, Berkshire Baby Box is launching among the first countywide distributions of the box in the United States.

The box fits seamlessly with the new recommendations. With the firm mattress, fitted sheets and portability, the box allows families to follow these recommendations with ease. 

As a specialist in infant mental health, I well recognize the central role of sleep, both for parent and child, in healthy development. I work with many families where infants'  frequent night waking exacerbates parental depression and marital conflict, two factors known to have negative long-term effects on both mental and physical health. In these families, teaching a baby to sleep independently has been a lifesaver. 

In many American families both parents work and lack extended family for support. In such situations the natural frequent night waking of a baby who relies on a parent to fall asleep can place extreme stress on a family, negatively impacting relationships between parents and with older siblings. 

As I have written in all of my books, teaching independent sleep should never be done under the age of 4 months, the age at which most infants acquire the developmental capacity to self-soothe. However, I am concerned that the AAP recommendations, taken out of context, for a baby to sleep in the parents’ room for 6-12 months, will complicate these situations significantly. This issue is intimately intertwined with the second recommendation I wish to address:

Keep soft objects and loose bedding away from the infant’s sleep area to reduce the risk of SIDS, suffocation, entrapment, and strangulation.

My concern here is with the "soft objects."

In 1953, D.W. Winnicott published his paper Transitional Objects and Transitional Phenomena in which he described, from his perspective as both pediatrician and psychoanalyst,  the significance of what many parents term  "lovey," or that particular soft object that has a seemingly magical power to comfort a young child. When my children were 4 months old, I bought them each a pair of puffalumps. These small soft lightweight animals immediately took on the role of transitional objects, comforting both children through many a challenge over the years, even making their way to college with my daughter. I learned that Fisher Price made a new line of large ones (the original were 8"-10") in 2006 that were subsequently discontinued. This is unfortunate in my view. When I speak with new parents, I recommend that when an infant turns 4 months, they introduce a small soft toy that does not pose any suffocation risk, that can serve as this transitional object. I recommend getting two so that one at a time can go in the wash, and in case one is lost.

This object is intimately intertwined with the issue not only of separate sleeping but also the way our culture places value on separateness and independence, a view that is in many ways unique to western culture. We value our children's independence and self-reliance. Sleeping independently is often the first of many such transitions in a typical American child's life. The transitional object can play a very important role in this process.

It may be that a change in this view is indicated. Perhaps we would find, as these recommendations are put in place, if they go together with national distribution of baby boxes, and the full range of government support given to families in countries like Finland, we would continue to see a decline in SIDS.

But the risk is that without attention to the social and cultural realities of raising children in a country that does not offer paid parental leave, does not invest in quality child care, and in general does not significantly support parents or children, these recommendations may leave parents in a difficult or even untenable bind.

The guidelines clearly ask that pediatricians to fall in line.

Health care professionals, staff in newborn nurseries and NICUs, and childcare providers should endorse and model the SIDS risk-reduction recommendations from birth

The guidelines do state: "Health care providers are encouraged to have open and nonjudgmental conversations with families about their sleep practices." However, the above recommendation makes me uneasy about what I hope is thoughtful questioning.  My anxiety, perhaps a mirror image of parental anxiety, leads me to add: Babies are to be put to sleep on their back. Smoking and bed sharing, as well as co-sleeping on a couch, are unequivocally to be avoided.

I feel pressure to have certainty on the subject.  I wonder if most parents and professionals feel the same pressure. Perhaps this wish for certainty is an inherent part of parental love. As I write in my recent book, The Silenced Child:

"When we become parents, we have the opportunity to open our hearts to a love unlike any other. But in opening ourselves to this love, we become vulnerable to loss. Loss is an inevitable part of parenting. That simple step of putting a baby to bed for the first time in his own room is full of poignancy. It is the first of many losses as our children grow up. The first day of kindergarten, going off to college, and all the many small steps toward becoming a separate, independent individual are mixed with ambivalence and loss for both parent and child. And though the idea is mostly out of our conscious awareness, in becoming parents we make ourselves vulnerable to an unlikely but real possibility of unbearable loss." 

Perhaps the 19 guidelines help to empower us, to assuage our feelings of helplessness in the face of this unthinkable possibility. 

Sleep is central to our emotional and physical well being. It represents complex issues around separation and independence that are inextricably linked with social and cultural support of parents and children.  I am hopeful that as these guidelines are implemented, we make room for discussion of these important and profound questions. They have bearing on the future of our children, and of our society as a whole.