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.

Saturday, November 22, 2014

Lessons from Adam Lanza: Listen Early and Listen Well

The just released report, Shooting at Sandy Hook Elementary School, from Connecticut's Office of the Child Advocate offers a searing account of the holes in our mental health care system. The report is careful to point out that no causative link exists between their findings and the events at Sandy Hook. However, this in-depth investigation offers an opportunity, if we are able to hear and take action on its recommendations, to begin to fix a system that without significant attention may lead to an ever growing epidemic of serious mental illness.

I highlight 4 key points addressed in the 114-page report:

1) Early means early.

When significant problems in social-emotional development are identified, the greatest investment of resources ideally should come well before age three. In this time period, when the brain is rapidly growing and changing,  opportunity exists to set development on a healthier path. The report states:
A review of information regarding AL’s early years with his family does not reveal any profound tragedies or traumas. However, records clearly indicate the presence of developmental challenges and opportunities to maximize therapeutic and intensive early intervention. These observations underscore the importance of parental and pediatric vigilance regarding children’s developmental well-being. AL was referred for early intervention late in his toddler years, when he was almost three. By this time, he presented with several developmental challenges, including significant speech and language delays, sensory integration challenges, motor difficulties, and perseverative behaviors.
I would also like to highlight the report's important statement:" Research-based intervention to support improved sensory processing through occupational therapy is a critical service for these children."

2) The problem is located not exclusively in the child, but in parent-child relationships.

The report describes significant ongoing marital conflict, with Adam's father described as a "weekend father" who was not involved in the emotional lives of his children. There is evidence that Adam's mother might have had significant emotional illness. She was preoccupied with her own health and mortality despite the fact that her doctors reports do not show signs of physical illness.  While these findings do not represent " profound tragedies or traumas," the story is one of a biologically vulnerable child with two parents preoccupied and emotionally unavailable.

When a problem is placed squarely in a child,  the relational nature of these problems may be missed. Perhaps by addressing the issues in the marriage and the mother's mental health, room could have been made in their minds for thinking about the meaning of Adam's increasingly disturbed behavior.

3) Need for collaborative care with adequate reimbursement. The report states:
Pediatricians’ offices must have resources to conduct comprehensive and ongoing
developmental and behavioral health screening for youth, with appropriate reimbursement strategies to support this work.
 Children and their families should have access to quality care coordination, often reserved only for children with complex medical needs, but beneficial for children with developmental challenges and mental health concerns. Care coordination should facilitate more effective information-sharing between medical, community, and educational providers.
When people are stressed and vulnerable, they will share what is important only when they feel safe. Parents may experience terrible shame in the face of a child who is struggling and a marriage that is collapsing. Clinicians need to be reimbursed for time spent listening to parents. Time spent in coordination of care, a critical part of comprehensive treatment, also should be reimbursed.

4) Listening, not placing blame, will lead to meaningful change.

The report concludes by emphasizing that it "in no way blames parents, educators or mental health professionals for AL's heinous acts." I remain hopeful that blame can stay out of the conversation. Already media coverage has focused on the one adversarial aspect of the report that suggests the school "appeased" his mother, perhaps because she was white and wealthy.

All the accumulated evidence points to extreme suffering in the Lanza home over many years; suffering that went unheard and unrecognized. Blaming the school or the mother is not only unhelpful but also diverts attention from the critically important recommendations in this report.

 We are in the midst of an epidemic of violence and mental illness. The recommendations, particularly those I have outlined above, may offer a way off that path. I hope that those in a position to effect these changes will be open to listening. If this comprehensive report can be used to make substantive changes in the education, health care and mental health care systems, then some meaning may be found in the senseless, tragic loss of life at Sandy Hook.

Tuesday, November 11, 2014

ADHD: The Role of Curiosity

3-year-old Cara smiles impishly in to the camera.” You see she’s standing on the kitchen table,” her proud yet concerned grandmother, my dental hygienist, Anne, says to me. She explains that Cara was standing on the table because she never listens, and runs away when her mother tries to take her picture.

She knows that I am a pediatrician and “expert” in behavior problems, so, after showing me the picture, as she cleans my teeth she shares with me that her granddaughter might have ADHD. “She won’t sit in the circle with the other kids for the whole story time. They’ve started an evaluation.”

I nod in shared concern while she works on my teeth, and she goes on. She’s known me for many years, so the conversation flows easily. “It’s hard,” she says, “because Mindy (her daughter) just broke up with her boyfriend. “So she’s a single Mom, “ I say after a rinse. “Yes, and she works nights and lets Cara stay up til 11 so she can be with her.” At the next pause I comment, “So Cara must be tired in school. That can lead to problems of attention.” As Cara’s grandmother resumes her work on my mouth, she agrees. Then she goes on to explain that Cara is the youngest in her class of mostly 4-year-olds.  She begins to wonder if all of these things she is telling me might be related to the problems Cara is having in school. Her tone shifts.

“She’s just so engaged and curious,” Anne explains. “Maybe we need to channel that energy and help her to find ways to use it in a positive way.” Then she reflects, “Actually Mindy was like that as a child. She was so smart that she got bored in class and sometimes got in to trouble. But after some struggles during those years she found her way.” She tells me that Mindy is passionate about her work as a neonatal nurse.

During my visit I feel a shift in Anne’s thinking. Simply by talking with me, a captive audience with whom she has a longstanding relationship, she goes from describing her granddaughter in terms of “disorders” and “evaluations” to a stance of curiosity.

As we both stand to schedule our next appointment, Anne again looks at the impish face of her granddaughter, trapped on the kitchen table. She sees the picture, cute as it is, as a kind of sign that things may feel out-of-control for Cara. She even begins to wonder if her daughter is too stressed, and perhaps needs more help from her. Maybe, she says, if Mindy had a bit of time to herself, she could be more patient with Cara. She decides to offer her daughter a day of babysitting.

Recent statistics indicate that diagnosis of ADHD has increased 42% in the past 8 years. 3-year-old Cara might be on her way to joining that statistic. I am hopeful that the system of care will offer space and time to listen to the whole story. When her grandmother was able to wonder about the meaning of that photo, Cara’s communication, in the form of behavior, was understood. Being heard and recognized in this way gives Cara the opportunity to become not another statistic, but instead to develop in to her own true self.

Monday, October 27, 2014

Childhood Anxiety: Treating the "What" Rather Than the "Why"

Recently, while studying for my recertification exam as required by the American Board of Pediatrics, using the PREP course offered by the American Academy of Pediatrics, I came across this question:
     A 7-year-old girl is having difficulty establishing relationships with other children despite repeated opportunities to do so. The girl prefers to stay near her mother or her teacher and will avoid other children. She sometimes cries and can be difficult to calm down after being dropped off at school, so her mother frequently remains in the classroom for a few minutes before quietly leaving. On days when morning transitions to school are significantly difficult, her mother will allow her to stay home. Her mother reports that, in preschool, things were worse in that she usually "couldn't" leave her daughter in the classroom. The girl typically speaks little when in public, but she speaks normally when home alone with her mother. She is an only child and the parents are divorced. When the girl spends the weekend at her father’s house, she often expresses worry that something bad is going to happen to her mother. Her mother frequently allows the girl to sleep with her to avoid temper tantrums or nightmares about sleeping alone. Of the following, the BEST next step in this child’s care is  
       A.   Initiate treatment with an SSRI (selective serotonin reuptake inhibitor)
B.   Reassure her mother that her daughter’s problems should resolve without intervention
C.   Refer for neuropsychological evaluation to assess for cognitive impairments
D.   Refer her to a cognitive behavior therapist to work on skills for managing her distress
E.    Refer her to a play therapist to assist the child in recognizing the cause of her distress 
The “correct” answer is D- refer her to a mental health specialist to initiate cognitive behavioral therapy (CBT). Medication is suggested as a second line of intervention if CBT is not effective. In other words change her behavior, but do not offer opportunity to discover the cause. Play therapy, the only alternative form of therapy suggested, leaves it up to the child and therapist to discover the cause.

What might be the cause of her anxiety? Is her mother depressed? Her father? Is there substance abuse in either parent? Did she observe conflict, perhaps even violence, between her parents in the years preceding their divorce? Is there a family history suggesting a genetic vulnerability for anxiety? Does she have sensory processing challenges that cause her to be overwhelmed in the stimulating classroom? Some combination of all of these?

One child I saw with such symptoms had a mother who lay in bed all day in the wake of a pregnancy loss. This child was terrified that something would happen to her mother while she was in school. 

Perhaps this child’s mother had similar struggles with anxiety as a child. But rather than being met with understanding, she received a slap across the face. She may be terrified that her daughter will suffer as she did. If she is flooded with stress in the face of her daughter’s behavior, she might, without thinking, lash out. Or more likely, as her maternal instinct to protect her child overrides a rage response, she might shut down emotionally. Either way, her child will be alone with these difficult feelings. 

I took care of one child who had been diagnosed with anxiety disorder by her previous pediatrician and came to me to get her prescription refilled. After several hour long visits, some with her alone and some with her mother, I learned that every weekend her father drank heavily, leaving her at the age of eight to care for her two younger brothers.  

Where in the treatment plan recommended by the AAP is there opportunity to uncover such a story? Parents may experience terrible shame about their own behavior. Taking a history, in one visit, that reveals "no psychosocial stressors" is inadequate. Parents share this kind of information when they feel safe. Safety comes in the setting of time and space for nonjudgmental listening.  

One much-cited study compared CBT, SSRI, the two in combination, or placebo. No treatment arm existed for listening to the parent, for discovering the meaning of the behavior.

This child’s behavior is a form of communication. Behavior management, and the close second of medication, serves to silence that communication. When we teach a child skills to manage behavior, the story may be buried, emerging years later, sometimes in the form of serious mental illness

When parents can make sense of a child's behavior,  they are in an ideal position to support that child in managing his or her unique vulnerabilities. In a way, parents are best suited to provide a kind of cognitive behavioral therapy. They can help a child to name feelings,  identify provocative situations and develop strategies to manage these experiences.

By bringing in to awareness the way a child's behavior may provoke their own difficult feelings, and in a sense moving these feelings out of the way, parents can be fully emotionally present with a child in a way that supports healthy emotional development.

When a child is young, there is opportunity to offer support for parents and children together and so alter a child’s developmental path. But when, rather than supporting parent-child relationships, we treat the problem as residing exclusively in the child,  such opportunities are missed.

Friday, October 10, 2014

The Time-Out Wars: A Case for Curiosity

Dan Siegel's new book No-Drama Discipline is calling attention to our innate need for connection. In his Time magazine piece provocatively titled Time-Outs Are Hurting Your Child he writes:
The problem is, children have a profound need for connection. Decades of research in attachment demonstrate that particularly in times of distress, we need to be near and be soothed by the people who care for us. But when children lose emotional control, parents often put them in their room or by themselves in the “naughty chair,” meaning that in this moment of emotional distress they have to suffer alone. 
Not surprisingly, his views are causing significant backlash from the pediatric community. This is from the Journal of Developmental and Behavioral Pediatrics
TIME magazine recently highlighted an editorial by Drs. Daniel J. Siegel and Tina Payne Bryson in their parenting section. In it, the authors claim that the time-honored tradition of time-out for discipline may actually be harming our children as a form of traumatizing experience. This has caused a wave of black lash from the behavioral health community, who retort that Drs. Siegel and Payne Bryson's claims are not only unsupported by research, but show a lack of understanding of proper use of time-out.
Extreme views generate publicity and lots of “hits” A more nuanced view is less popular in social media, as evidenced by this wise blog post on Psychology Today that got a meager 25 tweets:
To me, “time-ins” don’t solve it. But the concept does expose a nuance of giving time-outs that we don’t talk about enough. Namely, there’s a massive difference between giving your child a time out in anger and giving your child a time out in a loving, calm way. Too often we apply the technique, but not the spirit of technique. Time-outs are meant to deescalate a volatile situation and to help our children regain control, as much as they are to provide a consequence for unruly behavior.
The essence of Dan Siegel’s point is not to leave a child alone with out-of-control feelings. It is not the time out per se but rather the sense of abandonment that is potentially harmful. I articulate this point in a previous post entitled Never Leave a Child Alone During a Meltdown.
When a child is repeatedly abandoned both physically and emotionally in the middle of a meltdown, that experience in itself may be traumatic. In such a situation frequency and intensity of meltdowns often worsens.
A recent American Academy of Pediatrics document Bringing Out the Best in Your Child makes the important distinction between discipline, which means to teach, and punishment, which is rarely effective in changing behavior in a positive way. For young children, a matter-of-fact time out in the face of biting or hitting can help to teach them that this behavior is unacceptable. The shortcoming of this document is that it is very focused on the behavior, rather than the meaning of the behavior.

Taking time to listen to our child, and to take care of ourselves, is key. Rather than an either-or approach, a stance of wondering, of curiosity, will lead to the answer of “what to do.” We might ask the question, why is my child feeling out-of-control? Is he stressed from fatigue or hunger? Is he responding to tension in the home from marital conflict, a new sibling, or a parent’s new job with long hours? And what about my child’s behavior is provoking such anger, anxiety or some other intense response in me? Is it my fear that he will suffer as I did as a child with similar challenges? Is it my embarrassment, or even worse, shame, that I am not a good parent? Am I feeling alone and abandoned myself, by a spouse or parent, and so unable to tolerate my child’s need for me? When parents feel recognized and understood, they are better able to listen to their child. They are better able to connect with their natural intuition. They know "what to do."

Our ability to find meaning in behavior is essential to our humanity. Listening, being present in a way that supports connection, leads to healthy development. It is not so much about “what to do” as “how to be.” We are a culture of advice and quick fixes. Dr. Siegel's book is rich with important information and ideas. However, perhaps rather than spending precious free time reading another "how-to" parenting guide, taking a walk with a friend or going to a yoga class might be a better use of parents' all-too-limited time for themselves.

Thursday, October 9, 2014

Antipsychotics for ADHD: A Big Unknown

Polypharmacy, or use of multiple psychiatric drugs, for treatment of Attention Deficit Hyperactivity Disorder(ADHD) is on the rise. A recent study compared treatment with "basic therapy"-stimulants plus parent training- with "augmented therapy" those two plus risperidone, an atypical antipsychotic. The study concluded that treatment with risperidone was "superior." 

When children show dramatic improvements in behavior on risperidone, now being prescribed with increasing frequency for ADHD and a range of other disorders that represent difficulty with emotional regulation, we need to ask ourselves one question. Does this change in behavior represent increased capacity for organization and self-regulation, or does it reflect a kind of compliance?

We have over 40 years of longitudinal research in developmental psychology showing that safe, secure relationships support development of the capacity for emotional regulation, cognitive resourcefulness and social adaptation. We have evidence from the field of epigenetics that these relationships, through changes to gene expression, change the structure and function of the brain.
Top of Form
Bottom of Form
When children struggle with emotional and behavioral regulation, many evidence-based interventions can support development of these capacities. These include child-parent psychotherapy, DIR floortime, the Neurosequential Model of Therapeutics, and mentalization based treatment.  These relationship-based interventions foster our innate need for connection.

The mechanism of action of risperidone is to block dopamine receptors in the cortex. We do not know what changes in the lower regulatory centers of the brain, if any, are occurring. It is possible that these centers remain dysregulated, and that this dysregulated signal is blocked by the medication. The antipsychotic might promote compliance, with improvement in behavior, but the underlying disorganization might remain. If that is the case, then the medication is not changing the brain in the way that we know relationships can change the brain.

This is an important question to answer. It goes well beyond the known significant side effects of antipsychotics. For when medication is so effective at controlling behavior, the motivation for investing time and effort in relationship-based interventions may be lost. Prescribing medication takes much less time. With atypical antipsychotics the results are often immediate, and can be dramatic.

If risperidone is found to significantly alter the brain’s capacity for emotional regulation, then it might have a role to play. But if it does not, and we have well-established methods of intervention that do, then the possibility exists that by prescribing this medication to children, particularly in the absence of relationship-based interventions, we are actively interfering in their development. 

I am hopeful that all professionals who strive to promote healthy development in children can work to answer this question in a timely manner.

Sunday, September 28, 2014

Days of Awe and the Certainty of Neuroscience

Just like the digital codes of replicating life held within DNA, the brain's fundamental secret will be laid open one day. But even when it has, the wonder will remain, that mere wet stuff can make this bright inward cinema of thought, of sight and sound and touch bound into a vivid illusion of instantaneous present, with a self, another brightly wrought illusion, hovering like a ghost at its centre. Could it ever be explained, how matter becomes conscious?
The actual words written by Ian McEwan, in his novel Saturday about a day in the life of a neurosurgeon, are worthy of awe of the human mind. In a recent blog post I referred to a piece by psychologist Gary Marcus in which he calls attention to "the trouble with brain science." Perhaps inspired by this very piece of writing, he refers to the lack of a bridge between neuroscience and psychology comparable to the bridge between genetics and living beings that discovery of the double helix provided.

I describe how absence of this bridge is the problem inherent in the oft-used comparison between depression, or ADHD, and diabetes. NIMH director Thomas Insel has called for a study of the neuroscience of mental illness in the same way we study cancer, food allergies, and diabetes.

Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. For the pancreas, there is no corresponding mind in the realm of thoughts and feelings. The pancreas does not love, does not grieve, does not produce great literature.

This wish to compare psychological experience to physical illness ostensibly comes from a wish to destigmatize emotional suffering. But in fact it may have the opposite effect, as it devalues the  human relationships. It is an effort to apply certainty to situations ripe with uncertainty.

There is a dark side to the certainty of neuroscience. Years ago I treated a young girl, Charlotte, who had been diagnosed with ADHD by a previous doctor.  I took over her care, following the standard practice in pediatrics for visits every 3 months for review of "symptoms" of hyperactivity and inattention and adjustment of medications. When she continued to struggle, her parents paid a large sum of money to have a brain scan done by a doctor who claimed to identify the exact location of her problem. Despite the alleged certainty of these results, her "symptoms" continued. I referred the family to a therapist, but lost touch with them when I left that practice.

Recently I learned from her mother, Jennifer, when I ran in to her on the street, that she was doing much better. "I know why," she told me. She had hidden from me, and from herself, that all along Charlotte's stepfather had been physically and emotionally abusing her. Only now, with this story brought to light, could she begin to heal.

Missing from treatment of this girl was not knowledge of brain science, but time for listening.  In 30-minute visits every three months, with Charlotte and Jennifer together in the room, neither she nor her mother felt safe enough to share what was really going on.

The week between Rosh Hashannah, the days of Awe, and Yom Kippur, the day of Atonement, seems an appropriate occasion for contemplating these issues. It offers an opportunity for awe at the wonder of the human mind. It might also offer opportunity to atone for not listening to children like Charlotte. When we make diagnoses, and use brain scans to verify them, we may miss the complexity of human experience. The essence of being human is the ability to find meaning in behavior. I hope that going forward, we can protect space and time to listen, to discover that meaning. We are not likely to find it on a brain scan.

Tuesday, September 9, 2014

Postpartum Mental Illness: Ability to Soothe Baby Helps Mothers Most

Fascinating research at the Yale School of Medicine shows that in poor families who are under-resourced and overburdened (a more meaningful phrase replacing "high-risk,") "diaper need" or lack of reliable access to clean diapers, is the factor that most impacts on mothers' mental health. In a study published in Pediatrics, lead researcher Megan Smith found that 30% of mothers living in poverty report diaper need.

When mothers were worried about when they would be able to get the next diaper, self esteem was diminished in the face of their inability to soothe their baby, in turn negatively impacting their relationship with their baby, setting the stage for a downward spiral.

One take home message of this research is the importance of providing clean diapers. The National Diaper Bank Network, along with many local organizations, is making efforts to meet this significant need.

A second broader implication is the remarkable finding of how much the baby's well being impacts on the mother's mental health.

The converse of the finding that diaper need negatively impacts a mother's mental health, is that reliable access to clean diapers can improve a mother's mental health.

Generalizing this observation to a broader population of mothers with mental illness, the ability to soothe a baby, to take care of a baby's basic needs, may be integral to that mother's emotional well being. For that reason, the baby's behavior, including excessive crying, feeding issues, sleep issues should be an integral part of treatment of postpartum mental illness.

Traditionally treatment of postpartum depression focuses on the mother, often in the form of medication, but also support groups and psychotherapy. The baby's behavior is addressed separately, usually by a pediatrician. Innovative programs such as the Infant Behavior, Cry and Sleep clinic in Rhode Island explore the relational nature of these problems.

In a recent talk at the Austen Riggs Center Smith described a brochure addressing the question that many mothers ask- how can I prevent my baby from experiencing the effects of mental illness? Much of Smith's audience laughed at the brochures recommendations: "establish good relationships," reduce conflict," help with anxiety."

For families struggling to obtain life's basic necessities, these suggestions are laughable but certainly not funny. But for any family where a mother is struggling with mental illness, these goals may be unattainable without significant help.

In the new MCPAP for Moms program, a statewide initiative to improve identification and treatment for mothers who are struggling with perinatal emotional complications, efforts are being made to incorporate treatment of the mother and infant together.  Supporting a mother's efforts to effectively soothe and feed her baby by helping her to make sense of her baby's unique qualities and communications, is an integral part of preventing the negative impact of maternal mental illness on child development. A positive cycle of interaction can be set in place. This innovative research on diaper need offers evidence for the wisdom of this direction.