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.

Tuesday, December 28, 2010

A Baby's Intuition

2-month old Max sat comfortably on his mother's lap and intently studied his hand. "He discovered them a few weeks ago. He's working hard to get his thumb in his mouth," Ellen told me." Ah ooh," Max cooed to me when I smiled at him and commented on his new skill. "He's talking a lot too," Ellen said proudly. We wore huge grins of delight with Max's obvious talents.

Our visit three weeks earlier, in contrast, was painful and difficult. Max slept the whole time, but Ellen wept as she spoke of debilitating anxiety and periods of inexplicable sadness. "I sometimes feel so lost, she had said." We spoke about her strained relationship with her husband, John. She described an intrusive ever present mother-in-law who always managed to make her feel bad. Arguments between her and John were escalating. She felt increasingly that he didn't support her when she was overwhelmed. I was worried about the degree of her emotional distress, and asked if she wanted the name of a therapist to talk with about her sadness and anxiety. She said yes. I gave her some names, and also made a follow up visit to see her with the baby.

Ellen hadn't called the therapist, and explained that she was having longer periods where she felt better. Max was becoming such a delight that he was pulling her along. "I have three or four good days, but then the bad feelings return." I followed Ellen's lead, focusing on all the positive changes she had made. She was learning to take care of herself and was excitedly thinking about going back to work. As she described these good feelings, Max's little body was relaxed and content in her arms. After the trauma of the last visit, she seemed to delight in telling me the good parts. I wanted to give her the space, yet wondered to myself if the anxiety had indeed passed.

Then in the middle of telling me about the holiday it happened. She started calmly enough to describe a visit to her in-laws. But quickly her distress escalated. Her voice became tense, her face contorted with anger. I tried to follow the details of the story, but noticed that Max had begun to squirm on Ellen's lap. He pushed his head back and his legs extended. She distractedly held him up against her shoulder, increasingly agitated by her rage at her husband's behavior. But Max would not be calmed, and soon his fussing escalated to an all out cry. I sensed that Ellen was asking me to validate her position in the argument with her husband. But this was not my role, and I took a different approach.

"This anger you experience seems to be making you feel bad." She paused. "Yes-I'm really a nice person and I don't like to feel so mean." "I bet if I took your blood pressure right now it would be sky high." She readily agreed. As she shifted her focus from her rage, Max's fussing decreased. Ever mindful of not wanting to make her feel blamed, I commented on how Max was reacting to her mood. Fortunately she did not respond defensively, but rather observed, "He's very intuitive. He can tell exactly what I'm feeling."

Extensive literature, much of which I have discussed on this blog, describes the negative effects of a mother's depression and anxiety on a baby's development. My visits with Max an Ellen offer a close up snapshot of what this can look like and what might be done to help.

Elizabeth Meins, PhD and colleagues have shown in their research that a mother's capacity to think about her baby's mind is a associated with secure attachment. Secure attachment, in turn, is linked to many positive outcomes including emotional regulation, cognitive resourcefulness and social adaptation. Ellen's noting of her son's intuitiveness represents a perfect example of thinking about her baby's mind. She showed a non-defensive willingness to reflect on his experience. She could think about what might be going on in is 2-month-old mind when her anxiety took over.

Ed Tronick,PhD and colleagues have shown that if parents and infants are attuned 30% of the time, but disruptions occur in up to 70% of interactions, as long as most of these disruptions are recognized and repaired, development proceeds in a healthy direction. Ellen was able to repair the disruption caused by her momentary agitation, and to help Max to calm down.

Ellen, Max and I will meet again in a few weeks. Perhaps Ellen will need more intensive treatment for depression and anxiety. She still has the number of the therapist. Perhaps she and John will need support for their marriage. But I feel hopeful about Max and Ellen. She has seen how Max thrives when she is feeling good. This knowledge I believe, will motivate her to take care of herself so that she can continue to be emotionally available for Max in the way he needs and loves.

Sunday, December 19, 2010

Promoting children's healthy development: An inspirational poem

Below is a poem written and read by Chris Corrigan at the conclusion of a conference entitled "Applying the Science of Early Childhood Development to State Policy and Practice: a Case for Action and a Call for Innovation." The still face refers to Dr.Ed Tronick's paradigm that he articulates and demonstrates in this three minute video. The ACE in the poem refers to Adverse Childhood Events.

No more still face
a poetic harvest of the conference on science and early learning

by Chris Corrigan

November 4, 2010
Seattle, WA

Face it – relationships
language and emotion
700 synapses
babies are an ocean of potential for growth.
Reach out -
read and react
serve and return
the simplest skills for any parent to learn
ACEs are wild
don't poker face that child
ACEs are wild
don't poker face that child.

We need traction for action
no more funding for reactions
but positive interventions
systemic reinvention
health promotion and prevention
well placed intention.

Founders and funders
get this under your skin
When society is the still face
we create the ACE
When society is the still face
we create the ACE

So what do we do?

We partner early and often
And surely that softens
the hard blows of a cold world
a banner unfurled
a revolution of solutions
of iLabs and Head Start
exposure to the reading arts
bring parents together
to talk and train each other
raise kids in community
and pursue a unity of purpose
and hope and inspiration
for this nation can be
the demonstration project of population in relation
and information dissemination.

For a world of compassion
can fashion its future
synapse by synapse
and not relapse into a state
of comatose siloitis.

Because you know what?
We are the ACE
when society is the still face
we are the ACE
when society is the still face.

So let's get on the continuum
and at a minimum
shout out for Thrive by Five
Bring partnerships to life
Reach out and read
Everywhere plant seeds
Base policy on science
increase community self-reliance
reach parents where they are
at home and in their cars
at salons in Central Park
on the streets after dark
supporting healthy choices
hearing a diversity of voices.

Bring it to schools
deposit all the tools that every family needs
common methods that lead us
to children at the center
parents as mentors
resilience enters through doors
pried open by relationships
the community is the trajectory
the way to connectivity
caf├ęs and conversation and new forms of evaluation
spark the realization
that T.X.T 4 B.A.B
Educare, P3 and all the rest we see
is about relationality.

Fusion makes change
the core is rearranged
fusion makes change
the core is rearranged

So people in this State
we can no longer wait for fate to have its day
here are the ways
we get traction for action:

One science fits all

So tear down the walls
that keep parents from all
the riches that help them call
the future to their kids
open up learning, cultivate a yearning
for society's embrace

A bill of rights that rights political will
that allocates the resources to relationships

This is STILL public health – why the stealth
approach to early learning? Let's be turning
this science to common sense
and then let's invest this sense to finance a dense campaign
to build better brains
better babies
break the chains that hold us back
keep us from conceiving
of new tender maybes...

Because in every single case
There is only this to chase:

No more ACE
No more still face
No more ACE
No more still face
No more ACE
No more

still

face.


This poem offers a hopeful antidote to the depressing yet powerful Boston Globe piece about the SSI system that I wrote about in my previous post. That post concluded with the words "this piece demonstrates with disturbing clarity how much we need to intervene early to support parents and their young children, before they get to such a point of desperation that they are willing to label a child as disabled in order to survive." The website of the Harvard University Center on the Developing Child offers a wealth of information about why and how to intervene early to promote healthy development.

Tuesday, December 14, 2010

Rising SSI benefits for young children and marketing of atypical antipsychotics: a possible link

A legacy of unintended side effects, a powerful piece of investigative reporting in Sunday's Boston Globe, offers a view of the desperation of poverty. Parents speak to reporter Patricia Wen of seeking diagnoses and psychiatric medication for their young children in order to receive SSI(Supplemental Security Income)benefits. In order to qualify for SSI a child must have a recognized disability. In 1990 8% of children qualified because of mental, learning or behavioral issues. In 2009, that number had jumped nationwide to 53 percent. Wen writes:

In New England, the numbers are even higher — 63 percent of children qualify for SSI based on such mental disabilities. That is the highest percentage for any region in the country. And here and across the nation, the SSI trend line is up, with children under 5 the fastest-growing group. Once diagnosed, these children often bring in close to half their family’s income.
There are many alarming issues raised by this piece, and Ms. Wen is brave to tackle the subject, given that questioning benefits for troubled children is likely not to be a popular position among Globe readers.

One particular statistic jumped out at me. Wen outlines the historical shift in the program, from its inception in 1972, to the spike in mental disability cases following a legal ruling in favor of a boy whose disability payments had been cut off, through the identified abuses of the system in the 1990's followed by cracking down by federal law makers. Wen writes:

The children’s SSI disability rolls instantly shrunk — but the decline would be short-lived. Families and clinicians began to adjust to the new rules, which emphasized extensive medical records for any claimed disability. From 1997 to 2007, the number of children who qualified under behavioral, mental, and learning disorders more than tripled from 180,000 to 562,000.
What else happened in exactly that time period of significance for children's mental health? In June of 2001 I took a course sponsored by Harvard Medical School on Major Psychiatric Illnesses in Children and Adolescents. I attended a lecture given by Janet Wosniak entitled "Juvenile Bipolar Disorder: An Overlooked Condition in Treatment Resistant Depressed Children."

Little did any of us at the lecture know at the time that, largely as a result of Dr Wosniak her close colleague Joseph Biederman's ideas, we would over the next nine years see a 4000 percent increase in diagnosis of this "overlooked condition." These children were described as irritable with prolonged, aggressive temper outbursts that she called "affect storms." Some children were as young as 3 and over 60% were under age 12. In a previous blog post on the subject I wrote;
So here we have a perfect storm. A new disease with no clearly identified treatment. A new drug. Between 2000 and 2010 six atypical antipsychotics, Clozaril, Seroquel, Zyprexa, Risperdol, Abilify and Geodon were approved for treatment of pediatric bipolar disorder. The number of prescriptions for atypical antipsychotics for children and adolescents doubled to 4.4 million between 2003 and 2006. Prescribing of antipsychotics for two to five year olds has doubled in the past several years. Atypical antipsychotics are among the most profitable class of drugs in the United States.
I can't help but wonder if these events- rapid increase in SSI benefits for children under five for a mental health disability, and the rapid rise in diagnosis of bipolar disorder in young children in parallel with the explosion of development and marketing of atypical antipsychotics, are closely linked.

We urgently need a different paradigm for understanding emotional and behavioral problems in young children from that offered by the pharmaceutical industry. Money needs to be redirected to supporting parents in their ability to be physically and emotionally present with their very young children at times of most rapid brain development. Many interventions, such as Yale's Minding the Baby program, have been successful in setting children on a healthy path of development even in the context of significant economic and psychosocial risk. A wealth of high quality research is showing that children learn to regulate emotions in the context of relationships, and that this learning takes place at the level of gene expression and biochemistry of the brain.

Wen writes, "This abrupt climb in cases is a sign, some researchers say, that the SSI program has veered far from its original purpose." Aid for children with true disabilities, whether physical or mental, is extremely important, and the take home message should not be that the program is a bad one. Rather this piece demonstrates with disturbing clarity how much we need to intervene early to support parents and their young children, before they get to such a point of desperation that they are willing to label a child as disabled in order to survive.

Friday, December 10, 2010

How Parents and Children Regulate(and Dysregulate) Each Other

When parents and children come to see me in my behavioral pediatric practice, they are angry, disconnected and sad. In moments of explosive behavior, both parent and child feel terribly out of control. My aim it to help them reconnect and in doing so, to calm down and find pleasure again in their relationship.

Recently I saw a 4 year old boy,David, whose mother, Alice, described him as "explosive." She told of a typical scene- a request to get ready for bed was met with a firm "no," and soon mother and child were head to head in battle. An hour later, David was kicking and screaming on the floor and Alice was crying, horrified at herself for having threatened to hit him.

Rather than launching right in to "what to do" I took some time to listen to Alice's story while David played on the floor. Many things emerged, but most striking was the fact that the family had moved three times in the past year after David's father,Ron, lost his business, leaving the family in financial ruin. Ron had been severely depressed, but according to Alice, they were settled now and he had a good job. When I commented that it sounded like a very stressful year, she immediately responded with," Yes, but we didn't let it affect David."

From my position, this clearly seemed impossible. Such an experience is inevitably stressful for a four year old child. But for some reason, Alice, who was an intelligent woman, did not see it. Perhaps she felt so much guilt, or even shame, about what had happened to her family that could not let herself recognize this truth.

I saw my task at that moment as helping Alice to understand David's experience, to recognize that his increasingly frequent battles for control were likely in part due to feeling things were out of control for whole past year. But I needed help Alice recognize this without increasing her guilt and shame. It was a difficult and sensitive procedure.

When I saw them two weeks later, the explosive episodes had significantly decreased. Alice told me that his behavior no longer seemed so bewildering to her. Rather than getting angry, she listened to him, yet set more firm limits. She was delighted with the results and felt proud of her ability to regain a sense of joy and stability in her relationship with her son.

In recent blog posts, I have written about my experience as a fellow with the Infant Parent Mental Health Post Graduate Certificate Program at U Mass Boston, which is lead by Ed Tronick. At our first weekend Dr. Tronick, who is perhaps best known for developing the still face paradigm, talked to us about his mutual regulation model. In a paper we read for that weekend, Dr. Tronick writes:
"The MRM(mutual regulation model) stipulates that caregivers/mothers and infants/children are linked subsystems of a dyadic system and each component, infant and caregiver/mother, regulate disorganization and its costs by a bidirectional process of behavioral signaling and receiving."
The still face paradigm, in which a mother interacts face to face with her infant as she usually would, then for a two minute period presents a completely still face, followed by a reunion episode of resumed face to face interaction, in Dr. Tronick's words "demonstrates the costliness of an experimental disruption of the mutual regulatory process...as it serves as a model for the stress inherent in normal interactions." Dr. Tronick's model is compelling and very complex. I admit that while I was fascinated, I had a difficult time connecting this construct with the daily interactions I have with children and families in my office.That is until my "aha" moment this week.

I have recently been in contact with another leading researcher in the field, Arietta Slade. She has written extensively about what is referred to as parental reflective functioning. This is also described as "holding a child's mind in mind."It essentially refers to a parent's capacity to reflect on the meaning of her child's behavior. Slade, along with other researchers, has shown how enhancing a parent's capacity for reflective functioning is associated with many positive outcomes for a child's emotional development, including flexibility, cognitive resourcesfulness and the ability to manage complex social situation. I have been heavily influence by her work in my practice, and have written about the concept of holding a child in mind on this blog and in my forthcoming book.

In this "aha" moment, I suddenly understood that when things go well in my office, it is not only because a parent increases her capacity for reflective functioning. Supporting her in her efforts to her to reflect upon the meaning of her child's behavior is simply the point of entry. Once the child feels understood, or held in mind, he becomes calm. As I have written about elsewhere on this blog,it is likely that this change is on a neurobiological basis, occurring at the level of the structures of the brain that produce stress hormones. When a child is calm, a mother begins to feel better about herself. In fact, often a child's out of control behavior itself produces a feeling of shame in a parent. When parent and child are more in control, this sense of shame decreases. In turn, when a parent feels less shame, and less stress, she can think more clearly. She is better able to reflect on the meaning of her child's behavior. In turn a child feels even more calm and in control. Voila! Mutual Regulation! This is where we aim to be.

Sunday, December 5, 2010

The Pharmaceutical Industry, Psychiatric Drugs and Primary Care

An article last week in the New York Times, entitled Drug makers wrote book under 2 doctors names reported on a book that was written by two psychiatrists for an audience of primary care clinicians. The book, whose aim was to teach these clinicians about how to treat psychiatric disorders, was in fact ghostwritten by the drug company then known as SmithKline Beecham.

Robert Whitaker, author of Anatomy of an Epidemic, comments on his blog in a post entitled Ghostwritten book hints at much larger problem He offers a larger context, stating that
In fact, this ghostwriting revelation simply hints at a much larger, pervasive problem, which is that financial bias profoundly affects the authorship of psychiatric textbooks at every turn. And it is quite easy to document that this is so.
Most concerning to me, as a pediatrician, was a comment on Mr. Whitaker's blog from an MD who states
The Amer. Acad Child and Adolescent Psychiatry Psychopharm conference this November seemed to me to reflect commercial bias in a level I found unsettling -given that AACAP has long been a refuge where quality of care has tended to come first.
Last week, I wrote in a blog post about the possible influence of the pharmaceutical industry on the recommendations child psychiatrists give to primary care clinicians. I describe a supposedly successful program that aims to increase access to mental health care. The program in fact simply supports primary care clinicians in prescribing psychiatric medication to children.

The New York Times article, Whitaker's post, and the comment on it all confirm my fears of the heavy influence of the pharmaceutical industry on how psychiatry is guiding primary care clinicians in treatment of of psychiatric problems, in both adults and children.

An alternative paradigm is urgently needed. A primary care clinician has a long standing relationship with a family than can be put to great use in addressing mental health problems in a preventive model. With the enormous financial influence of the pharmaceutical industry moving the ship of mental health care in one direction, getting it to move in a different direction will take an enormous effort. Add to this a cultural expectation of a quick fix, and this seems an almost impossible task. But when it comes to supporting children's healthy emotional development, I believe we have no choice but to make the effort to change direction.

Friday, November 26, 2010

Understanding Behavioral Epigenetics vs Increasing Access to Psychiatric Drugs for Children

These two topics could be two different blogs posts, but I decided to put them together because, in considering the larger question of where we invest our resources in promoting children's mental health, the two are subjects are linked. The first fills me with excitement and optimism, the second with despair.

My blog posts have been less frequent because I have been hard at work, under the guidance of the brilliant behavioral geneticist David Reiss, revising the section of my book that covers the critically important topic of epigenetics. Knowledge in this discipline is exploding, and he generously offered me the most up to date references. I am eager to see how this complex information translates for a general audience. Any comments to that effect will be much appreciated.

Epigenetics puts a whole new spin on the “nature vs. nurture” debate, which has historically viewed genes and environment as separate independent factors in determining the course of an individual’s development. Rare genetic disorders that result from a single change in the gene sequence have strengthened this misconception that one’s genetic makeup inevitably determines one’s future. Epigenetics refers to changes in DNA structure which alter gene expression, and hence individual characteristics, that do not involve changes to the sequence of DNA. According to leading researcher Michael Meaney, behavioral epigenetics specifically refers to the way environment, or life experience, influences gene expression and subsequent behavior and development.

The significance of this research for parenting is that that a child may be born with a particular gene for some problematic trait. But the effects of that gene on behavior will vary according to the environment. If parents do not respond negatively to difficult behavior, the effects of that gene may be altered and the problematic behavior may not occur. Conversely, negative response to challenging behavior will lead to expression of behavior associated with the problematic gene. These genes directly affect the development of the structure and biochemistry brain.

(For those readers who interpret this material as blaming parents when things go wrong, I refer you to an earlier blog post Guilt, Blame and Responsibility)

The importance of family environment on moderating genetic influence have been demonstrated widely in infants, children and adolescents. One particularly striking example is research on the (S) or short allele of the serotonin transporter gene . This gene is associated with stress responsivity and also with structure and function of the amygdala and medial prefrontal cortex, brain structures which are critical in emotional regulation. A person may have the short allele, but its expression, or its effect on behavior, is strongly affected by life experience. For example a person with the short allele has an increased risk of depression if he experiences stressful life events. Frances Champagne, a major figure in the field, writes in her paper, How social experiences influence the brain
Although these examples of interactions between genotypes and early environment are striking, we are only starting to fully appreciate the complex interplay between genetic backgrounds, social environments and brain development. Indeed, it is likely that such interactions[between genes and environment} will be found to be common and significant in development of most behavioral phenotypes[individual characteristics].


While hard at work wrapping my mind around these important research findings, I received, in AAP smartbriefs, a daily email about pediatric related news stories, an item about a recently published study in Pediatrics about a Massachusetts based program designed to improve access to child psychiatry services, known as MCPAP. Internal Medicine News sums up the study as follows;
A state-funded initiative to offer free mental health consultations to pediatric primary care physicians increased the proportion of pediatricians who said they were able to meet the needs of their psychiatric patients from 8% to 63% in 3.5 years.
Translation: Primary care doctors significantly increased their prescribing of psychiatric medication to children. In my opinion, this is not a statistic to be proud of. From 2005 to 2010 I was part a pediatric practice receiving the services of the MCPAP program. In May 2009 I heard Barry Sarvet, the lead author on the current study, speak at the 5th Annual Child Psychiatry in Primary Care Conference. At this conference he clearly and unequivocally supported the prescribing of psychoactive medication by pediatricians to young children, including atypical antipsychotics. Granted, this prescribing is under the guidance of a MCPAP psychiatrist. Some of these children are seen for a one time consultation, but in many cases the psychiatrist simply speaks with the pediatrician on the telephone.

In March of 2009 I wrote an op ed for the Boston Globe entitled Backed into a Treatment Corner. In the article I describe two very troubled patients for whom who I felt forced into prescribing psychiatric medication. I made the analogy to expecting a primary care clinican to treat a brain tumor.The article made no mention of the MCPAP program. It was widely praised, and many of the letters to the editor spoke to the importance of exposing this widespread problem. A few days after it was published,however, I received a call from Dr. Sarvet. He was furious. Apparently he had gotten in trouble with the powers that be that provide funding for MCPAP. My piece apparently made them look bad. I found this interesting, because in fact one of the patients was from New York State and thus not under the jurisdiction of MCPAP. Yet Dr. Sarvet experienced my piece as a condemnation of his program. When I explained that this had been far from my intention in writing the piece, his response was,"Well, its too late to take it back."

Certainly MCPAP was successful in accomplishing what it set out to do. My individual experience was that the participating psychiatrists were very helpful. They responded to my questions, which almost exclusively were about prescribing medication to older children with a diagnosis of ADHD, in a timely manner. But read the fine print in the current Pediatrics article:

FINANCIAL DISCLOSURE: Dr Prince serves as a consultant to
Astra-Zeneca, is a member of the speakers bureau for McNeil
Pharmaceutical, and has received a speaker’s honorarium from
Shire, and Dr Bostic serves as a consultant to Forest
Laboratories and GlaxoSmithKline; the other authors have
indicated they have no financial relationships relevant to this
article to disclose.
I can't help but wonder if all of the MCPAP psychiatrists have at some point in their career,if not specifically in relation to this article, had significant associations with the pharmaceutical companies who profit from prescribing of psychiatric medication to children. Has this relationship affected their recommendations regarding prescribing practices? I am hard pressed to believe that it has not.

So how to fit these two seemingly disparate topics together? Rather than channelling money into programs that increase use of psychiatric medication for young children, wouldn't it make more sense to turn our attention to prevention, and to supporting families in promoting children's healthy emotional development? If the research in epigenetics is showing that with such interventions we might actually impact on gene expression, and in turn grow and development of the brain, this seems a far better path to pursue than changing young developing brains with powerful psychiatric medications.

If health care providers on the front lines have the time to develop relationships with young families, if there is a strong system of mental health care to support families who are struggling, and a medical education system that supports clinicians in their efforts to listen to parent’s stories, we will be well on our way. The image comes to mind of a set of Russian dolls. The highly valued primary care clinician, reimbursed by the health care system, listening to the whole of parent’s experience, can help bring out their basic wisdom and inherent intuition. Then we as a society could be said to be holding all children in mind.

Friday, November 12, 2010

High Tech Baby Monitors Prey on Parent's Vulnerabilities

Recently I was interviewed by a reporter about the effects of the newest baby monitors on parent-child relationships. A teddy bear with a camera in its nose hooks up to a TV, allowing parents to watch their baby's every move. One product called an exmobaby is actually worn against the baby's skin and measures heart rate and respirations. A CEO of the company is quoted a saying, presumably as a selling point, “This continuous monitoring in realtime will allow for an ‘emotional umbilical cord’ between mother and child.” My conversation with this reporter got me thinking.

When we become parents we have the opportunity to open our hearts to a love unlike any other. This love may begin at the moment a mother learns she is pregnant. But in opening ourselves to this love, we take a risk. 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.

A central task of parenting is to manage our anxiety around this possibility. Not only when we put our children to bed, but when we let them go down a slide, go to preschool, go skiing in Europe. We allow them to separate and grow up. All along we must learn to manage our anxiety.

When I was pregnant with my son, we were told that he might have a very serious heart condition. He was followed with yearly tests and then last spring, when he was 12, we were told that he and his heart had grown to the point where the doctors felt we didn't need to worry about it. Even now, every night when I say "Goodnight, I love you, see you in the morning," I remember the gripping fear of loss. But when at the age of eight he begged to go to sleep away camp like his big sister, we let him go.

Now along come these baby monitors which, in my opinion, abuse this vulnerability for profit. Certainly if a baby has an identified medical condition, monitoring of heart rate and respirations may be indicated. But these monitors need to be used carefully and under supervision of a health care provider. For a baby who has no such identified risk, there is no reason to monitor him. Putting a child under the age of six months to sleep on his back does more to protect him than any baby monitor ever could. A simple audio monitor that allows parents to hear a baby if he cries during the night many be helpful. But unless you have a huge house, or are having a party, you will generally be able to hear your baby's cry during the night, and even that may not be necessary.

Another drawback of these monitors is that they send parents a message that it is not OK to leave your baby to do adult activities. What about watching a movie instead of your baby on TV? I read a recent blog post with the title"Attachment Parenting-Is It a Prison for Moms? "Attachment parenting is a style of parenting described by William Sears that advocates for a mother to be with her child as much as possible, including carrying and cosleeping. (It is distinct from and unrelated to John Bowlby's attachment theory.) These are fine choices if parents wish to make them. But it is important to recognize that solid relationship between parents, one that is often fostered by having adult time together, can contribute significantly to a child's healthy emotional development. It helps both parents and child negotiate the challenging task of separation.

As I approach the age of 50, I am aware that I need to work hard to be open minded to new technologies. But to high tech baby monitors, I give it an unequivocal thumbs down.

Friday, November 5, 2010

Diagnosing Autism in Infancy?

Two juxtaposed slides presented at a talk by William Singletary on autism at last years annual American Psychoanalytic Association's meetings capture, in my opinion, the essence of the disorder. In one, a baby is held in the soft embrace of mother's arms, gazing back into her adoring face. In another, a baby screams as he looks into the wide open mouth of a fang bearing snake. These photographs vividly demonstrate that these children experience the world not as as soft and loving, but rather as harsh and frightening.

When the gene for autism is finally discovered, I believe it will be closely linked to the processing of sensory input. While non-autistic newborns experience touch and a loving face as comforting, autistic children are overwhelmed, and so retreat to the world of inanimate objects.

A New York Times article this past week At the Age of Peekaboo, in Therapy to Fight Autism describes current research into diagnosis and treatment in infancy, using an intervention based on the Early Start Denver Model. I referred to this intervention in my Boston Globe op ed about the limits of medication in treatment of autism.
An intervention, the Early Start Denver Model, was offered in the homes of families, with parent, child, and therapist playing together. In the two-year study period, toddlers diagnosed with autism showed significant improvement in behavior, language, and IQ. The authors attribute the success of their intervention to the fact that it is “delivered within an affectively rich, relationship-focused context.’’
While I have some concerns about diagnosing autism in infancy (more about that below) I feel strongly that a relationship based intervention is the way to go. If I am correct, and the primary problem lies in the way an infant experiences his environment,it is a quality with which he enters the world. But immediately after birth, this genetic vulnerability begins to wreak havoc on the environment.

Holding, feeding, comforting-these are the actions that give a new mother not only pleasure, but growing confidence in her mothering capacities. When she fails at even one of these, such as with a spitty baby who has difficulty tolerating feeds, a sense of inadequacy can follow. But if you multiply that to cover all the senses-if being held is not comforting, if singing provokes screaming,smiles are too much, that inadequacy can be devastating. Mothers may become depressed. Marriages are severely strained. Siblings may be neglected, become resentful and act out. For these reasons, it is essential that from the very beginning these problems are treated in the context of relationships.

Another study published this past week described in a Reuters article Autism risk gene may rewire brain looks at the brains of children with autism using functional MRI.
The team measured the strength of brain connections as the children worked. They found children with the version of the gene linked with autism called contactin associated protein-like 2 or CNTNAP2 had strong brain connections within the frontal lobe, but weaker connections to the rest of the brain."In children who carry the risk gene, the front of the brain appears to talk mostly with itself," Ashley Scott-Van Zeeland, now at Scripps Translational Science Institute, said in a statement.
In a previous blog post, I have describe the way in which early mother infant interactions wire the brain.
When a parent gazes into her baby’s eyes, she literally promotes the growth of her baby’s brain, helping it to be wired for a secure sense of self. The medial prefrontal cortex(MPC) has been referred to as the “observing brain.” It is where our sense of self lies. When a mother looks at a baby in a way that communicates with him, not with words but with feelings, “I understand you,” he begins to recognize himself, both physically and psychologically. This mutual gaze, literally and figuratively being “seen,” actually facilitates the development of the baby’s brain. As the MPC matures in this kind of secure loving relationship, the brain is wired in a way that will serve him well for the rest of his life. He will be able to think clearly and to regulate feelings in the face of stressful experiences.
It makes perfect sense that if this mutual gaze process goes awry from the start, the projections from the frontal lobe to the rest of the brain would not develop properly. Again this leads back to the critical importance of relationship based treatments.

All of which leads to my concern with the labeling of young infants with a devastating psychiatric disorder. I wish there were a way to recognize the infant's experience of the world, and to support parents efforts to interact with their infants in a way that reflects this understanding, without pathologizing it from the start. This would mean acknowledging that there is something different about these children that makes caring for them extremely challenging. It would mean offering services to families, such as the Early Start Denver Model, but without necessarily labeling infants as autistic.

Some parents may find comfort in a label. It demystifies their difficulties and relieves alot of the guilt and sense of inadequacy. But there is a process of mourning that goes along with receiving such a label and may affect the way parents see their child for the rest of his life. Also there is a risk that the family context of the problem is overlooked when the problem is seen as residing exclusively in the child.

I don't have an easy answer for this dilemma. But these news stories have motivated me to put the ideas out there, and I hope start a discussion about these challenging questions. Of one thing I am certain. The answer lies in continuing to devote resources to identifying these problems early, and supporting early parent-child relationships, with the long term goal of facilitating the healthy emotional development of the next generation.

Tuesday, November 2, 2010

Ode to Grandmothers

Last week, a friend told me a story that motivated me to recognize the important role of grandmothers, not specifically for their grandchildren, but for their adult daughters who are now mothers.

My friend, mother to a fifteen year old boy in the throes of adolescent turmoil, did not have a close relationship with her mother when her children were young. Her mother preferred "not to meddle," despite her daughter's clear requests for her involvement. My friend struggled with this for years, seeking help and support from others, particularly her husband and close friends. Still she very much longed to connect with her mother. So she continued into her forties to put a lot of effort into this relationship. The other day, she told me, the effort seemed to have paid off.

She was having a particularly bad moment with her son, who chose an afternoon when she was feeling tired and stressed by her own work, to regale her with all of her faults and accuse her of being the cause of all his misery. The more she tried to talk to him, the more the conversation degenerated, to the point where she couldn't stand it anymore and got in her car and drove off. Much to her surprise, she found herself driving to her parents house, something she never spontaneously did, despite the fact that they lived close by.

Both her mother and father were overjoyed at her unexpected appearance. They made her tea and listened while she unloaded her distress. Then her mother, in a most uncharacteristic way said to her, "I know I might not have done all the right things when you were a kid, but I do remember that sometimes the only option was to keep a sense of humor."

My friend, who had been so caught up in her conflict with her son, suddenly saw that she had been fighting with him like she herself was a teenager. In the heat of the moment she forgot, though at saner moments certainly knew well, that teenagers are at times incapable of rational discussion. But until her mother heard her and reflected back what was happening, she had been unable to see it herself.

Dan Stern, in his book The Motherhood Constellation that outlines the basic principles of parent-infant psychotherapy, refers to the “good grandmother transference” to describe the kind of relationship a parent develops with the therapist who is working with a parent and child together. Transference is a psychoanalytic term that refers to the way people tend to transfer feelings from one relationship, often from childhood, to another current relationship. He writes:
The transference that evolves in this situation involves a desire to be valued, supported, aided,taught, and appreciated by a maternal figure.This desire for such a maternal figure is evidenced in many situations outside of the therapeutic one. Beginning in the hospital with the birth of the baby, mothers frequently find someone to fill this role or part of it. It is often a nurse, a nurses aide, the cleaning lady, or someone else who takes a moment to share personal experience and give heartfelt encouragement. It is amazing how important these short encounters can be. They are overwhelmingly with other mothers more experienced in motherhood...Later other mothers met in the park may fill this role, to say nothing of the mother's actual mother, grandmother, older sisters, and experienced friends.
Berry Brazelton, in his book Touchpoints: Birth to Three, in the section devoted to grandparents writes:
The best thing that has happened to me as a grandparent has been the chance for my children and me to have a whole new relationship...Each grandchild is a miracle, but a new relationship with your own children is an even greater one.
My forthcoming book, now in the final editing stages, speaks to the importance of supporting parents' efforts to be fully emotionally available for their children. Many of the mothers I describe in the book, mothers who have come to see me in my pediatric practice because of struggles with their children, have strained relationships with their own mothers. In effect they develop a kind of "good grandmother transference" with me. This is often very helpful to them in the task of raising their children. Though perhaps not within the scope of my role as pediatrician, I certainly wish for these mothers, and support them in any way I can, that they find peace, as my friend seems to have achieved, with their own mothers.

Tuesday, October 26, 2010

American Academy of Pediatrics Endorses Management of Postpartum Depression in Pediatric Practice

Its nice to know I'm on the cutting edge. After no fewer than four recent posts about the importance of identification and management of postpartum depression, I learned yesterday that in the November issue of Pediatrics, the official Journal of the American Academy of Pediatrics, there is an article entitled: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice It is an excellent, thorough article that speaks to the many issues I have raised. A couple of sample quotes are:
Maternal postpartum depression threatens the mother-child (dyad) relationship(attachment and bonding)and, as such, creates an environment for the infant that adversely affects the infant’s development. The processes for early brain development—neuronal migration, synapse formation,and pruning—are responsive to and directed by environment as well as genetics. For example, it is known that an infant living in a neglectful environment,which is common with depressed mothers, can have adverse changes visible on MRI of the brain.
and
The primary care pediatrician, by virtue of having a longitudinal relationship with families, has a unique opportunity to identify maternal depression and help prevent untoward developmental and mental health outcomes for the infant and family.
The article addresses the associated problems of, among many others, marital discord, breast feeding issues and difficulty managing chronic health conditions.

In addressing what pediatricians have to offer, the article speaks to the roles of screening and referral as well as support of the parent-child relationship within the context of a pediatric practice.

It is in this last role that I think pediatricians may have more to offer than is generally recognized, even by pediatricians themselves. This morning I was thinking about a successful intervention for PPD Peter Cooper described at the course I recently attended(see previous posts). The intervention was done in a South African peri-urban settlement with marked adverse socioeconomic circumstances. In this study:
Women were visited in their homes by previously untrained lay
community workers who provided support and guidance in parenting. The purpose of the intervention was to promote sensitive and responsive parenting and secure infant attachment to the mother.
The intervention was successful in that it:
had a significant positive impact on the quality of the mother-infant relationship and on security of infant attachment, factors known to predict favourable child development.
I was wondering to myself if the therapeutic action in this intervention was actually the relationship between these workers and the mothers. The mothers became very attached to these women, viewing them as a kind of grandmother figure. I think it likely that this relationship in turn fortified them in their efforts to be more fully emotionally available for their infants.

If this is in fact correct, then a pediatrician, by virtue of a long standing relationship with parents that is usually one of trust and respect, is in an ideal position to promote the mother-infant relationship.

I hope that with the AAP endorsement of this important issue will also come a recognition, cultivation and valuing of this role. This would involve changes not only in how pediatricians think about themselves, but also in more global changes in such areas as reimbursement and medical education. But that's for another blog post!!

Monday, October 25, 2010

Research and stories: both have a role to play in advancing knowledge

Last weekend, as I listened to leading researchers grapple with the question of how to design a feasible study of intervention for postpartum depression, I held in my mind an image of a particular moment in my office.

I was sitting on the floor with 10 month old Madison and her mother Nancy, who was struggling with postpartum depression. Nancy spoke of the strain Madison's refusal to take a bottle and her frequent night wakings were placing on her marriage. Madison contentedly played with the toy her mother had brought and then began to expand her exploration to the other toys in the office. We proceeded through the history, beginning with Nancy telling me about her pregnancy. Then I asked about her family. “My mother was severely depressed and frequently suicidal,” she said. Tears welled up in her eyes. “I don’t want Madison to go through what I did.” As she spoke, Nancy was freely crying.

Madison stopped her exploration of the toys. At first she sat completely still, observing her mother. This only made Nancy cry harder, as she saw the effect of her tears on Madison. Then Madison crawled up on to her mother and help on tight. They were both quiet for a bit. Madison began to fuss and reach for Nancy’s breast. Nancy got her settled to nurse, and very soon Madison fell fast asleep.

I understand the need for what is known as "evidence based medicine" to advance our knowledge of effective treatment. But given the constraints of research design, I could not help but wonder how to capture the complexity of this tiny moment. The researchers who spoke that weekend were trying to design interventions that would affect not only the mother's depression, but also the mother-child relationship.

In that moment I was literally inside in the mother-child relationship and witness to its enormous richness. I saw how Nancy was using the nursing to protect Madison from her depression. I understood that if I were to help Nancy her find time for herself and her marriage, I would need to help her find an alternative way to comfort Madison when her depression threatened to overwhelm her. I could only understand this by actually being in the moment of interaction between Nancy and Madison. By listening to Nancy and recognizing her experience as a mother, I could support her efforts to think about Madison's experience and how she could help Madison manage these difficult moments.

I struggled that weekend with the question of the relative role of research and clinical experience in advancing knowledge and promoting the healthy emotional development of children and parents. Upon my return home, my sixteen year old daughter handed me a paper she had written. The assignment was to write a daily theme on a subject of her choosing. That day she chose to write about the power of books. In her conclusion, she said:
Reading has power. A good author has the ability to craft words from his thoughts and change lives without even leaving his desk. A book is timeless, and can be read over and over by generation after generation and never lose its charm. A book is timely, and can erupt a change in the thoughts and opinions of people in the time period.
I believe she is right-that a book, or stories, have the power to change the way people think. Interestingly the Infant-Parent Mental Health Post Graduate Certificate Program, that I have written about in previous blog posts, brings together leading researchers with a group of fellows who are primarily clinicians immersed on a daily basis in the complexities of struggling families. I hope together we can join forces to make the world a better place for children.

Tuesday, October 19, 2010

Postpartum depression: A well recognized problem, but what is the treatment??

When I see children in my pediatric practice for behavior problems, I often hear stories from mothers who struggled terribly when their children were very young infants. A most dramatic example of this was a mother with severe postpartum depression whose father died suddenly when her baby was four months old. Much to my astonishment, she described being relieved by this event. It wasn't because she didn’t love her father. Rather, in sharing the grief with her siblings, mother and extended family, she no longer felt so completely alone.

A Massachusetts law passed this summer calls attention to the public health problem of postpartum depression (PPD). The most common complication of pregnancy, extensive research has demonstrated its significant long term effects on a child’s development, with increased risk for behavior problems in childhood and depression in adolescence.

The new law requires Massachusetts health insurers to submit annual reports on their efforts to screen for postpartum depression. The department of Public Health will develop regulations and policies to address postpartum depression. In addition the law calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.

The Boston Globe editorial board endorsed this legislation with the following statement: "Early detection could stave off far more serious problems for mothers and their babies, whose well-being is deeply linked to the first few months of care. And universal screening would ensure that no woman falls through the cracks. The sooner new mothers can be diagnosed, the sooner they will recover."

The critical step in bringing this last statement from a wish to a reality is to find effective treatment for PPD. Ideally an intervention would both improve a mother’s depression and positively impact on her child’s development. Unfortunately is it far from clear exactly how to accomplish this goal.

Last weekend, I learned all about the latest research on the subject of postpartum depression as part of the Infant-Parent Mental Health Post-Graduate Certificate Program that I have described in previous posts. I was eager to learn from these world experts about effective treatment. These researchers, however, described difficulty defining, in a way that would be feasible for a well designed research study, what an effective intervention for PPD would look like.

Perhaps the mother I described above offers a clue. Being understood by a person you love is one of our most powerful yearnings. The need for understanding is part of what makes us human. When our feelings are validated, we know that we’re not alone. The truth of this statement is reflected by such sources as literature, philosophy and religion.

The necessary intervention, therefore, is perhaps more of a societal intervention. The most important component of an effective treatment for PPD may be that a new mother have an opportunity to be understood. She needs to feel supported over time in relationships that are of value to her. When partner, family members and friends are not sufficient for this role, or when there are enormous strains on these other relationships, the disciplines are available to support a mother include social workers, educators and primary care clinicians. These are among the lowest paid professionals in our society.

The law promoting PPD screening is a small step in the right direction. But in addition to focusing on the specifics of treatment interventions, it is critical to maintain a larger focus on the value we as a society place on the role of mother.

Thursday, October 14, 2010

An Exquisite Parenting Moment at the General Store

As I stood at the counter of our little general store waiting to buy my newspaper, I turned suddenly, along with all the other customers, to find the source of a loud, insistent voice coming from below the counter. "I want candy now!" We looked down to see a little boy who was about three years old. He tugged at his father's arm. His father calmly replied."Lunch first. Then you can have your candy." "NO! CANDY NOW!" said the not so little voice. The other people in the store, including myself, shared knowing smiles. After several exchanges like this, his father, seemingly unperturbed by his fellow town members listening in, said firmly "OK, then you can't have the candy." "Noooo! I want candy!!!" he cried. His mother, who had been quietly standing behind them chimed in. "Now you're really mad," she observed in a respectful tone. With this he began to stomp around the store, wearing an intense scowl on his face. His father, a rather large man, began to stomp around after him. After passing by the grocery aisle a couple of times, the little boy dissolved in a fit of giggles. I paid for my paper and went home, thankful for the inspiration for a blog post.

It was such a small moment. One of millions that make up the day to day challenges of being a parent. Yet such grace under pressure!! His parents were calm and sure of themselves. They were willing to face the consequences of setting a limit with their son, even if it precipitated this public display of three-year-old outrage. His mother conveyed, simply with the tone of her voice, that she accepted his reaction and understood his feelings, but she and his father were not going to change their minds. His father playfully showed him that they both could survive this disruption and move on.

This interaction has all the elements of holding a child in mind, the central theme of my book, which is due to be published in the fall of 2011. These are: 1) understanding a child's behavior from the perspective of his stage of development, 2) empathizing with a child's feelings, 3) containing and regulating both the feeling and behavior, and 4) and perhaps most difficult, staying present with a child without letting one's own distress get in the way. When parents do this repeatedly a child learns to understand his own mind. He develops the ability to regulate intense emotions, think clearly and manage himself in a complex social world.

Those parents in the general store likely thought they were simply saving their son's appetite for a good lunch. They were actually taking one more small but important step in the direction of promoting their son's healthy emotional development.

Saturday, October 9, 2010

Supporting Infant-Parent Relationships: The Right Choice

Though not the major aim of this blog, it turns out that it is also serving to document the trajectory of my professional life. I am certain now that where I have landed is the right place.

My earlier posts documented my sense of frustration seeing many patients for "ADHD evaluation." I listened to story after story of mothers alone and depressed with their fussy, "difficult" infant. This infant then became an "explosive" toddler. Child and parents continued to struggle until now at the age of seven, ten or even fifteen, they came to see me in search of a diagnosis and medication. More often than not their symptoms did meet DSM criteria for some diagnosis, usually ADHD. Between imminent failure in school, intense pressure from teachers and a severe shortage of quality mental health services, medication often seemed to be the only option.

It caused me great pain to see a child's life experience reduced in this way, and, as is also documented on this blog, I decided that I needed to focus my efforts on prevention.

Next weekend is my second installment of the Infant-Parent Mental Health Post Graduate Certificate Program I have referred to in the two previous blog posts. As I review the material in advance, I am learning about research providing evidence that postpartum depression, particularly if the depression is chronic, affects a child's cognitive development, and is associated with behavior regulation problems and depression.

Last week, I saw a mother and her 3 month old daughter. A single mother struggling with depression and anxiety, she hadn't slept in a long time. Her baby fussed and squirmed on her lap. I held the baby, walking her around the room to quiet her while her mother talked of feelings of helplessness and frustration. The other doctors in my practice, who had been called almost daily by this mother with problems of feeding, sleep and crying, didn't know what to do for her. Pediatricians, who are seeing these mother-baby pairs on a regular basis, are mostly unaware of this important field of study.

I am well aware that there are many other professionals who have been doing this work for a long time. One social worker in my program does home visits with high risk pregnant women and then together with their newborns for a year after delivery. Sadly, they are paid practically nothing for this critical work.

John Bowlby, the father of attachment theory, in a 1980 lecture said:
Successful parenting is a principal key to the mental health of the next generation. In most societies throughout the world these facts have been and still are, taken for granted and the societies organized accordingly. Paradoxically it has taken the world’s richest societies to ignore these basic facts. Man and woman power devoted to production of material goods counts as a plus in all our economic indices. Man and woman power devoted to the production of happy, healthy, and self-reliant children in their own homes does not count at all. We have created a topsy turvy world.
Next weekend I will learn more about effective interventions for these mother-baby pairs. I am very much looking forward to it. For now, sitting in a room with this mother and her young infant, at least I know I am in the right place to start.

Thursday, September 30, 2010

Postpartum Depression: A View From the Front Lines

My town is home to Fairview hospital, the smallest land based hospital in Massachusetts. With its 24 beds and about 170 newborn deliveries a year, Fairview is a wonderful place. For years as a primary care pediatrician I examined newborns and attended many a delivery in the middle of the night. So after deciding(for reasons I have described elsewhere in this blog) to focus my behavioral pediatrics practice on the 0-5 age population, I went to pay my friends the maternity nurses a visit. What better place for a preventive intervention than the newborn nursery? I wanted to hear about the problems they were seeing and their assessment of what the needs were.

Recently I have been reading the most current research on the impact of postpartum depression on infant development. This reading is in the setting of the The Infant-Parent Mental Health Post-Graduate Certificate Program that I referred to in my last blog post. Quoting from the program's website:
This program is based on the award-winning Napa Infant-Parent Mental Health Fellowship Program developed by Dr. Ed Tronick, Chief of the Child Development Unit at Children’s Hospital Boston...Dr. Kristie Brandt, Director of the Parent-Infant & Child Institute in Napa, California...the present program is designed to address the increasing need for skilled, interested and appropriately trained professionals to provide infant-parent mental health services for families with children ages birth to five years.
Given what I am learning, the stories I heard from the nurses were alarming. I will diverge slightly to describe the research I am referring to before returning to my visit to Fairview. Much of the contemporary research has been done by Peter Cooper and Lynne Murray and is described in their book, Postpartum Depression and Child Development. In a more recent paper they write that considerable evidence exists indicating that postpartum depression (PPD) limits a mother’s capacity to engage positively with her infant. Several studies have shown that PPD compromises child cognitive, behavioral and emotional development. To quote them directly:
PPD is now recognized, by virtue of the distress caused to mothers, as well as the wider adverse impact on the family, as a significant public health issue...Since adverse child outcomes associated with PPD are more likely to occur in the context of chronic or recurrent depression, it is particularly important that this group be identified and targeted for intervention...It is crucial that attention be given in the treatment to the quality of the mother-child relationship and that specific therapeutic measures be introduced to help mothers engage optimally with their infants.
Back to Fairview. The maternity nurses estimate that 15 to 25 percent (and perhaps as high as 50%) of mothers delivering at Fairview have major mental health problems. These range from mothers carrying multiple psychiatric diagnoses such as bipolar disorder and depression, to those without a specific diagnosis but with multiple psychosocial risk factors. For this group of patients, nurses feel that 100% do not have adequate follow up after delivery. Mothers may have one home visit with a nurse. A part time social worker sees some of them prenatally, but there may no plan for follow up.

The distress in the room was palpable. The nurses worried for these babies, feeling that they often sent them home "on a wing and a prayer." They described one mother with a diagnosis of depression who gave birth to her third child. A two year old with no shoes sat strapped in a stroller , while a ten year old who was on multiple antipsychotic medications wreaked havoc in the hallway.

What would happen, I wondered with them, if I were to meet for one or two sixty minute visits with these high risk mother-infant pairs in the hospital?(more time than is usually available for an in-hospital visit by a pediatrician) My aim would be to forge a relationship between myself and the parents as well support the new relationship between the parent and her infant. In my pediatric practice I could continue to follow them when the almost inevitable challenges of crying, feeding and sleep problems arise. "When can you start?" they asked.

It would be a small intervention in a small hospital in a small town(to put it in place, the complex questions of diagnosis and insurance coverage must be ironed out.) One can only hope, however, that it would help to put a dent in what is potentially a very big problem.

Saturday, September 25, 2010

Dyadic Therapy: Working with the Parent-Child Relationship

One of the things of which I am most certain, based on my years of practicing pediatrics together with my years of being a mother (and also just my experience as a human being) is that what children need most is for the people who love and care for them to understand them, and to be with them in a way that communicates that understanding.

For this reason, I have never understood why a young child would be ever seen in psychotherapy without his or her primary caregiver. Psychoanalytic theory contends that a young child has hidden conflict and fantasies that can be brought to light through imaginary play. This may well be true, but given the limited time and resources, is it really important?

This weekend I have begun what will be an intensive year long training in Infant-Parent Mental Health. Already I can see that perhaps the two most valuable piece of this experience will be one, to have this viewpoint validated by the world leaders in this newly emerging discipline and two, to be learning with a group of like minded clinicians from a wide range of disciplines, including social work, early intervention, infant massage, psychology, psychiatry and pediatrics.

This point was brought home for me yesterday when in our first full day we heard a case presentation and watched a video. Being ever mindful of confidentiality issues, I will describe only the basic points. The identified patient was a young child who had experienced significant neglect, with multiple losses and disruptions. This "dyadic therapy" we watched in the video was conducted with the child and adoptive parent together. The way in which both the setting and the therapist served to connect this mother with her very troubled child was magnificent.

Some of the most painful cases I have seen in my practice are those of children adopted out of situations of severe abuse and neglect. Parents come to me for medication when the children have been diagnosed with ADHD. When I hear these stories of terrible trauma, I work hard to convey to the parents that while medication may be helpful in controlling the symptoms, it is not sufficient.

Yet I immediately come up against intense resistance. The assumption is that I will recommend therapy. and the parents, for good reason, do not understand the purpose of individual therapy for such a young person. Yet a recommendation to work together with their child in therapy is also met with resistance. The difficult behavior is not their fault, and their loving and safe home should eventually cure the problems.

Here in lies the beauty of this program. My biggest challenge is a paucity of colleagues to refer to. In my community there is not only a shortage of child therapists, but even fewer who work from a conceptual framework that supports treatment of parent and child together.

My fantasy is that one day, when I see such a family, I will have a group of colleagues, all on the patient's insurance plan, who I trust to work to bring a parent and child together in the way I watched in that video yesterday. I know it's a dream, but at least as I sit with all of these colleagues who will one day be leaders in the field, I am hopeful that perhaps mental health care for children is moving in the right direction.

Sunday, September 19, 2010

True Empathy: A Physical Sensation

Emily brought her son Micheal to see me when he was 3 and 1/2 months old. He had been born one month premature, but it was clear from a first glance that he was doing well. I remember noticing that his mother was so close, physically close. She hovered over his carriage, reluctant to let me pick him up. She stood inches from him while I examined him.

He was robust little boy who gave a big smile as he intently followed his mother's face. Emily felt he was doing well. So well, in fact, that she was attributing qualities to him for which he seemed to young. "It's good for him to comfort himself, right? I should let him cry, right?" She seemed very anxious.

About a year earlier, Emily had lost a baby, Christopher she called him, in her ninth month of pregnancy, when she was in a car accident. She conceived again almost immediately. And here was this miracle baby. I watched Michael sleeping in his blue jumper. He seemed so small and vulnerable.

"He's doing great," I said. Emily continued to wear that uncertain look as I tried to reassure her. She asked about sleep. "Is it OK if he is still in our bed? Is it good for bonding?" she asked. I was puzzled by this question and paused, asking her to tell me what she meant.

"Is he bonded to me?" she asked. I started to attempt an answer when she interrupted me. "Can you bond in utero? I mean I bonded to Christopher, but he died. I didn't let myself bond to Michael when I was carrying him."

I felt a tingling in my arms and a clutching in my chest. Tears came to my eyes as I watched them run freely down her cheeks. We sat this way for a while, living in the unbearable pain of her loss.

I thought of this moment when listening to Francine Lapides, in her terrific course "Keeping the Brain in Mind," explain the neurophysiology of empathy. It was an "aha" moment for me. Empathy is a commonly used word in mental health, and I admit to having used it for years without really appreciating its meaning.

Empathy, she explained, is largely mediated by a structure called the insula. It is predominantly a right brain structure that connects to the visceral organs-the heart and intestine. It also connects the brain with the skin and mediates sensations of touch and temperature. It is responsible for what is commonly referred to as a "gut feeling." Empathy, then, in its truest form, means to literally feel what another person is feeling.

Daniel Siegel, in his paper Mindful Awareness, Mindsight, and Neural Integration defines empathy as "the capacity to put yourself in the mental perspective of another person." It is not an intellectual understanding, as in "I understand how you feel," which is primarily a left brain activity.

True empathy, an actual physical experience, is somewhat rare. Empathy has healing power, both for the listener and the person being heard. It represents a profound attunement between two human beings. It is something to strive for in all relationships.

With Emily I wondered aloud if getting pregnant so quickly had prevented her from doing the difficult work of grieving the loss of her first child. She said to me, "I feel like I can't give all of myself to Michael. I have to hold back to protect myself."

At that visit with me, perhaps fortified by our moment of connection, of true empathy, she found the courage to face this task of grieving. She recognized it was critically important not only for herself, but for her relationship with her infant son.

Wednesday, September 15, 2010

Advice to Parents: Remember to Breathe

There is a well know saying in medicine that before doing CPR you should first check your own pulse. This very important point was brought home to me several years ago. I was on my way to a meeting at Austen Riggs, a psychiatric hospital in Stockbridge MA, when I noticed a large commotion in the hall. As I came closer, I observed many panic stricken people standing outside an office where a woman was in dire straits, in fact taking her last breath. Many of them were psychiatrists with MDs after their names, yet they seemed paralyzed. Perhaps this was because they knew her well, perhaps because they were used to talking rather than taking action, or perhaps it was a combination of both.

A friend who knew I was a doctor asked if I would help. As a pediatrician, I had never done CPR on an adult, yet I immediately took over. I lowered her to the floor and began CPR while simultaneously giving tasks to the others in the room. People moved carefully and deliberately. There was no shouting, no throwing of objects. Not only did she live, but her brain survived completely intact. The statistics for this kind of survival are 2-3%.

I am convinced that her unlikely survival is due almost entirely to my ability to remain calm in the face of this crisis. This calm, in turn, allowed all the participants, each of whom performed an essential function in the resuscitation, to think clearly and to get past the panic that had paralyzed them to inaction.

This blog post, though, is not about CPR, but rather a response to a friend's comment on my facebook wall. I'm new to facebook and haven't been in touch with her for a while. She wrote: "Where were you last night when I needed the advice of a sane parent??? OY...11 and 8 plied with sugar (?) is NOT good...OK, breathe...!"

Those of you who regularly read my blog will know I'm not a great fan of giving advice. First of all, I can't really understand the situation without having an actual conversation. Second of all, I prefer helping parents find their way back to trust in their own natural instincts over telling them what to do.

Yet I didn't want to come across as cold or uninterested. So after giving it some thought, I replied, "breathing sounds like a good idea!"

Staying calm in the face of a stranger's medical crisis is one thing. I probably learned this skill in the course of my years attending deliveries and taking care of sick children. But staying calm in the face of your own child's distress is quite another.

In my experience, both as a parent and a pediatrician, I am convinced that seeing your child in distress, and particularly if that distress is directed at you, is the most dysregulating experience there is. Wild, out of control thoughts of epic disaster come unbidden. Rage, self doubt and other destructive feelings quickly cloud your thinking.

What if you could work to push those thoughts aside, and in a way analogous to meditation, concentrated on being in the moment, concentrated on remembering to breathe? It would help you focus on your child, and on the immediate task before you rather than its global implications.

This exchange led me to think about my experience saving that woman's life, and to the idea that just as taking your own pulse is the most important part of doing CPR, remembering to breathe is perhaps among the most important things to do as a parent when helping your child through a child size crisis, whatever it may be.

Monday, September 13, 2010

Value Those Early Months of Parenting

Today in the Boston Globe I have an op ed entitled By the book, but breaking a bond, that is based on a previous blog post about the Massachusetts law enforcing 8 week maternity leave. Already at six am there are comments, and as is common when one puts ideas out into the world, some are none to friendly.

My aim in writing this piece, as well as one aim of my book (today I am sending the complete manuscript to my editor-thus the long absence from my blog) is to call attention to the critical importance of parent-child relationships in the early months of life.

When I see older children for consultation for behavior problems, I often hear stories from mothers who struggled terribly when their children were very young infants. Sometimes the memories are vague, but these mothers recall vividly the sense of being completely alone.

The most dramatic example of this was a mother with severe post partum depression whose father suddenly died when her baby was three months old. Much to my astonishment she described being relieved by this event. It wasn’t because she didn’t love her father. Rather, in sharing the grief with her siblings, mother and extended family, she no longer felt so terribly alone. In order for mothers to be available for the kind of preoccupation their newborns require for healthy development, it is essential that they not be left alone.

If I were to give one piece of advice to mothers, families and our culture as a whole, it would be to recognize that while what a mother does with her newborn may look ordinary, it is in fact extraordinary and deserves to be valued as such.

The relatively new field of Infant Mental Health has recognized this fact. The organization Zero to Three offers this definition if infant mental health, which is thought to be a characteristic of the child. “The young child’s capacity to experience, regulate and express emotions, form close and secure relationships, and explore the environment and learn. All of these capacities will be best accomplished within the context of the caregiving environment that includes family, community, and cultural expectations for young children. Developing these capacities is synonymous with healthy social and emotional development.” Research, clinical interventions and policy all aim to support parent-child relationships in the early months and years.

My aim is not to make parents feel bad for working, nor to imply that mothers need to stay home for years. Rather it is to bring readers inside those critical early months. My hope is that our culture as a whole will support, value and nurture parents of young children, parents who have the awesome responsibility for raising the next generation.

Friday, August 27, 2010

Parenting Blog Posts with similar theme to Child in Mind

Being on vacation has led to a sparsity of blog posts, and now its full speed ahead with the book. I decided once again to borrow from fellow bloggers and post a few links. The first is to a parenting blog by child psychoanalyst Kerry Kelly Novick. This particular post, Wise parents a welcome sight on road trip offers an excellent demonstration of a parent holding a child's mind in mind.

Another is Reading the Baby's Mind by developmental psychologist Charles Fernyhough. Along with Elizabeth Meins, he is doing research that demonstrates the importance of parents thinking about their baby's mind in facilitating healthy emotional development.

A third, Small Steps by psychoanalyst Paul C. Hollinger offers an example of supporting a parent's efforts to reflect on the meaning of her child's behavior.

Tuesday, August 17, 2010

The Mess of ADHD Evaluation and Treatment

Two events today cause me to crash head-on into the terrible state of affairs that define ADHD diagnosis and treatment in our country. First, in my AAP SmartBrief, the daily listing I receive via email of important news stories related to pediatrics, I read this item Youngest in Class Get ADHD Label in USA today. The article states
Kids who are the youngest in their grades are 60% more likely to be diagnosed with ADHD than the oldest children, according to a study out today from Michigan State University, given exclusively to USA TODAY. A second study, by researchers at North Carolina State University and elsewhere, came to similar conclusions. Both are scheduled for publication in the Journal of Health Economics.
In my previous job,when the majority of my work consisted of seeing children who had been referred for "evaluation of ADHD" I commonly encountered children who were having their first structured school experienced. Many were among the youngest in their class. They were described as "impulsive." They found difficult to sit at circle time, and unfathomable to sit at a desk to do a written assignment. Yet parents would frequently tell me that the teacher had confided that while she wasn't supposed to make diagnoses, she was sure this child must have ADHD. The findings reported in this article confirm my suspicion that for many of these "ADHD evaluations" referred to me, it was the environment that didn't fit the child, rather than that the child had a "problem."

A few hours after reading this article, I received a phone call from the office manager from the pediatric practice I recently left. As I have written about in my blog, I changed practices to focus on working with young children and their parents in the setting of a community health center. This was in part because I was struggling with the expectation, in keeping with the standard of care in pediatric treatment of ADHD, that I fill many,many prescriptions without any opportunity to understand the complex life experience of these children.

I was sure to refer every child I had been seeing to an appropriate provider. Many of them would be followed, in keeping with the standard of care in pediatrics, by the other primary care clinicians in the practice. Some, who I felt needed more intensive help, I referred to an excellent child psychiatrist in my community. Just before I left, I learned that she had a new policy that she would only see patients for medication evaluation if they were engaged in psychotherapy. I thought this policy was very wise.

One patient, the office manager called to tell me, was very unhappy with this plan. (details,as always, have been changed to protect privacy) "He's never been in therapy before," his irate mother apparently told the office manager. I had a vivid flashback. Mother and father at opposite ends of the room, tense and angry. A small, thin 9 year old boy slumped into the corner of the exam table nervously chewing his nails. As his parents argued about his "laziness" he seemed to want to disappear into the wall. At our last visit together, however, his parents agreed that things were perhaps more complex than simply inattentive ADHD. They accepted my referral to the psychiatrist.

But apparently they had a change of heart. Just getting the prescription filled by their pediatrician was their preference. "He doesn't need any therapy." his mother said. Perhaps he doesn't. But I can be sure of what he does need. He needs someone to listen to him.

I am sad for these many children whose voices are not heard. It made me agitated to think about the state of affairs in children's mental health care that has led to a situation where countless children are mislabeled, their complex life experience tucked into vastly oversimplified categories.

Now I'm going to take a deep breath and go back to working on my book. In this task I immerse myself in describing a model of child development that acknowledges the importance of understanding children's feelings from the moment they are born. By letting children's voices be heard and recognizing the meaning of their behavior, we can facilitate their healthy emotional development. I can already feel my blood pressure going down!

Thursday, August 12, 2010

Comment on MA Enforcement of 8 Week Maternity Leave

It is not until about eight weeks of age that an infant has a fully developed capacity for mutual gaze. Then a baby looks directly into his mother’s eyes, while she, in turn, reflects back this loving gaze, cooing softly in response to her baby’s earliest communication. When a mother looks at a baby in a way that communicates with him, not with words but with feelings, “I understand you,” he begins to recognize himself, both physically and psychologically. He begins to be able to regulate his feelings. This mutual gaze, literally and figuratively being “seen,” actually facilitates the development of the baby’s brain.

The Massachusetts Supreme Judicial Court now has proposed to interrupt this newly emerging dance of co-regulation by ruling this week that woman workers are entitled to only eight weeks of maternity leave. This ruling applies only to women whose maternity falls under state law, and differs from the wiser federal Family and Medical Leave Act of 1993 which provides up to 12 weeks of unpaid leave and job protection.

Research at the interface of neuroscience and infant development is offering great insight into how mutual gaze actually grows the brain. Our knowledge about early brain development is derived from a combination of detailed video observations of mother-infant interaction and studies of the brain known as functional MRI. These imaging studies can actually see which parts of the brain are responsible for what behaviors. This research has shown that healthy wiring of the brain is contingent on attuned responses of caregivers. This attunement is not only in gaze but in touch, sound of voice and facial expressiveness.

When baby is born, the amygdala, the lower center of the brain that responds to fear and stress, is fully formed. The amygdala connects directly to the hypothalamus, which in turn connects directly with the parts of the body, like the adrenals, responsible for the release of hormones that lead us to experience the physical sensations of stress.

At about 2 months of age, another part of the brain known as the medial prefrontal cortex(MPC) begins to develop. It serves to regulate and control the smoke alarm. When a mother engages in this dance of co-regulation with her baby, she is wiring his brain, helping the fibers of the MPC to grow. The MPC continues to develop well into a person’s twenties. An infant’s brain, however, doubles in weight in the first year of life. A lot of wiring goes on in the third month.

When these connections are not well developed, intense emotions are not regulated. In the face of difficult feelings a person may be flooded with stress hormones. He may become overwhelmed by feelings of rage, anxiety or sadness.

Interesting research by Dr. Hilary Blumberg at Yale offers food for thought. Using MRI, she has found that adolescents with bipolar disorder have structural abnormalities in the amygdala and underdeveloped prefrontal cortex. She points to hopeful research using medication to rewire the brain to treat the emotional dysregulation characteristic of the disorder.

This is not to say that stressed early relationships inevitably lead to psychopathology. But doesn’t it make sense to do all that we can to insure that brains are wired well in the first place?

Important changes happen not only in an infant’s brain but also in a mother’s brain in her baby’s third month of life. When a mother sees her loving gaze reflected back at her from her baby, she develops a sense of competence. This trust in herself is critical in helping her face the many challenges ahead in her role as parent.

Certainly a mother who works full time is well able to facilitate her child’s healthy development if she is receiving appropriate support. But even under the best of circumstances, returning to work means that a mother will be stressed. Offering her the option for a full three months of what D.W. Winnicott, pediatrician turned psychoanalyst, referred to as “primary maternal preoccupation” seems an important and wise investment in the next generation.

Thursday, August 5, 2010

How to Grow a Child's Brain

Last week I took an amazing course at the Cape Cod Institute. The course, taught by Francine Lapides, was entitled "Keeping the Brain in Mind." Over the week, extensive evidence was offered to show how a parent's attunement with her child's emotional experience, or her ability to, as I have referred to elsewhere in this blog as "holding her child's mind in mind," leads to a capacity for emotional regulation and healthy emotional development at the level of structure and biochemistry of the brain.

At the end of the course, I rewrote a clinical vignette from an earlier blog post, Holding a Child in Mind, incorporating the language from the course. A very brief discussion of the structures of the brain responsible for regulating emotions will be necessary to make sense of the new piece, which follows below.

The medial prefrontal cortex(MPC), which is made up of the orbitofrontal cortex and anterior cingulate gyrus, is primarily responsible for emotional regulation. When a person has a well developed MPC he experiences a sense of emotional balance. He can feel things strongly without being thrown into a state of chaos.

The amygdala, the structure referred to by trauma researcher Bessel van der Kolk as the “smoke alarm of the brain,”, connects directly to the hypothalamus, which in turn connects directly with the parts of the body, like the adrenals, responsible for the release of these stress hormones, the hormones that lead us to experience the physical sensations of stress. Lapides describes how the medial prefrontal cortex, by virtue of its location, wrapped around the amygdala, literally hugs the amygdala. It serves to regulate and control the smoke alarm.

When these connections are not well developed, intense emotions are not regulated. In the face of difficult feelings a person may be flooded with stress hormones. He may become completely overwhelmed and unable to function. Thus in the face of fear, for example, with a well developed MPC, a person will experience the feeling, but his hormonal response will be turned down by the MPC so that he is not overwhelmed or paralyzed.

If, on the other hand, he does not have a well developed MPC, the amygdala will go off and he will be flooded with fear that he cannot manage. When the amygdala acts unopposed in this way, it impairs a person’s ability to make use of the higher cortical centers of the brain, meaning that he cannot think clearly in the face of overwhelming distress. In fact, the amygdala is overactive in PTSD and all anxiety disorders.

When a parent gazes into her baby’s eyes, she literally promotes the growth of her baby’s brain, helping it to be wired for a secure sense of self. The MPC has been referred to as the “observing brain.” It is where our sense of self lies. When a mother looks at a baby in a way that communicates with him, not with words but with feelings, “I understand you,” he begins to recognize himself, both physically and psychologically. This mutual gaze, literally and figuratively being “seen,” actually facilitates the development of the baby’s brain. As the MPC matures in this kind of secure loving relationship, the brain is wired in a way that will serve him well for the rest of his life. He will be able to think clearly and to regulate feelings in the face of stressful experiences.

The story of Sam and Jane illustrates the way in which supporting a parent’s efforts to hold her child in mind may actually promote the healthy development and growth of her child's brain.

Sam burst into the office, a two year old wild little bundle of energy. Squealing with delight, or was it distress-it was hard to tell- he ran from toy to toy not looking at me or his mother, and seemingly unable to engage with anything. His mother had brought him to see me in my pediatric practice because “he hits me, has explosive tantrums and I can’t take him anywhere.”

Jane sank into the couch in a way that suggested she was feeling discouraged and dejected in her role as mother. She needed to be heard. I sat on the floor, wanting to listen to Jane, but also to include Sam in the visit. At first, I focused my attention on her story, while Sam continued his frantic exploration of the room. Things had not been easy for her. Sam’s father had abused her and was no longer involved in thier lives. Jane was afraid when she felt Sam’s anger that he would turn out like his father. Of her own mother she said, “She was never there for me”. Jane was frustrated and bewildered by the fact that Sam could relate to other people, but seemed to reserve all his difficult behavior for her.

At the beginning of the visit, Jane made several awkward attempts to interact with Sam, but without success. She was anxious and her body language felt intrusive, which seemed to cause Sam to withdraw. However, as she opened up and shared more of these difficult, painful feelings with me, an interesting transformation occurred. Jane’s whole body relaxed and she leaned forward on the couch toward Sam. Sam, in turn, began to engage in more focused play. Jane and I talked about what Sam was doing, observing together how he was calming down. At first he talked to me, bringing me toys and naming them and describing what he was doing. But then he spontaneously ran over and gave his mother a hug. Her pleasure and relief were palpable in the room.

Sam began to engage her in his play, and to communicate with her. It seemed as if the very act of being held in mind by his mother served to calm him down. He could feel her thinking about him. She looked directly into his face, speaking with him in a soft intimate way. They were engaged in a private dance. As I observed this scene, I literally felt as if I was watching Jane growing Sam’s brain. By holding him in a loving way that reflected her recognition of him, I thought that I could see the projections forming from the MPC and reaching down to hug his amygdala.