DSM-V, Warner and Winnicott

In today's Boston Globe I have an op-ed about DSM-V: " Warning label on a new diagnosis." Interestingly, while I wrote the piece before I knew anything about Judith Warner's new book, it reads like a rebuttal to her thesis.

I will try to have this be the last post to mention her. As an antidote to the distress her book has caused me, I have been reading a book by D.W. Winnicott, a pediatrician turned psychoanalyst who has been a very important influence on my work.

As a scholar with the Berkshire Psychoanalytic Institute, I read many of Winnicott's academic papers that were written for psychoanalysts. I wanted to read more of what he had written for a broader audience. Winnicott on the Child is a collection of his work, some of which addresses an audience of parents and some speaks to range of professionals who work with children. There are wonderful introductions by Benjamin Spock, T.Berry Brazelton, and Stanley Greenspan.

The book is full of riches. Here is just one example. Winnicott is addressing the change a woman experiences in her life when she becomes a mother.

Then, one day, they find they have become hostess to a new human being who has decided to take up lodging, and like the character played by Robert Morley in The Man Who Came to Dinner, to exercise a crescendo of demands til some date in the far-extended future when there will once again be peace and quiet; and they, these women, may return to self-expression of a more direct kind. During this prolonged Friday-Saturday-Sunday, they have been in a phase of self expression through identification with what with luck grows into a baby, and becomes autonomous, biting the hand that fed it.

All of this talk about how medication can protect the brains of young children makes me hypertensive. But when I read Winnicott's writing, which, though he does not use this language, is essentially about how relationships between people can protect the brain, I take a deep breath, relax, and think to myself "Now this is what life is really all about!"

Comments upon the release of Judith Warner's new book: We've Got Issues: Children and Parents in the Age of Medication

As I wrote in my previous post, I was quite disturbed at the implications of Judith Warner’s recent New York Magazine article, where she suggests that to deny medication to children is to let them suffer. Therefore, I was much relieved when I read an interview with her where she discusses her book that is coming out this week.

I fully agree with her main argument that children with mental health problems suffer, and that there is a severe shortage of quality mental health care services for children in this country. Her premise before she did her research, a premise which likely grew out of spending time immersed in the culture of wealthy, high achieving families, was that mental illness is a “mirage”, a sign of “cultural malaise.” After speaking with many parents and psychiatrists, she changed her mind.

But her original premise, in my opinion, was, so far off the mark that her ”soul-searching” journey, as it is referred to by her interviewer, still leaves her miles from a full understanding of the problem of over-reliance on medication for our nation’s children. As a pediatrician working on the front lines with children and families, and scholar of contemporary developmental theory and research, I offer a different view.

The combined forces of the pharmaceutical industry and health insurance industry prevent our culture from exploring meaningful alternative interventions. Had Warner spoken to researchers and clinicians in behavioral genetics, developmental psychology and psychoanalysis, she might have gotten a different view.

Emotional problems in children result from a complex interplay of biology and environment. Children may be born with a genetic vulnerability to a particular mental health problem, but the environment, and in particular the degree to which the parents can reflect and contain the child’s experience, have a significant role to play in how those genes are expressed. In other words, parents have the ability to positively influence their children’s development.

Like Warner, I believe there is a lack of empathy for parents whose children are suffering from a range of mental health problems. But empathizing with these parents, in my opinion, does not mean we should promote use of medication. True empathy for parents involves listening to them, giving them time and space to have their experience heard. Addressing children’s emotional problems in their full complexity is very hard work. It may involve exploring painful issues, in parents' relationship with each other and from parent’s own history. There are insufficient resources to help parents with this task.

The influences of the pharmaceutical industry, in promoting the idea of the quick fix, and insurance companies, favoring short, medication based interventions over more time consuming, relationship based ones converge to move parents away from exploring difficult but important issues. I would argue that over-reliance on medication for children allows our culture to shirk responsibility for truly listening to parents and children.


There are circumstances where use of medication for children is indicated. In fact, in my practice I have many children on medication for ADHD. But there is both an over-use of medication and an over-reliance on medication to treat complex problems.

We cannot, though Warner says we can, separate out discussions of treatment of mental illness from discussion of medication. The road to improved treatment for children’s mental health care involves health care reform, specifically loosening the grip of the health insurance industry and the pharmaceutical industry. We need to work towards creating a system that values early intervention, primary care and quality mental health care.

Drugs or No Drugs: Comments on Judith Warner's New York Magazine Article: Are Too Many Kids Medicated?

PART ONE

No parent wants to see their child suffer. It goes against human nature. Thus I found the implication of the last sentence of Judith Warner’s recent New York magazine piece Are Too Many Kids Medicated quite alarming.

Try preaching the noble beauty of honest suffering to a suicidally depressed 6-year-old. It’s probably fair to say he or she would choose happiness over authenticity any day.

She seems to be saying that our choice as parents is to let our children suffer or give them medication. It made me wonder, as one reader commented, whether she is under the influence of the pharmaceutical industry.

There is a third option. Being understood by a person you love is one of the most powerful feelings there is. The need for understanding is what makes us human. When our feelings are validated, we know that we are not alone. For a young child, this understanding facilitates the development of his mind and his sense of himself. Research at the interface of neuroscience and developmental psychology demonstrates that when a parent can “hold a child in mind’ without being overwhelmed by his or her own distress, he or she may influence a child’s development at the level of gene expression and biochemistry of the brain.

Being fully emotionally present with your child in this way is a very difficult task. Parents and other family members may themselves have suffered from similar problems, increasing their desperation to find a quick easy fix for their child’s troubles. Marriages are strained when children struggle, and parents then may not be able to rely on each other.

Under certain circumstances, when children are incapacitated by symptoms, medication may be indicated. But the choice is not between prescribing a pill or letting them suffer. As a society, we must support parents in their efforts to be fully emotionally present with their children. Parents are the ones who can best help their own children.

PART TWO

When addressing the question of overmedication of children, it is important to make a distinction between ADHD and the newer diagnoses such as pediatric depression and bipolar disorder.

ADHD is a diagnosis that has been around for well over 50 years. We understand a great deal about the neurobiology of the disorder. Stimulants, the medications used most commonly to treat the disorder, have a good safety profile. They have clearly been demonstrated to improve attention and organization. When kids struggle in school, self esteem suffers. These medications have been shown to improve academic performance(though studies of long term benefits are less optimistic) The major problem is our over-reliance on medication to treat complex problems. I address this issue in a previous blog post.

Pediatric depression and bipolar disorder are much less well understood, and the side effects of medications used to treat them are much more serious. As a pediatrician with over 20 years experience, I have no doubt that there are children who from a very young age, are chronically unhappy. In addition many families struggle with children who have explosive, irritable behavior. But there are other ways to understand and help these children that do not necessarily involve prescribing a pill. It is essential that we keep our minds open to alternative ways of thinking about these children other than that offered by the powerful pharmaceutical industry.
Please see my two pieces in the Boston Globe, Mind Altering Drugs and the Problem Child and A Dangerous Label For Children for further discussion of this issue.

Guilt, Blame and Responsibility

In my pediatric practice, it is not uncommon for a mother, given the time, to move quickly away from telling me about her child’s behavior problem, to talk about herself, sharing vivid stories of emotional distress from her own life. I may suggest that this distress could make it difficult for her to deal with the challenging behavior of her child. Rather than finding this
statement helpful, she might collapse back into her seat and exclaim in hopeless despair, “Then it’s all my fault!” I feel terrible when this happens. My intention had been to support her, not to blame her. I have thought long and hard about the reason for this reaction, and believe the source lies in the three closely related concepts of guilt, blame and responsibility.

Let’s start with guilt. Any parent will tell you that a hefty dose of guilt comes with the job. Where does this guilt come from? In large part from the natural but usually unspoken mixed feelings that parents have toward their children. Hundreds of parents, in the privacy and safety of my office, have told of being startled by the intensity of rage towards their young child for whom they also feel powerful love. A mother may even confess her disappointment that a difficult child who cries all the time is not the child she dreamed of when she was pregnant.

Yet her child expresses similar intense but opposite feelings. A wise toddler on a YouTube video tells his mother from his high chair,”I love you but I don’t like you.” And,like the mother who wishes for a different child, “I only like you when you give me cookies.” Strong opposing feelings are a part of any passionate relationship.

When a parent has these ambivalent feelings but does not acknowledge and accept them in herself, when a parent believes these feelings are “wrong” or “bad,” guilt soon
follows. The trip from guilt to blame is a short one. If parents feel guilty simply for having feelings, any suggestion that their behavior might contribute to their child’s development will naturally be heard as blaming them when things go wrong. If they feel guilty, they easily assume blame. This kind of guilt can be debilitating. Yet if we acknowledge and accept these mixed feelings in ourselves, rather
than being paralyzed by guilt, we can turn this whole idea on its head. Guilt can actually become a thingof value if we realize that “I’m guilty” can also mean “I’m responsible.” And “I’m responsible” also means “I can help.”

D.W. Winnicott, a kind of British Dr. Spock of the 20th Century, summed up these ideas in the following
way in Talking to Parents (Perseus Publishing, 1993): “I think on the whole if you could choose your parents… we would rather have a mother who felt a sense of guilt—at any rate who felt responsible — and felt that if things went wrong it was probably her fault. We’d rather have that than a mother who immediately turned to an outside thing to explain everything… and didn’t take responsibility for anything.”

Guilt and blame are negative words, and responsibility is a positive one. People generally feel good about themselves when they take responsibility for their lives. They feel empowered. But taking on theresponsibility for raising a child in a meaningful and effective way is not an easy task. In the setting of
fragmented families, financial stress or a parental history of abuse or neglect, it is especially difficult.Add to this a child with a challenging temperament, and the responsibility can easily feel overwhelming.

A child’s behavior is certainly not a mother’s fault. In fact, it may in large part be due to the qualities a child is born with. However, it is a mother’s responsibility to understand how troubles from her own life may affect her ability to respond to her child in the way that he needs. It important to address these troubles just enough so that she can move them off her child.

I continue to offer parents the opportunity to tell me about experiences from their own lives because I see again and again how this unburdens them and almost immediately helps them to feel competent in their parenting role, which in turn improves their child’s behavior. But this responsibility is an unfair burden to place on an individual parent if the society as a whole does not recognize both the difficulty and the value of effective parenting.

DSM-V and the Riley Murder Conviction

Carolyn Riley’s act of giving her daughter Rebecca an overdose of prescribed medication may have been the immediate cause of Rebecca’s death, the conclusion reached by the jury that convicted her of murder. Even if, as the prosecutor argued, Carolyn and her husband concocted symptoms of mental illness and the psychiatrist, who diagnosed bipolar disorder, was a gullible enabler, the real guilty party in this story is, in my opinion, our health care system. With our over-reliance on psychoactive medication to fix complex problems, we condone the actions of the psychiatrist. We have failed to create a system that values prevention and meaningful, relationship based intervention. If she didn't have the drugs, Rebecca would not have died.

A recent announcement by The American Psychiatric Association that it intends to include a new diagnosis in its upcoming fifth edition of the Diagnostic and Statistical Manual(DSM-V) has me feeling optimistic. The new condition will be called temper dysregulation with dysphoria(TDD). The hope is that new label will be used instead of the bipolar label, allowing clinicians to describe a serious behavior problem without committing children to a chronic lifelong disorder.

Gabrielle Carson, a child psychiatrist at Stony Brook University offers this perspective on the issue in an NPR piece.. Many of the behaviors associated with what is currently referred to as “bipolar disorder” were previously described as “conduct disorder”, She says, “If you’ve got something that is not a medical problem, insurance is not going to pay for it. Conduct disorder is bad parenting, lousy environment, poor supervision, you’re a bad seed. It ain’t a medical problem. Bipolar they’ll pay for.”

Concerned about the large numbers of children being placed on powerful medications with serious side effects, David Schaffer, a psychiatrist on the DSM-V committee, proposed to create a new diagnosis. The hope is that this new disorder TDD, will be understood as a biologically based disorder that does not necessarily need to be treated with medication.

What if, instead of being prescribed medication to control her young children’s behavior (all three were on psychoactive medication by age 3), Carolyn had received a different type of intervention, one that aimed to repair relationships? For example at the Yale based Minding the Baby program, Carolyn would have been given the opportunity, in the presence of a caring and non judgmental person, to consider experiences from her own troubled past that contributed to her difficult handling her daughter’s challenging behavior. That person would have worked with Carolyn and Rebecca together over time to support Carolyn in her efforts to think about her daughter’s inner world. Such interventions have been demonstrated to have a significant positive impact on a child’s mental health.

There is convincing evidence that psychoactive medication reduces problem behavior. But just as an Escher print offers two completely different ways to look at the same picture, research at the interface of neuroscience, developmental psychology and behavioral genetics offers a different paradigm from that offered by the pharmaceutical industry.

Problem behavior is a symptom. Children with behavior characteristic of bipolar disorder have difficulty with emotional regulation. Young children learn to regulate emotions in relationships. When people who care for a child can think about his experience of the world, when they can help him to contain intense emotions without becoming overwhelmed themselves, that child learns to manage himself in a complex social environment. A child may be born with a genetic vulnerability for difficulty regulating emotions. Responsive parenting, however, may alter the actual expression of these genes, and even change the chemistry and structure of the brain.

As a pediatrician, I understand why we are so quick to turn to drugs. Parents feel overwhelmed. The combination of a temperamentally difficult infant and a parent with few supports who may herself have been abused is particularly challenging. Mental health resources are severely limited. Parents are pressured by teachers, whose classrooms are disrupted by these children. Pediatricians, psychiatrists, parents and teachers are bombarded by intense marketing efforts of the pharmaceutical industry.

Just because a problem is biologically based does not mean drugs are the answer. Relationships, too, can change the brain. I hope we can get health care reform moving again and build a system that values prevention and early intervention. It is too late for Carolyn and Rebecca Riley. But let’s not make the same mistake twice.

Who Listens to the Doctor?

A recent editorial in the Boston Globe addressed the dearth of primary care physicians. The piece concluded: “Federal funding for new residency slots should follow reforms that address the underlying reasons - principally money - that lead doctors to choose to specialize.”Money is certainly important. But there is another obstacle to attracting primary care doctors that is more subtle, though perhaps equally important. Consider the following story.

Recently I had the opportunity to teach a group of pediatric interns and residents about contemporary child development research. As they filtered into the room, I overheard one young doctor wearing scrubs say to another, “I was up in the NICU (neonatal intensive care unit) all night - I’m going to sleep through this one.”

About halfway through the talk, I asked the group if they had ever been surprised by the things parents tell them in continuity clinic -the primary care experience doctors in training have where they follow children over a three year period.

I admit to having felt pleased when this doctor's hand shot up. She told the story of frustration trying to teach a mother how to control her three year old son’s increasingly explosive behavior. This young doctor explained how she felt like she was “beating her head against the wall” as the mother of the little boy seemed unable to follow through with anything she said. Then one day, what seemed to her “out of the blue,” the boy’s mother began to cry. She told the intern about the death of her own mother shortly after her son was born. She admitted to debilitating feelings of depression that made it hard for her to even be with her son, much less set limits as the doctor had been prescribing.

This mother’s unresolved grief was in the way of her ability to take in this young doctor’s “advice.” Her trust in the doctor, a result both of the relationship they had developed, and the implicit trust people often feel for their pediatrician, had enabled her finally to share these feelings of grief. If this problem had not been uncovered, it is likely that the intern’s continued efforts at “giving advice” would have failed.

I asked the doctor to tell us what she had been experiencing while this mother shared her story. She described feeling panicked and inadequate. Not only was she worried about the waiting room full of families who might have to wait longer if she got “stuck” with this grieving mother, but she didn’t know “what to do.” The idea that listening to this mother was actually exactly what she needed to do had not occurred to her.

This intern had conveyed to this mother that it was OK to talk about these difficult feelings. If doctors do not communicate this interest, it is not because they are not interested. It is because they fear that they will be inadequate to the task of “solving the problem.”

In addition, just as the mother needed to have her experience heard in order to be available for her child, this intern needed the support of her colleagues to help her manage her feelings. She was fortunate to have an opportunity to share with us her feelings about this upsetting experience.

To hold someone’s pain in the way that this intern had to do is not easy. Imagine hearing 10 stories of trauma and loss over the course of a week. It is very hard to hear these stories without having a place to share the burden. As a matter of self protection, doctors in training may not let on that they want to hear.

This dilemma occurs not only in training programs. Primary care clinicians are struggling under many pressures, including decreasing reimbursement necessitating more visits in less time to cover the administrative costs of accepting many different insurance plans. Doctors know the importance of listening to their patients, but don’t have the time or the emotional support to open up in this way.

Financial reward is critical for attracting doctors to primary care. In addition, our culture, including our medical education system, needs to value the role of doctor as listener, or these young clinicians will burn out before they even start.

On Not Giving Advice

"Parenting behaviors impact young children's development'" says an interesting study by Frances Glascoe, PhD and Shirley Leew, PhD in the February issue of the journal Pediatrics. Using well validated measurement tools, they demonstrate that the way a parent interacts with her child has an impact on language development as early as six months of age. In addition, specific risk factors, including multiple moves, more than 3 siblings and parental depression are associated with interactions less likely to promote language development. In the discussion, the authors suggest that "future research in parenting behaviors that affect child development is crucial," and that "in the interim, clinicians should advise parents routinely on the value of talking frequently with their children... and describing what they are doing."

This is an important study, supporting extensive existing research demonstrating the critical role of early parent-child relationships on brain development. But I wonder, if in the discussion, pediatricians might do well to borrow some ideas from our psychoanalyst colleagues.

Pediatricians are trained with a model of "giving advice." We are the experts and people look to us to be told what to do. Psychoanalysts, on the other hand, are trained to listen.

Being understood and having your feelings recognized by a person who is important to you is one of the most powerful experiences there is. When our feelings are validated, we know that we are not alone. I wonder if these parents in the study whose children were not on a healthy developmental path, parents who are clearly stressed, might benefit more from time spent sharing their feelings with an attentive and non-judgemental person, than they would from being given advice about talking more to their child.

As a scholar of psychoanalytic thought, I have applied a psychoanalytic model in my pediatric practice. Recently I sat with Ashley, the mother of 4 month old Brian, while her husband Tom held the baby and walked around the office. Ashely cried as she spoke of her debilitating depression. She shared her feelings of inadequacy as a mother when she was too overwhelmed to respond to Brian's crying. She did not want to increase her medication because she was breastfeeding, but she longed for some relief. She spoke of a strained relationship with her own mother, who she found to be cold and unhelpful. Two weeks later I again met with Ashley and Brian. Ashley described a complete transformation in their relationship. I watched the two of them exchange joyful smiles. I asked her what had changed. She explained that at our last visit, she had felt understood, both by me and by her husband. This understanding gave her the strength to be more responsive to Brian. In turn, she said, he seemed to be more calm.

Pediatricians, who are on the front lines with growing children and families, may understand child behavior and development better than any profession. Psychoanalysts understand how to use relationships to help people make meaningful changes in their lives.

I have been to several conferences with such titles as "Pediatrics and Psychiatry: An Essential Partnership" many of which end up being primarily discussions of how to work together around prescribing medication. My wish is for a collaboration entitled "Pediatrics and Psychoanalysis: An Essential Partnership." We have a tremendous amount to teach each other.