Prevent Bullying and Violence by Nurturing Parents and Supporting Families

“Momma, have you ever felt like there’s a puzzle and there’s a piece missing and you find the piece and it fits? When I’m with the Maasai all the pieces fit.” This is a quote from my friend Roland, a seven year old boy, on a trip to Tanzania with his mother. He was on a safari and, using a stick, he was learning how the Maasai use spears to protect them from lions. His mother told me how at home in the United States, she always feels like she is apologizing for his aggression.

Her story made me think of many 2 year olds who I see in my pediatric practice. They come because they hit and are “too aggressive.” Their parents want help controlling the behavior. Once they feel comfortable talking with me, these parents frequently confess that when they see their child hit another child or throw a toy they have “visions of Colombine.”

We as a culture seem to be on a road to outlaw aggression. The fact is, however, that aggression is a normal, healthy feeling. Assertiveness, a quality generally considered to be a positive one, actually has a similar meaning, but looks different in a two year old than in an adult. Lacking the verbal skills to express intense emotion, Johnny, wanting the red truck another child just took out of his hands, may not have a calm discussion, but rather might grab the truck and whack the other child on the head.

Parents clearly have the responsibility to teach a child that such behavior is unacceptable. But, in order to avoid having a child grow up like Roland, with a sense that a piece of him is missing, it is essential that not only parents, but our culture, is accepting of the feeling behind the behavior.

In fact, the latest research at the intersection of neuroscience, behavioral genetics and developmental psychology is demonstrating that a parents’ ability to reflect and contain a child’s feelings will help that child learn to manage these feelings, and may change the way his brain handles strong emotions. He may be less likely to behave aggressively in the future. If, on the other hand, a child gets the idea that his feelings are “bad” and “wrong”, these feelings don’t go away. They just become disconnected from the child’s sense of who he is, like Roland’s missing puzzle piece.

If a child does not have a way to think about his feelings, he is likely to simply act them out. Children who continue, as they grow up, to behave in aggressive ways that are inappropriate for their age are often describes as “impulsive.” Impulsive literally means to act without thinking. A child needs to learn from the adults around him how to think about his feelings.

So where does this difficulty thinking about aggression come from? Many mothers and fathers reveal that they have experienced violence somewhere in their past. When Johnny whacks another kid with a truck, or hits them, it brings back a surge of feelings of intense stress and even rage. These feelings are completely unrelated to Johnny, but make it very difficult to think about Johnny’s experience from his two year old perspective. Other parents, like Roland’s mom, tell of having a sense from extended family and/or their social environment that aggressive feelings are bad.

Just as it is important for parents reflect and contain their toddler’s aggressive feelings, when children go to school and are behaving in unacceptably aggressive way it is essential to recognize the meaning of the behavior. Simply enforcing “bully –free zones” will not work. Often bullying reflects children’s experience of stress and violence at home. It may be more intense if as young children they did not learn to contain their aggressive feelings.

All of which points to two very specific needs. Our society must support parents in the challenging task of being fully present emotionally with their young children. We must provide a high quality and accessible mental healthcare system to support families in their efforts to help children who are struggling to contain and manage their aggression in the school setting. An acceptance of and respect for healthy aggression may in the long run decrease the risk of another Columbine.

Cell Phones and "Primary Maternal Preoccupation"

Recently I was on vacation at a pool with my kids. I noticed a father with his infant daughter who looked to be about 3 months old. Perched on a table in her car seat, she sat kicking and smiling. Her father faced her, but was talking on his cell phone. He distractedly shook the rattle hanging in front of her as he spoke in an animated way with the person on the other end of the line. His daughter continued to smile and kick for a while. Gradually, however, she slowed down. She became quiet. Then she began to fuss. Still on the phone, he made more intense efforts to engage her with the rattle. But he was not successful. Her crying escalated. Finally he had to abandon the cell phone as he needed two hands to take her out of the car seat. Then he picked her up and held her, walking around the pool in an effort to quiet her, which eventually he did.

I was thinking about this scene when re-reading about D.W. Winnicott's notion of what he called "Primary Maternal Preoccupation'(One shortcoming of Winnicott is that he essentially ignored fathers, so when referring to his work I only refer to mothers. To compensate for this inequality I refer to babies as "he"). This idea captures the way in which parents in a healthy way are completely absorbed with their young infant and attentive to his every nuance of expression. It is through this kind of mirror role that an infant begins to make sense of who he is.

Linda Mayes and colleagues, in fascinating research at the Yale Child Study Center, are examining the neurobiology of this maternal behavior and its effect on the developing infant brain. For example they have shown that oxytocin, which is present in high levels in a new mother, is connected to what under other circumstances might be called obsessive compulsive behavior, but in the setting of having a new baby is not only normal but highly adaptive both for mother and baby.

So what does this have to do with cell phones, which are now ubiquitous in our culture? Adam Phillips , in his biography of Winnicott writes:

When the infant looks at the mother's face, he can see himself, how he feels reflected back in her expression. If she is preoccupied by something else, when he looks at her he will only see how she feels. He will not be able to get 'something of himself back from the environment.' He can only discover what he feels by seeing it reflected back. If the infant is seen in a way that makes him feel that he exists, in a way that confirms him, he is free to go on looking.

When a parent is on a cell phone, he or she is "preoccupied with something else." It is certainly understandable that a person, who may have previously been absorbed with a successful career and is suddenly in the role of spending most of her time with a being that does not talk and requires enormous amounts of care 24 hours a day, would be drawn to the possibility of adult conversation. But I wonder if new parents are aware of the importance to a baby's development of that 'primary maternal preoccupation.' Perhaps if they were, they would consider spending a little less time on the phone.

DSM, Drugs and Labeling the "Troubled Child"

In this past week's New England Journal of Medicine there is an article with the captivating title Pediatric Mental Health Care Dysfunction. Gabrielle Carlson and her colleagues address the controversy over the new DSM V diagnosis Temper Dysregulation Disorder with dysphoria(TDD). They write: "No existing DSM diagnosis conveys the appropriate severity and complexity of these children's moods and behaviors: the "bipolar disorder" label was meant to provide a home for children who were "diagnostically homeless."

But why, I wonder, do young children need to have any label at all? What is the purpose of such a label? Dan Carlat in his new book Unhinged: The Trouble with Psychiatry has a wonderful chapter about the history of DSM, source of these labels, offering a balanced portrayal of the benefits and limitations of this so called "Bible of Psychiatry."

He writes, "DSM assigns each slice of craziness with a name and a number." When parents are struggling with a troubled child, there may be great comfort in having an answer. They may also have the idea that a label points to the correct treatment. But there are serious downsides to this approach.

Since the mid-1990's when a "small but influential group of child psychiatrists" proposed to label children with severe mood dysregulation as "bipolar" the number of children receiving this diagnosis increased 40 fold. Carlson writes: "These children, some preschoolers, were primarily treated with mood stabilizers and a new generation of antipsychotic drugs. But, as Carlson acknowledges in her article, the evidence for efficacy of the medications used to treat bipolar disorder in childhood, medications with very serious side effects, is "sparse at best." The argument that labelling leads to appropriate treatment falls flat.

Moreover, she offers the alarming research finding that "a recent study of large data bases of privately insured individuals showed that most young children prescribed antipsychotic medications did not receive adjunctive psychosocial treatment."

This past March I had an oped in the Boston Globe addressing the TDD diagnosis entitled Warning Label on a new Diagnosis. I describe what a child with severe explosive behavior looks like, and what "psychosocial treatment" might involve.

I saw 5-year-old Alex with his parents in my pediatric practice (details have been changed to protect privacy) for “explosive behavior and irritability.’’

One morning Alex’s father, Ben, called to Alex upstairs and asked if his younger sister could have some of his pancakes. There was a misunderstanding; Ben thought he said “yes’’ but Alex insisted he had said “maybe.’’ Alex came into the kitchen and found his sister eating his pancakes. He immediately began to scream, and threw her plate on the floor.

He hit his mother, Carla, who, overwhelmed with rage herself, grabbed him and carried him up the stairs to his room. There he attempted to kick the door down. After about 45 minutes, both Alex and Carla collapsed in tears of exhaustion and frustration. This type of scene occurred in their home several times a day.

I met with Ben and Carla alone, and they described Alex as a challenging baby from the start. Carla cried as she spoke of her own abusive father and her difficulty managing her anger. She decided to address these issues in her own therapy. Ben told of stresses in their marriage that they felt had resulted from having such a difficult child. Over time, as these issues were brought to light, Ben and Carla felt better equipped to help Alex contain and manage his frustration. Though the problems are far from resolved, a more positive pattern of interaction was set in place, and Alex’s development is on a healthier track.

In Carlat's discussion of DSM he writes, "The tradition of psychological curiosity has been dying a gradual death, and the DSM is part cause, part consequence of this transformation of our profession. These days psychiatrists are less interested in "why" and more interested in "what."

When young children are labeled with any diagnosis, the "why" is often not explored. Yet it is the "why" that offers the path to effective treatment. As I wrote in my op ed:

I hope that this new diagnosis will open up discussion about the meaning of these children’s behavior. Use of the word “dysregulation’’ is an important first step. Extensive research at the interface of developmental psychology and neuroscience has demonstrated that young children learn to regulate emotions in the setting of relationships with their caregivers.

A child may be born with a genetic vulnerability for emotional dysregulation. Responsive parenting, however, may alter the actual expression of these genes, and even change the chemistry and structure of the brain.

Emotional “dysregulation’’ is an accurate description of Alex’s behavior. DSM-V is primarily a descriptive document that does not address cause. However, if clinicians treating this new disorder think about emotional regulation as a quality that is learned in relationships, it may open up a path to considering meaningful alternative interventions.

Use of psychiatric drugs and not answering the "why" are two significant downsides to labelling to young children with a psychiatric disorder. I propose a third downside, in my opinion perhaps the most compelling reason not to label a young child.

In my blog, I have been writing about the ideas of D.W.Winnicott, pediatrician turned psychoanalyst. Another brilliant contribution was his notion of the "true self." A complex idea beyond the scope of a blog post, I will simplify it by saying that a child develops a healthy sense of self when the people who care for him recognize the meaning of his behavior, rather than substituting their own adult meaning. Parent's who receive a diagnostic label for their child inevitably go through a period of mourning. The child they had is gone and replaced by the child with a "disorder." For a very young child whose development is unfolding, his "true self" might be lost. Given that we know so little about either the diagnosis of bipolar disorder or the new temper dysregulation disorder, I would argue that the comfort of a label is never a valid reason to risk such a loss.

The "Transitional Space" and its Relevance to Pediatrics

When parents come to see me in my pediatric practice for a child's behavior problem and I begin to explore the parent's own life experiences, he or she may say in a resigned tone, "then its all my problem!"

D.W.Winnicott, pediatrician turned psychoanalyst and one of the main guiding influences on my work, is perhaps best known for his description of the "transitional object." A related idea, less well known, is of the transitional space. I have found this idea to be very helpful in locating where the "problem" is in response to such a reaction.

When my daughter was five months old, we bought her two soft puffalumps with a bell inside.(I knew to follow the advice I had been giving parents for years- get two so you can wash one) She and the toy, which, when she began to talk, she named "mousy," almost immediately became inseparable. When, at about age 2, she fell at the playground, she immediately cried out, "MOUSY!! Now 15 years old, the worn and tattered mousies sit on my daughter's bed and receive almost no attention, though I suspect she will take them to college.

Winnicott referred to the transitional object at the first "Not-Me possession." As a baby begins to become a separate person, but does not yet have the capacity to regulate himself in the face of difficult feelings, such as occur when separating at bedtime, he or she makes use of this highly valued object.

The "transitional object" is the physical form of the transitional space between a child and his parent. In this space a baby begins, with appropriate encouragement from his parent, to grow into a separate person.

So how is idea of the "transitional space" helpful in evaluating and treating "behavior problems?" Consider 18 month old Kevin, whose mother, Amy, brought him to see me because "he hits too much." The three of us sat on the floor. Kevin played while we spoke. When he became restless and threw a toy at his mother, she had a vivid memory of having been slapped across the face by her father as a child. She realized that she would retreat emotionally when Kevin hit her, even physically leaving the room when it happened at home. The "problem" was neither in Kevin nor in Amy but in the transitional space between them. His experience as a healthy toddler with normal aggressive feelings met her experience of trauma.

Kevin was certainly contributing his share to the problem. The hitting was getting worse, perhaps beyond the level of what might be considered "normal". He had a very persistent temperament and was repeatedly testing Amy, likely looking for help managing his feelings rather than the emotional abandonment he was experiencing.

By sitting on the floor as a threesome, we were able to be in this transitional space, which is easier to see when there are three people. Only then could we gain a true understanding of what was wrong and begin to know how to solve the problem. Addressing either Kevin's behavior alone, or Amy's history alone, would not offer this opportunity. Certainly giving advice about how to do a "time out" would have missed the point. Amy was an intelligent woman and had access to the myriad of parenting books and articles that explain how to set effective limits. Only when she was able to understand the meaning of his behavior, both for him and for her, was she able to respond appropriately. She knew what to do.

So when I listen to the story of a "difficult" child I think of the problem as being neither in the child nor in the parent. The location of the problem is in the relationship. We can come to understand it by being in the transitional space between these two very close yet separate people.

New Paradigm Needed for Primary Care

A recent blog post of mine, in which I describe a visit with a family whose toddler was not sleeping, was reposted on another blog, kevinmd.com (which offers an excellent collection of articles related to health care). It received the following comment:

How exactly does a general pediatrician bill for a “full 50-minute visit” to discuss toddler sleep problems. No insurance company would pay for it anyway. Most private practice pediatricians would be out of business with this sort o advice. This doesn’t seem very realistic for the general pediatrician

Another wrote that, "This is exactly the kind of visit that can be delivered with a cash-only practice."

This is absolutely not true. I have been taking care of children in this way for many years in the setting of a busy small town pediatric practice. All insurance companies reimburse for a 50 minute visit for a behavior concern. I use standard pediatric billing codes. As I am the identified "behavioral pediatrician" in the practice I devote several hours a week to these longer visits. For many years I did this in addition to the full range of pediatric care, including check-ups, ear infections, sick asthmatics, etc. About 4 years ago I stopped doing primary care, not because this model of care did not work, but only because the needs of my 2 school age children made taking call very difficult.

This rather angry fatalistic attitude of these two readers brought to mind a terrific article from last week's New York Times entitled Delivering Better Primary Care It addresses the impending onslaught of 40 million new patients into a primary care system that is already overburdened and undervalued. Much of the article is devoted to an interview with Dr.Richard J. Baron, who has written extensively on the subject and has developed an innovative model of care for patients with chronic illness. I quote here in its entirety the end of the interview.

Q. What are the lessons from your experience?

A. I think that we primary care practitioners need to think about redesigning our practices not so much around the payment system but around what we think are the opportunities to add value to our patients. It’s going to be a different kind of primary care in the future. If we free ourselves to ask what we can do to make a difference for patients, I think we will find ourselves full of ideas.

The policy people on the other hand have to figure out how to encourage people to unlock themselves and give better value in primary care. They cannot expect that to happen in a system that so punishes people who are trying to do this.

People do not make the best doctors or policy people or advocates from a position of anger. We have to think more about what we all want and how we can move toward that.

I wholeheartedly agree with Dr. Baron. I have written at length in my blog and elsewhere about the wealth of research demonstrating how supporting early relationships will promote children's healthy emotional development. It is imperative that we find a way to apply these ideas on a large scale in the primary care setting. This will involve some significant changes, in the medical education system, in the way primary care is reimbursed and in the value placed on listening. But simply saying that it won't work is not an option.

Holding a Mother in Mind

This past week in my pediatric practice I saw, with their babies, three mothers who all described highly troubled relationships with their own mother. The relationships were full of grief and loss (to protect privacy, I will not give any details). Now mothers themselves, they were struggling. Their babies were clingy and irritable. They were poor sleepers, waking many times a night to nurse. They refused to take a bottle.

John Bowlby, under the influence of Charles Darwin, described the essential role of attachment relationships in survival. He spoke of a child's need for what he called a secure base, from which to explore the world and grow into a separate person. He similarly recognized the need for a mother to have a secure base of her own in order to provide this for her child. In a 1980 lecture entitled "Caring for Children," reprinted in his book A Secure Base, he said:

I have referred to the ordinary sensitive mother who is attuned to her child's actions and signals, who responds to them more or less appropriately, and who is able to monitor the effects her behavior has on her child and to modify it accordingly...This is where a parent, especially the mother who usually bears the brunt of parenting during the early months or years, needs all the help she can get-not in looking after her baby, which is her job, but in all the household chores...In addition to practical help, a congenial female companion is likely to provide the new mother with emotional support or, in my terminology, to provide for her the kind of secure base we all need in conditions of stress and without which it is difficult to relax.

In some cultures an extended family can fill this role. A supportive grandmother can be very important. If a new mother holds in her mind a warm loving relationship with her own mother, even the grandmother is not nearby or even if she is deceased, this relationship can provide the secure base she needs when she becomes a mother.

But these three mothers did not have this secure base from which to parent their young child( and they certainly didn't have help with household chores!!)

Sometimes when I sit on the floor with these mother-baby pairs, and listen to the mothers' story while the child explores the room, I feel that I am in a way in the role of good grandmother. I give a mother time and space to relax and be heard with the hope that this will fortify her in her efforts to be a secure base for her child.

One mother came in with her toddler, collapsed on the couch and proclaimed,"He's having a terrible day." Her son was very fussy and easily exploded in frustration. But as she and I spoke, he seemed to relax. He climbed off her lap and explored the different toys in the room. At a few instances we could see that he might lose it, such as when his mother told him not to draw on the table with markers, but she was able to redirect him without precipitating a tantrum. When towards the end of our 50 minute visit I commented at how well he had done, she agreed that he was much more calm than he had been the rest of the day.

I am certainly not alone with this idea. The field of infant mental health grew out of the work of Selma Fraiberg who, in her groundbreaking 1974 paper, Ghosts in the Nursery, describes what was termed the ‘Infant Mental Health Program”. A staff of experienced psychologists and social workers went into the homes of mothers who had been abused. By forming a close connection in a supportive and understanding way while these mothers were interacting with their children in their own home, they were able to significantly improve the parenting capacities of these traumatized mothers. The most important part of this intervention turned out to be the relationship between the therapist and the mother. But it was different from therapy with the mother. The aim of the intervention was to help the mother to connect with her child in a meaningful way. Daniel Stern, Tessa Baradon and Alicia Lieberman, among many others, have continued and elaborated upon this tradition.

The difference between my practice, however, and that of infant mental health practitioners, is that parents come to a pediatrician expecting "advice" about what to do. The slew of parenting books and articles with such titles as "How to Get Your Child to Listen" or "Seven Essential Steps for Effective Discipline," support this way of thinking. The father of one of these babies became very frustrated when after two visits I had failed to "make the baby sleep at night."

Our culture's endorsement the use of psychoactive medication for very young children similarly promotes the idea of the "quick fix." The parents of one of these babies were so convinced that his irritable nighttime behavior was actually a seizure that I referred them to a neurologist. After an EEG determined that there was, in the neurologist's words, "nothing wrong," he recommended a tricyclic anti-depressant.

My sense is that our culture is moving away from a simplistic, "quick fix" view of mental health, which has been promoted by the combined influences of the pharmaceutical industry and health insurance industry. I hope that the wealth of knowledge about human development, and the critical role of early relationships in promotion of mental health, emanating from the discipline of infant mental health, will continue to penetrate throughout our healthcare system.

Mindful Psychopharmacology

I was pleased to read the overwhelmingly positive response to Daniel Carlat's New York Times Magazine piece Mind Over Meds in the letters to the editor, including my own.

Perhaps we are at the end of an era where, under the influence of the pharmaceutical industry and health insurance industry, clinicians prescribe psychoactive medication in 20 minute visits, with minimal attention to the experience of the person they are treating.

I am not "against" psychoactive medication, which can, in certain circumstances, offer significant benefit. Framing of the discussion as being pro or anti-medication leads to antagonism and polarization, which is not useful. Rather I would advocate for "mindful" use of medication.

David Mintz and Barri Belnap, psychiatrists at the Austen Riggs Center, in a 2006 article in the Journal of the American Academy of Psychoanalytic and Dynamic Psychiatry propose the term "psychodynamic psychopharamcology." Such an approach looks at the patients experience as a whole rather than focusing exclusively on symptoms and dose of medication. They reference a 1996 NIMH study showing that patients who had a good relationship with their doctor and took a placebo had a greater reduction in symptoms than patients who had a poor relationship with their doctor and received an active drug.

Mintz and Belnap quote Sir William Osler, the father of modern medicine, who said, "It is much more important to know what sort of patient has a disease than what sort of disease a patient has." In the conclusion, they write,

A straightforward "scientific" approach to prescription establishes a "rational" basis for treatment choice, but runs the risk of neglecting the unique impact of the patient's subjectivity, failing to attend to the patient's authority and missing the importance of relationships and of meaning to cure.

Both Carlat and Mintz's articles focus on use of medication in adults. For children the issue is equally important and significantly more complex. Family and developmental issues must be taken into account.

For example, a 10 year old boy I treated did very well initially on stimulant medication. As he entered adolescence, he began to display developmentally appropriate argumentative and occasionally oppositional behavior. His parents attributed his behavior to a "symptom" of his ADHD. All family conflict was channeled into discussion of his dose of medication. In turn he became increasingly angry, perhaps because his experience was not recognized and his legitimate feelings attributed to a "disease." The long term consequences on this boy's development of such behavior cannot be good. Dr. Mintz, in his work with seriously troubled young adults, has seen up close the ill effects of disregard for a child's developmental context, and in his words,"funnelling" of all family problems into a child's medication.

Kyle Pruett,a child psychiatrist at the Yale Child Study Center, has an eloquent discussion of this subject in Pediatric Psychopharmacology: Principles and Practice.Two Harvard psychiatrists, Peter Chubinsky and Nancy Rappaport, have an article in the 2006 Journal of Infant, Child and Adolescent Psychotherapy entitled, "Medication and the Fragile Alliance: The Complex Meaning of Psychotropic Medication to Children, Adolescents and Families"


I hope that clinicians who prescribe psychoactive medications for children, including both pediatricians and child psychiatrists, will incorporate "psychodynamic psychopharmacology" into their practice, and think about the complex meaning of medication for children and their families. Equally important is that our culture change our expectation, and accept the limitations, of the role of medication in promotion of children's mental health.

Resource for Parents

This will be a very brief blog post, simply meant to call attention to a valuable resource for parents. The Pacella Parent Child Center, which is located in New York City, offers the kind of support for parent-child relationships that I write about in my blog. The website also offers articles for parents on such common challenges as post partum depression, crying, sleep and separation issues.