Drugging Children to Sleep

A recent study published in the journal Sleep Medicine revealed that most child psychiatrists prescribe medication for sleep at least once a month, despite the fact that no sleep medications are approved for use in children. The study was funded by Sanofi-Aventis, makers of Ambien.

Managing sleep is one of the greatest challenges of being a parent. It represents the first major separation and can be fraught with complex ambivalent feelings. As children get older, battles for control often play out around sleep. Most significant behavior problems are associated with major emotional dysregulation. Calming down sufficiently to fall asleep may be very difficult. Sleep deprivation, in turn, exacerbates emotional dysregulation. Children learn to regulate emotions in relationships with the people who care for them. Efforts to help children regulate emotions must focus on supporting these relationships.

The trend towards medicating away these complex sleep problems, rather than getting at the root cause, is, in my opinion, quite disturbing.

Consider the following story. I first saw Charles when he was three. His mother, Anne, described terribly disrupted sleep (details, as always, have been changed to protect privacy.) He would wake multiple times at night and scream for his mother who was, in fact sleeping right next to him. Even as she held him he would continue to thrash and cry out. His behavior was so wild and out of control that his parents feared he was having a seizure. To reassure both them and myself, I sent him to a neurologist, who after an exam and EEG, declared that there was "nothing wrong." He prescribed a tricyclic anti-depressant.

His mother threw the pamphlet about the drug in the garbage and arrived at my office horrified, yet ready to do the difficult work addressing this problem in a meaningful way entailed.

Charles had been a dysregulated baby since birth. In addition, as we came to understand in or time together, Anne had been abandoned by her own mother, who had severe mental illness. Not only had she been left alone in her crib as an infant, but as she grew up, her mother had not been emotionally available to her, though she had provided physical care. Anne recognized that in order to be emotionally available to Charles in the way he needed, she would have to address her own trauma.

With time and lots of hard work, Anne came to understand that Charles' neediness at bedtime was so disturbing to her that in a sense she was not there emotionally, though physically she was present. Once she felt supported and understood, she was able to be emotionally present with Charles at bedtime as well as other times that were difficult for him. Gradually the sleep disruption subsided. By the time Charles was in Kindergarten he was sleeping well and thriving in school.

There may well be a role for short term use of sleep medication for children in situations where families are spiralling dangerously out of control. But routine use, without careful thought, as was the case when the neurologist prescribed a tricyclic for Charles, represents a risky oversimplification of often very complex problems.

Toddlerhood, Teenagers and Winnicott's Wisdom

Psychoanalyst Peter Blos describes the "second individuation process of adolescence," referring to the way in which adolescence shares many qualities with toddlerhood in terms of developmental tasks. Sometimes when I listen to parents describe their struggles with their teenage children, I have an image of trying to contain a person, often bigger than themselves, with advanced thinking skills. The tantrums of adolescence involve not thrashing arms and legs, but rather words, often cruel and vicious words.

Once again D. W.Winnicott, pediatrician turned psychoanalyst, comes through with some words of wisdom that I believe can serve well to guide a parent through this challenging and often tumultuous period. He writes, in his book Playing and Reality

If you do all you can to promote personal growth in your offspring, you will need to be able to deal with startling results. If your children find themselves at all they will not be contented to find anything but the whole of themselves, and that will include the aggression and destructive elements in themselves as well as the elements that can be labeled loving. There will be this long tussle which you will need to survive.

This idea resonated with Pam, mother of 16 year old Eva, who had come to see me for a consultation. She described the following scene. Pam and Eva had planned to have a nice lunch together. Eva was busy at school and had developed an increasingly serious relationship with her boyfriend, Chris. Eva and Pam had always been close and both eagerly anticipated this opportunity to spend a bit of time together. Things started off well enough. Eva excitedly told her mother about the latest social happenings at school and about a paper she was working on.

But then over some little thing, Pam couldn’t even remember what it was when she told me the story in my office, Eva had exploded with a burst of venomous rage. “You never think about my feelings,” she’d started with, calmly enough. But when Pam tried to get her to explain what she meant, Eva’s anger only increased. Vicious insults started flying at her. Caught off guard, Pam found herself becoming defensive.

Their discussion escalated into a shouting match as they quickly paid their bill and left the restaurant. Pam, in an effort to get home without being in an accident, stopped talking to Eva, who, she felt, was becoming increasingly irrational in her verbal assault on her mother. Pam’s silence only further enraged Eva and she screamed at her mother, who held tight to the wheel, hands shaking.

They made it home and immediately went their separate ways. Pam called her husband. As he was not the recipient of the full intensity of Eva’s distress he was able to support his wife and help her to calm down. Eva closed the door to her room and called her boyfriend. Several hours later Eva emerged from her room. “I’m sorry, Mom, she said. I’ve been feeling so much stress trying to balance work and friends and Chris.” “I understand that this is a very difficult time for you,” Pam had replied. “But," she went on to say, "it is not acceptable for you to speak to me the way you did.”

Pam was feeling beaten down by these repeated interactions with her daughter. She had experienced what she described as a highly traumatic transition to adolescence. When she was 16, her parents divorced. She recalled seeking comfort from her mother, who was so bereft about her own circumstances that she was totally unavailable for any meaningful emotional support. Pam had descended into a serious depression and only many years of therapy had gotten her to a place where she could have her own family.

While she had been able to negotiate the prior stages of development with Eva, the intensity of feelings directed at her from her teenage daughter sometimes was too much to bear. I told Pam that she was doing just what she needed to do, namely withstand the full intensity of her daughters feelings , both the negative and positive ones, yet set limits on her behavior. Pam needed to show Eva that she loved and supported her daughter, but would not allow her destroy her mother.

Winnicott offers a hopeful look at the future if a parent has withstood the “long tussle”of adolescence. He writes, also in Playing and Reality

Your rewards come in the richness that may gradually appear in the personal potential of this or that boy or girl. And if you succeed you must be prepared to be jealous of your children who are getting better opportunities for personal development than you had yourselves. You will feel rewarded if one day your daughter asks you to do some baby-sitting for her, indicating thereby that she thinks you may be able to do this satisfactorily; or if your son wants to be like you in some way, or falls in love with a girl you would have liked yourself, if you had been younger. Rewards come indirectly. And of course you know you will not be thanked.

Thoughts on a Toddler's Declaration of "Mine"

As a child makes moves to assert his independence, he begins to test the limits of what he can and cannot do. Limit setting is not only about controlling your child’s behavior. It is about teaching the essential life skills of frustration tolerance, impulse control and emotional regulation. Setting limits helps children learn to manage healthy aggression.

“Mine” is favorite word of most toddlers. This word represents not greed, but rather joy in a newly emerging sense of self. Toddlers delight in their expanding language and motor skills and the power these skills give them in the world. Recently I was visiting a friend whose 20 month old son described everything he touched as "mine." Then he proclaimed happily, "Run!" as he toddled back and forth across the kitchen floor.

But imagine that your toddler sets his sight on your glasses and declares proudly, “mine.” In an appropriate way, you might calmly say, “No, those are Mommy’s. I need them to see.” Suddenly he is confronted with the fact of his relative smallness and powerlessness. If your child happens to be in a particularly vulnerable state, such as before lunch or naptime, he might become enraged that you, his beloved mother, have burst the bubble of his omnipotence. Unable to contain his intense feelings, he might lash out and hit you.

Feeling angry at such an assault is a natural reaction. Yet it is important to contain your own response and to recognize the two year old meaning of his behavior. What he needs from you at that moment is the assurance that you accept his feelings but that you will help him to contain and manage his rage. This might be in the form of a firm statement of “no hitting” or even a brief time out.

A toddler on a Youtube video who declares to his mother, “I love you but I don’t like you,” offers an example of the fact that intense but opposite feelings are a healthy part of any passionate relationship. John Bowlby has written extensively on this subject. His ideas are well summarized by Miriam Steele when she writes: ‘What distinguishes healthy individuals from unhealthy individuals is the extent to which the inevitable conflict between feelings of love and hate, often directed towards the same person, are controlled, regulated and so resolved. For children, Bowlby tells us this will develop naturally if young children have the loving company of their parents who put up with outbursts of hostility by showing that they are not afraid of hatred and conveying a belief that it can be contained and controlled.”

Neither Bad Parents nor Bad Seeds

As a pediatrician I have listened to many parents speak of their child in very negative terms. Dr. Richard Friedman, in his NY times article entitled Accepting That Good Parents May Plant Bad Seeds shares his patient's description of her "rude and defiant" teenage son. Like the parents in his piece, the parents of my patients have other children with whom they have had no such difficulty. The conclusion Dr. Friedman draws from this and other similar stories, is that perhaps these are simply "toxic" children.

I find this conclusion horrifying. Dr. Friedman's piece brought to mind two children from my pediatric practice who were described in similarly negative terms. These negative characterizations were openly discussed in front of them. Both were teenagers when I first saw them and for years had been identified as the "difficult child" in the family.

Rather than focus on whether or not these children had something "wrong" with them , I spent a visit with each mother alone(the fathers were welcome but didn't come) exploring what her experience of the child had been starting in infancy.

Both described very fussy infants who cried easily and did not like to be held. As they became toddlers these children were alternatively clingy and explosive. In addition they had many sensitivities to touch , taste and sound. These mothers recalled intense feelings of inadequacy. One mother remembered that she had similar sensory difficulties as a young child. She had suffered terribly as her own parents were drawn to her older and younger siblings who were much more easy going than she.

Yet when their children were young, these mothers did not have an opportunity to reflect on what was happening. Instead, a negative pattern of interaction was set in place. These mothers described becoming enraged with their children whose behavior in turn became more difficult. Marriages were strained and there were high levels of conflict and tension, all of which were increasingly blamed on this "problem child."

For both of these children the world did not feel like a safe, comfortable place from day one . But that does not mean there was something "wrong" with them. They needed more help than other children who did not have these biological vulnerabilities, to make sense of the world and manage their feelings. Research has shown that children learn to manage difficult feelings when their parents can reflect on and contain their experience.

The mother in Dr.Friedman's story describes her son as being "unsympathetic." It is in toddlerhood that children learn, by having their parents understand and contain their feelings, to think about not only their own feelings, but other people's feelings.

Rather than drawing the conclusion that this child was a "bad seed" I wonder, what were this child's particular biological vulnerabilities? What kind of stresses did his parents experience when he was very young? How did these stresses affect his parents ability to help him to learn to think about and manage his feelings? Only with this knowledge would I venture to understand how he has become the person he is today.

My two patients are both in therapy of their own. By the time a teenager has lived all those years being identified as a difficult child, and has not learned to think about his own and other people's feelings, he needs intensive help.

My patients are not "bad" children and their parents are not "bad" parents. Rather, they are children with biological vulnerabilities whose parents needed to work alot harder to help them learn to regulate their feelings.

In retrospect, these parents recognized that they needed someone to help them contain and manage their own experiences raising these challenging children. But they didn't have such help.

The difficulties these families faced were neither in the child nor in the parent, but in the relationship. When parents have support in their efforts to be fully present with their young child, their children feel understood. This understanding in turn helps them to manage difficult feelings. Behavior improves. Parents' sense of competence increases. A positive cycle of interaction is set in place. Development moves in a healthy direction.

Limit Setting and Discipline

As I am now devoting most of my creative energies to writing my book, producing two worthwhile blog posts a week(as Danny Carlat recommended for a successful blog) can sometimes be challenging. So I decided to borrow from a colleague, and instead post a link to a new article on the website of the Pacella Parent Child Center on Limit Setting and Discipline. Authors Alice Rosenman and Joan Musitano make many very important points, including the role of limits in teaching children to regulate emotions, and the importance of recognizing the way in which a child's behavior evokes feelings related to a parent's own life experience.

"Trust Yourself" The Wisdom and Challenge of Dr. Spock's Opening Words

Mary had found her center. After many months of struggling with uncertainty as a new mother, she spoke to me of a new found confidence. We had been working on the common challenges of having an infant- sleep problems, difficulty weaning, conflicts with her husband Gordon in their struggle to find their way as a threesome.

Based on our discussions, Mary had made some decisions about teaching her son Bennett, who was now one year old, to sleep independently. She had elicited Gordon's help in weaning him. Now that she was able to sleep more than three hours at a time, she could finally think clearly. The low grade depression that had plagued her since Bennett was born had lifted. Mary was positively joyful as she spoke of her sense of accomplishment.

A month later, when I saw her for follow- up, she again seemed crushed, plagued by self doubt. She rambled from question to question. She was scattered and unsure. "I need to know who to ask, what books to read," she said. "What you need," I replied, "is to find your way back to that person who was here last time, who believed in herself. Where did she go?"

Mary agreed with my assessment of the problem. She told of a week long visit with her own parents. She experienced her mother as highly critical and undermining of her abilities as a parent. This visit, she realized, had thrown her off center. She recognized how much better things went with Bennett when she had that center, when she felt sure of herself. We needed to work together to help her find that self confidence again.

Dr. Spock's opening words of his book Baby and Child Care in a way speak to the importance of positive self esteem in any significant human endeavor. Trusting yourself as a parent is critical because it gives you a strong place from which to act. Finding that center, that trust in yourself, as we can see from the story of Mary and her family, is not always easy. Thinking of Mary, I was reminded of a time when I was training to be a doctor and had lost that center.

I was a second year resident on rotation in the NICU. It started with a minor incident-a newborn who I had sent to the well baby nursery ended up having some difficulty breathing and had to be transferred to the NICU. But soon the insecurity and self doubt threatened to overwhelm me. My grandmother at the time was very sick in the hospital. I was distracted. The combination of her illness and my minor misjudgement was enough to throw me off center. It was a terrible feeling.

I sought out the help of one of my teachers, the director of residency training. He was very kind and sat with me while I wept in his office. He told me that a senior resident, someone who I considered among the most competent and confident, had the year before had a similar crisis of confidence. I remember he said to me, "You could be my kid's pediatrician any day." Within a short time I felt like myself again. That experience showed me with striking clarity how much I needed that self confidence to be able to effectively do my job.

Last week I was visiting with a new mother in the hospital. While we were talking the baby began to fuss. I recognized in myself a temptation to offer my interpretation-he needs to be swaddled, he needs to be fed. But I kept quiet and simply watched. She and her husband exchanged ideas about what the problem was. She stroked the baby's face, tried a different angle. He continued to fuss. She persisted, remarkably sure of herself given that she had been a mother for less than 24 hours. We continued talking and after some time had passed, we noticed that the baby was sound asleep. "You see," she said to me, clearly pleased with herself, "He was tired."

I hope she never loses that trust in herself. Given the enormity of the task of raising a child, is likely, however, that at some point she will be thrown off center. If this happens, I hope, both for her and her baby's sake, that she will always have someone there to help set her back on track.