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.

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
cafés 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.

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.

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.

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.