Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary developmental science can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Friday, December 30, 2011

Baby Docs Need Time to Listen to Parents

The American Academy of Pediatrics(AAP), the major organization representing pediatricians in this country, has just issued an important policy statement: Early Childhood Adversity, Toxic Stress and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health.

Citing a large body of evidence on the long-term effects of "toxic stress" in early childhood, on not only psychological health but physical health, they address the pediatrician's role in promoting first relationships that can be protective against the effect of this stress. They write:
In contrast to positive or tolerable stress, toxic stress is defined as the excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships..toxic stress early in life plays a critical role by disrupting brain circuitry and other important regulatory systems in ways that continue to influence physiology, behavior, and health decades later.

It is the absence or insufficiency of protective relationships that reinforce healthy adaptations to stress, which, in the presence of significant adversity, leads to disruptive physiologic responses... that increase the risk of health- threatening behaviors and frank disease later in life.
Much of the evidence they site comes from what is referred to as the ACES study. On ongoing study begun in 1995, it documents the close correlation between adverse childhood experiences, including abuse and neglect, parental mental illness, substance abuse and family discord, and long term health outcomes, not only in the form of mental illness but also chronic illnesses such as obesity, diabetes and heart disease. The study is a collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente's Health Appraisal Clinic in San Diego.

Not to toot my own horn, but this is exactly what I have been writing about on my blog for the past two years and in my book Keeping Your Child in Mind.

For example, a post from March 20011, Early Relationships and Brain Development as the Core of Medical Practice describes an outstanding pediatric practice in California run by Dr. Nadine Burke, that incorporates the ACES study into the everyday care of children. I raise the issue of the emotionally challenging of this work for the doctor, who in the absence of a culture that values careful listening, may suffer from "burnout" taking in so many stories that often involve significant trauma. The beauty of Dr. Burke's program is not only that they take the time, but also that the culture of the practice supports collaborative care. Multidisciplinary team meetings give clinicians an opportunity to share not only ideas and insights, but also the burden of carrying these stories.

One place where the AAP policy falls short is in describing exactly what implementation would look like in a pediatric practice. This policy states
Because the essence of toxic stress is the absence of buffers needed to return the physiologic stress response to baseline, the primary prevention of its adverse consequences includes those aspects of routine anticipatory guidance that strengthen a family’s social supports, encourage a parent’s adoption of positive parenting techniques, and facilitate a child’s emerging social, emotional, and language skills
It then goes on to list some programs. But what does the pediatrician actually do? The bottom line is taking the time to listen. As I write in my book
Being understood by a person we love is one of our most powerful yearnings, for adults and children alike. The need for understanding is part of what makes us human. When our feelings are validated, we know that we’re not alone. For a young child, this understanding helps develop his mind and sense of himself. When the people who care for him can reflect back his experience, he learns to recognize and manage his emotions, think more clearly, and adapt to his complex social world.
The new policy statement recognizes the potential value of the relationships between pediatricians and the families they care for.
High expectations are grounded in the public’s deep respect for pediatricians as trusted guardians of child health.
As a culture we need to value the primary care clinician, not only in the form of payment equal to the more lucrative subspecialties, but in the form of recognizing the role of relationships in healing. It makes sense that if we are recognizing the importance of family relationships in preventing poor health outcomes, that we should recognize the importance of doctor-patient relationships in supporting these families.

When primary care clinicians take time to carefully listen to stressed parents, parents feel supported in their efforts to carefully listen to their children, thus promoting healthy development. In turn, our culture needs to support and value primary care clinicians ( and its not only pediatricians, the subject of this policy statement, but all those entrusted with primary care of children.) As the report wisely states:
Rather than continuing the current trend of “doing more with less,” as pediatricians take on a wide range of additional responsibilities, payment reforms should reflect the value of pediatricians’ time and knowledge, as well as the importance of a pediatrician-led medical home serving as a focal point for the reduction of toxic stress and for the support of child and family resiliency.

Friday, December 23, 2011

Early Relationships and Brain Development

The research and knowledge about how early relationships shape brain development has been exploding in recent years. Three new studies caught my attention. The more we know about this area, the more we recognize how important it is to support parents and young children in the early years when the brain is most rapidly developing and so most "plastic," or able to change.

The first study, using neuroimaging techniques, showed that children exposed to severe maternal depression since birth had larger amygdalas at age 10. Much research has shown that postpartum depression can have long term impact on child development. In addition we know that the amygdala plays a critical role in emotional regulation. Trauma researcher Bessel van der Kolk has referred to it as "the smoke alarm of the brain." It makes sense that when mothers, because of their own emotional distress, are not able to be attuned with their babies as the would wish, the centers of the baby's brain responsible for emotional regulation may not develop as well. So the amygdala is, in a sense, unchecked.

The take home message is not that mothers should feel guilty if they are depressed, but that they should get help. I have written in a previous post about the dearth of services for women with PPD and new initiatives to address this problem. I have added my efforts to the cause by starting the Early Childhood Social Emotional Health Program at Newton Wellesley Hospital where mothers struggling with a range of perinatal emotional complications can be seen with their baby.

The second study, is also about the amygdala: Amygdalar Activation and Connectivity in Adolescents With Attention-Deficit/Hyperactivity Disorder. Also using neuroimaging, these researchers showed that the amygdala was overactive in a group of teenagers with the diagnosis of ADHD. I have written previously about ADHD as a problem of regulation of emotion, attention and behavior. The authors of the study link this finding to the difficulties with emotional reactivity seen in teenagers with ADHD. If we combine these findings with the previous study, it seems that treating mother-baby pairs in the setting of postpartum depression might in fact prevent ADHD! Such a study, known as an intervention study, is yet to be done, but certainly it seems to make sense to place our efforts in that direction.

The last study comes out of the Minnesota Longitudinal Study of Risk and Adaptation, which has followed a group of children from birth into adulthood. They showed a link between secure early attachment relationships and satisfying romantic relationships in young adults. The results were affected by quality of social skills in preschool and having a best friend in adolescence. The authors conclude that early relationships are very important, but other relationships along the way to adulthood can influence the effects.

While this study is not about neuroimaging, if we think about how being in a successful romantic relationship as an adult requires a good degree of emotional regulation, we can make a connection. Secure early attachment relationships are characterized by attunement between mother and infant. When something is amiss, as in the case of postpartum depression, these relationships may develop a quality of insecurity. This may show itself in the brain as an overactive amygdala, perhaps with relative underdevelopment of the centers of the brain responsible for regulating the amygdala. These studies together offer insight into how brain development may affect later adult relationships.

These studies span the developmental spectrum, from childhood to adolesence and on to adulthood. With such far reaching implications, it certainly makes sense to put our efforts into helping these young brains to grow in a healthy way from the start.

Sunday, December 18, 2011

A Troubling Parenting Moment at the Airport

The little boy, who looked to be about two, darted away in a fit of giggles. His young mother, who seemed thoroughly worn out and exasperated, ran after him, grabbed him by the arm and said in a harsh whisper, "You must stand here!"

We were on line waiting to board a Southwest Airlines flight. For those of you not familiar with the Southwest system, there are no assigned seats. Rather, when a passenger obtains a boarding pass, a number indicates a place in line. Then before boarding, passengers line up according to the number they have been given. It is a very well organized system, but doesn't necessarily work for a two-year-old.

I've been thinking a lot about what happened next. While I do not know anything about this mother-child pair, I have imagined many reasons why the situation unraveled as it did.

The above scene repeated itself two or three times. The mother had a companion, another young woman about her age, maybe a friend or her sister, who was fully absorbed with her phone for a few rounds of chasing before she looked up and said to the boy, "Do you want to watch a movie?" Immediately he stopped his darting and stood quietly looking at the phone, but the woman said, "You have to wait til we get on the plane." He screamed and ran off again. This time he threw himself on the ground in the middle of the two lines of people (interestingly right at my feet-perhaps he sensed a sympathetic observer.) At which point his mother said in a loud voice, "If you don't listen, all of these people are going to tell Santa you've been a bad boy!"

I was horrified, and might have even been tempted to intervene (probably not a good idea in the absence of frank abuse) but fortunately at that moment they began to board the plane.

So what went wrong? I start with the mother's perspective. Likely she was experiencing a flood of shame and humiliation, as parents of young children do when they "act out" in public. On every radio interview I've had, I am asked about the dreaded "supermarket scene," another place where a child must conform to the rules under the watchful eye of the general public.

The fact is that the "public eye" is generally either sympathetic or too involved in their own life to even notice. Yet shame pervades. In this situation it must have been particularly intense, as the mother passed this shame on to her son. She put the experience of humiliation directly in to him with her comment about Santa.

Next, I go on to the four aspects of holding a child in mind, as I describe in my book Keeping Your Child in Mind: Overcoming Defiance, Tantrums and Other Everyday Behavior Problems by Seeing the World Through Your Child's Eyes

The first is to be curious about the meaning of behavior. I wonder if this boy had some difficulties processing sensory input. As I mention in a previous post, a recent study showed that sensory over-responsiveness occurs in 25% of cases of problem behavior. An airport is a very difficult place for a child with sensory processing problems. Or perhaps he had just had a difficult separation- an event that may precede a trip on a plane. Or he may simply have been tired or hungry.

The second component is empathy. His mother, likely because of her own distress(see step four) was particularly unempathic, not recognizing how even in the absence of the above possible stressors, standing still can be a challenge for a two-year-old.

The third component is regulating and containing behavior. The little boy likely felt very stressed by this out of control situation. He needed help containing his experience. The mother's companion was on the right track in offering the phone. He needed something that would help him to regulate himself. Reading a book, offering a movie or game, or even a snack, might have helped him to feel less out of control.

The last, and most difficult, is to manage your own distress. This mother might have been tired herself, might have been angry with her companion for being so unhelpful, or any countless number of feelings, in addition to the shame I describe above, that can get in the way of seeing things from your child's perspective. When a person is flooded with stress, the higher centers of the brain responsible for rational thought do not work well. Had she been thinking more clearly, it might have occurred to her that her companion could hold the place in line. She could have let her son run around before being confined to the plane. Likely the other passengers would have been fine with that.

It's a lot to think about for such a tiny moment. But it deserves this kind of attention, because repeated experiences of shaming are not good for a young child. Who says being a parent isn't the hardest job there is?

Monday, December 12, 2011

Limit Setting as Containment of Feelings

Two recent experiences have gotten me thinking about the concept of "containment." It is the third component of keeping your child in mind, an approach to supporting healthy emotional development that I describe in my book, Keeping Your Child in Mind. In its most concrete form it refers to the importance of setting limits on your child's behavior. For example, by giving a "time out" every time your child hits, you show him that this behavior will not be tolerated. In doing so, you protect him from the intensity of his feelings by making sure that things do not get out of control. When young children are so consumed with anger and frustration that they hit, they feel out of control, and clear limits help them learn to regulate and manage these difficult emotions. (Combining limits with empathy, as I describe in my previous post, is essential.)

The first experience was a radio interview I had last week on the program Radio 2 Women on WBCR in the Berkshires. My interviewer, Serene Mastrianni, was among the best I've encountered. She had read the book twice, the first time going right to the section corresponding to her own child's age, and then again from the beginning. She had given it some careful thought. She had begun to actively use the book, not only in her own family, but to support friends. She told me the following story.

One such friend, the mother of a 12-year-old boy, had called her in tears. Her son had just had an explosive tantrum and at its height, he screamed at her, " I know you hate me, but I didn't know Dad hates me too!" Her friend was devastated. Serene's response to her hysterical friend was (after, "you've go to to read this book") "sit with him find out what this is all about." So her friend, rather than reacting in anger or hurt, did just that. And with time, the story unfolded that he had been bullied at school. He was a very successful student, president of his class, and he had never had this experience. He was furious with his parents for having failed to protect him, even though in reality they knew nothing about it.

This story combined with the second experience, attending the Zero to Three conference,"the premier conference for professionals dedicated to promoting the health and well-being of infants and toddlers," this past week in Washinton, DC, led me to consider the deeper meaning of the term 'containment." At a lecture I attending on teaching therapists to work with parent-infant pairs, the speaker described containment as "tolerating and sitting with feelings until the meaning unfolds." This is exactly what Serene's friend had done.

Tolerating your child's feelings in this way can be very difficult for a parent, as your child's behavior, particularly when it involves either physical or verbal assault, may provoke intense reactions. But the rewards, as this story shows, are great. Containment requires that, for the moment, you put your own distress aside (the fourth component of keeping a child in mind.) The beauty of Serene's story is that she was able to help her friend with this challenging task. It points out that for parents to be able to keep their child in mind in this way, there must be someone keeping them in mind. That person could be a friend, spouse, family member, pediatrician, or therapist.

"What about positive feelings?" Serene asked. I love this question. Much attention is given in the parenting literature to negative feelings, such as anger, frustration and sadness. But meeting a child’s experience of excitement and joy is in many ways equally important in promoting healthy development. Failure recognize and contain joy may slip under parents' radar as the behavior that follows may not be disruptive. But a child brimming with excitement over an experience with a friend or teacher who is met by a distracted parent may feel unrecognized, as the above child would have been if rather than being listened to he were sent to his room for "talking back." A parent who is depressed may have particular difficulty meeting a child's joy. This is one of many reasons why it is critical for parents who are struggling with depression to get help.

Serene told of a time when her daughter came home in just such an excited state, and she busy with something and did not respond. Later that day, however, Serene recognized what had happened and said to her daughter, "you were really happy when you came home and I wasn't listening. I'm sorry. Come here now and tell me all about it."

In the everyday stress of life, there are many times when a parent will not be available to contain a child's feelings, whether positive or negative, in the way I have described. But this very process of recognizing such a moment of disruption, and subsequently repairing it, is, in itself, essential for promoting healthy emotional development.

Tuesday, December 6, 2011

Why "Defiant" Behavior Pushes Parents' Buttons

Recently NPR had a story about temper tantrums, describing a new study showing that the sounds children make during a tantrum indicate that they are primarily sad rather than angry. The written version of the story opens with description of tantrums as " the cause of profound helplessness among parents."

I thought this was an interesting choice of words, as I have always thought of tantrums as representing a sense of helplessness in children. In fact, in my over 20 years of practicing pediatrics I have told parents that, for the most part, tantrums are a normal healthy phenomenon. They occur when young children emerge for a stage of omnipotence in the first year to recognize that they are relatively powerless. An excerpt from my book describes the phenomenon.
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 he 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.
The NPR piece got me thinking that we often describe children's behavior in negative terms, which immediately sets up a relationship of antagonism and confrontation. A colleague of mine, Suzanne Zeedyk, wisely has suggested that we reframe "challenging" behavior as "stressed" behavior. Then the language itself puts us in a position to empathize with the child's perspective.

The word"defiant" is a perfect example of this negative language. That word(as well as "tantrums") is actually in the title of my book Keeping Your Child in Mind: Overcoming Defiance, Tantrums and other Everyday Behavior Problems by Seeing the World Through Your Child's Eyes. The first part of the title was my doing, as it comes from an important concept in contemporary developmental science. The subtitle was my publisher's doing, but I understand why it was chosen, as this is a common language. Perhaps, however, it is time to rethink that language.

Recently I was asked to do an email interview for a parenting blog about defiance. The interviewer also used the word "impudence," another highly negative word. I suggested that this word projects intentions onto the child that are likely not there. In fact, "defiant" behavior almost always has its origins in a feeling of being out of control. From the child's perspective, his experience is not being recognized or understood. In a way he is not "seen."

Herein lies the explanation of why defiance pushes our buttons. In a sense a parent is having exactly the same experience as the child. He or she is not being "seen" or recognized as an adult deserving of respect. A parent might have had other experiences of not being "seen,” perhaps by a spouse, co-worker or by her own parents, that makes her particularly vulnerable to getting upset about not being “seen” by her child.

In almost every instance of “defiant" behavior, if one digs a bit below the surface, there is a way the child is also not being seen, or a way in which her experience is not recognized. For a particularly dramatic example, a six-year-old was brought to my practice with a chief complaint of “defiant behavior”. Further history revealed significant trauma in the child’s life. An alcoholic father who had abandoned the child as a toddler had recently been making visits, at which time he was often drunk and very loud. Yet her feelings about visits had not been discussed until they came to see me for “defiant” behavior,” which was worse around bedtime.

This child began sleeping all night in her bed after a couple of visits with me. We discussed this experience, recognizing her need for her mother's company at bedtime for stories, comfort and reassurance. Once a child feels that he is being seen, that his experience is recognized and understood, the "difficult" behavior often evaporates.

In general, if there is increasing “defiance” it is important to take a step back and try to understand what feels out of control for the child. It might be that he is very sensitive to loud noises or taste, and battles around "making a scene” at a family outing or being “picky eater” are related to these sensory sensitivities. It might be that there is a new baby and everyone is chronically sleep deprived. Or there may be financial stress or marital conflict. Simply recognizing that these things are difficult for a child and acknowledging his experience, even if the stressors are still there, goes a long way in having a child feel understood, and in turn decreasing “defiant” behavior.

Limits on behavior are essential, and my book goes on to say that the above toddler must be taught that hitting is never OK. But understanding, empathy and managing our own distress are all equally important. Reframing "difficult" behavior as "stressed" behavior is an important first step.

Friday, December 2, 2011

When Time and Space is the Treatment

In my pediatric practice, it is not uncommon for a parent, given the space and time, to reveal a critical and unexpected piece of information. Consider these two stories, with details changed to protect privacy. Jennifer’s Mom was desperate for a change in her ADHD medication. A previous doctor had diagnosed her and now she was increasingly distracted in school. In telling me Jennifer’s story, Mom focused on all the different medications she had been on and how they had controlled her symptoms. Towards the very end of the 50 minute visit Mom almost casually dropped this information. “She’s wary of therapists because of what happened with DCF (Department of Children and Families.)” I asked why. Recently, Jennifer had told a therapist about her stepfather’s behavior and it had been reported as possible abuse.

Five year old Kevin’s Mom was distraught about his constant fighting with his younger sister. He always had to have everything first, his demands were escalating. They were having increasing difficulty getting out of the house in the morning. I saw them for 2 fifty minute visits. The first involved the whole family and we talked about some common approaches to managing behavior. I was struck by Mom’s level of distress, which seemed out of proportion to this fairly typical sibling rivalry. Towards the end of the second visit, when Mom was alone with Kevin, she quietly began to cry. I looked puzzled. She told me of the horrible accident that had taken the life of her older brother when she was a child. Her family had never mourned this loss. That trauma came flooding back now that she had two children of her own.

“If you ask questions you get answers-and hardly anything else.” This well know aphorism in medicine comes from a book, The Doctor, HIs Patient and the Illness by Hungarian psychiatrist Michael Balint. In this book he documents his experience running groups for primary care doctors. He writes of the “doctor as drug,” describing how doctors use themselves and their relationship with their patients as an important part of the care they offer.

Time and space, then, is the treatment. It gives patients a chance to say what is really important, the things that won’t come out if doctors just ask questions. For parents who feel stressed and alone, an opportunity to sit in a quiet room with respected and attentive listener for 50 minutes is invaluable. It gives them an opportunity to think about their child, rather than simply get advice about what to do. In both of these cases, telling their story was essential for effective treatment. For Jennifer, she needed an acknowledgement of the trauma of that experience with DCF, which now got in the way of her asking for help. Kevin’s mother recognized how her own unresolved loss interfered with her ability to respond effectively to her children. In a brief visit structured by questions, parents are unlikely to develop the comfort required to open up.

The world of business has its own saying: “Time is money.” For the private health insurance industry it is more profitable to cover a brief "medication check" than a 50 minute visit. Put this together with huge marketing efforts from the pharmaceutical industry and you have a big problem. Prescribing medication takes much less time than sitting with someone until they trust you enough to talk about what is important.

Primary care practices must have a large staff to manage the complexities of multiple different insurance plans. Office managers spend hours making calls and filling out forms to get insurance companies to give prior authorization for such things as MRIs and neuropsychological testing. In order for the practice to be viable and support this staff, the doctors are forced to see more patients in less time.

The interests of the private health insurance industry and the interests of children can stand in direct opposition to one another. As health care reform (I hope!) proceeds, the perspective of this non-voting population must be taken into account.

Friday, November 25, 2011

Sock Bump Anxiety Disorder? Understanding Children with Sensory Over-responsiveness

In the December issue of the Journal of the American Academy of Child and Adolescent Psychiatry there is an article, with an accompanying commentary, that encourages me to think that perhaps the discipline of psychiatry is making moves from the "what" to the "why" of mental illness. Alice Carter, a brilliant researcher at UMass Boston, has an article entitled Sensory Over-Responsivity, Psychopathology, and Family Impairment in School-Aged Children.

In their editorial in the same issue Cynthia Rogers and Joan Luby write:
This work suggests that developmental scientists and mental health clinicians should recognize sensorimotor processing as an important independent developmental domain and key area of challenge in early childhood that has tangible implications for behavioral and emotional functioning.
Interestingly Joan Luby has written about the validity of diagnosing major depressive disorder in preschool children, an idea about which I have grave concerns. I wrote, in a response in the Boston Globe when her work on this subject was first published:
My sense is that these children process the world differently. One mother described carrying her screaming son for hours until she realized that he didn't want to be held. Another mother said her daughter was "not cuddly" and difficult to feed. As they become toddlers, the issues change. I hear about what I call "sock bump anxiety," where many changes of socks are required to find the one with the right seam in the toes. "Fun" family outings to a county fair can end in disaster as kids become overwhelmed by all of the sights and sounds. Intense tantrums and meltdowns are frequent.
Now I wonder if Luby an I are more on the same page than I had thought. The question, in my opinion, should be not "what is the disorder" but rather "what is the expereince of this particular child and family?" Unfortunately, as Dan Carlat states in his book Unhinged: the Trouble with Psychiatry
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’.
My clinical experience is consistent with Dr. Carter's findings. I see young children with a wide range of behavioral concerns. Sometimes they have symptoms of anxiety. Others are "explosive" or "hyperactive and impulsive" Still others have rigid rituals, and teachers have raised concern about autism spectrum disorder. In almost every story, there are symptoms of sensory over-responsiveness. These symptoms are inevitably accomapied by problems of self-regulation and in fact have been called "regulatory disorders" in the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood–Revised(DC:0-3R). And as Dr. Carter describes, these symptoms are very disruptive to family functioning. Often siblings are the most dramatically affected when their needs are relegated to the back burner, as families struggle to avoid and then manage the frequent meltdowns that inevitably accompany these sensory difficulties.

I have wondered what it is that makes one child with sensory over-responsiveness and concurrent problems of self-regulation develop depressive symptoms, other autistic symptoms and yet another hyperactivity and attention problems. I suspect we will find that the gene(s) responsible for sensory processing are associated with different genetic vulnerabilities, and so the symptom takes a different path.

Occupational therapists have long recognized the significance of these problems, and many have advocated for adding a diagnosis of "sensory integration disorder" to the DSM list. Rather than debate whether sensory over-responsiveness is a disorder in and of itself, it is in my opinion, enough to recognize, as Dr. Carter has done, that it can be a significant problem for a child and family. Then primary care clinicians, mental health care providers as well as friends and family can offer the validation and support these families need. Waiting for a DSM defined diagnosis to emerge may narrow thinking and cloud our view of the complexity of the family's experience (Such a label maybe necessary, unfortunately, to bill insurance for services.) As I have said before on this blog, these "problems" of sensory over-responsiveness may be transformed into adaptive assets when children, validated and understood by their caregivers, develop the language skills and capacity for self-regulation that come with growing up.

Tuesday, November 22, 2011

A Small Town, A Little Boy, and a Terrible Disease

(This post was written for a former patient from my days of doing general pediatrics, who turned 11 on 11/11/11)

Charley was with his mother in my office for his three-year-old check-up. Having taken care of Charley since he was born, I knew his family well. They had relocated from New York to our small New England town. As often happens in a small town, we shared many other connections. Tracy, Charley’s mother, taught at the school my children attended. We had many friends in common. Shortly before this visit, I ran into her outside the community center after dropping my kids at camp. Tracy was 5 months pregnant with a girl. “How’s your summer going?” I asked. Her smile was huge. “Great!” she replied. “Sam (her older son) is in camp so I get to spend all this special time with Charley.” She looked over at him as he ran around on the grass. “I fall more in love with him every day.”

Charley sat quietly on the exam table as our conversation flowed easily from social events to sleep habits. He was generally healthy, but was in early intervention for low muscle tone and mild language delay. His language was progressing, and the physical therapist, Tracy told me, was not concerned. “But he’s having some trouble climbing stairs,” she said. This struck me as odd, as Charley was a very active boy in an athletic family, and I made a mental note. Later that afternoon, I called our local pediatric neurologist. “I should see him,” he said. “And send him to the lab for a CPK (an enzyme made by muscles).” I called Tracy. She and her husband Benjy decided that they preferred to go to a neurologist in New York, and would schedule their own appointment, but agreed to pick up the lab slip for the blood test.

One evening several months later I was on call, the only doctor in the office with a sick child. I was on the phone with the ICU doctor at the hospital when my nurse handed me a slip of paper.

Charley S.
Critical Value
CPK 21,000

An hour later I was home, having somehow managed to transfer the little girl. I held the message in my hand. I had never seen a CPK this high, the normal number being under 100. After anxiously pacing around for a few minutes, I paged the neurologist I had originally spoken with. “He has muscular dystrophy,” he said without pause. I hung up the phone, trembling. I would have to tell a family that their son was going to die.

I needed to speak with the neurologist who had seen Charley. But I didn’t know who it was. So I had to call Tracy. I tried to be calm, explaining that the test results weren’t quite normal and that I wanted the name of the neurologist they had seen in New York. She gave me his number and asked, “How abnormal are they?” “They are high”, I replied. “I’ll speak with the neurologist tonight and meet you in the office first thing in the morning.” “OK”, she said. I hung up the phone and said to myself, “She knows.”

I spent the next hour on the phone with the New York neurologist. He said it was most likely Duchene’s muscular dystrophy (DMD). He described the current prognosis as “wheelchair by 10, death by 20”. But he suggested that I share with Charley’s parents that current research in gene therapy might offer a cure in the next 10-20 years. He wished me luck. During the few minutes that I slept that night, I had tormented dreams about telling them.

Tracy came alone. Years later she told me, “I purposefully kept quiet that morning as Benjy kissed the kids goodbye and went off to work just to give him one more morning of a normal life. ”

The nurse led her to an exam room and reported to me, “She’s a little shaky.” “That makes two of us,” I replied. I took a deep breath and walked in the room. I sat next to Tracy and held her, both of us sobbing. However, I was sure to reinforce that there was hope- that current research offered the possibility of a cure.

After a few weeks of living in shock, Tracy and Benjy took action. They started Charley’s Fund, whose sole aim is to raise money for research to find a cure for DMD. In seven years they have raised over $17 million. In the Fund’s most recent brochure, they write, ”All that “plugging away” has led to a very exciting moment in DMD history: first-ever human clinical trials for DMD boys.”

Tracy told me of a recent visit to the neurologist. “The doc examined Charley and just blurted out "Wow...this is epic!" He could barely believe that Charley can hold his head off a pillow when lying on his back for 60 seconds. The fact that he can even jump off the floor, let alone a considerable distance, is amazing and I know that is due to the fact that we received his diagnosis early and started steroids, supplements, night braces, and a nightly physical therapy routine. I know many, many parents of DMD kids who were not diagnosed until 6 years old or even later because teachers, physical therapists, friends, even pediatricians tell them that all kids develop at their own pace and your son will catch up in time.”

I think often of that moment I stood looking at the lab slip. It was a last moment of calm before a collision between the small town doc and the family whose life would be forever changed. I sometimes wonder if it was the intimacy of the small town life that in some way led to the early diagnosis, and to the explosion of energy now propelling Charley’s family, and all the other boys with this devastating diagnosis, forward toward a cure.

Friday, November 18, 2011

Parenting in China: Academic Achievement or Empathy and Resourcefulness?

Recently I learned that a publishing company in China with the delightful name of "Good Morning Press" has purchased the rights to publish my book Keeping Your Child in Mind. I admit that China was the last country I expected to publish my book, which is in many ways the antithesis to the controversial book Battle Hymn of the Tiger Mother that received so much attention earlier this year. It made me wonder if, just as many Americans question the need to replicate the very rigid parenting methods espoused in the book in order to "compete with China," the Chinese (or at least some segment of the population) have recognized the value of instilling not high level skill, but rather empathy, flexibility, cognitive resourcefulness and social adaptation. The approach I describe in my book, based on over 40 years of developmental science research, points the way towards these qualities.

When Chua's book came out, I wrote the following post (I repeat it here, as it predated my Boston.com presence):

"All this talk about Amy Chua’s parenting techniques has me thinking about Brandon Fisher, the manufacturer of drilling equipment who President Obama recognized in the State of the Union Address for his critical role in the rescue of the Chilean miners. While I cannot claim to know anything about Fisher's upbringing, I do know a great deal about what qualities in a parent-child relationship lead to the characteristics he exhibited, namely empathy, flexibility and resourcefulness.

I wonder if the anxiety being experienced on a grand scale by American parents in the wake of Chua’s book is due to the fact that that while severe parenting techniques designed to achieve academic success may not be palatable, parents feel a void when it comes to finding an acceptable alternative model, as exemplified by the Boston globe op ed, The tiger mother roars, and slacker parents shudder.

John Bowlby, the father of attachment theory (no relation to “attachment parenting” as described by William Sears) describes the importance of a secure early relationships in raising a child who, in Bowlby’s words, is “self-reliant and bold in his explorations of the world, co-operative with others, and also-a very important point-sympathetic and helpful to others in distress.”

Contemporary research offers a close up view of a secure parent-child relationship that can instill these qualities. It involves a balance of empathy and limit setting. There are four key elements. The first is wondering about the meaning of a child’s behavior rather than responding to the behavior itself. The second is empathy. This is more than saying “I know how you feel.” It means actually feeling what your child is feeling, but reflecting it back to him in a way that says, “I know you’re upset, but we’ll manage.” The third is containing difficult emotions, often in the form of setting limits. Limit setting is about teaching the essential life skills of frustration tolerance, impulse control and emotional regulation. And forth, and perhaps most challenging, is doing all this without letting your own distress get in the way.

Lest this list cause a parent to feel overwhelmed by the enormity of the task, research of Ed Tronick, child development expert, offers hope. If parents are attuned with their child only 30% of the time, if 70% of the time you don’t connect with your child in the way I describe, as long as most disruptions are recognized and repaired, development moves forward in a healthy direction. In fact, disruptions and their subsequent repair are essential in instilling resilience, an important fourth attribute to add to Bowlby’s list. D.W.Winnicott, pediatrician turned psychoanalyst coined the phrase the “good-enough mother” to describe a mother who is not perfect, and in her very imperfection helps her child to manage life’s challenges in direct proportion to what he is capable of.

Chua’s book, in addition to creating mass unease in American parents, has raised fear regarding our ability to compete with China. Towards that end, raising a generation of Brandon Fishers, citizens with the qualities of empathy, flexibility, resourcefulness, and resilience, is essential. In order to accomplish this task, we must support parent-child relationships from the beginning. There is extensive evidence that children learn these skills in infancy, when the brain is making as many as 1.8 million neural connections per second.

Unfortunately our country does not value parents in this way. Our lack of support of early parent-child relationships is exemplified by our maternity leave policy that lags far behind other countries, as well as the rapid increase of prescribing of psychoactive medication to very young children. This second phenomenon is in turn inextricably linked with the very powerful health insurance industry and the lack of value placed on primary care and mental health care services.

Public policy to support early parent-child relationships is essential. For example, postpartum depression can negatively impact a mother's ability to be present with her child in a way that promotes healthy emotional development. Recently a new law was passed in Massachusetts that calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.

Contemporary research in child development offers an answer to the questions raised by Chua, both on a small scale: a model of parenting to follow, and on a large scale: a model of social policy to support parents in this task. I thank her for providing the motivation to address issues that are critical for the future of our children and of our country."

Perhaps this interest in my book implies that China (at least in some small way) has caught on to the importance of valuing parent-child relationships. If so, now more than ever is the time for our country to recognize the need to nurture these, in a sense, American qualities of empathy, flexibility, resourcefulness and resilience.

Sunday, November 13, 2011

Antidepressants in Pregnancy and Autism: A Possible Link

Studies abound that aim to answer both the question "What causes autism?" and "What is the reason for the increase in incidence and prevalence of autism?" A study published in the November issue of the Archives of General Psychiatry, Antidepressant Use During Pregnancy and Childhood Autism Spectrum Disorders caught my attention. As both the prevalence of autism and the use of SSRI's (selective serotonin reuptake inhibitors) have increased dramatically in recent years, and SSRI's are powerful medications that act on the brain, the findings do seem plausible.

Writing about research for a general audience, I want to say at the start that this is a preliminary investigation, one that simply raises a question. Pregnant women or those planning to conceive who are on these medications should not rush to go off them. The authors of the study are careful to say that, "The potential risk associated with exposure must be balanced with the risk to the mother or fetus of untreated mental health disorders." Untreated mental health disorders do pose a risk to mother and fetus. Women who are pregnant or of childbearing age and contemplating getting pregnant who have been on SSRI's may have a great difficulty getting off of them even if there is a question of risk to a fetus.

In this population based study done at the Kaiser Permanente Medical Care Program in Northern California, the researchers found
a 2-fold increased risk of ASD(autism spectrum disorder) associated with treatment with selective serotonin reuptake inhibitors by the mother during the year before delivery, with the strongest effect associated with treatment during the first trimester.
They found that there was no increase in risk for ASD if a mother had been treated for mental health problems but did not receive SSRI's. This finding attempts to answer the question of whether it is the depression or the drug that is associated with ASD. Their findings suggest that it is the drug.

The authors conclude:
Although the number of children exposed prenatally to selective serotonin reuptake inhibitors in this population was low, results suggest that exposure, especially during the first trimester, may modestly increase the risk of ASD. Further studies are needed to replicate and extend these findings.
My reaction to the study is not its implication for women who are pregnant now, but for young girls and adolescents who are being placed on these medications, often by pediatricians, for relatively mild symptoms. SSRI's have been shown to be effective for severe depression, and certainly in the setting of suicidal behavior, the urgent need for treatment may outweigh the potential long-term risk.

Recently I had the privilege to read an advance review copy of a book due to come out this April with the compelling title Dosed: The Medication Generation Grows Up. A well-researched book written by a journalist who has herself been on SSRI's since her teenage years, it shows how these drugs are often not a quick fix, but rather may be followed by a decades-long relationship with psychiatric medication. One particularly striking story is of a woman started on a SSRI at age 11 who, now pregnant in her thirties, is unable to get off them despite her strong desire to protect her unborn child from the potential risks of the drug.

Because these medications can cause such dramatic symptom relief, it is understandable how parents, physicians and teenagers themselves are drawn to them. Seeing your child in emotional pain is one of the greatest challenges of being a parent. However, in the absence of suicidality, holding them through these crises, with a combination of careful listening and quality psychotherapy, may in fact give them the tools to manage future crises they may encounter as they venture out into the world on their own. In my book, Keeping Your Child in Mind, the chapter on adolescence shows how these interventions can promote healthy emotional development.

Shortage of quality mental health care services, as well as lack of support for parents of teenagers, may make this kind of help difficult to attain. But now that this risk of SSRI's to a fetus is out there as a possibility, I believe it is more important than ever that we as a society make an effort to provide treatment for children and adolescents with mild to moderate depression that does not include prescribing psychiatric medication.

Monday, November 7, 2011

Supporting Fathers' Emotional Health is Essential for Children

Sometimes in my behavioral pediatrics practice I have the privilege of doing in depth work with a mother and father together. Recently I saw a four-year-old girl with "explosive behavior." After a number of session spent focusing on a range of issues, her father began to speak about his alcoholic, emotionally abusive father. He found himself full of rage, rage that he now recognized was unfortunately often misdirected at his daughter. Perhaps because of the trust he had developed in our work together, he accepted a referral to therapist, with the hope of being able to put his feelings of anger in their rightful place.

More often that not, however, fathers do not come to these visits. I hear stories from mothers of their spouse's terrible emotional stress. Often there is intense conflict between mother and father over discipline techniques. Because the mother is in the room with me, I can listen in depth to her story . But when I encourage the father to come so I can hear about his experience, there are many obstacles. Most common is "he can't get off from work." A close second is "he doesn't believe in this kind of help," or "he doesn't like to talk about feelings."

I hope that a new study published in the December issue (online today) of Pediatrics, Paternal Depressive Symptoms and Child Behavioral or Emotional Problems in the United States will encourage fathers to seek help, and motivate clinicians to strive to include fathers in treatment of young children with emotional and behavior problems. The study shows, not surprisingly, that paternal depression and other mental health problems affect the emotional state and behavior of children.

The literature on postpartum depression in mothers, and its long term effect on child development, has exploded in recent years. Yet services for women struggling with perinatal emotional complications are often hard to come by. Many people, as I describe in a previous post are working hard to address these needs. Unfortunately fathers have not received this kind of attention.

This past weekend my local paper ran a story Swedish dads swap work for childcare about fathers making use of Sweden's very generous parental leave policy. Sweden has the right idea, not only in generous paid parental leave, but also in supporting fathers taking on the role as primary caregiver.

We need to take a good look at why we have lagged behind on this front, despite significant increased presence of fathers in the lives of their growing children. This latest study published in Pediatrics shows that the time has come to pay attention. I for one will continue to give fathers of my child patients careful thought, and encourage their participation in treatment. The vast majority of parents, when they see that getting help for themselves will help their children, are motivated to do this difficult and sometimes painful work.

Wednesday, November 2, 2011

Creativity Needed in Balancing Family and Career

This past summer I wrote a post in response to a New York Times Op Ed that criticized women physicians who work part time. I concluded:
Being a mother is both an awesome privilege and an awesome responsibility. It is in a sense the greatest act of creativity. It makes sense that women who create in this way can also create their own professional lives. By embracing this creativity, both as mothers and as professionals, we can aim to find new and important ways to contribute to society, while at the same time being present in the lives of our children in ways that support the healthy development of the next generation
This idea holds particular relevance for me now, on the eve of starting a new job.

When I was in my late 20's, I had what in many ways was an ideal job. I was practicing pediatrics at Revere Community Health Center, an affiliate of Massachusetts General Hospital. I loved my colleagues and had a wonderful patient population. I was on staff at MGH and on the faculty at Harvard Medical School, where I had the opportunity to teach interviewing skills to first year medical students.

One of the best parts of the job was that I did supervision around my cases, a form of training usually reserved for mental health professionals, with Michael Jellinek, chief of child psychiatry at MGH. He helped me address the complex emotional needs of my most challenging patients and sort out my feelings when they got in the way.

One particularly memorable patient was a young teenager with poorly controlled diabetes who had experienced significant emotional trauma. As an example of enactment of my rescue fantasy, I always agreed to see her, even when she came very late for her appointment. On a couple of occasions, when she was on the verge of hypoglycemia, I gave her my lunch. Speaking with Dr. Jellinek allowed me to be a more effective doctor for her.

The only downside of that time in my life was that I was single. Then I met my husband, who lived in New York. As he had an established ophthalmology practice and a daughter from a previous marriage, in order to be with him I would have to move. As I was in love and wanted to start a family, it was an easy decision to make. But leaving my job, and in particular my work with Dr. Jellinek, was sad and painful.

To sum up the next 20 years- I had two children, worked part time, teaching and practicing general and behavioral pediatrics. In 2000 my family relocated to the Berkshires where I took a job in a busy small town practice. In 2004 I began to study as a scholar with the Berkshire Psychoanalytic Institute in Stockbridge. There I discovered, among others, the work of Winnicott and Fonagy, and the growing discipline of infant mental health. I stopped doing general pediatrics in order to be able to keep up with the increasingly busy lives of my then school age children. I began my writing career, first for the Boston Globe and then for my new book. Keeping Your Child in Mind. I enrolled, in the fall of 2010, in the UMass Boston Infant-Parent Mental Health Post-Graduate Certificate Program in which a group of fellows from a range of disciplines met for one 3-day weekend a month for 10 months.

On the Saturday of our February weekend there was an op ed in the New York Times about a mother's struggles with managing her rage toward her child. With my mind in high gear as a result of the intellectually stimulating environment of the weekend, I composed a letter to the editor, which was published the following weekend.

That night I received an email from a pediatrician on staff at Newton-Wellesley Hospital who I had met at a conference a few years earlier. He had read my letter and had an idea.

Dr Jellinek, who is still chief of child psychiatry at MGH, but now also president of Newton-Wellesley Hospital, was embarking on a major initiative to expand child psychiatry services. This pediatrician had followed my work through my writing, and knew that I had once worked with Dr. Jellinek. Perhaps, he thought, there would be a place for me in this new plan.

Nine months and many meetings later, plans have been finalized for me to start a program (one day a week for now, as I still live in the Berkshires) at Newton-Wellesley Hospital integrating services of OB, pediatrics and psychiatry to promote early childhood social and emotional health. It will focus on perinatal emotional complications and address the emotional needs of the 0-5 age group. Dr. Jellinek is as kind, smart and thoughtful as I remember him. The only difference is now I call him Mike.

Though I could not have recognized this as they were happening, the discontinuities in my professional life, made to accommodate family, have led me to a very good place!

Friday, October 28, 2011

Over-reliance on Psychiatric Medication in Children: A Pediatrician's View

This weekend I was scheduled to speak at a conference in LA sponsored by the International Society for Ethical Psychology and Psychiatry entitled "Alternatives to Biological Psychiatry." Unfortunately, due to a family emergency, I was unable to attend. As I had already prepared my talk, I decided to translate it into a blog post.

Recent studies predict that treatment of mental illness and mood disorders will soon makeup 30-40% of a pediatrician’s office practice. A study that appeared in the journal Pediatrics revealed that 8% of pediatricians felt they had adequate training in prescribing antidepressants, 16% felt comfortable prescribing them, but 72% actually did. The cover of the October 2011 issue of Pediatric Annals reads: "Assessment of Pediatric Mental Health:Primary care providers are now on the front lines in the diagnosis of mental health issues". While this over-reliance on medication in children has complex social and political roots, the fact is that pediatricians are the ones putting prescriptions into parent's hands.

There are a number of realities of pediatric practice that have led to this situation. Clinicians in most communities are faced with severe shortage of quality mental health care services. The health insurance industry contributes to this poor access, as low reimbursement and complex administrative rules are disincentives for therapists to participate in these plans. In addition, primary care clinicians are under intense time pressures. Again the health insurance industry plays a role, as in order to maintain a staff to manage multiple insurances, clinicians must see more and more patients in less and less time. In addition, there is often great pressure from teachers, parents and other clinicians to prescribe medication. And last, the
AAP endorses the biological model of psychiatry, as evidenced by the recent recommendation to extend diagnosis of ADHD down to age 4. Prescribing psychiatric medication to young children is a common endpoint of all of these factors.

The growing discipline known as Infant Mental Health offers a different paradigm. Research at the interface of neuroscience, epigenetics and developmental psychology offers both a different way to understand the emotional and behavior problems of young children, as well as a different model of intervenion. While in pediatrics the term infant refers to the first year, this discipline addresses the 0-5 age group.

While it is not my intention to cover this topic in depth, there are some key concepts. First, it is infant-parent mental health, and interventions always involve working with parent and child together. Second, symptoms (or behaviors) have meaning and come from somewhere. And third, the developmental trajectory of any individual child is a result of a complex interplay of genes and environment.

This model is best illustrated with an example. Following my recent appearance on the Diane Rehm Show, I received many emails from parents describing their experiences. One mother gave me permission to use her story, provided she could not be identified. I have selected out key aspects of the detailed story she sent me to illustrate how these principles can be applied to help young children and their families. I have divided her experience into obstacles to care and paths to success.

Obstacles to care:
Dysregulated from birth, with severe colic and poor sleep.
Pediatricians did not recognize signs early
Structured preschool setting “stressed him out”
Frustrated teachers diagnosed ADHD
Previously happy boy now crying all the time
Parents depressed, marriage severely strained

Paths to success:
Parents discovered Stanley Greenspan’s book Overcoming ADHD
Recognize difficulties as problem of self-regulation
Adjust environment and alter expectations without using label
Play-based preschool
Occupational therapy to address sensory processing challenges, with parents in attendance
Minimize media exposure
Calm, happy child, happy parents
Excels at chess, top of his class

So how can we help more children and families find this path to success? Changes need to be made at a policy level, including improving access to primary care and mental health care, calling attention to impact of pharmaceutical industry, and addressing problems in the health insurance industry, perhaps with a single payer system. The second front is through education of professional who work with young children about the growing body of knowledge coming out of the discipline of infant mental health, and its application to their work. This includes primary care providers, mental health clinicians, teachers and child care workers

A wonderful piece in the November 2009 issue of Atlantic entitled The Science of Success describes the "orchid hypothesis." Children with genetic vulnerabilities, like many of these children who are dysregulated from birth and have multiple sensory processing challenges, who grow up in an environment where they are misunderstood, "bad behavior" is punished, or "symptoms" are medicated away, may develop more serious forms of mental illness. On the other hand, in an environment that helps them to make sense of and manage their experience, as the parents of this child above did, they can grow up to be society’s most creative, successful, and happy people.

I conclude with a number of quotes from Ralph Waldo Emerson, who my daughter is currently studying in high school.
Whoso would be a man [woman] must be a non-conformist
For non-conformity the world whips you with displeasure
Nothing can bring you peace but yourself. Nothing can bring you peace but the triumph of principle.
This time, like all times, is a very good one, if we but know what to do with it.

Saturday, October 22, 2011

Learning from parents-a most important education

Recently I had an "aha" moment of sorts. I was speaking to a group at the Pacella Parent Child Center in New York. I was explaining the path that had led me to write my book, Keeping Your Child in Mind. I was telling the group how in 2006, when my own kids were both school age, I stopped doing primary care and began doing exclusively behavioral pediatrics. I was still working within a general pediatrics practice. The major change was that I started scheduling all my patients for 50 minute visits. Where previously an "ADHD evaluation" had been, at most, one 50 minute visit, and many visits for behavior problems only 30 minutes in length, I began insisting on a minimum of two 50 minute visits for any behavior problem, preferably the first with parents alone.

Many practitioners might now dismiss what I am about to say, insisting that this is not a financially viable plan. But the fact is that I have been reimbursed for these visits on average $150. It is possible for a practice to have one or two clinicians devote several 50 minutes a week to addressing "behavior problems," especially given the potential gain. As I describe in my book, when parents are simply given advice about "what to do" both clinician and parent often experience failure. In contrast, giving a parent time and space to be heard often results in dramatic improvements in behavior.

With this change in my practice, I began to listen more carefully to my patients, specifically to parents. I heard stories of struggles with infertility, newborns who were difficult to soothe from day one, parents who struggled with depression when their children were infants, among many other things. But I also learned about what made things better. Once parents were given the time and space to tell their story, they came up with many resourceful solutions to address their children's difficulties.

Certainly the ideas I have developed over the years come in large part from studying contemporary research from leaders in the field of child development. I am a graduate of the Scholar's program of the Berkshire Psychoanalytic Institute and of the UMass Boston Infant-Parent Mental Health Post-Graduate Certificate Program. But perhaps my most important education has been in carefully listening to the experience of parents.

Last week I had the privilege to be on the Diane Rehm Show speaking about the new guidelines from the American Academy of Pediatrics extending age of diagnosis of ADHD down to age four. To sum up the position I presented on the hour- long show, I advised using caution before prescribing medications to kids under six. I advocated for early intervention, even in infancy when problems of self regulation can present. I argued for validating parent's experience without using a major psychiatric diagnosis, and for recognizing the meaning of behavior rather than focusing exclusively on symptoms.

A mother who had listened to the show emailed me, thanking me for being "the voice of reason." She shared in detail her experience with her now six-year-old child. She described terrible struggles for the first five years until she and her husband discovered Stanley Greenspan's book about ADHD (his ideas and approach are very similar to mine) and everything "clicked." They took matters into their own hands in advocating for their son, who is now thriving. There were many details in her story- both the obstacles to help and the elements of the path to success.

Recently I have seen myself referred to in the media as a "child mental health expert." I appreciate this description, as it affords an opportunity for recognition of this important perspective that my infant mental health colleagues and I bring to the conversation. But reading what this mother wrote reminded me again that parents are always the experts with their child, and that there is still much that I can learn.

Sunday, October 16, 2011

Diagnosing ADHD Under Age 6: A Mistaken Idea

Once again ADHD is in the news. At the American Academy of Pediatrics National Conference and Exhibition this weekend in Boston, the new guidelines for diagnosis and treatment of ADHD were unveiled with much fanfare. The most significant change is that the AAP now endorses diagnosing the disorder from age 4-18, a change from the previous guidelines which recommended diagnosis from age 6-12. I take no issue with extending the age of diagnosis upward. But the new recommendation to extend the diagnosis down to age 4 is very worrisome.

As I describe in a previous post, what is now called ADHD is a constellation of symptoms that represent problems of regulation of behavior, attention and emotions. These problems have complex causes. There may be a biological vulnerabilities, which often have a genetic component. Often there are associated sensory processing problems. Family conflict, including parent-child conflict as well as marital conflict, is clearly associated with problems of self regulation. Sleep and eating problems often occur within the context of family conflict and can exacerbate problems of self-regulation.

Children who are struggling in a variety of ways are scheduled in pediatric practices for an "ADHD evaluation." The question asked is: "Do symptoms meet diagnostic criteria?" The more appropriate question should be "What is the experience of this particular child and what can we do to set things in a better direction?" By invoking the label of ADHD, thinking may stop. Curiosity about the meaning of behavior ends. However, years of longitudinal research, as I describe in my book, Keeping Your Child in Mind, has shown that children develop the capacity for empathy, flexible thinking and emotional regulation when parents respond to the meaning of behavior rather than simply the behavior itself.

A press release regarding the new guidelines describes the recommendations for children under 6 as follows.
According to the AAP guidelines, in preschool children (ages 4 and 5) with ADHD, doctors should first try behavioral interventions, such as group or individual parent training in behavior management techniques. Methylphenidate may be considered for preschool children with moderate to severe symptoms who do not see significant improvement after behavior therapy, starting with a lower dose.
Certainly children with problems of self-regulation are struggling, and they absolutely should receive treatment. But receiving a diagnosis of ADHD should not be the only route to receiving treatment, particularly if that treatment consist primarily of "parent training" "behavior management" or medication. There are a whole range of other interventions that can be very helpful to these struggling children and families. These include parent-child psychotherapy and occupational therapy that aim specifically to improve a child's capacity for self-regulation. Getting a label should not be a prerequisite for getting help.

Addressing "comorbidities" does not solve the problem. What this means is simply adding more letters to the child's diagnosis such as ODD (oppositional defiant disorder) CD(conduct disorder) that represent meaningless descriptions of symptoms without any consideration of underlying cause. In my experience, almost all children who have the diagnosis of ADHD are oppositional and defiant. But there are as many variations to the causes of this behavior as there are families.

Under age six children can get the greatest benefit from alternative interventions. This is the time when the brain is most plastic. Changing relationships can change the brain. In addition there are not, or at least should not be, the academic concerns that begin in first grade. Once kids begin to fall behind academically it can affect their self-esteem, and so the pressures to treat with medication increase.

A study done last year showed that kids who are the youngest in their class are 60 percent more likely to be diagnosed with ADHD than kids who are the oldest. There is a wide range of maturity rate. A four or five-year- old who is among the youngest in the class is at particular risk for being diagnosed with ADHD for what is in fact a normal developmental variation.

Recent reports show a dramatic rise in both diagnosis of ADHD and prescribing of stimulant medication for ADHD. We can be sure that with the implementation of these new guidelines, this trend will continue.

Thursday, October 13, 2011

What is infant mental health? A case of a hitting toddler

In a few weeks I will launch a new program in the Boston area (more information to follow when the details are ironed out) where I will see children under the age of five. The working name is "Early Childhood Social-Emotional Health" program (ECSH) It is an infant mental health program, drawing on the explosion of knowledge coming out of this growing discipline. I had the privilege of learning about the most current research first-hand from leaders in the field in an excellent a yearlong program at UMass Boston: The Infant-Parent Mental Health Post-Graduate Certificate Program.

There are two major problems with the term "infant mental health." First of all, it implies that there is such a thing as infant mental illness, which is, in my opinion, not the case. Second, when say that I am a pediatrician who treats behavior problems in children under age five, most people are puzzled. I tell them that I give parents space and time to reflect, and to be curious about the meaning of behavior, with the aim of getting development back on a healthy path. Still the blank look. I have found that the best way to explain it is through stories, as I do in my book Keeping Your Child in Mind. As always, I protect privacy by changing identifying details.

"She always hits! I don't know what's wrong with her!" Jane despaired at the start of her visit with me. She came with her three-month-old son, who slept in his carrier. She was horrified that her 18-month-old daughter Callie (who did not come to this visit, so Jane and I could talk freely) was behaving this way. She and her husband never hit. She couldn't understand where this behavior came from. The worst time, she said, was when she was trying to nurse the baby. Callie would try to climb up on her, and when told to get down she would hit her mother, the baby or both. Jane felt tense and angry. Her husband worked long hours and she was alone with the two kids most of the day. "What can I do to make her stop?" she asked.

This is not an uncommon occurrence. I frequently hear parents describe "visions of Columbine" when they see aggressive behavior in their toddlers. Rather than jumping right in with what to do, I took some time to listen to Jane's story. She told me of a difficult pregnancy and how hard it had been when she was alone much of the time when Callie was an infant.

Then she began to talk about her own family. Her father was an alcoholic who was verbally and sometimes physically abusive to her mother. There was constant yelling. She told me that she "hated aggression." When she saw Callie hitting she had an immediate physical sensation of stress. Jane just wanted her to stop.

We began to wonder together about why Callie might be hitting. Jane described how close she and Callie had been before the baby was born. With her husband gone much of the time she rarely had time alone with Callie anymore. "Perhaps she misses me," Jane said. She was surprised when I suggested that while clearly hitting was not acceptable, aggression in a toddler could be seen as a healthy thing. It was not the same as adult aggression, which carried a whole host of complex meanings. We might reframe Callie's behavior as claiming what she felt was her rightful place. We talked about how toddlers are asserting their emerging sense of self . Yet they recognize that they are in fact powerless in many situations. "Wow!" Jane exclaimed. "I feel that way sometimes, but I have words to express my feelings!"

We talked very little about what to do. I was careful to frame the issue of her childhood trauma and its relation to the current situation. This history did not mean that Callie's hitting was her "fault." Rather Jane needed to move her issues out of the way so she could see the situation from Callie's perspective. I was confident that she would then know what to do.

Sure enough, when she returned two weeks later, this time with Callie, the hitting had almost completely resolved. "I give her a bottle," Jane said. She had thought that she was "supposed to" get rid of the bottle by a year. But when the baby was born, Callie had become interested in the bottle again. So the three of them now sat quietly while Jane nursed the baby. Callie would drink an ounce or two and then lose interest in the bottle. She would play at her mother's feet until Jane was finished nursing.

Callie was a delightful little girl who played quietly while Jane and I spoke. Then we got to see the essence of toddlerhood in action. Callie went to her mother's purse and said "passie." Jane explained to me that as with the bottle, Callie had a renewed interest in the pacifier. "I decided to just let her have it." Jane rummaged in her bag and pulled it out, handing it to Callie, who took it, looked it over and gave it back. She returned to her play. A few minutes later she again said, "passie. " Again her mother gave it to her, and again she gave it back. This, I said, is the ambivalence of toddlerhood. Part of her wants to be a baby, but she also wants to grow up and be a big girl. Jane, by being respectful of Callie's perspective, was enabling her to sort this through naturally, Had Jane refused to let her have the pacifier, it is likely that, as an assertion of her wish to control the situation, Callie would have insisted on having it, and a battle would have ensued. She might have started using the pacifier again.

Jane, through her natural intuition about her daughter, figured out what to do. I simply offered her the space and time to think and to be heard. I hope that this small intervention has set the whole family on a different path. The baby now can nurse in peace. Jane is less worried that there is something wrong with Callie, who is in turn free to express her emerging self. For a young family, a little reflection goes a long way.

Friday, October 7, 2011

ADHD: The role of diet and sleep

I recently had a guest post published on the CNN news blog, The Charts, entitled Calming your child's ADHD symptoms. The subject clearly needs a fresh look, given the startling statistic from a recent CDC report that diagnosis of ADHD was up by 29% from 2000 to 2009, and evidence that medication use for ADHD increased at an average yearly rate of 3.4% from 1996 to 2008.

In a nutshell, I describe ADHD as a problem of regulation of emotion, behavior and attention. I offer three points of approach. The first is to address family relationships. This is because children learn self-regulation in context of relationships with primary caregivers, and family conflict is clearly associated with increased risk for ADHD. Second, I recommend involving kids in activities that promote self-regulation including, but not limited to, horseback riding, swimming, martial arts and drumming. And last I recommend careful use of medication when a child's symptoms interfere with learning and social relationships.

A number of people commented that I had not addressed the issues of diet or sleep, both of which have been associated with symptoms of inattention and hyperactivity. I gave some careful thought to why I had not included these issues among the top three. The reason is that, in my experience, problems around sleep and diet are usually embedded in problems in relationships (the major exception is obstructive sleep apnea, a sometimes overlooked condition that can cause of hyperactivity in children. This topic is well covered in a recent post by an ENT specialist on the blog KevinMD.)

For example, I took care of one teenage girl with symptoms of inattention who met diagnostic criteria for ADHD. I learned that up until her thirteenth birthday, her mother lay in bed with her every night until she fell asleep. Then on the day of her birthday, her mother decided that her daughter was too old for this habit, and abruptly stopped, insisting that she fall asleep on her own. Not surprisingly, her brain and body had no idea how to fall asleep independently, so she was staying up until two or three o'clock every morning, sneaking her laptop into bed with her.

Many children with a range of behavior problems crave sweets. Parents describe constant battles around food choices. It is likely that these problems have complex causes: sweets may be used to reduce stress, and food is a place where children can exert absolute control by simply closing their mouths.

Certainly it is important for growth, development, and learning that children eat a healthy diet. Ideally they should have three meals a day with sufficient fresh fruits, vegetables, and protein and a minimum of processed foods. However, if all attention in management of ADHD is focused on diet, to the exclusion of relationships, then the intervention is off the mark. In addition, evidence for more specific food restrictions, such as dairy, wheat or food dyes, is more anecdotal, and some of these diets can be quite restrictive.

Similarly, getting enough sleep is essential to healthy brain function and regulation of behavior, emotions and attention. But, with the exception of obstructive sleep apnea, most sleep problems develop in the context of relationships. In my work with the teenager I describe above, we needed to understand what about family relationships, between mother and father as well as between mother and daughter, led to this problematic situation. Only then could we could begin to solve the "sleep problem." Many children I see with a diagnosis of ADHD have been engaging in battles with their parents for years around sleep, but almost always in the setting of a range of conflicts within the family.

My answer to those who question the omission of sleep and diet from my discussion of ADHD is that yes, these issues are important. In my CNN piece I describe inattention, impulsivity and hyperactivity as symptoms, and urge parents and clinicians who treat ADHD to not simply treat symptoms, but rather to address the underlying cause. Similarly, problems with sleep and diet are often symptoms of problems in relationships. Many parents describe being overwhelmed by the volume of information coming at them about this complex entity known as ADHD. I believe both parents and professional would do well to be open to a variety of ideas while maintaining a focus on supporting relationships and repairing disruptions in relationships.

Monday, October 3, 2011

Prevention and Primary Care

One main objective of the Affordable Care Act, or health care reform, is to focus on prevention. This has been translated into requiring insurance companies to cover annual physicals and a variety of screening tests. Of course primary prevention is done in the setting of primary care. Unfortunately the government is, in a sense, working against itself because of the current system for determining reimbursement for medical services. Pauline Chen documents this well in her recent piece in the New York Times: How One Small Group Sets Doctors' Pay She writes:
Why are there so many medical specialists in a time when we need more primary care doctors? Meet the RUC, a committee of 29 men and women who play a critical role in dividing the Medicare pie.
She describes the close connection between the RUC and the Centers for Medicare and Medicaid Services, or C.M.S.
First, C.M.S. historically has approved 90 percent or more of the recommendations from the RUC. Second, while the RUC makes its recommendations based on an anonymous two-thirds majority vote, about 80 percent of those voting to begin with — accounting for 23 of the 29 seats — are physicians representing professional societies. Third, almost all of those physicians are specialists (currently only five RUC members are doctors from primary care fields).
Prevention happens through the relationships that develop over time in the primary care setting. Consider this story from my pediatric practice( details, as always, have been changed to protect privacy) Six year old Kevin’s mom, Robin, was upset about his constant fighting with his younger sister. I had taken care of both children since they were infants.

Robin was distraught over Kevin's need to always have everything first, and his demands were escalating. They were having increasing difficulty getting out of the house in the morning. I saw them for 2 fifty-minute visits. The first involved the whole family and we talked about some common approaches to managing behavior. I was struck by Mom’s level of distress, which seemed out of proportion to this fairly typical sibling rivalry. Towards the end of the second visit, when Mom was alone with Kevin, she quietly began to cry. I looked puzzled. She told me of the horrible accident that had taken the life of her older brother when she was a child. Her family never spoke about it. That trauma came flooding back now that she had two children of her own. She recognized that she had to mourn this loss in order to be present with her children in the way she wanted to be.

This was 10 years ago. Recently I ran into Kevin. He is now a talented musician as well as an excellent student. I saw him in town with his arm around a girl. He gave me a big smile and a friendly "hello." Of course I can't say what path his life would have taken had this trauma of his mother's not been addressed. But I suspect that it had a role in freeing him to develop into the person he is today.

Prevention can only happen in a meaningful way if the value of primary care is recognized. This involves not only monetary value. Certainly with the burden of loan repayment, financial issues are paramount in determining what field doctors-in-training chose to go in to. But in addition we as a society need to recognize that listening, particularly listening that occurs in the context of a relationship that develops over time, is an important form of treatment. Prevention is not only about screening tests.

Wednesday, September 28, 2011

Parenting Toddlers and Teenagers: Much in Common

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, who has advanced thinking skills. The tantrums of adolescence involve not thrashing arms and legs, but words, and often cruel and vicious words.

D. W.Winnicott, pediatrician turned psychoanalyst, offers some words of wisdom that can guide a parent through this challenging 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. 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.

A toddler needs similar kinds of limits as he tries to make sense of who he is as a person separate from his parents. While two-year-olds will not say "thank you for setting limits," when parents contain both their behavior and their intense feelings, it helps them to feel safe and secure. This safety and security is needed just as much for teenagers as they begin to separate and develop their emerging identity. Ironically just when a teenager is most actively and aggressively pushing you away, she most need you to be there.

Winnicott offers a hopeful look at the future if a parent has withstood the “long tussle” of adolescence. He writes:
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.

Friday, September 23, 2011

Music Therapy

Recently in my behavioral pediatrics practice I saw James, a 5-year-old boy (details, as always, have been changed to protect privacy) who struggled with severe social anxiety. The lunchroom and gym were particularly difficult, and he would retreat into silence. In a visit with his parents we were discussing how to approach the teachers about making him comfortable in school. We had a full 50 minute appointment so we were, in a sense, free to let ideas emerge. That's when his father observed, "You know, he loves classical music." His mother described a recent outing where there had been a lot going on and James was quite agitated. But when someone put on some classical music, James became completely calm and seemed at peace.

It was an important detail. We began to brainstorm about how they might make use of this observation in the school setting in addition to social experiences outside of the classroom.

This story led me to wonder how this piece of information might help us to understand James' brain. For some reason he couldn't process all the sensory information coming at him in a busy social scene. But with the help of classical music, it was as if the neurons, the cells of his brain, lined up and began to work properly.

This visit got me thinking about a movie I recently saw The Music Never Stopped. It is based on the story of an actual patient as described by neurologist and writer Oliver Sacks in his essay "The Last Hippie." The movie's main character is a young man who suffered severe brain injury, and was socially disconnected even from his immediate family. But he had been a passionate musician, and when when he listened to music he loved from the time before his injury he became completely clear thinking and engaged. Like my young patient, his brain was a place of confusion and disorganization until the music allowed things to, in a sense, fall into place.

Interestingly, while working on this post I received an email from the publicist at Berklee College of Music alerting me to an upcoming program (October 5th-6th) about music therapy for autism spectrum disorders. The press release for the program states:
There is scientific evidence that music therapy influences children on the autism spectrum in several ways, like enhancing skills in communication, interpersonal relationships, self-regulation, coping strategies, stress management, and focusing attention,” says Berklee’s Music Therapy Department Chair Dr. Suzanne Hanser.
Similar to my young patient with social anxiety, children diagnosed with autism spectrum disorders are often overwhelmed by sensory input. It makes perfect sense to me that music would help them to organize their experience and engage with the world around them.

There is currently an explosion of research at the intersection of neuroscience, genetics, and developmental psychology to help us understand young children who are struggling with a range of what are usually referred to as "behavior problems." I am a clinician, not a researcher. However, I listen carefully to my young patients. I encourage their parents, as James' parents clearly were, to be curious about what the world is like for them. If we listen and observe in this way, these children can be our greatest teachers.