Infant-parent mental health care-where does it fit in?

When I tell friends, office staff and even some colleagues in pediatrics that I am building a behavioral pediatrics practice that is focused on infants, they sometimes give me a puzzled look. I was recently asked to write a guest post for a blog called "FreelanceMD:the cure for the common physician." The blog advertises itself as being for doctors taking charge of their own practice of medicine,and even has a section entitled "non-traditional medical careers". As the way I practice pediatrics doesn't fit into any defined category, I thought this might be a good community to join. I invite you to take a look at my guest post today, Inside Infant-Parent Mental Health Care. It has some similar themes to what I have written about elsewhere on this blog, and offers a specific example of what a pediatrician who follows the principles of the discipline of infant mental health actually does.

Extensive research has shown the long term negative effects of maternal depression and anxiety on child development. Untoward effects on development occur even when symptoms are below the level to qualify for a diagnosis, as is common in today's culture where new mothers are often struggling with minimal help and/or emotional support. We need to intervene early, when these brains are rapidly growing, when an infant’s brain is making as many as 1.8 million neural connections per second.

This kind of work fits very well in a primary care practice, where mothers and babies are seen early and often. Many programs that implement the principles of parent-infant mental health care are in university settings, or in large cities or specifically target high-risk groups. Being seen in a primary care practice avoids the stigma that still may be associated with a referral to a mental health care practitioner. It also offers the opportunity to help families that might not fit into an identified high risk category, but are struggling nonetheless.This is a model that could be applied in practices of any size in any location.The first step would be to integrate the growing ranks of mental health professionals who practice parent-infant psychotherapy into primary care practices. Next would be a large scale effort to teach these principals and practices to primary care providers themselves.

This model has worked well for me for many years. At first I did both primary care and behavioral pediatrics, but when my children reached school age and I could not meet the needs of my family if I were to continue taking call, I switched to doing exclusively behavioral pediatrics, but within a primary care practice. As far as the insurance companies are concerned I am credentialed as general pediatrician. I have always been well reimbursed for my services even when I see patients often and for 50 minute visits.

I hope that many pediatricians will follow a similar path.

A Vote for Repeal of Health Care Reform is a Vote Against Children (and so our country's future)

My forthcoming book, that has a publication date of September 2011, offers over 150 pages of evidence, based on more than 30 years of research as well as my 25 years of experience as a pediatrician, that supporting parents' efforts to be fully emotionally present with their children, to be curious about their children's minds and the meaning of their behavior, will lead to a generation of citizens who are emotionally healthy, resourceful, and adaptive to a complex social world.

The last chapter, entitled "Beyond Medication" places this view up next to an alternative paradigm offered by the combined forces of the health insurance industry and pharmaceutical industry. I am currently in the final stages of editing this last chapter. This morning I came upon this sentence, that occurs following a section in which I describe obstacles to quality care for children and families. The sentence reads:

Often when I see a family in my office [with a mental health concern] we can clearly see what is needed but cannot get from here to there. I believe there is hope, however, in this age of health care reform.

As I write this, repeal of health care reform is being debated in the House. Fortunately repeal is unlikely to happen, given its support in the Senate and Obama's veto powers. So I probably won't have to take that sentence out of my book. Still, the fact that repeal is even being discussed makes me very uneasy.

Health care reform as it stands does not directly address these obstacles to care, but is, in my opinion, a critical beginning. Next must come a renewed value on prevention, primary care and mental health care. These changes will serve to promote our children's healthy emotional development.

A vote against health care reform is a vote for the insurance companies. The powerful health insurance industry together with the pharmaceutical industry obstruct true progress in promoting children's healthy emotional development, because both support the quick fix over more difficult, yet safer and more lasting relationship-based interventions.

In this last chapter of my book, I also describe the 40 fold increase in the diagnosis of bipolar disorder in children and the exponential increase in prescribing of atypical antipsychotics, a highly profitable class of drugs, to very young children. I put the issue in perspective by including a sentence about the influence of the pharmaceutical industry on Joseph Biederman, the child psychiatrist at Harvard who is primarily responsible for this phenomenon. Here is the sentence I added this morning.

Further complicating this story is the fact that Biederman was found to have earned at least $1.6 million in consulting fees from companies that make these drugs, while reporting only $200,000 of this income to his employer, Harvard University. He is currently under investigation for possible violation of federal and university research rules designed to police potential conflicts of interest.

The health insurance industry and the pharmaceutical industry often seem not to have our children's best interests in mind. Yet as Nobel Prize winning economist James Heckman has argued, an investment in young children is an investment in our country's future. Health care reform as it stands is an essential first step in the right direction.

An Epidemic of Uncontained Aggression

Josh Marshall, a guest of Keith Olberman's news program Countdown, made a brilliant analogy when discussing the recent assassination attempt on congresswoman Gabrielle Giffords. He compared the current climate of incitement and violent rhetoric to a flu epidemic in which, while many are affected, the weak and infirm are the most vulnerable. Similarly, the mentally ill, like Jared Loughner appears to be, are most vulnerable to act on the inflammatory and hateful words so rampant in our culture today. But what is the cause of this epidemic? What is the "virus" responsible for this "illness?" Many blame the political situation which has become increasingly polarized and divisive. Others point to the media and the talk show hosts who promote the free expression of rage and hate.

I propose that while these may be proximate causes, the true cause may have much deeper roots. Extensive research has shown that children learn to regulate emotions, including aggression, at a young age, in relationships with their caregivers. This learning takes place at the level of gene expression and biochemistry of the brain. The centers of our brain responsible for observing and monitoring our behavior actually grow fibers that control lower centers of the brain responsible for fear and the fight-flight response. This growth takes place in the context of attuned loving relationships in which children feel understood.

We as a society now seem to be failing at this task of regulating aggression. I wonder if this failure is in some way connected to our culture's failure to nurture and support early parent-child relationships, as exemplified by our maternity leave policy that lags so far behind other countries, as well as the rapid increase of prescribing of psychoactive medication to very young children. The 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.

Aggression is a normal healthy emotion, which, if all goes well, children learn to regulate and contain. It then may be transformed into assertiveness, which is considered a positive trait. When children lack close secure relationships that help them to think about and understand their feelings, these aggressive feelings don't go away. Without the ability to think about feelings, a person is more likely to impulsively act them out.

This weekend I will have the privilege, as part of the UMass Boston Infant Parent Mental Health Post Graduate Certificate Program
to hear leading researcher Peter Fonagy present the most current research demonstrating the critical role of understanding children's minds and helping them to contain intense feelings in promoting their healthy emotional development.

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 teaches him to regulate intense feelings. Program leader Ed Tronick has been instrumental in calling attention to this very important issue, and this past summer a new law was passed that requires Massachusetts health insurers to submit annual reports on their efforts to screen for postpartum depression and calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.

Certainly there are other angles for intervention in the aftermath of this horrific event, in the political realm as well as in the media. It may also inspire those strive to support these early relationships to, in the words of Dr. Tronick, "Press on with our work for children and families."