Early Relationships and Brain Development as the Core of Medical Practice

Given the current explosion of knowledge about the effects of early relationships on brain development, I believe that research at the interface of developmental psychology, neuroscience and genetics will soon need to be at the center of our medical education system. Thus I was excited and heartened to read about the Bayview Child Health Center and its medical director Nadine Burke in this week's New Yorker. An article entitled The Poverty Clinic describes a practice in a poor inner city neighborhood that applies this research to their daily care of patients.

Burke was most heavily influences by what is referred to as the ACE study, a retrospective review that showed a strong connection between adverse childhood experiences(including such parental divorce, abuse and neglect, being raised by a family member with mental illness) and many long term health outcomes. These include chronic medical conditions as emphysema and heart disease illness, substance abuse and other mental illness. She is also influenced by research in neuroendocrinology and behavioral genetics, including work of Michael Meaney and Bruce McEwen.

Burke's idea, drawing on the evidence that adverse experiences affect the brain and body on a molecular level, is to treat early childhood trauma as a medical problem. She describes "multidisciplinary rounds" modeled on treatment of cancer where care is coordinated among surgeons and other specialists. The article states:

At Bayview clinic, having the patient's ACE data, and a theoretical framework for discussion the effects of trauma, has inspired Burke and her colleagues to be more vigilant about abuse and neglect. It also makes them more likely to help children get the social services they need, and better prepared to talk to parents early about the importance of secure attachment.

Treatment interventions may include one or more psychological interventions and alternative therapies including yoga and medication. Alicia Lieberman, a leader in the field of infant parent mental health, is collaborating with Burke.

I wonder if Dr. Burke's medical model is successful in part because it allows clinicians to put the emotional component of this very difficult work at a distance. Bruce Perry, a brilliant psychiatrist at the Child Trauma Academy who has written extensively about working with traumatized children, describes very similar interventions. It may be that for clinicians who have not chosen a mental health profession, such as internists and pediatricians, viewing early trauma as a biological problem may be adaptive. It may allow them to do the work without being overwhelmed by feelings that the emotional suffering of their patients may bring up. This form of defense may be particularly important for clinicians who themselves have experienced some kind of early trauma, and for whom their patient's experiences are a bit too close to home. In the mental health professions, there are opportunities to discuss these types of reactions to the work. However, training in medicine and pediatrics rarely offers such opportunities.

In a sense analogous to testing for iron deficiency because of our knowledge about its importance in brain development, primary care clinicians on the front lines with young children and families will need to know about and apply our knowledge of the importance of early relationships on brain development. Dr Burke's clinic is an important step in the right direction. As this model makes its way into medical practice, however, it will be important to find a place for recognizing the emotional piece of the work. Not only will this avoid clinician "burn out" but it will give value to the relationship between clinician and patient. It can be the clinician him or herself who is the most important part of the treatment.

Psychiatric "Disorders" in Young Children: Proceed With Caution

"Mental Health Disorder" are big words to put on a small person. Sensory processing disorder, major depressive disorder, anxiety disorder, to name a few, are being given to preschoolers, toddlers and even infants. Certainly young children and their families can suffer terribly with the symptoms that characterize these "disorders." Yet I worry that a child's "true self," to quote pediatrician turned psychiatrist D.W.Winnicott, can be lost under the weight of such a label.

Based on my years of clinical experience as a pediatrician, together with evidence offered by contemporary research in developmental psychology, genetics and neuroscience, I believe that supporting parents efforts to understand their child's experience of the world, to help him or her to make sense of whatever particular vulnerabilities he or she has, without labelling him or her with a disorder, is a better approach.

An article just published in The American Psychologist, Developmentally Sensitive Diagnostic Criteria for Mental Health Disorders in Early Childhood, a comment on my new Psychology Today blog and a family I recently saw has got me thinking further about this controversial issue.

I met with Joanne and Peter, parents of five-year- old Andrew, in my behavioral pediatrics practice (details,as always, have been changed to protect privacy) He was having increasingly inflexible and explosive behavior. They wanted to know "what to do" so he would stop getting upset about "little things." They described him as challenging since birth, a picky eater who had difficulty with loud noises. He could take hours to put on his socks because he hated the bumps.

Recently, he and his parents were at the playground and his younger sister fell and hurt herself. It wasn't anything major, but they had to leave suddenly without giving him usual warnings that made transitions less difficult for him. The result was that he was inconsolable for hours-unable to stop repeating, "Its not fair! I didn't get to go down the slide!" His parents tried to be patient and understanding, while simultaneously tending to their other child, but eventually Peter lost his cool. He yelled at Andrew and sent him to his room.

What prompted them to call me, after months of increasing frequency of similar scenes, was what happened next. Andrew kicked the wall and threw his toys. Then he began to call out,"I'm so sad!! I'm a bad person" I'm so sorry." It was his words that most frightened them. Joanne admitted to being worried that he might intentionally hurt himself. After a while, when she felt more comfortable with me, Joanne spoke of her own longstanding struggle with depression. There were other family members with similar difficulties. Both parents confessed their fear that Andrew was depressed.

Drawing on the research of Peter Fonagy and others, I sought to help Joanne and Peter in their efforts to help Andrew make sense of the world, to manage his inflexibility and sensory difficulties. It seemed to me, based on his history, that he had some biologically based genetic vulnerabilities. To them it seemed that he got upset about "little things." But it sounded from their description that at times for Andrew the world felt like an overwhelming and incomprehensible place. Joanne and Peter needed to help him learn to manage himself in the face of his particular challenges. Trying to reason with him when he was out of control did not work. I explained that at moments such as the playground incident, the higher centers of his brain were likely temporarily not working, and so Peter and Joanne hit a brick wall. They needed, in the heat of the moment, to find other means to help Andrew to regulate himself, even something as simple as going for a walk. Talking about what happened could come after he calmed down. Eventually their repeated efforts would give him the tools and language to regulate himself in these difficult moments.

Andrew's mother had a vivid memory of being taken to the psychiatrist as a child and given medication. She did not want Andrew to come to my office-to get the feeling that there was "something wrong with him." We agreed that they would try this new way of being with Andrew, and come back and see me in a few weeks to talk about what happened. Within a week or so of simply thinking differently about Andrew, he was more calm. Joanne and Peter felt more relaxed and sure of themselves. They found it easier to be with him and help him manage these moments of frustration.

Several weeks after this visit, I received the following comment on a blog post questioning the use of antipsychotics for young children. As a pediatrician I don't have the opportunity, other than stories from parents like Joanne, to hear adults describe their experience of being diagnosed and/or medicated, and I find these comments to be helpful. I quote him in full:

I was a so called HFA when I was a kid, "Aspergers Syndrome" they called it and was tortured on Risperdal.
Dropped out of school when I was 13 and finished my education on the
internet. Looking back I never fail to notice that 100% of my problem was not
that I was sick but that other people considered me so.I say leave them alone. I once bit myself and screamed cause someone was chewing paper (Couldn't stand paper, pencils, chalk, people bending their
hands and about 10 other things) and so what? Get me out of the room for a
minute and I'm fine. Any kid should have the right to take that over
permanent drug induced damage.

While I can't claim to know anything about this person, his wish to be recognized and understood, rather than labeled and medicated, comes through loud and clear. I wonder how many others have a similar experience without the opportunity to give voice to it until many years later.

Those who advocate for a new system of diagnostic criteria for mental health disorders in early childhood are not advocating for use of medication in this age group. It is a reasonable concern, however, that a consequence of psychiatric diagnosis, in the age of intense marketing efforts of the pharmaceutical industry and limited access to quality mental health services, will be an increase in prescribing of psychoactive medications to young children. In fact, an article in today's New York Times Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy offers a close up look of the realities of the practice of psychiatry today.

Even putting the issue of medication aside, the label of mental health "disorder" may obscure parents efforts to truly understand their child's experience. It is this kind of understanding that Peter and Joanne are working towards. In the setting of such recognition and understanding, children, even those with Andrew's quirks and vulnerabilities, have the opportunity to develop a strong, healthy sense of self.

Protecting infants from the ill effects of mental illness

Three-month-old Jenna sleeps peacefully in her mother’s lap. The cards seem stacked against her. Cara at 17 is struggling to finish high school. She has been diagnosed in the past with depression and anxiety, but currently is receiving no treatment. Her primary care doctor, who referred her to me, has been prescribing an anti-anxiety medication as a temporizing measure. Cara has been playing phone tag for over a month with the therapist at the community mental health center, whom she needs to see in order to get an appointment with a psychiatrist.

Cara is scheduled as my patient in my behavioral pediatric practice. I put anxiety as the diagnosis on the billing form. But in truth the aim of my work with this mother-infant pair is to protect her daughter’s developing brain from the well-documented ill effects of maternal mental illness on child development.

Cara talks in a rambling manner about a range of subjects- her older sister at 20 pregnant with her second child, but neglectful of the first, her father who abandoned the family when she was two. She is particularly focused on her difficult relationship with James’ father, Ed. She tells of his drug use, his neediness and his difficulty accepting his role as father.

An infant’s brain makes as many as 1.8 million neural connections per second. The way in which these connections are formed is highly influenced by human relationships. As Cara responds to Jenna’s face and voice, is attuned with her rhythms and needs, both physical and emotional, she is literally growing her brain.

Important research has shown that when a mother can think about her baby’s mind and attribute meaning to his behavior, she helps him to develop a secure sense of himself and of his relationship with her. This security helps him to regulate himself in the face of difficult emotions. As he grows older he will have the capacity to think clearly and flexibly and manage himself in a complex social environment.

When I work with mother-baby pairs like Cara and Jenna, I focus on one simple thing. I listen to these mothers with the aim of helping them to reflect on their baby’s experience of the world and the meaning of their behavior. It never ceases to amaze me that with this singular focus, meaningful communication happens even in what appears to be chaotic and dismal circumstances.

As I listen to Cara’s rambling story, I know I need to help her start thinking about how all of this affects her relationship with Jenna. I use a technique I learned from leading researcher and clinician Peter Fonagy to help a person who is stuck in this kind of non-reflective thinking. I hold up my two hands. “Wait, I say. “I want you to help me understand how you think these problems with Ed connect with your relationship with Jenna.”

She pauses for a moment and then begins to cry. “When Jenna is so needy of me, it makes me think she’s just like her father, and I get so mad. Then I feel terrible for getting angry at her.” It’s a remarkable insight. But she isn’t done. She looks down at Jenna. “See how relaxed she is when I am calm. But when I get upset, she starts to cry.” Then she tells me of a time when she felt about to lose control, but somehow had managed to make Jenna laugh. “We were having a conversation,” she says joyfully, “even though she doesn’t say any words!”

It is a small moment in one 50-minute visit. I am confident, however, that with a string of moments like this, where Cara is fully present with her daughter, there is hope that she may break the cycle of intergenerational transmission of mental illness and help to grow a healthy brain.