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.

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.

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?

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.

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.

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.