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 research in child development 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.

Monday, January 16, 2012

Mothers, Babies, Psychoanalysts, Pediatricians

For many people the word "psychoanalyst" conjures up an image of a man sitting silent behind a patient lying on a couch. In stark contrast to this image, the National Meeting of the American Psychoanalytic Association(APsAA) this past week prominently featured women analysts presenting their work with mothers and infants.

Among the most striking presentations was a pair of videos shown as part of the main research symposium by Nancy Suchman, PhD of the Yale Child Study Center. Substance abusing mothers who had histories of significant emotional trauma received an intervention that specifically aimed to listen to the mother and support her efforts to listen to her child. This is known as "mentalization based therapy." In my book Keeping Your Child in Mind, I show what mentalization, or holding a child's mind in mind, looks like in everyday parenting moments as well as in the clinical setting of a pediatric practice.

In the first video, before treatment, the mother was tense and angry, describing her infant's clingy behavior and night wakings as his attempts to make life difficult for her. After the 6 week intervention, she was calm and thoughtful, wondering about the meaning of her baby's behavior. She recognized how much her baby needed and loved her. In a related study, part of the Minding the Baby program at Yale, children of mothers who were similarly at risk but without the history of substance abuse received this mentalization based treatment. Their children showed fewer behavior problems, and the mothers reported less parenting stress several years after the intervention. Another researcher, Dana Shai, PhD, spoke of how a parent's ability to hold her baby in mind is reflected in her body and the way she physically interacts with her baby. This "embodied mentalization" was clear in the second video, when not only the mother's words and tone of voice were different, but her whole body was relaxed and welcoming. This was "evidence based medicine" at its best -an intervention founded on a solid conceptual framework, used in a high quality research design, demonstrating meaningful and significant improvement in developmental outcome.

When I was being interviewed on the Diane Rehm show about the new AAP guidelines regarding diagnosis of ADHD in children under age six, one of the other participants, a professor of pediatrics who clearly supported the new guidelines, identified behavior modification followed by medication as an evidence based intervention. I responded that there were in fact other quality interventions, citing the Minding the Baby program as an evidence based practice. As they had not heard of it, and didn't have any idea what I was talking about, I'm afraid my comment got lost. Here is the actual exchange.

GOLD
I want to just address this issue of behavior therapy because, again, when you start with the much younger children when they're two or three, there are a number of very well-established interventions, such as the Minding the Baby program at Yale, Circle of Security, Promoting First Relationships, that work with parents and children together to promote the ability to self regulate, which is really what ADHD is a problem of, self regulation.

So there are other forms of intervention besides behavior therapy. And, again, that kind of undermines the parents' natural authority if you give them training. But there aren't that many services. The problem is if the AAP kind of endorses medication in very young children, it will decrease the motivation to improve access to other interventions. And that's my biggest worry in very young children.

REHM
What do you think, Dr. Ostrander?

OSTRANDER
Well, I think that, you know, by far measure, the behavioral therapies tend to be the ones that has the greatest empirical support. Now, I'm not to say -- that's not to say that there are not other interventions that are not effective. But, you know, if -- what you -- it seems to me, the most prudent course is to take the medications that have the greatest demonstrated efficacy and try those first.

In another APsAA program, two psychoanalysts from the Parent-Infant Psychotherapy Program at Columbia University, Talia Hatzor and Christine Anzieu-Premmereur, described beautiful individual work with mother-baby pairs. The settings included both private practice and an early head start program, with mothers dealing with poverty and their own abuse histories. The presenters bemoaned the fact that pediatricians do not refer to them. We talked about the gap between primary care clinicians, who are seeing mothers and young infants, and the wealth of knowledge coming out of the discipline of psychoanalysis.

I have been writing about the new AAP policy statement on Early Childhood Adversity and Toxic Stress which emphasizes the need for pediatricians to intervene early to support parent-infant relationships. As I have said, the policy statement is lacking in specifics what such intervention actually looks like. After being at this meeting, it is my wish (fantasy) that there be a combined meeting of pediatricians and psychoanalysts to share experiences and ideas. I would also include health care policy makers, for to do this important work clinicians need freedom from the current restrictive environment imposed by the health insurance industry. The pediatricians (as well as other primary care clinicians) are in the right place at the right time. The psychoanalysts have a great deal to teach us about how to make use of this privileged position.

2 comments:

  1. CBT therapists like to brag about their therapies being the most "evidenced-base," but greatly exaggerate the strength of their evidence.

    They also denigrate the type of evidence you talk about above. And half the time, what they do is very much like what more humanistically-oriented therapists do anyway, only they call it something else.

    They also block researchers from other schools of therapy from getting funding through the NIMH.

    Just like with the drug companies, much of the time their studies are more like marketing masquerading as science.

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  2. I actually caught part of that Diane Rehm interview, but didn't catch the beginning so I had no idea it was you.

    I have to say, I think medications have their place, but that place is getting way overblown. It's nice to see someone talking about behavioral therapies and how effective they can be. Not everything has to be solved with a pill.

    Said another way, parents of 4-5 year-olds often come to me and say, 'My kid has ADHD.' After working with the children for a couple of days, I have to give the parents my limited professional opinion and say, 'I think your kid is a kid.'

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