Adam Lanza and Preventive Mental Health Care

In keeping with my wish for continued meaningful dialogue in the wake of last week’s horrific events, I would like to expand upon what I mean by "preventive mental health care." I am referring to relationship-based care that focuses on young children and families. All of the best science of our time, at the interface of neuroscience, genetics and developmental psychology, tells us that by supporting parents and young children together we will have the best chance to promote both physical and emotional health.

This is not to say that when there are problems it is a parents "fault," nor certainly, as many parents fear, that a young child who is struggling is at risk for becoming a mass murderer. But the brain grows in relationships, and supporting relationships supports healthy brain growth. 

Early reporting suggests that Adam Lanza struggled with severe social anxiety from a young age. This is a description, not a DSM diagnosis.  His mother apparently had some kind of conflict with his school and ended up home schooling him (early reports that his mother worked at the school where the shooting occurred, that I refer to in my previous post, turned out to be incorrect.) 

I wonder if our best chance at preventing this horrific event would have been to carefully listen to these parents, including the father, when Adam was a young child, to understand their experience and find meaningful help for the whole family.

The  piece I Am Adam Lanza's Mother originally published in the Blue Review, that has now gone viral, offers a striking up-close view of how parents suffer in the face of a troubled young child. It offers evidence for the need for intensive help for parent and child together.  Simply labelling the child with a psychiatric disorder and prescribing medication is grossly inadequate care. 

Current standards of care in psychiatry, including both the focus on DSM diagnostic category, in psychiatrist and author Daniel Carlat’s words the “what” rather than the “why,” as well as over-reliance on psychiatric medication, is more narrow than my definition. Preventive mental health care consists of careful listening and support of parent-child relationships. 

On NPR this week there was a comment made that other countries with better gun control laws do not have these kind of events. But what if the important difference is that we are seriously behind in supporting young children and families with such things as parental leave for newborn care?

I wonder if there is some insight to be gained from the venom directed against me in some of the comments on my last post. I see similar venomous in comments on similar posts.They seem to represent an underlying rage (at least among those who comment on blogs) as well as the loss of the capacity to listen to each other.  Assumptions are made about me that are completely unfounded and could easily be dispelled by simply reading my bio and or most recent blog post.

We are as a society traumatized by this event, and by the continued horror of watching the funerals of these young children. To find a way to take meaningful action in the wake of this trauma, we all need to calm down and take a collective deep breath. Perhaps the opening point of meaningful dialogue would be an effort on all sides to take the time to listen to each other.

Gun control and preventive mental health care to honor the lost children of Newtown

For the families who lost children, their world as they knew it has effectively ended. Yet somehow the sun rises again and the next day is here. For the rest of us grieving along with these families, the only way to move forward is to take what President Obama called "meaningful action." I interpret this to be action that is radical and significant enough that it will somehow give meaning to this unimaginable loss.

The first and most obvious front is gun control. Without access to guns, apparently the same rifles used by troops in Afghanistan and Iraq, one individual could not have done this degree of harm. The politics of gun control is not my area of expertise, but certainly the politicians must now be motivated to, as Obama said, "put aside differences" and honor these children with dramatic changes to gun control laws.

The second front is preventive mental health care. This event is the result of a deeply disturbed individual with access to guns. My inbox this morning was full of emails from mental health colleagues referring to pieces they had written for other massacres such as Virginia Tech. I hope that this unspeakable horror will be  the one that will finally lead to real change in access to preventive mental health care.

One of these colleagues wrote of how these events are often perpetrated by young adults who have not been "acting out," but rather have been quietly bullied for years and seriously neglected at home. Their symptoms may be more subtle. Yet it is difficult to imagine that there were not people in this family's life who did not recognize that this boy/young man was mentally ill.

The emerging information speaks to  a deeply troubled relationship between the shooter and his mother as being at the root of the event. Apparently he first shot his mother and then went to the school to deliberately kill the children at the school where she worked. I wonder, was the hurt he experienced in his relationship with her magnified by his witnessing of the care she gave her young charges at her job?  Of course I don't know, and this is only theory as I struggle to make sense of something that doesn't make sense.

As I said to my editor when she asked for our thoughts on this event, the trauma is perhaps too fresh for an in-depth discussion of theory and policy change. However, I am hopeful that the coming weeks and months will be filled with meaningfully dialogue of how we as a society can honor the dead children, both through gun control and improved access to quality preventive mental health care.

Where is the media coverage of the DSM V vote?

Last Sunday I awoke to a news story in our local paper, The Berkshire Eagle, about the vote by the American Psychiatric Association the previous day approving massive revisions for DSMV, the newest version of the Diagnostic and Statistical Manual of Mental Disorders. The article stated:

Board members were tight lipped about the update, but its impact will be huge, affecting millions of children and adults worldwide (italics mine.)

Figuring that this would be big news, I asked my husband if we could delay our morning hike while I wrote a blog post about it. I was sure there would be an active public discussion on the subject.

But I was wrong. Mainstream media had virtually nothing on the story. There was not one word about the DSM vote in the New York Times.  The Boston Globe similarly did not cover the story. There was a brief mention on NPR's Morning Edition on Monday. Boston.com  had my piece as well as an article about Asperger's being dropped from the new version.

There was news on the blogs. Most striking was from Allen Frances, MD, professor of psychiatry at Duke University, who was chair of the DSM IV task force. On his Huffington Post blog he wrote:

This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM-5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public -- be skeptical and don't follow DSM-5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. 

While he defends his colleagues against accusations that they have been influenced by big pharma, he  writes that:

The APA's deep dependence on the publishing profits generated by the DSM-5 business enterprise creates a far less pure motivation. There is an inherent and influential conflict of interest between the DSM-5 public trust and DSM-5 as a best seller... The current draft has been approved and is now being rushed prematurely to press with incomplete field testing for one reason only -- so that DSM-5 publishing profits can fill the big hole in APA's projected budget and return dividends on the exorbitant cost of 25 million dollars that has been charged to DSM-5 preparation.

When MGH psychiatrist Joseph Biederman was found guilty of violating conflict of interest rules in accepting large amounts of money from the pharmaceutical industry, the news was announced on July 2nd 2011, a Saturday of a holiday weekend. A number of bloggers suggested that this timing was deliberate: an effort to bury the story.

Some may suggest that the weekend DSMV vote and lack of media coverage is related to the power of the APA and big pharma to squash controversy. For the sake of children, families and adults who struggle with mental illness, I hope that there is a more benign explanation.

A relational view of DSM V: a care-rationing document?

Because DSM V the newest version of the Diagnostic and Statistical manual, sometimes referred to as the "bible of psychiatry" set to come out in May 2013, makes no mention of relationships, the relational perspective is that it is a flawed instrument. The whole discussion about what categories should and should not be included is off the mark. Nonetheless, as it currently dictates who will and who will not receive treatment, it is a force to be reckoned with.

Psychiatrist Daniel Carlat, in his book Unhinged: The Trouble with Psychiatry writes:

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’.

In an excellent NYT piece on the subject, Not Diseases, but Categories of Suffering, the author states:

And as any psychiatrist involved in the making of the D.S.M. will freely tell you, the disorders listed in the book are not “real diseases,” at least not like measles or hepatitis. Instead, they are useful constructs that capture the ways that people commonly suffer.

He goes on to say that the problem with DSM is that it has been taken “too seriously.” This is reflected by the fact that even though these diagnoses are artificial constructs, they dictate who does and who does not receive treatment. In other words, if you meet diagnostic criteria you are suffering enough to get help. If not, you’re on your own.

Consider the new diagnostic category, voted on Saturday to be included in the new version: Disruptive Mood Dysregulation disorder. The boy I describe in the following story(details as always have been changed to protect privacy) may or may not meet the criteria for this label. Either way, he and his family are in trouble. Even asking the question of diagnostic category diverts us from the task of helping them.

Four-year-old David's mother, Alice, described him as "explosive." She told of a typical scene- a request to get ready for bed was met with a firm "no," and soon mother and child were head to head in battle. An hour later, David was kicking and screaming on the floor and Alice was crying, horrified with herself for having threatened to hit him. Similar scenes occured several times a day.

Rather than launching right in to "what to do" I took some time to listen to Alice's story while David played on the floor. Many things emerged, but most striking was the fact that the family had moved three times in the past year after David's father, Ron, lost his business, leaving the family in financial ruin. Ron had been severely depressed, but according to Alice, they were settled now and he had a good job. When I commented that it sounded like a very stressful year, she immediately responded with,"Yes, but we didn't let it affect David."

From my position, this clearly seemed impossible. Such an experience is inevitably stressful for a four-year-old child. But for some reason, Alice, who was an intelligent woman, did not see it. Perhaps she felt so much guilt, or even shame, about what had happened to her family that she could not let herself recognize this truth.

I saw my task at that moment as helping Alice to understand David's experience, to recognize that his increasingly frequent battles for control were likely in part due to feeling things were out of control for whole past year. But I needed help Alice recognize this without increasing her guilt and shame. It was a difficult and sensitive procedure.

When I saw them two weeks later, the explosive episodes had significantly decreased. Alice told me that his behavior no longer seemed so bewildering to her. Rather than getting angry, she listened to him, yet set more firm limits. She was delighted with the results and felt proud of her ability to regain a sense of joy and stability in her relationship with her son.

The research coming from the field of infant mental health offers a way to make sense of this change. It gives us a completely different model from DSM for both understanding and treatment.  Ed Tronick, a leading researcher in developmental psychology who is perhaps best known for developing the still face paradigm,  has described mutual regulation model.

The MRM(mutual regulation model) stipulates that caregivers/mothers and infants/children are linked subsystems of a dyadic system and each component, infant and caregiver/mother, regulate disorganization and its costs by a bidirectional process of behavioral signaling and receiving.

The still face paradigm, in which a mother interacts face to face with her infant as she usually would, then for a two minute period presents a completely still face, followed by a reunion episode of resumed face to face interaction, in Dr. Tronick's words "demonstrates the costliness of an experimental disruption of the mutual regulatory process...as it serves as a model for the stress inherent in normal interactions."

In other words, it is impossible to understand the behavior of a child without looking at the behavior in the context of this mutually regulating or dysregulating relationship.

Another leading researcher in the field, Arietta Slade, has written extensively about what is referred to as parental reflective functioning. This is also described as "holding a child's mind in mind."It  refers to a parent's capacity to reflect on the meaning of her child's behavior. Slade, along with other researchers, has shown how enhancing a parent's capacity for reflective functioning is associated with many positive outcomes for a child's emotional development, including flexibility, cognitive resourcefulness and the ability to manage complex social situation.

When things go well in my office, supporting a parent's efforts to reflect upon the meaning of her child's behavior, as I did with David, is simply the point of entry. Once the child feels understood, he becomes calm. Evidence indicates that this change is on a neurobiological basis, occurring at the level of the structures of the brain that produce stress hormones. 

When a child is calm, a parent begins to feel better about herself. In fact, often a child's out of control behavior itself produces a feeling of shame in a parent. When parent and child are more in control, this sense of shame decreases. In turn, when a parent feels less shame, and less stress, she can think more clearly. She is better able to reflect on the meaning of her child's behavior. In turn a child feels even more calm and in control. This is what is meant by mutual regulation.

Any parent-child pair who is suffering in this way deserves to get help.

DSM V might have some role if it is used simply as a way to guide thinking. One of its original aims was to offer a structure for clinicians to recognize similarities and differences among their patients and to talk to one another about them. (The DC 0-3,  a similar document, includes a relationship classification and offers a much more comprehensive model for understanding emotional problems.)

But that is not how it is used. It is essentially a document that rations care.  The issue of the elimination of the diagnosis of Asperger's is a complex one and beyond the scope of this post. However, the frequently made objection that people who have this diagnosis will no longer be eligible for help, supports this way of understanding the DSM. 

If DSM, then, is a care-rationing document, the solution is not to spend years refining the categories. The solution is to improve access to care. 

Yale lab calls babies bigots- a worrisome interpretation

A CBS 60 minutes segment: Born good? Babies help unlock the origins of morality is getting a lot of attention. The opening observation that babies are in fact not blobs is certainly apt. Pediatrician T. Berry Brazelton has been telling us this for over 40 years, since he developed the Neonatal Behavioral Assessment Scale that clearly shows babies as young as a few hours having complex capacities for communication. When I teach pediatric residents I show them a 2-minute video clip of a three-day-old baby following my gaze and moving his mouth as if in conversation with me. Clearly not a "blob."

However, when the researchers at Yale went on to interpret their findings as indicating an innate capacity for bigotry, I became alarmed. Certainly their research results are robust in showing a baby's preference for stuffed toys that exhibit behavior that is "like them." Researcher Paul Bloom states in the program:

If you want to eradicate racism, for instance, you really are going to want to know to what extent babies are little bigots, to what extent is racism a natural part of humanity.

Here is Webster's definition of bigot:

A person who is obstinately or intolerantly devoted to his or her own opinions and prejudices. 

Using such a negative word to describe a baby feels a bit like a prejudice itself.  Elizabeth Young Breuhl in her book Childism: Confronting Prejudice Against Children, describes prejudice as projection of bad feelings from inside out on to another person.

At another point in the interview Bloom suggests that there might be sets of genes and areas of the brain responsible for such things as resilience and morality.  This rings of the approach of "biological psychiatry" with its history of placing complex developmental/relational problems squarely within a child.

I wonder if another interpretation of the results is in order. I immediately thought of Daniel Stern, a brilliant child psychoanalyst who recently passed away. In his book The Interpersonal World of the Infant he points to the explosion of infant research as evidence of an emerging sense of self in early infancy. He writes:

Recent findings about infants...support the view that the infant's first order of business, in creating an interpersonal world, is to form the sense of core self and core others. The evidence supports the notion that this task is largely accomplished during the period between two and seven months.

So these 3-5 month old babies in the Yale lab, shown out of relational context in interaction with a toy, are in the heart of this process of developing a sense of self in relation to others. An adult, who has a fully developed sense of self, must exercise extreme caution in interpreting their behavior using negatively charged words such as bigot and racist. The behavior must be interpreted in the context of this complex developmental task.

In keeping with the subject of sameness and difference,  the day that I learned of the CBS program I read a review of the new book Far From the Tree: Parents, Children, and the Search for Identity.  The book explores the issue of individual differences, and the complex interplay of genes and environment, through extensive interviews with families of children with various forms of difference or disability. Author Andrew Solomon is not a scientist, but a father and a writer who has done an enormous amount of research.  Though I have only read the first few pages of the over 900-page tome, I am already captivated. On page one he writes:

Our children are not us: they carry throwback genes and recessive traits and are subject right from the start to environmental stimuli beyond our control. And yet we are our children; the reality of being a parent never leaves those who have braved the metamorphosis. The psychoanalyst D. W. Winnicott once said, "There is no such thing as a baby, you will find you are describing a baby and someone. A baby cannot exist alone but is essentially part of a relationship."

 New York Times reviewer Julie Myerson writes of the book:

 This is a passionate and affecting work that will shake up your preconceptions and leave you in a better place.

This book seems an appropriate bookend to the Yale research, with all of the extensive research at the interface of neuroscience, developmental psychology and genetics on how a person develops a healthy sense of self in relation with other people in between.

Massage and music for mothers and babies

One of the best things about the work I do is that I get to meet great people and learn about wonderful programs that support parents and children.

Last week I was away in New Jersey speaking at the ICDL conference (Interdisciplinary Council for Learning and Development) In the afternoon, after giving my presentation, I attended another workshop. In the minutes before it started, a woman sitting in front of me turned to me and commented that she had enjoyed my presentation. I asked her what she did.

I learned that that she works at Newark Beth Israel Medical Center where she does massage in the Pediatric Intensive Care Unit and Hematology/Oncology unit. When I commented that this must be a very progressive hospital, she said that if she had come with the program fully formed, it was unlikely they would have used it. But she started out just doing a consult here and there, and when the doctors saw the value of her work, they expanded the program to what it is today.

In addition, she told me, in her program Nurturing Touch she does massage with drug addicted moms and their babies who are being treated for withdrawal symptoms. She explained that at first she just worked with the babies, and held what she soon recognized were incorrect assumptions about the mothers. She observed that "we rip the mothers and babies apart" when there is a positive tox screen (drugs found in the urine.)  When she actually met the mothers, she found that they were in deep pain over being separated from their babies and longed to reconnect with them. She began to use her massage techniques on the mothers as well, recognizing that many of them had histories of abuse, and might never have experienced touch in a positive and caring way. She did this simply with gentle hand massage. Her aim was to begin to relax their bodies enough to enable them to hold their own very dysregulated babies;  providing comfort both mother and baby so desperately needed.

Earlier that day I had received an email from someone who had been referred to my website by her pediatrician. She wanted to share her work with me. She is a musician and music therapist who began studying clinical psychology after the birth of her first child. But rather than complete her PhD, she produced an album for mothers and babies, Good Morning My Love, that won the Parent's Choice Gold Award. I found the following on her website:

The benefits of music are intuitive to most people. Music is a natural endorphin that bypasses intellectual thought and directly connects you to emotions. It can simultaneously engage both your playful, spontaneous side and your soulful, tender side. For many reasons it is one of the best ways to connect to your baby: Music, with its inherent melody, rhythm, and repetition, is a language that babies can understand from day one. It also has a way of organizing experience and enhancing it. Both you and your baby can use music to create routine, develop reliable patterns of expectations, and foster a sense of security - all of which help to create a familiar and loving environment. 

As a lover of folk music, I was captivated. One song that is excerpted on her website perfectly captures the ambivalence of toddlerhood with the lyrics, "Mama leave me be but don't leave me." In groups she runs for moms and babies, she uses music to address the anxiety and isolation that new moms often feel.

On my return home, these experiences came together in my mind when I read a study in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry suggesting that ADHD and Autism Spectrum Disorder (ASD) may actually represent one overarching diagnosis. Interestingly, at the conference I had been speaking with a colleague, an occupational therapist, about the overlap in symptoms not only of of ADHD and ASD, but also anxiety.

Stanley Greenspan, founder of ICDL, eloquently described the very close link between sensory and affective experience. He recognized these "disorders" as variations of ways in which these systems have been derailed, and created the DIR floortime model as a way to help children and their families to address problems of sensory and affective experience.

I suspect that as we learn more about the biology and genetics of these problems, we will find that the diagnostic categories as described in the DSM system represent artificial constructs.

Rather than figuring out what diagnostic category a child fits in to, we need to focus on supporting parents' efforts to understand their child's experience and to help him to manage his unique vulnerabilities.  The research that I describe in my book Keeping Your Child in Mind offers evidence for this model as a way to promote healthy emotional development.

At the conference, in collaboration with Dana Johnson, an occupational therapist who reached out to me after reading my work, we advocated for integrating the two models in our presentation: Development of the Parent: the Child's Contribution.

I hope that "alternative" therapies, as represented by music and massage, will someday be considered primary therapies, as they address the primary problem. Even better, offering these kinds of interventions for stressed mother-baby pairs may go a long way in preventing the development of more complex problems of sensory and affective experience, problems that we now label "psychiatric disorders."

Infant Mental Health and Child Protection: an Essential Partnership

Michael Bush, a bright, open-minded third-year student at West Virginia University College of Law, contacted me this past summer when, in his role as an editor of the Law Review, he was organizing a symposium on Child Protection in the 21st Century. In our subsequent email conversation he wisely observed that those in the legal profession are often in a position to decide what is "in the best interest of the child" with little substantive understanding of what exactly is in the best interest of the child.  He invited me to share my knowledge as an expert in infant mental health.

This week, his efforts and those of his fellow law review editors-a remarkable group of intelligent and thoughtful young people-came to fruition. It was an extraordinary experience that opened up many opportunities for meaningful collaboration.

 In my presentation I contrasted the historical view of Child Protection as a child-saving service designed to prosecute parents with the model of relationship-focused preventive intervention promoted by the field of infant mental health (those who are interested may see the talk in its entirety on the webcast.)


Rather than giving specific ideas about what to do, I offered a different way to think about work with very troubled families.  While many in the legal profession view their task as "proving what the parent has done wrong," (this is a direct quote from a CPS social worker) I encouraged them to think about creating a "holding environment" where there is room for non-judgmental curiosity about the meaning of behavior. I presented an overview of the research that supports this paradigm.

Many very important things came out of this trip. A number of people from CASA, a non-profit organization in Virginia that supports volunteer advocacy for abused and neglected children, attended my talk. Amber Moore, the editor-in-chief of the Law Review, told me that they had requested my PowerPoint because "they couldn't write fast enough." They want to use what I was teaching to train their volunteer workers. I discovered that people were starved for knowledge about contemporary research in child development in a form that they could understand.

I quoted from my book Keeping Your Child in Mind, explaining that while it was being marketed as a parenting book, it is actually a book about infant mental health written for a general audience. I wrote it with my pediatric and mental health colleagues in mind, but now I see how useful it could be to the legal profession, specifically those working in the area of child protection.

One of my co-presenters was a delightful judge from central West Virginia who has been doing child protection work for over 20 years. He openly admitted to his lack of knowledge on the subject of contemporary child development research and bought 5 copies of my book.

I met a remarkable young woman who, in addition to attending law school, works at the Industrial Home for Youth in Salem, where prior to a recent lawsuit, children as young as 13 were routinely placed in solitary confinement. As part of a law school class, she is drafting a bill to require multidisciplinary meetings every three months for these young offenders, who currently may not meet with anyone who is advocating for them for their entire stay. Because WVU is the only law school in West Virginia, the students' bills are presented to the state legislature, and a percentage of them actually become law. I am hopeful that she and I will keep in touch and that I can support her in her efforts.

As Keynote speaker of the symposium, I have been invited to write a paper for the West Virginia Law Review that will then be available for citation in legal work.  Another of my co-presenters, who spoke about the legal challenges of adolescent parents, already told me that she intends to cite my work.

This trip was well outside my comfort zone. I had never been to West Virginia (or even Pittsburgh-where I had to fly to get there) and certainly had never spoken with an audience of lawyers. My infant mental health colleagues are "my peeps." In a few weeks they will gather in Los Angeles at the wonderful Zero to Three National Training Institute. Sadly, I will miss it, in part because of this trip.

I have often said to my infant mental health colleagues that we need to work on communicating the wealth of ideas that will be presented at that conference widely beyond our borders.  It was like a dream come true to have the opportunity to speak to a group of bright young law students- the future lawmakers and policy makers of our country. The experience left me hungry for more.

A happy story in stressful times

It was quiet on the mountain. My husband and I were on an early morning hike with our dog up Monument Mountain. As we approached Inscription Rock, a landmark near the top, we saw a man and woman who looked to be in their late 60's, healthy outdoorsy types. The man was asking the woman to sit on the rock so he could take her picture.

As we passed by, the man walked towards me and asked me to take their picture. "Sure," I replied, taking his camera. Then, as the woman got settled on the rock, he whispered to me, "I'm about to ask this woman to marry me." Signaling to my husband to stay back with the dog, I began clicking away. He approached her and got down on one knee, pulling a small box out of his jacket pocket. There was much laughter and embracing. When the deed was done, they turned to face me, arms around each other, and asked me to take their picture together.

"It was meant to be," I said, referring both to our arrival at this spot at the exact moment of the proposal, as well as, I hope, their marriage. My husband and I continued over the top of the mountain and down the other side, exhillarated by this chance encounter with new love.

( Between the elections, hurricane Sandy and my preparations for two major presentations in the next two weeks-more about those soon- a relevant and meaningful blog post has not been forthcoming. I hope readers enjoy this little tale instead!)

Preventive mental health care for children falls through the cracks

The current issue of the Journal of the American Academy of Child and Adolescent Psychiatry has an excellent article, Integrating Mental Health Care Into Pediatric Primary Care Settings, identifying the causes of this problem.

Pediatric training provides limited experience in screening or intervening for mental disorders. In contrast, child psychiatry training emphasizes the treatment of children with established psychiatric diagnoses and typically offers limited experience with children at risk for mental disorders or children whose symptoms do not reach the threshold for diagnosis. 

In other words, the current structure of the health care system does not have room for prevention. Primary care clinicians, who have the main contact with young children and families, do not have adequate education in prevention, and specialists who children are referred to when problems arise only know how to treat identified "disorders." The article further elaborates on the reasons for this situation:

Current financing structures reward treating established diagnoses, not providing preventive services, because payment for visits, with few exceptions, requires a DSM-IV diagnosis.

This problem is currently being addressed in the refinement of the DC: 0-3, a classification of disorders of infancy and early childhood that recognizes the significant role of relationships in problems in this age group. If the DC:0-3 is "cross-walked" with a DSM diagnosis, then reimbursement is possible.  That word "disorder" is still part of the conversation, but it is a step in the right direction.

Another problem intrinsic to the system is that for billing purposes the child is the identified patient, making work with the family challenging.

Research on the treatment of child mental health conditions has strongly indicated the benefit of treating the child and the caregiver as “the patient,” but public and private plans frequently do not pay for family-focused treatment... the need to identify the child as the patient makes family-focused interventions difficult to support financially; likewise, payment for caregiver-only or collateral sessions is lacking.

Another problem identified is the lack of financial support for collaborative care. In my work with families in the Early Childhood Social Emotional Health program at Newton Wellesley Hospital I speak regularly with a child's primary care doctor. This is an essential part of care, as that person often has a longstanding ongoing relationship with the child and family and knows them well. In addition, if I refer a family on to more specialized care, such as with a psychiatrist, it is important that I fill them in on the work I have been doing with the family. Working as a team we can hold the family through a difficult time, and get development going in a healthy direction. I spend a lot of time on the phone because it is good care, and I know that many of my pediatrician and child psychiatry colleagues do the same. Yet none of this care is reimbursed.

The article offers this ray of hope:

The Affordable Care Act (Public Law 111-148) requires mental and behavioral health coverage in an essential benefit package at parity with medical benefits. This could incentivize the integration of care.

Of course for this to happen, President Obama must be reelected.

Yoga for autism, movement for learning

When I listen to parents of young children (under 5) in my behavioral pediatrics practice, they often describe a child who is very overwhelmed by sensory input, inflexible and easily dysregulated. They worry that their child is "on the spectrum." We talk about how their child does not feel calm in his body, and work together to help him find ways to feel calm. With this approach, there can be significant improvement in behavior.

Thus I was pleased, though not surprised, to learn of two studies validating this approach in children who have been diagnosed with autism. One, published in the current issue of the American Journal of Occupational Therapy, demonstrated that a 17 minute yoga program, called "Get Ready to Learn," significantly decreased anxiety, social withdrawal and aggression.

The second, published last year in The Journal of Alternative and Complementary Medicine demonstrated significant improvement in core features of autism in a group of children age 3-16 who participated in an 8 week multimodal yoga, dance and music therapy program.

In a related story, this morning on NPR's Only a Game, a program entitled Does Exercise Help Kids Learn? referred to the research of neurologist Majid Fotuhi showing that exercise improves learning efficiency. He stated:

I am also in favor of shorter teaching sessions which are intermittent with 20 minutes of P.E. or some kind of physical activity that’s somewhat structured.

In a previous post I refer to psychiatrist Bruce Perry, whose neurosequential model of therapeutics, primarily applied to work with traumatized children, uses self regulating activities interspersed between both learning and therapy. I conclude:

Often when kids are struggling in school, teachers express concern that they are "over-scheduled." But if extracurricular activities are carefully planned and well thought out, they can be considered an essential part of treatment. It is best to have some kind of a calming activity interspersed with homework, tutoring or therapy. These can be tailored to a child's particular talents and interests.

Whether a child has symptoms associated with autism, has experienced trauma, or is struggling to learn, promoting self-regulation by using the body to help the brain is important. If we can incorporate this approach into treatment and education of young children, we will support healthy development of regulation of emotion, attention and behavior,  perhaps even avoiding the need to label them with a disorder.

New study asks; what happens to the dysregulated infant?

When I see children in my behavioral pediatrics practice, whether they are 2, 5 or 15 it is very common to hear from parents that as a baby their child "cried all the time" never slept" had "terrible feeding problems" or some variation of this. Therefore I was not surprised by the findings of a large longitudinal study published this week in Pediatrics: Long-term Outcomes of  Infant Behavioral Dysregulation. The researchers in Australia had information about over 5000 babies starting at 6 months, and found that when mother's reported symptoms of "dysregulation" at this age, they were significantly more likely to report of behavior problems at age 5 and age 14. This association was affected by such things as mother's level of education, marital status and presence of anxiety and/or depression. The authors conclude that:

By facilitating early referral to appropriate professionals, such as public health nurses, family therapists, psychologists, and social workers, clinicians may aim to improve not only behavioral out- comes in childhood and adolescence, but also parents’ perceptions of their children and the needs of the parents themselves.

While I am pleased that this conclusion is reached in a prestigious journal, what is lacking in this study, is understanding of how infant dysregulation and later behavior problems are linked, and so in how to treat these problems. Here are three points that speak to this issue.

1) This model places the "dysregulation" squarely in the baby. However, any new mother (I refer to mothers because that is what the study does- see below for thoughts about fathers) will tell you that the baby's behavior has a huge influence on a mother's behavior and emotional wellbeing.  The mother and baby regulate and dysregulate each other. For example, if a baby has difficulty settling to sleep, a parent will likely be severely sleep deprived. This in turn may affect her ability to respond to her baby's cues. If she is struggling with postpartum depression, the sleep deprivation likely will worsen her symptoms. When a mother is herself struggling in this way, it may lead to further symptoms of "dysregulation" in the baby. But conversely, if a baby is dysregulated and the mother gets help,  in the form of such things as a mother-baby group, yoga and/or therapy, and she is able to be calmer, she will be better able to help her baby manage his symptoms of dysregulation. In turn, as her baby becomes more calm, she will feel more competent and better about herself as a parent.

2) Fathers have a critical role to play. A study published last year in Pediatrics showed a significant link between paternal depressive symptoms and later child behavior problems. Again, looking at the positive side of this, when a father's emotional wellbeing is supported, he can be more emotionally available for both his partner (this study does identify stability of partner relationships as well as marital status as an important factor) and his child.

3) Symptoms of dysregulation are usually present before 6 months of age. For example babies born prematurely are very likely to be behaviorally dysregulated. One particularly vulnerable population is what is referred to as the "late preterm." When babies are born at 35-37 weeks, they are often in the regular nursery and parents have an expectation that they are "normal." However, these babies may be difficult to feed, have difficulty settling to sleep as well as increased sensitivity to sensory input. When there is this kind of mismatch between the parent's expectations and experience, significant feelings of inadequacy may emerge. In turn, these feelings, together with sleep deprivation may lead to symptoms of depression in a parent. This is another example of mutual dysregulation.

I was motivated to develop the Early Childhood Social Emotional Health program at Newton Wellesley hospital exactly because of the findings that this study calls attention to. I wanted to help families before their child was 5, 10 or 16 and being diagnosed with ADHD. Recognizing that the roots of these problems are usually present very early, it made sense to  devote resources to helping families of young children.

The risk of this study however, is that "infant dysregulation" becomes the new "ADHD," placing the problem squarely in the child, and failing to recognize that the problem occurs in relationships.   As it stand now, the study adds to the rapidly growing body of literature offering evidence that devoting resources to early childhood is important. But it is only by focusing on interventions that promote healthy relationships, and for vulnerable parent-child pairs starting these interventions at or close to birth, that this research can have a positive and meaningful impact.

ADHD: biology or environment?

When I write from my clinical experience as a behavioral pediatrician, I am careful to change identifying information to protect the privacy of my patients. It is rather freeing, therefore, to write  about characters in a novel. Left Neglected by Lisa Genova, who is also a neuroscientist (perhaps she took the story from some real cases) offers some important insights into this complex subject.

The story revolves around Sarah, a 37-year-old mother of three young children, who, distracted by her cell phone on her drive to her high-powered job, crashes her car and suffers a traumatic brain injury. In the days just before the accident, she and her husband are called in to see their seven-year-old son's teacher who says, in not so many words, that they should have him evaluated for ADHD and possibly medicated. During the time that Sarah is hospitalized, he is in fact diagnosed and started on Concerta.

But there is another relevant story line. We learn that when she was a child, Sarah's 6-year-old brother accidentally drowned in a neighbor's pool. When Sarah's mother comes to take care of her in the wake of her accident, we gain further insight into the havoc this event wreaked on their relationship. Her mother is holding her hand in the hospital. She writes:

After Nate died, at first she held my hand a little tighter. I'm seven, and my hand is in hers when we cross the street, when she leads me through a crowded parking lot, when she paints my nails. Her hands are confident and safe. And then I'm eight, and my hand must be too awkward to hold along with all that grief, so she just lets go. Now I'm thirty-seven, and my hand is in hers.

Sarah acknowledges that her intense drive to succeed has been at least in part powered by this double loss of her mother and brother. In her pre-accident life she is a master multitasker who works very long hours and is rarely home for in time dinner. She clearly adores her kids and is devoted to them, but is usually answering emails while getting them ready for school.

As she and her mother work to heal their relationship, we see a new kind of calm in Sarah (part of this is necessitated by the restrictions on her life imposed by her brain injury.)  In a lovely scene where she is helping her son with his homework, she is present with him in a way that she was not in her prior frenetic lifestyle. Together they figure out that he works better standing up. If they cut out the problems, he can do them individually and not be distracted by all of the questions on the page. Both are thrilled by his success.

Jubilant pride skips along every inch of his face. It strikes me that he looks like me.

I recognize that these are fictional characters. Yet I think that an assessment, as I do with real patients I see in my practice, can offer some insight into this complex question of the interaction between biology and environment.

There is likely a genetic vulnerability for attention problems in Sarah's family. Her brother's accidental death may have in part been due to an impulsivity that can go along with these traits. Sarah herself may have some attention problems, but her behavior is also in large part fueled by the loss of her brother and her troubled relationship with her mother.

Her son may have this same genetic vulnerability, but his symptoms are also tied to his mother's intense, driven behavior. She may have difficulty being emotionally present with him, particularly as he reaches the age her brother was when he died. As Sarah's relationship with her own mother is healed, in turn she is able to be more fully emotionally present with her son.

My hope for these fictional characters is that Sarah's process of grieving and healing with her mother will in turn help to lessen her son's symptoms of inattention and distractibility, and so support his healthy development.

Grief and loss are frequently present in the family history of children who have been diagnosed with ADHD. But often, as in this story, these losses go unacknowledged for many years, sometimes for generations. They may take the form of "family secrets."

As I was working on this post, I suddenly recognized the double meaning of the book's title. Left neglect is the name given to the disability that results from Sarah's injury. But Sarah was also left neglected by her mother's grief.  Ironically it takes the first to repair the second. My hope for real families confronting similar issues to this fictional one is that they can find a way to address these unmourned losses and heal relationships without needing a devastating life event to motivate them. 

Program inspired by Daniel Pearl teaches kids to use music for peace

An extraordinary program, Music in Common (MiC), takes on particular significance in light of recent events in the Middle East, when a video that author Salman Rushdie referred to in an NPR interview as a "disgraceful, shoddy little thing," seems to be at least in part responsible for terrible violence and death. In stark contrast, MiC's mission statement reads:

By producing free, publicly accessible concerts, school programs, and multimedia productions with an interest in underserved areas and communities where there is a history of conflict, Music in Common (MiC) provides a platform for the exchange of ideas and collaborations that can lead to positive social change.

Originally called FODfest (Friends of Daniel) the organization was founded by Pearl's close friend and bandmate Todd Mack in response to Pearl's tragic death in 2002. Pearl was kidnapped while working as a journalist in Pakistan, and subsequently beheaded by his captors.

Groups of students in the MiC youth program work together with industry professionals to write, record, perform, and produce a music video of an original song, participating in all aspects of the creative and multimedia production process. Their website states:

MiC Youth Programs are free educational programs that extend the FODfest concept of community building through music to youth, serving to educate, inspire, and empower junior high and high school students.  MiC Youth Programs take place in local schools or community centers where FODfest concerts take place and provides an experiential education to students, teaching the essential life skills of team building, collaboration, and mutual respect. 

MiC international focuses on the Middle East, and has produced music videos with groups of Arab and Israeli students working together, including this one Peace*Shalom*Salaam.

I am fortunate that the organization's founder lives in my town, and has brought the program to my son's school. For the past two weeks, a group of nine high school students have worked long hours together in an intensive process to create a song and produce a music video.  I had the privilege to sit in on a group of kids discussing what they are learning. One said that in the age of the Internet, it is important to think carefully about how your message will be received by a large audience. Another reflected on the responsibility of using creativity for peace, not war.

Following the production period, there is a performance,  referred to as a "FODfest community concert." Here the song and video are debuted for an audience, and musicians swap songs and jam together onstage. The Mic brochure describes these events as:

Powerful and healing experiences generating a sense of community and hope, serving as a call to action for individuals and communities to discover common ground.

Never leave a child alone during a meltdown

A commonly held belief among parents is that one should leave a child alone, or "ignore" him, when he is having a meltdown. Yet all of the best of developmental science tell us that this approach is completely wrong.

When I work with families who are struggling with a child's out-of-control behavior, I explain that in the middle of a meltdown, a child feels completely helpless. If left alone, he will feel not only frightened, but also abandoned. I explain that at such a moment, the higher cortical centers of the brain responsible for rational thought are not functioning properly.

These types of severe meltdowns are common in children who have experience early trauma, at the time when the higher cortical centers of the brain were not yet fully developed. Stress of a seemingly minor nature can lead the rational brain to in a sense go "off-line."  The child will have access only to the lower brain centers that function more instinctively.

I recall working with the parents of a four-year-old child who had been adopted from another country. There he had lived on the street with his mentally ill mother, from whom he had been separated at one year of age and placed in an orphanage. His adoptive parents where both horrified and overwhelmed by what they interpreted as "anger." He would scream at them,  spit at them, kick and hit them. Not only would they get angry in return, interpreting his behavior as "defiant," but they would send him to his room, saying, "I'll be back when you can calm down and behave nicely."

When I explained that during a meltdown he was developmentally more like a newborn than a four- year-old, their approach to him completely changed. Rather than react in anger, they would ask calmly, "Do you need a hug?" Or they would try to hold him. If he were too out-of-control to allow physical contact, they would take him to a place where he was physically safe, and speak to him reassuringly until he began to calm down. Not only did the tantrums subside, but his parents began to learn to recognize when he was about to descend into what they now understood as a lower center of brain function. They would try to engage him when the thinking part of his brain was still working.

Similar mechanisms are at play in a child who has not had this kind of severe trauma. Frequent meltdowns are common in the setting of sensory processing problems and developmental problems such as speech and language delay (as apparently was the case for Rose, the child described the New York Times piece.) When a child is repeatedly abandoned both physically and emotionally in the middle of a meltdown, that experience in itself may be traumatic. In such a situation frequency and intensity of meltdowns often worsens.

Parents often feel that holding a child in this way is counter intuitive. "Won't I teach him that he can get whatever he wants? " they often ask. But the opposite is true. When a child feels held and understood, with time he learns to manage these difficult moments on his own. 

Discipline, both in the home and in the school setting, should be founded in contemporary developmental science. This science tells us that when we aim to see the world through the child's eyes, and approach his behavior from a stance of empathy and understanding, he learns to regulate emotions, think clearly, and manage himself in a complex social environment. 

A Conversation with Paul Tough: How Children (Don't) Succeed

I had the privilege of speaking with Paul Tough on the very day that his new book How Children Succeed: Grit, Curiosity and the Hidden Power of Character was released. In the middle a massive publicity tour, including NPR interviews and major speaking engagements (he is speaking September 6th at Harvard), his publicist arranged for him to speak on the phone with me. Despite being under what I imagine to be intense pressure, he was very gracious and thoughtful.

It was really more of a conversation than an interview, as my hope was to introduce some ideas that were not addressed in his book. It was understandably relatively brief, and I am using my blog to elaborate on what we discussed. I am thrilled that his book is receiving the attention it is. In presenting his thesis that character, rather than cognitive skill, is the key to success,  he brings some very important research to the forefront of public discussion.

Extensive research has shown that in the setting of a safe secure caregiving relationship, children develop the capacity for emotional regulation, cognitive resourcefulness, resilience and the capacity for social adaptation. He uses somewhat different words-including grit, curiosity, self-control, and gratitude, and refers to these traits as a whole as "character."

From my view as a pediatrician and scholar of developmental theory, I see significant obstacles to promoting character development in the way he is advocating for.  I wonder if, in addition to funding programs that promote character, or funding research to study these programs, as Tough effectively argues we should be doing, we need to understand the nature of these obstacles.

With that in mind, I asked Tough about three interrelated issues. These are; our society's undervaluing of primary healthcare, overreliance on psychiatric medication, and childism.

Consider the following scenario, variations of which are exceedingly common. It starts with a mother who is under significant stress in pregnancy. Then she has a baby who "cries all the time." Stress in pregnancy is associated with this kind of behavioral "dysregulation" in the newborn.  She may struggle with postpartum depression(PPD). The combination of depression and a fussy baby makes providing the kind of attuned relationship a newborn needs extremely difficult. But in the absence of an effective PPD screening and treatment program, the pair may not get help. There is severe sleep deprivation, marital stress and many other factors that make it difficult to be responsive in the way that supports character development.

By age three, the child has significant trouble with emotional regulation. His pediatrician, under the time constraint of the 10-15 minute visit, likely will offer behavior management advice about such things as time out. She likely will not have the opportunity to hear about the stressed marriage or the mother's depression, much less to take the time necessary to make an appropriate referral.

At age four, the child is disruptive in preschool. An ADHD evaluation is recommended by his teachers. He meets diagnostic criteria as defined by DSM. He is started on stimulant medication and immediately his behaviour improves. But soon the problems resurface as the underlying issues have not been addressed. The dose is increased. The medication is changed. This continues throughout the rest of his childhood. When he gets to high school and confronts the barrage of tests Tough writes about in his book, he starts abusing his stimulants.

I'm a clinician, not a policy person, but  I do have some thoughts about what needs to happen to get children off this path and on to one where relationships and character development are supported.

1) Transform education of health care professionals, who are on the front lines with young children and families, to focus on relationships as the 4th vital sign. The American Academy of Pediatrics Early Brain and Child Development Initiative is an important step in the right direction.

2) Educate all professionals who work with children and families about practical application of contemporary developmental science  (I actually wrote my book Keeping Your Child in Mind, for this purpose)

3) Change the system of reimbursement so that primary care clinicians are among the highest rather than the lowest paid

4) Value time as a clinical intervention

5) Offer comprehensive screening and treatment for postpartum depression and other perinatal emotional complications. Representative Ellen Story working to implement just such a program in MA

6) Address the overreliance on psychiatric medication use. There is a severe shortage of qualified mental health care professionals, related in large part to low reimbursement rates for treatments other than medication. 

Just before I spoke with Tough, I read  the following from an interview with him in the Hechinger Report:

Is part of the problem in higher-education and K-12 policy circles that we’re myopic—and that it takes longer than we’re willing to wait to determine if something is working?

In general, yes. I think any time you’re talking about child development and public policy, there’s that problem, which is that any intervention is going to take a long time. There’s a good case to be made that the most effective interventions are early interventions, and quite literally you’re not going to see the payoff for years and years—and our political system is not set up to fund those sorts of things.

So we have all this evidence of the importance of promoting healthy relationships in early childhood, as well as compelling evidence from University of Chicago professor James Heckman that investing in early childhood is economically very wise, and still we are so short-sighted and impatient? I asked Tough if perhaps this was a manifestation of childism.

Childism: Confronting Prejudice Against Children is a brilliant book by Elisabeth Young-Bruehl who tragically died suddenly just before the book was released, depriving us of the opportunity to learn about her work through the kind of publicity tour that Tough is now having. I describe it in detail in a previous post, that I will summarize here.

Young-Breuhl, an analyst, political theorist and biographer, calls attention to the way human rights of children are threatened. Childism is defined as “a prejudice against children on the ground of a belief that they are property and can (or even should) be controlled, enslaved, or removed to serve adult needs.”

Young-Breuhl provides ample evidence for her assertions, including a detailed history of the field of child abuse and neglect.

She describes Child Protective Services (CPS) as a “rescue service-a child saving service-not a family service supporting child development generally and helping parents…” Rather than setting up a system of treatment, CPS became "an investigative service...a situation in which bad families suspected of making their children bad will be invaded and infiltrated." Young- Breuhl has empathy for both parent and child, arguing that failure to support families is a manifestation of childism. 

Overreliance on psychiatric medication is in her view is example of childism:

She writes of “a childism of the sort that is now fueling an epidemic of diagnoses of bipolar II disorder and the prescription of medications to children who are, in effect, being doped into acquiescence." 

Young-Breuhl compares the situation in our country with comparable developed countries that have lower rates of child abuse and neglect.

There, “children have a range of preventative and development-oriented services: universal health care, health services, and parent support services in homes after the birth of a child; maternal and parental leaves for infant care; developmental preschool programs; after-school programs; and economic supports of various kinds.”

I don't claim to have the answer to the problem of childism, but I do think that if we are going to be able to make use of Tough's very important book to implement meaningful change, it a least needs to be acknowledged.

Pediatrician T. Berry Brazelton, whose work is featured as an antidote to childism, endorses [Young-Breuhl's] book, recommending that all who are involved with children and families should read it. This book has helped me, like nothing else I've read, to understand why it is so hard to get the kind of help for children that all the best science of our time is telling us they need. I hope everyone reads it. As Young-Breuhl states, “prejudice has to be recognized in order to be overcome.

Paul Tough Speaks at Harvard: How Children Succeed

One of the highlights of Paul Tough's new book How Children Succeed:  Grit, Curiosity and the Hidden Power of Character comes in the final chapter, when he describes how he and his wife interact with their three-year-old son Ellington to help develop the qualities he spends the rest of the book demonstrating are associated with success.

He describes helping Ellington to calm down after a tantrum or bad scare, providing discipline and rules, and, in addition to lots of hugs and comfort, helping him learn to manage failure. These are exactly the parenting behaviors that research has shown lead to the capacity for emotional regulation, cognitive resourcefulness, resilience, and the ability to adapt to a complex social world.

The thesis of this book, whose primary focus is the education system-Tough is speaking on Thursday September 6th at the Gutman Library of the Harvard School of Education-, is that the conventional wisdom about the key to success has been misguided. Rather than focus on promoting cognitive abilities, our focus should be on development such things as gratitude, curiosity, self-control and grit, all of which are distilled into the word "character."

While Tough does not explicitly make this point, but rather demonstrates it in writing about his son, character develops in relationships.  When a person has a relationship with someone who not only cares about him, but also thinks about him, understands his perspective and unique challenges, helps him calm down in the face of difficult feelings, sets limits on his behavior and trusts him enough to let him fail, he is more likely to develop the "non-cognitive skills" associated with success. He will be able to think clearly and flexibly in the face of stress.

The first chapter offers an excellent overview of the current explosion in research on toxic stress, or stress in the absence of such a secure, safe relationship. Tough refers to the  ACES (Adverse Childhood Experiences) study, a huge longitudinal study that dramatically demonstrated the association between early adversity, including such things as abuse and neglect, parental mental illness and substance abuse, and family discord, with many negative health outcomes including not only mental illness but also chronic illnesses such as diabetes, asthma and heart disease.

Particularly important is the work of Alicia Lieberman, one of the pioneers in the field of infant mental health. Tough writes of Lieberman's collaboration with pediatrician Nadine Burke Harris in an innovative San Francisco based program that applies the ACES study to preventive work with children and families.  Lieberman recognizes that providing a secure attachment relationship "takes a superhuman quality" in the face of poverty, uncertainty and fear. Her model of intervention works with parent and child together.

Lieberman's treatment is relatively intensive, administered in weekly sessions that can continue for as long as one year. But the principle behind it-improving children's outcomes by promoting stronger relationships between children and their parents-is increasingly in use across the country in a wide variety of interventions. And the results, when the interventions are evaluated, are often powerful.

The rest of Tough's book focuses on interventions for school age children. The implication is that these children have had stressed early relationships, but that interventions in the school setting that focus on character development may mitigate against these early experiences. He writes:

It is hard to argue with the science behind early intervention. Those first few years matter so much in the healthy development of a child's brain; they represent a unique opportunity to make a difference in a child's future. But one of the most promising facts about programs that target emotional and psychological and neurological pathways is that they can be quite effective later on in childhood too-much more so than cognitive interventions. 

Tough describes successful school programs that have focused on character development. The Youth Advocate Program, or YAP, in Chicago offers an intensive mentoring program for high-risk teenagers.  At KIPP (Knowledge is Power Program) in the South Bronx, where there is a curriculum designed to teach character, and even a character report card, one student describes how the teachers were devoted to him and his fellow students. " They were like my second family, in essence...that's the vibe we all ended up getting, that we were like a family."

Yet another program is OneGoal in Chicago, run by CEO Jeff Nelson:

Nelson's belief is that underperforming high-school students can relatively quickly transform themselves into highly successful college students- but that it is almost impossible for them to make that transition without the help of a highly effective teacher. OneGoal has signed a unique partnership deal with the Chicago public schools that lets the organization work directly with individual teachers...the teacher sticks with the same class for three years...And when the students are freshmen in college the teacher keeps in close touch with them...providing support and advice."

Tough shows how relationships can be stressed not only for the very poor, but also the very wealthy.

Riverdale, a private school in a very different part of the Bronx from KIPP, offers an example of wealthy students who are similarly at risk. Referring to the work of psychologist Madeline Levine, he writes:

Wealthy parents today, she argues, are more likely than others to be emotionally distant from their children while at the same time insisting on high levels of achievement, a potentially toxic blend of influence that can create "intense feelings of shame and hopelessness" in affluent children. 

Stressed relationships of this kind may have a negative impact on character development. Riverdale's headmaster, Dominic Randolph, is concerned that students are lacking in important character traits.

Traditionally the purpose of a school like Riverdale is not to raise the ceiling on a child's potential achievement in life but to raise the floor. What Riverdale offers parents, above all else, is a high probability of nonfailure...The problem, as Randolph has realized, is that the best way for a young person to build character is for him to attempt something where there is a real and serious possibility of failure.

The book takes an interesting turn when, after focusing on a number of programs that measure their own success in terms of rates of college graduation, Tough reveals that he himself did not graduate from college. Clearly Tough is a highly successful person. This information led me to wish that more of the book had been devoted to exploration of the definition of success.

I thought of how Sigmund Freud defined mental health as the capacity to love and to work. I though about creativity and empathy as two qualities that are intimately tied to success. I found myself remembering Brandon Fisher, the manufacturer of drilling equipment who was recognized by President Obama in the 2011 State of the Union address for his critical role in the rescue of the Chilean miners.

These other aspects of success are mentioned in Tough's book. For example:

At KIPP, teacher Mike Witter explains to a parent, "The categories [of character traits] we ended up putting together represent qualities that have been studied and determined to be indicators of success. They mean you're more likely to to go to college. More likely to find a good job. Even surprising things, like they mean you are going to get married, or more likely to have a family."

A related body of research, coming from the fields of infant mental health and psychoanalysis, supports the notion that the way Tough interacts with Ellington will in fact lead to this broader definition of success. This literature, and in particular the work of leading researcher Peter Fonagy, refers to the central aspect of a secure attachment relationship,  a capacity that is unique to humans, as mentalization, or "holding a child in mind."

John Bowlby, considered the father of attachment theory, writes how in the setting of such a relationship a child becomes, "self-reliant and bold in his exploration of the world, cooperative with others, and also- a very important point-sympathetic and helpful to others in distress." 

Tough is applying his considerable talents as a journalist and writer to a critically important task. The question he asks is not only how children succeed, but also how the answer can inform meaningful social policy. He is bringing this issue to the forefront of public discussion.  I am thrilled to be in the company of Tough, as in my work I have also been asking:  What can we as a society do to promote healthy relationships, that in turn promote both character and success, from infancy through adolescence? Tough writes:

Parents are an excellent vehicle for those interventions, but they are not the only vehicle. Transformative help also comes regularly from social workers, teachers, clergy members, pediatricians, and neighbors. 

Tough tackles this issue in his whole body of work, including not only this book, but also his first book,  Whatever it Takes, about Geoffrey Canada and the Harlem Children's Zone, and his New Yorker article The Poverty Clinic about pediatrician Nadine Burke Harris' program.   I am eager to see what he does next.