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.

Sunday, July 29, 2012

Sibling conflict: untangling the complexities

A number of years ago I was asked to see six-year old Sam for a second opinion after a local "ADHD expert" had diagnosed that disorder and written a prescription for Ritalin based on one visit with Sam and his mother.   My first visit had been with Sam, his four-year-old brother Jake, and their mother. At that time I learned that Sam's "behavior problems" occurred mostly in the form of conflict with his younger brother. Sam was "impossible," always provoking Jake, who had to follow along when family activities were disrupted by Sam's "difficult" behavior.

I was immediately struck, when I met with his parents together, at Sam's father's close physical resemblance.  Like Sam, he had a full head of curly red hair. He was silent and sullen for the first part of the visit while his wife unleashed a torrent of complaints about Sam. Interestingly, she looked like Jake, who was a handsome blond boy.

As I shifted my focus to Dad, and expressed interest in his experience of Sam's behavior, it immediately became clear that he was an unwilling partner in this evaluation. He had no concerns about Sam. "I was just like him as a kid" he said. Then things began to get complicated. I learned that Sam's father was temperamentally not only very much like Sam, but also shared many qualities with the maternal grandfather, with whom Sam's mother had a difficult relationship. The sibling conflict was actually a symptom of difficulties in the marriage, which were in turn related to relationships from the parent's past.

In almost every child I see for behavior problems, there is a similarly complex story in the background. Lest I feel tangled in an impossible web of multigenerational conflict, it is important to step back and focus on the task at hand, namely to evaluate this child, Sam.

My aim is simple. It is to help these parents to recognize Sam's "true self," to quote D. W. Winnicott. My task is to, in a sense, clear the brush of this complex tangle of relationships to enable parents to see Sam for who he is.

When qualities are placed in a child that actually belong to some other relationship, it is often out of parent's awareness, or to use the psychoanalytic term, "unconscious." When I participated in at a Parenting conference at Austen Riggs last weekend, I learned that most of the adult patients there, who struggle with serious mental illness, feel that they were born to play a role, in a sense robbing them of their own unique identity. It occurred to me at the conference, where I spoke about the Newborn Behavioral Observation system as a way to bring out a baby's unique characteristics at birth, that this intervention might offer a tool to prevent such a dynamic from being played out.

The beauty of working with young children is that it is possible set things in a better direction by clearing conflicts belonging to other relationships off the child.  Parents need to be given the space and time to tell their story to a nonjudgmental listener. This process may allow unspoken and even unconscious feelings to be brought to light. Once his caregivers recognize a child's true self,  he is free to develop in a healthy way.

In the case of Sam and Jake, once the conflict was put in its proper place, Sam's "difficult" behavior decreased. Interestingly, when his parents were less stressed by his behavior, tension in the marriage lessened, setting in place a positive cascade of change. Sam was, to use another therapy term, the "identified patient" in a larger family dynamic. If he had been medicated for his behavior symptoms, however, the full story might never have been brought to light.







Wednesday, July 18, 2012

Pediatrics and Psychoanalysis: An Essential Partnership

D.W Winnicott, pediatrician turned psychoanalyst, has been among the most important influences on my work. Unlike him, however, I have been determined, in my professional life, not to "defect" from pediatrics to become a psychoanalyst. I have always felt it was important to bring the wealth of deeply meaningful ideas coming from the discipline of psychoanalysis to the practice of pediatrics.

For example, in my current position as a behavioral pediatrician at Newton-Wellesley Hospital I teach the pediatric residents and  medical students about colic by starting with Winnnicott's notion of "primary maternal preoccupation." I read to them from my book: Keeping Your Child in Mind, itself an effort to bring psychoanalytic ideas to a general audience:
Winnicott described the first weeks to months of motherhood as a period deserving of a name, a psychological state, which for both a newborn and mother is not only healthy but highly adaptive. The name Winnicott gave this state was “primary maternal preoccupation.” He referred to a mother who is preoccupied in this way with her baby as an “ordinary devoted mother.” This way of being in tune with the baby happens naturally and does not look like anything particularly dramatic. A mother knows what her baby feels through her intense identification with him. He is a part of her. Though her role is in this sense “ordinary,” it is in fact hugely important. Winnicott writes: “It will be observed that though at first we were talking about very simple things, we were also talking about matters that have vital importance, matters that concern the laying down of the foundations for mental health.”
Rather than asking "what to do" to "manage" colic, I encourage them to think about the meaning of the behavior within the context of this intense infant-parent relationship. Similarly, when parents come to see me about how to "manage" their child's "behavior problem," I help them to recognize that they are engaged in a kind of "dance of dysregulation" with their child, and that they both need to learn a new way to dance that is calm and coordinated.

This weekend, however, I get to do exactly the opposite, namely bring my knowledge as a pediatrician to a group of psychoanalysts.  Just as psychoanalysts are experts in relationships, so pediatricians (and all professionals who provide primary care to children) are experts in babies.  We are immersed in child development in a way that is unlike any other profession.

I am speaking at a conference at the Austen Riggs Center, co-sponsored by the Yale Child Study CenterDevelopment of the Parent as a Person: Psychological, Biological and Genetic Contributions. Within minutes of looking at the proposed lineup of presentations, I knew exactly what I had to add. My talk is titled: "The Development of the Parent: the Child's Contribution."

 After more than 20 years of listening to countless parents and seeing thousands of babies, I have no doubt that babies come in to the world with their own unique set of qualities and characteristics, that from the first moment have a significant impact on the development of the parent. Almost every parent who is struggling with their child's challenging behavior has shared some variation of, "we saw this from the moment he was born."

I will use the photographs from Kevin Nugent's book: Your Baby is Speaking to You, that so beautifully captures the way babies are engaged in complex communication from the start. I have a video clip of a baby at three days of age having a conversation with me. I will introduce the Newborn Behavioral Observation system, a clinical tool designed to bring out these qualities in the baby, and promote healthy relationships from the start.

A number of years ago I attended a conference entitled "Pediatrics and Child Psychiatry: an Essential Partnership." I was hopeful, but sadly it ended up being primarily about prescribing medication, with a little bit about "parent training" thrown in. The word "relationship" was not mentioned once.

Here we have two parallel relationships: the parent-child relationship, and the pediatrics-psychoanalysis relationship. In each pair, one has the opportunity to have a profound and positive effect on the development of the other.

Sunday, July 8, 2012

A necessary mourning


I heard the phrase, "I don't want to live in the past" three times last week. The first was from Dr.Ruth Westheimer, famous sex therapist and Holocaust survivor. Her interviewer pointed out the inconsistency of that statement and the fact that she was in town to see a play about the story of her life. The second was a mother who wept in my office as she spoke of her troubles dealing with her young daughter's behavior. She recognized how her own issues got in the way, but wished to "live life forward."  The third was from my father.  We are working together to find a way to tell his remarkable story of his life in Nazi Germany, his escape to America, and his subsequent rescue of his parents from Theresienstadt when he returned as a soldier with the US army. His ambivalence is powerful-one day he will be eager to tell more stories about his life, and the next day he will shut it down. 

I find myself thinking-do these stories, often associated with very difficult and painful memories- need to be told? Virtually every person who hears my father's story says it must be told. But why?

I think there are two answers. The first is about history. History is essentially about telling stories from the past. Our hope is to make sense of things and so to better understand the present and future. But it may be difficult for the individual person who experienced the trauma directly to carry this burden. Perhaps history needs to be written by those who can study it from a distance.

The second answer is more personal.   It is about the hold that unprocessed grief can have on an individual, and on subsequent generations. When speaking with a friend about how little I knew about my father's life until very recently, she said, "Can you imagine how much energy it takes to hold all of that in?"

When loss on the magnitude of the Holocaust has occurred, it is very difficult to wrap one's mind around the effect of unprocessed mourning. In my work with parents and young children, however, its effect can be immediate and vivid. Here is an example from my pediatric practice.

Emily brought her son Michael to see me when he was 3 and 1/2 months old. He had been born one month premature, but it was clear from a first glance that he was doing well. I remember noticing that his mother was so close, physically close. She hovered over his carriage, reluctant to let me pick him up. She stood inches from him while I examined him.


He was robust little boy who gave a big smile as he intently followed his mother's face. Emily felt he was doing well. So well, in fact, that she was attributing qualities to him for which he seemed to young. "It's good for him to comfort himself, right? I should let him cry, right?" She seemed very anxious.


About a year earlier, Emily had lost a baby, Christopher she called him, in her ninth month of pregnancy, when she was in a car accident. She conceived again almost immediately. And here was this miracle baby. I watched Michael sleeping in his blue jumper. He seemed so small and vulnerable. 


"He's doing great," I said. Emily continued to wear that uncertain look as I tried to reassure her. She asked about sleep. "Is it OK if he is still in our bed? Is it good for bonding?" she asked. I was puzzled by this question and paused, asking her to tell me what she meant.


"Is he bonded to me?" she asked. I started to attempt an answer when she interrupted me. "Can you bond in utero? I mean I bonded to Christopher, but he died. I didn't let myself bond to Michael when I was carrying him."


I felt a tingling in my arms and a clutching in my chest. Tears came to my eyes as I watched them run freely down her cheeks. We sat this way for a while, living in the unbearable pain of her loss.


With Emily I wondered aloud if getting pregnant so quickly had prevented her from doing the difficult work of grieving the loss of her first child. She said to me, "I feel like I can't give all of myself to Michael. I have to hold back to protect myself." 


At that visit with me, perhaps fortified by our moment of connection, of true empathy, she found the courage to face this task of grieving. She recognized it was critically important not only for herself, but for her relationship with her infant son.

 Sometimes there is urgency to telling these stories, to protect the next generation from the effects of unprocessed grief by enabling parents to be fully emotionally present with their children. In the case of war or massive social trauma, the work of mourning may need to be done generations later, when people are safe and comfortable and do not fear for their lives.

The French psychoanalysts I refer to in my previous post on this subject make the distinction between "big history," and individual family history, noting that the second can sometimes be a reverberation of the first. Gerard Fromm, in his book Lost in Transmission: Studies of Trauma Across Generations, elaborates on this notion through case histories from his work at the Austen Riggs Center.

A friend who knew I was writing about this subject recommended that I watch the first scene of the film Angels in America. It is the funeral of an elderly Jewish woman. The old rabbi looks out at his audience of adult children and grandchildren and, speaking of this woman's life, hardship and coming to America, says, "that ocean crossing lives in you." When they are spoke of or not, these stories live in subsequent generations, and demand to be told.

Tuesday, July 3, 2012

Gestational age and academic achievement: relationships at risk

A study published in the July issue of Pediatrics suggests that babies born at what is considered full term, but at 37-38 weeks, have lower academic achievement in third grade than those born at 39-41 weeks gestation. They found this effect to be independent of birthweight or an other social or economic risk factors. Authors examined birth records from a large inner city hospital, and then looked at achievement test scores of these children in third grade.  They write:
For example, children born at 37 weeks’ gestation were found to be 33% more likely to experience a severe reading deficit (defined here as 2 SDs below the mean) relative to children born at 41 weeks’ gestation.
I suggest that the issue be framed not as "are these babies at risk?" but rather "are these early relationships at risk?" When a baby is born at 37 or 38 weeks, parents are discharged home with the message conveyed that the baby is "normal." But  these babies may be more difficult to feed, may not transition as easily from awake to asleep, or may have more difficulty settling. In a supportive, relatively unstressed environment, these differences may be hardly noticeable. But in a stressed environment, including such things as single parenthood, postpartum depression or any number of social stressors, it may be more difficult for a parent to help a baby manage these biological vulnerabilities. As parents get overwhelmed by feelings of inadequacy, there may be a rapid downward spiral of increased fussiness and feeding problems, sleep deprivation and parental depression. It is likely that the stressed relationship, not simply the gestational age,  is linked to later academic achievement.

As I have written about in previous posts, the Newborn Behavioral Observation system offers a wonderful tool to support potentially at-risk mother-baby, and father-baby, pairs. It offers a way to help parents to recognize their baby's unique behavioral characteristics and ways of communicating. It can be performed in as few as 20 minutes in the hospital setting. Ideally such an intervention would be available to all parent-baby pairs. At the very least, when babies are born at 37-38 weeks,  these parent-baby pairs deserve a bit of extra time. Clinicians can assess if these types of problems of self-regulation are present, and if they are, support parents efforts to help their babies manage these vulnerabilities.

Certainly more research is needed, as the authors, suggest, to elucidate the mechanisms underlying the association between gestational age and academic achievement. In addition, exercising care with regard to elective deliveries before 40 weeks is important. But in my opinion, this study points to the need  invest resources to support newborn-parent relationships.  We know that the newborn period is a time of rapid brain development, and that the brain develops in relationship with the primary caregiver. That the newborn period may be linked to what happens at age eight should come as no surprise.