Protecting a space for parenting in an age of expert advice

In my behavioral pediatrics practice, it never ceases to amaze me how, given the space and time, parents come around to making sense of their child's "difficult" behavior without my giving "advice" about "what to do." They may recognize that they share a trait with their child that has troubled them their whole life. They may become tearful, thinking of how that child represents a lost loved one.  There are countless variations. The process of telling the story, of finding the meaning in the behavior, is often itself the treatment. Once parents have these insights, "what to do" follows naturally. In contrast, if I give advice without a full understanding of the story, things may not go well.

Recently in working on a new book, I have had the pleasure of returning to a close look at the work of D. W. Winnicott, pediatrician turned psychoanalyst and a kind of British Dr. Spock. In my review of his writings on the subject of advice, I came across a wonderful piece from this past spring in The Guardian: Mothers on the naughty step: the growth of the parenting advice industry, that references Winnicott.

Winnicott abhorred the idea of giving advice. He believed that when mothers tried to do things by the book – or by the wireless: "They lose touch with their own ability to act without knowing exactly what is right and what is wrong." Yet today there are far more parenting advice books (each with their own regime to promote) than 30 years ago, and the radio and TV schedules are full of programmes such as Supernanny, which train a critical eye on what are generally called parents but most of us understand to be mothers. It sometimes seems it is mothers, rather than children, who are being dispatched to the naughty step...

Winnicott feared that focusing on pathological families rather than "the ordinary devoted mother and her baby" (the title of his most famous series) could excite anxiety in listeners without access to therapy. "I cannot tell you exactly what to do," he said, "but I can talk about what it all means." And so he did, extolling the role of the good enough mother – one who can be loved, hated and depended on – in enabling the baby to develop into a healthy, independent, adult. While many of today's parenting gurus focus on a child's deviant behaviour and the contribution of supposed misparenting, Winnicott tried to help mothers understand the significance of their child's behaviour, whether it was "cloth-sucking" or a display of jealousy, and the ways that they instinctively contained their child's anxieties.

The author refers to the British program "Supernanny," the "high priestess of behaviorist parenting."

Tracey Jensen, lecturer in media and cultural studies at Newcastle University, says Supernanny reverses Winnicott, offering up the spectacle of the "bad enough mother", usually working-class, who is shamed before she is transformed. Jensen watched the programme with a group of mothers, relieved that it was not their parenting practices being scrutinised, but those of someone else onto whom all their own worries and fears could be displaced. But they also shouted back at the programme, discomfited by the judgment and humiliation meted out to the mothers featured. Such series foster the very anxiety they claim to assuage, and substitute "training" for thinking and feeling.

This last phrase captures the essence of the issue. I shudder whenever I see the term "parent training."  But this phrase, as well as others such as "management of symptoms" or "parent education" are pervasive in our culture. These kinds of interventions may improve behavior in the short term. But if they substitute for "thinking and feeling" it is likely that symptoms will re-emerge at a later date, in a different form. 

When we talk about parents and children, we are talking about passionate love relationships. The feelings are deep, intense and sometimes painful. It makes sense that we might choose to avoid them. But this is not a long-term solution.  We would do well to instead make a space for them, starting from birth.

I borrowed this phrase "protecting a space" from my good friend Gale Pryor, who's wonderful book Nursing Mother, Working Mother was also heavily influenced by Winnicott. In such a space parents can connect with their natural intuition. It is in this space that we give room for healthy development of parent and child together.

In the age of DSM 5, what is normal?

In an interesting coincidence, a couple of weeks ago I received two emails on the same day asking me to write about books that are about the same subject. One is  Child Temperament: New Thinking About the Boundary Between Traits and Illness,  the second Back To Normal: Why Ordinary Childhood Behavior is Mistaken for ADHD, Bipolar Disorder, and Autism Spectrum Disorder.

The first was written by David Rettew, MD a child psychiatrist at the University of Vermont College of Medicine, where at the Vermont Center for Children, Youth, and Families ( VCCYF) they have an innovative family centered, strength-based approach to children's emotional and behavioral problems.

In a language that is based in science and research,  Rettew explores the overlap and interplay between the concepts of "temperament" and "psychopathology. He tackles the complex science of behavioral epigenetics- the impact of life experience on gene expression and subsequent behavior and development. He then describes how he integrates these ideas in to his care of children and families. For example, he describes how he might speak to a child patient:

I've heard a lot about you today and one of the things that I hear from you and your parents is that you are a very kind person who can really tune in to other people.  That is a wonderful quality that will serve you well in the future. At the same time, I also hear that you can get so concerned about what others think about you that you avoid things you like doing just so there is no chance you will feel embarrassed. Doctors sometimes use the term  social anxiety disorder to describe this situation, and if you are willing there are things we can do to help you feel more at ease in social situations.

He masterfully takes on very complex issues, including the way a child's behavior may provoke a parent's negative response.

A father of a temperamentally irritable boy who is prone to shout at the boy for  relatively minor infractions is certainly not relieved of responsibility for his behavior, but can be understood from a prespective that some of his suboptimal responses are evoked by the child's behavior, partially influenced by shared genes that cause both of them to escalate in negative ways.

The second book is organized around examples from the practice of the author Enrico Gnaulati, PhD, a clinical psychologist specializing in child and adolescent therapy. He examines our cultures rush to diagnose and medicate, and what he terms the "casualties of casual diagnosis." He writes:

In the past four decades we have gone from blaming parents for kids' problem behavior to blaming kids' brains....yet rarely can a child's behavior be explained exclusively in terms of child rearing or brain chemistry. In most cases, it is causes- plural, not singular- that explain why a child behaves the way he or she does. 

The underlying problem both authors address is embedded in the paradigm of mental health in which they practice.  Rettew seems to be trying to wrestle out of the paradigm in the last section where he describes an evaluation process that makes use of other tools besides DSM. However, the above example shows how the language of DSM permeates care, when albeit reluctantly, he uses the term "social anxiety disorder." This "disorder" may be in the DSM, but it is not a "real" disorder in the way, for example, diabetes is.

Earlier this year, the head of the National Institute for Mental Health tried to discredit DSM 5 by saying that they would not fund research based on the DSM system but rather aim to find the underlying "cause" in the realm of neuroscience and genetics. But as Gnaulati points out, we will never find the cause by just looking at the brain.

Gnaulati is similarly trying to find another way to think about this paradigm that offers oversimplified labels. But I am concerned that framing the issue as "normal" vs "disordered" is  misguided, and a result of the author being unable to see his way out of the DSM paradigm.

If a child and family are seeking help, then by definition the behavior is not "normal." Given the continued stigma associated with mental health problems, for a family to make the effort to call, make an appointment and actually show up, they are likely to be struggling in a significant way. Thus to call this "normal," even though the intention may be to be reassuring, is actually dismissive of the family's suffering. I wrestle with this dilemma every day in my clinical practice. Parents come to me and ask, "Is my child normal?"

I speak to this issue in a previous post: Answering the question: is something wrong with my child?
I refer to an article by Daphne Merkin on the question of whether depression is inherited:

The concept of "being attuned to your child's nature, especially when it differs from your own,"  is the essence of healthy parenting. She is describing a parent's recognition of what D. W, Winnicott termed the child's "true self." It involves recognizing a child as a person with thoughts and feelings that are his own. It is an excellent goal to work towards, though not always easy.   Issues that get in the way of recognizing the child's true self, including stresses in a parent's life and other relationships, may need to be addressed.

When viewed from this perspective, the question becomes not "is there something wrong with my child?" but rather "Who is this child, and how is he or she both alike and different from me?"

I wonder if Rettew and Gnaulati are so much a part of the prevailing paradigm that they do not recognize that what they are actually doing in their books is questioning the very paradigm in which they practice. If they were to step outside of the paradigm, they might, rather than asking the question "does a child have ADHD?" , asking the more salient question, "Is ADHD ( or autism or bipolar disorder or OCD for that matter) the way we as a culture use the term, a "real" thing, or is it an artificial construct defined by the DSM system and perpetuated by the pharmaceutical and health insurance industries?"

I believe that what both of these authors are actually doing is describing a new paradigm of mental health care that recognizes the relational nature of human development and offers opportunity for curiosity about the complex meaning of behavior. I'm calling them on it.

Investing in early childhood means investing in infants

Why is this so difficult for us to see? The United States has one of the most restrictive parental leave policies in the world, as my fellow blogger Claire McCarthy accurately described in a recent post. We fail to recognize the importance in investing in early relationships. The closest we seem to be able to get is age four. But the abundance of research at the interface of developmental psychology, neuroscience and genetics tells us that 4 years may be too late.

I wonder if the answer lies in child development researcher Ed Tronick's  still-face experiment. I remember well when I first learned of his research. I felt a kind of outrage, asking "how did he get this past the IRB( institutional review board for human subjects)?" In his well-known experiment, a mother plays with her infant in a usual way, then presents a still-face for a specified period of time, and then resumes normal interaction.

I now work closely with Dr. Tronick and well recognize the brilliance of his work. He sometimes remarks that it is his students in his Infant Parent Mental Health program at UMass Boston who seem to have the most initial outrage at seeing the experiment. I now understand that as a kind of deep empathy with the experience of both the mother and the baby. With that comes a passion for protecting this relationship, a passion that drives those of us who chose this field.

There is a great poignancy to recognizing the tremendous capacity of the newborn to communicate when we have a system that fails to support stressed early parent-child relationships. The Newborn Behavioral Observation System developed by T. Berry Brazelton and Kevin Nugent beautifully brings out these capacities.

But if a parent is stressed in the setting of such things as emotional distress, her own history of abuse, marital conflict and domestic violence, social isolation and poverty, being available to her infant in the way he needs is difficult. This is where the investment needs to be. Not 4 years, but 4 months, 4 days, 4 hours.

In Sunday's New York Times Nobel prize winning economist James Heckman has an op ed Lifelines for Poor Children where he again speaks to the need to invest in early childhood. He refers to Obama's policy proposal. However in the actual text of Obama's proposal there is relatively little for infants. The emphasis is on the four-year-old.

All we know about the science of early childhood tells us that the brain grows in relationships. The volume of the brain doubles in the first year. The brain makes millions of synaptic connections every minute. It is in infancy that the parts of the brain responsible for emotional regulation have the most rapid development.

 A startling article in the New York Times Can Emotional Intelligence Be Taught? begins with a vignette from a Kindergarten classroom where a child says, "My Mom does not like me," When he describes how his mother screams at him every day, he is taught how to handle the situation in a calm way. Somehow the tables are turned and it is the child's responsibility to manage his out-of control mother. The answer is not to teach this child emotional regulation, but to help this parent-child pair to grow together in a healthy loving way. And this help needs to start in infancy.

This week I will again attend a meeting of Representative Ellen Story's postpartum depression commission at the State House. It is always an uplifting experience as leaders in the field grapple with the question of how best to support parents and young infants. The commission recognizes that this work occurs primarily in the realm of health care, which is where young infants and their parents can most reliably be found.

Did Electroconvulsive Therapy or Storytelling Cure Simon Winchester?

Joe Donahue, the brilliant host of WAMC's Roundtable recently interviewed Simon Winchester about his short e-book "The Man With the Electrified Brain. In the book Winchester describes his four-year experience as a young adult with an undiagnosed serious mental illness that was at the time apparently successfully treated with electroconvulsive therapy (ECT.) 

There is much speculation of the nature of the illness. Winchester himself, on discovering DSM (Diagnostic and Statistical Manual of Mental Disorders) IV many years later while writing The Professor and the Madman, diagnosed himself with a "dissociative disorder." A professor of psychiatry at Stonybrook who is a proponent of ECT, based on correspondence with Winchester,  has diagnosed him with "simple melancholia," an illness he recognizes is not in the DSM and attributes to "abnormal hormone functions."  A Psychology Today post entitled What Did Simon Winchester Really Have?" refers to "psychotic episodes."

In his introduction to the e-book Winchester explains his reasons for writing about this subject so many years later. He describes living with feelings of shame, and, following the death last year of both his parents, a desire to "come clean." He writes; 

My mother and father, tough old greatest-generation Britons who lived well on into their nineties, belonged to a time and class that disapproved mightily of any kind of mental infirmity...Stuff and nonsense, my father would bellow on hearing of my troubles. Damn tomfoolery was his only diagnosis, Pull yourself together his only prescription.

The answer to my question may be found at the end of Donahue's masterful interview. After covering the scope of Winchester's story, Donahue moves on to material that is most definitely not in the book. "Without getting overly psychological," sharing that he, like Winchester, had recently lost his parents, Donahue wonders about a wish to " fill in the blanks," about his history, and in particular his genetic history.

What follows is, in my opinion, the most fascinating and important part of the interview. Winchester tells of his elderly mother going with him to Buckingham Palace in 2006 when he became an OBE (Officer of the Order of the British Empire) He describes her getting tipsy on two glasses of sherry and telling "unbelievable stories about her life," stories of "espionage and affairs." Winchester tells of his father's history of being badly treated as a prisoner of war, and in the final weeks of his life, after suffering a stroke, beginning to open up about his own history. He speaks of his father's growing tolerance of talking about mental illness. Then, most poignantly, Winchester says, “It was brimming, I could feel a sense that this is all going to break, and then he died."

After this comes an exchange where Winchester describes an uneasy sense that his illness may return, having been told by a number of people that the ECT, " didn't cure you."

I wonder if it is this very telling of the story, including his incomplete yet meaningful connection with his parents towards the end of their lives that will prove to be the “cure.” This telling of stories as cure is well known within the discipline of psychoanalysis. I describe it in a previous post Childhood Trauma: Stories that Must Be Told:

French psychoanalysts Francoise Davoine and Jean-Max Gaudilliere have an adage on the cover of their book, History Beyond Trauma; "Whereof one cannot speak, thereof one cannot stay silent." They argue that personal stories of war and societal trauma, if not told in words, emerge as symptoms, sometimes as mental illness, sometimes in subsequent generations. 

Of course I do not know if Winchester's family history had any relation to his illness. Yet I cant help but wonder, if this silence, this "British reserve" had a role to play, both in the illness and also in Winchester's chosen profession as a writer, or "storyteller." Perhaps it is his storytelling that was/is the cure.

We are currently in hot pursuit of the science of mental illness. This past Sunday, in an op ed in the New York Times, The New Science of the Mind,  Nobel Prize winning neuroscientist Eric Kandel writes about our growing ability to understand the biological basis of psychiatric disorders.

Listening to Winchester's story motivates me to again point to the need to attend to the relational and historical context of being human in our quest to understand mental illness. If we focus exclusively on the "biology" without attending to the way the brain grows and changes in the context of relationships, we miss what a colleague referred to as the "poetry" of human nature. 

I have great respect for the complexity of the kidney. But the way the proximal and distal tubules transport ions is likely not related to, for example, the owner of those kidneys' relationship with his mother, or his father's survival of the Holocaust. But the function of his brain/mind most certainly is.

My hope is that what we will take away from Simon Winchester's story, thanks to Joe Donahue's  interview, is that in our pursuit of the science of mental illness we must find a way to make room for storytelling.

Gym as treatment for ADHD?

An article in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry about the role of exercise in treatment of ADHD gives me hope that there is some movement in the direction of non-pharmacological treatment of problems of regulation of emotion, behavior, and attention. ( I do not use the term "ADHD" for as readers of my blog know, I believe that ADHD as defined by DSM is an oversimplified, artificial construct.)

However, the accompanying editorial entitled "Gym for the Attention Deficit/ Hyperactivity Disorder Brain?" gives me concern that this idea represents yet another oversimplification. The editorial calls for "empiric support" from "well- designed studies." Our culture has a love of "evidence-based medicine."  I hope that before embarking on these studies, there is consideration given to what a colleague referred to as "medicine-based evidence," or research based on what we have learned from both clinical experience as well as other disciplines.

Primarily what we have learned is that its not just "exercise" or "gym," but a very specific use of the body to help the brain with the task of self-regulation. In fact, for a child who is overwhelmed by sensory input and easily dysregulated, as many of the children carrying the "ADHD" label are, traditional "gym" may be a disorganizing experience.  I described this concept in detail in a previous post, Emotional Regulation in Children: Using the Body to Help the Brain. It preceded my Boston.com blog so I have re-posted it below:

I recently heard a great story from a parent in my behavioral pediatrics practice. Their son was very active and had a hard time settling down to learn, and so, before an early morning tutoring session, a very resourceful teacher suggested he ride a scooter down the empty halls to the room where a group of kids with reading difficulties met. To make it fair, the teacher allowed all of the students in the group to ride scooters to class. The kids lay on their stomachs and used their arms to propel them down the long hall. Interestingly, not only this boy, but also all of the kids in the class began to do better!

One of the best weekends of the Infant-Parent Mental Health Post-Graduate Certificate Program that I have been attending and writing about over the past year, was with child psychiatrist Bruce Perry. He spoke of the importance of what he referred to as "rapid alternating movements' in achieving emotional regulation. Dr. Perry's ideas grew out of his frustration with the traditional model of psychiatric care, where children who have experienced significant trauma are expected to sit and talk with a therapist about their experience( and of course are also medicated.) His model of intervention is based on knowledge of brain development and is termed the "Neurosequential Model of Therapeutics.'

While it is not my intention to describe the model in detail, one of the main messages, which has relevance not only to traumatized children, is that in order to think, learn and process experience, one must first feel calm. A range of activities can achieve this calm. Dr. Perry does therapy sessions with very troubled children while going on walks. Horseback riding, martial arts, drumming and dance are other activities that can serve to achieve this kind of calm. A group of fellows from the program got to try out the theory. After a long, very stimulating (and also somewhat dysregulating) day of learning with Dr. Perry, we went ice-skating. Not only was it a lot of fun, but it worked wonders in helping us to process the experience.

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. Many know the story that Michael Phelps struggled terribly with ADHD. Swimming can be a very regulating activity, but some kids with learning and behavior problems also have sensory processing difficulties and can't stand to have their head under water. Clearly swimming isn't the right choice for them.

The more children I see with a range of "behavior problems," the more I recognize the importance of using the body to help the brain. Occupational therapy for young children can accomplish this goal. But as children get older, and can learn to express their feelings, parents can help them identify what works for them. This same boy on the scooter, several years later, learned to recognize that when he was feeling overwhelmed, going down to the basement to play his drums helped him to regroup. This kind of awareness, both of mind and body, can serve kids well not only in childhood, but over the course of a lifetime as they learn to adapt to their particular vulnerabilities.

Central to this notion of using the body to help the brain is that movement take place in relationships. We know that children develop the capacity for emotional regulation in the context of relationships. Things like martial arts, horseback riding and swimming involve intimate relationships with teammates, coaches and instructors.

So I hope that before psychiatrists head down the road in search of "evidence" that "gym" is good for ADHD, there is sufficient thought and attention to what kind of physical activity, how and when it occurs, and if it occurs in the context of meaningful relationships.