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 developmental science can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Monday, April 22, 2013

Music, mourning, and family narrative


(I wrote this post before we learned of the complex family and historical background of the alleged Boston Marathon bombers. I was again going to postpone publishing it. But I wonder if these ideas of mourning and family narrative have something to add as we struggle to make sense of the events of the past week. There seems to have been a tragic and deadly coming together of what French psychoanalysts Francoise Davoine and Jean-Max Gaudelliere, in their book History Beyond Trauma, refer to as "big history" reverberating in individual family history. It is hard to say any more when at this time we really know so little. Rather than making any further explicit connection, I will simply share my post below. It offers what I think can be a message of hope.)

I have been meaning for some time to write a blog post about Dar Williams'  beautiful and profound song "After All." A chance meeting with Marshal Duke, the lead researcher referenced in a recent New York Times article, The Family Stories that Bind Us, provided the inspiration.

Duke's research along with that of Robyn Fivush, has shown a clear correlation between a child's knowledge of family narrative and such qualities as resilience and positive self esteem. In a 2008 paper they describe the "intergenerational self." They write:
It is this intergenerational self and the strength and guidance that seem to derive from it that are associated with increased resilience, better adjustment, and improved chances of good clinical outcomes.
William's song, both the lyrics and the music, provides solid evidence for this theory. In it she describes her struggles with pain and sadness, and her journey to find a way to embrace life.  The lyrics speak to the importance of family narrative. 

And if I was to sleep
I knew my family had more truth to tell
And so I traveled down a whispering well
To know myself through them

The historical nature of this narrative is clear in these lyrics.

Sometimes the truth is like a second chance
I am the daughter of a great romance
And they are the children of the war

For the full impact of the song, I hope that readers will listen to it. For in my view, it is not simply the telling of the story that is important. In order for parents to pass the family narrative on to their children in a way that is meaningful and useful, the feelings associated with the story, which often includes trauma, loss, and grief, must also have found a way to be expressed. This is easier said than done. It involves having a safe, containing, holding environment in which the stories can be understood.  A secure, trusting relationship with someone who can hear the story is important.  Art, including music and literature, can have a role to play as well. Those feelings are certainly present in Williams' music. In her introduction to this live version, she expresses surprise to have discovered a large community of people who could relate to her experience.

Go ahead push your luck
Find out how much love the world can hold
Once upon a time I had control and reined my soul in tight
Well the whole truth
Is like the story of a wave unfurled
But I held the evil of the world
So I stopped the tide
Froze it up from inside
And it felt like

A winter machine that you go through and then
You catch your breath and winter starts again
And everyone else is spring bound
But when I chose to live

There was no joy it's just a line I crossed
It wasn't worth the pain my death would cost
So I was not lost or found
And if I was to sleep

I knew my family had more truth to tell
And so I traveled down a whispering well
To know myself through them
Growing up my mom had a room full of books
And hid away in there

Her father raging down a spiral stair
Till he found someone most days his son
And sometimes I think my father, too, is a refugee
I know they tried to keep their pain from me
They could not see what it was for
But now I'm sleeping fine

Sometimes the truth is like a second chance
I am the daughter of a great romance
And they are the children of the war
Well the sun rose

With so many colors it nearly broke my heart
It worked me over like a work of art
And I was a part of all that
So go ahead push your luck

Say what it is you gotta say to me
We will push on into that mystery
And it will push right back
And there are worse things than that
'cause for every price and every penance that I could think of

It's better to have fallen in love
Than never to have fallen at all
'cause when you live in a world
Well it gets in to who you thought you'd be
And now I laugh at how the world changed me
I think life chose me
After all

Thursday, April 18, 2013

Mourning and music: a song for Boston

I had been working on a post on the subject of mourning and music. But with the trauma of the Boston Marathon bombing still so fresh, it did not seem appropriate to write about any other subject. I wondered, what could I add to the discussion? Then this morning, with the idea of music as a means to connect with feelings on my mind,  I heard on the radio the song Learn Me Right by Mumford and Sons. The lyrics, specifically the chorus (not the verses), are perfectly fitting to the moment, though the "scream" with hope will be one of joy,  not terror. And the music, particularly the version performed by Birdy for the movie Brave, captures the spirit of resilience. It can represent hope for the triumph of the people of Boston and of the Marathon itself. It may not be everyone's cup of tea, but for me, and perhaps for others, the music can help connect with the feelings of the day.

We will run and scream
You will dance with me
We’ll fulfill our dreams and we’ll be free
We will be who we are
And they’ll heal our scars
Sadness will be far away


Friday, April 5, 2013

Lost child psych beds at Cambridge Health Alliance: now prevention is essential

In the wake of the Newtown tragedy, many people, myself included, wrote about the need to address both gun control and mental health care. So it was rather jarring, on the same day that Connecticut's governor signed comprehensive new gun control legislation, to read that Cambridge Health Alliance was planning to cut 11 of 27 child inpatient psychiatry beds, including all inpatient service for children age 3-7.

But on closer consideration, I wonder if this loss in fact presents an opportunity. With no inpatient care for young children, it now behooves us as a society to make sure they never need such care. As a pediatrician with 25 years experience working with troubled children, I can be sure that when a child needs hospitalization at age 4, 5 or 6, his problems started way before that. The Globe article suggests that plans are headed in this direction.
Burke [chief of psychiatry] said the hospital is focusing more on efforts that can keep children out of the hospital, including services in schools and placing psychiatrists in pediatricians’ offices.
This is an excellent idea. But what does it look like in practice? Number one, we need a workforce experienced in early child development. There is an explosion of knowledge and research, coming out of the discipline known as infant mental health, that informs us of how to work with parents and children together to help set young children on a path of healthy development.

Such training programs are erupting all over the country. One superb program is right here in Boston- the UMass Infant-Parent Mental Health Post-Graduate Certificate Program under the direction of renowned researcher Ed Tronick.

Fellows in that program learn from leaders in the field, including child psychiatrist Bruce Perry, whose neurosequential model of therapeutics informs us of how to use knowledge of neurodevelopment to guide treatment.

We need these programs because most child psychiatrists have minimal to no education in early child development, and pediatricians, who live and breathe child development and have long-term relationships with families, are under pressure to see 6 patients an hour, and so have no time to help. In the ideal world, training in infant mental health would also be incorporated in to pediatric and child psychiatry training.

We cannot let the bottom fall out for these children. By taking away these beds, a preventive model is no longer optional. A person trained in early childhood mental health should be in every primary care office, and every childcare center should have easy access to early childhood mental health care professional for on-site consultation. I wonder if this might even cost less than maintaining inpatient beds.

Of course this does not help the children today who need inpatient care. Ideally we would be able to offer both forms of help. Perry's model is relevant for treatment of older children as well. I do not know the answer to this problem. However, I can be sure that parents, who are suffering terribly waiting with their severely troubled young child for an inpatient bed to become available, would have much preferred to get meaningful help years before.