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.

Wednesday, July 31, 2013

Potty training advice: take time to tell the story

Yesterday I had the pleasure of doing 22 radio interviews in 4 hours as part of a PR tour for a new potty training book Potty Palooza: A step-by-step guide to using the potty.  I did not write the book, which is a fun but quite quirky board book designed to introduce children to the process. Rather, after writing a blog last year entitled The Poop Wars, I was approached by the publisher to write the short   parent guide that comes as an insert in the back of the book.

As I explained to my interviewers, it is not a "how to" guide but rather a set of "guiding principles." For just as in the case of sleep , the path to successful  toilet training is to know the family story. This became very clear in one interview about halfway through the morning.

The five guiding principles, that I repeated in some form in response to the radio hosts' questions are: trust yourself and your child, look for signs of readiness, relax, have fun, and pay attention when your child resists.

This particular interviewer was the mom of a three-year-old. As it was a public radio interview, rules of confidentiality that I follow strictly in my practice do not apply. The bulk of the ten minute conversation was taken up by her telling me about her frustration with her son saying "no" to repeated requests to poop on the potty. As she was not in fact a patient, and the purpose of the conversation was to talk about the book, I repeated the "advice" from the parent guide. I explained that each child-parent pair is unique, and it is important  to tailor the process not only to each individual child, but also to the family circumstances under which toilet training is occurring.

With about two minutes to go, she mentioned that she was pregnant with twins. After giving me about 30 seconds to address the possible relevance of this fact, she switched to the topic of her husband, who rather than helping model for their son, locks the door to the bathroom to protect his private time. The other radio host, a man, wisely interjected with, "when the twins come there will be no private time." Now we were getting somewhere. Seconds later came, "Thank you for joining us on our program."

The whole process felt emblematic of the trouble with our culture of advice and quick fixes. If there is an exclusive focus on "what to do" about "problem behavior" there is no time to reflect on the nuances and complexities of relationships. These relationships, and the family stories they are part of, are inevitably inextricably linked to the "problem." In telling the full story, "what do do" usually becomes clear.

For the mom of this three-year-old, that might mean backing off on the toilet training until after the babies are born. It might mean that some more explaining about where babies come from is indicated (a three-year-old might very well confuse the babies in the tummy with poop and hold on to the poop in an effort to be like mom.) There might be some work that needs to be done in the marriage in terms of shared responsibility for parenting.

Of course I am part of our culture, and I'm the one who wrote the 1,000 word guide to toilet training. And I do think that some "advice" can be helpful.  But above all, parents know their child best, and should trust their judgment. When things get derailed, and families are stuck, taking the time to tell the story and make sense of the problem can be very useful.





Friday, July 19, 2013

Sleep and childhood behavior problems: a complex relationship

A study published in the July/August issue of the Journal of Developmental and Behavioral Pediatrics showing a connection between hours of sleep and childhood behavior problems has received a lot of media attention. Children who slept less than 9.4 hours of sleep had more impulsivity, anger, tantrums and annoying behavior. The obvious conclusion-more sleep, better behavior. If only it were that simple.

If one takes the time to look closely, one will discover that what is correctly described as an "association" in the original article is in fact two interlinked phenomena that have a common underlying cause. Sleep problems are behavior problems. To know the cause, one must know the family story.

Sleep is a developmental phenomenon. In infancy a child learns what is commonly called "sleep associations." The breast, a pacifier, a lovey or even a parent's hair may be what a child associates with falling asleep. Frequent night wakings, expected by parents in the early weeks and months, can become a problem if that sleep association requires a parents' physical presence. As the months wear on parents become severely sleep deprived, and often find that this pattern is not so easy to change. In toddlerhood as a child in a normal healthy way begins to assert his independence, he may resist bedtime in the way he says "no" to many things. Further complicating the picture is the fact that sleep represents a major separation. A child who handles the first day of preschool with grace may suddenly refuse to go to bed, or begin waking during the night.

Given the complexity of this process, there are many ways it can get derailed. If parents do not agree about teaching a child to sleep independently, a child in the bed can cause significant marital discord.  When  parents struggle with depression, and this includes both fathers and mothers, they will have aggravation of symptoms, which often includes irritability. in the setting of sleep deprivation. When a parent is quick to lash out at a child, he may become anxious. Sometimes this anxiety leads to "acting out" in the form of oppositional behavior. It seems illogical, but a two-year-old doesn't know how to say "I need you to be with me and I feel sad when you are angry." He may simply see that when he is "difficult" his parents are more engaged with him. Separation anxiety is common in these situations, and sleep is a major separation.  Bedtime refusal and frequent night wakings are common in this setting. This leads to a vicious cycle as both parent and child become increasingly irritable.

These are some examples, and there are as many different stories as there are families. By the time parents come to see me at the Early Childhood Social Emotional Health Program with behavior problems, which in my experience always include sleep problems, they may be hard pressed to describe moments of joy with their children.

I feel for the parent who reads an article with the title More Sleep Might Help Tots' Tantrums, with its recommendation to have a child get more sleep to improve behavior, and is unable to change the situation because the underlying cause is not addressed. This is where our culture of advice and quick fixes can lead parents to be overwhelmed by feelings of inadequacy and guilt.

The key to treating these complex problems is to give parents space and time to tell the full story. When parents themselves feel heard and understood, they are in a better position to be curious about the meaning of their child's behavior.

This study is important because it calls attention to the need to address sleep in the setting of behavior problems. However, when a child and family are struggling, simple recommendations have a child get more sleep are not only not helpful, but may make parents feel worse. A downward spiral of sleep deprivation and behavior problems will likely persist.

If a family and clinician has the time, then it is possible to make sense of the situation and take steps to set the whole family on a better path; to bring joy back in to relationships.  The younger the child, the easier this is to do.

Monday, July 8, 2013

How to grow a baby's brain


The Grow America Stronger Campaign was created to organize support for funding for investment in early childhood. This month the theme is early brain development. In support of these efforts I am publishing a short segment from my book Keeping Your Child in Mind that elaborates on how relationships grow the brain. It is a companion piece to my previous post that speaks to the need to support and value parents. Today's Rally 4 Babies, with featured guests Secretary of Health and Human Services Kathleen Sebelius, Secretary of Education Arne Duncan, and actress Jennifer Garner, will address the need for social policy supporting early learning.
A very brief discussion of the structures of the brain responsible for regulating emotions will, I hope, serve to demonstrate how parents can promote their child’s brain development in a healthy way… Research at the interface of neuroscience and infant development is offering great insights into how the exchange of looks between mother and baby actually grows the brain. Researchers have learned a great deal about infant development from a combination of detailed video observations of mothers and infants interacting and MRI studies of the brain in action. These imaging studies can actually see which parts of the brain are responsible for what behaviors. This research has shown that healthy wiring of a baby’s brain depends on attuned responses of caregivers. These responses can consist not only of words, but also looks, touch, sound of voice, and facial expressions.
A part of the brain called the medial prefrontal cortex (MPC) is primarily responsible for emotional regulation. When a person has a well-developed MPC, he experiences a sense of emotional balance. He can feel things strongly without being thrown into a state of chaos. The MPC controls and regulates the amygdala, a tiny, almond-shaped structure that is significantly more developed in the right brain and is responsible for processing such strong emotions as terror. Trauma researcher Bessel van der Kolk refers to this area as the “smoke alarm of the brain.” This structure, via another part of the brain called the hypothalamus, connects with the glands responsible for re- leasing stress hormones such as adrenaline and cortisol. These hormones give us the physical sensations of stress. 
The development of the amygdala begins in the third trimester of pregnancy; it is fully formed at birth. Development of the MPC begins in the second month of life and continues well into a person’s twenties. By virtue of its location, the MPC literally hugs the amygdala. It serves to regulate and control the smoke alarm and in turn the powerful “fight or flight response.”
A third important part of the brain responsible for emotional regulation is the insula. The insula, another primarily right brain structure, connects with the visceral organs of the body, including the heart and intestines, as well as the skin. When experiencing empathy for another person, one often has a number of physical sensations, such as a tightening in the chest and tingling in the skin. These physical experiences of empathy, literally feeling what another person is feeling, are mediated by the insula. Mirror neurons, a special set of neurons first discovered in the early 1990s, are also thought to be important in the experience of empathy. They activate when a person is either doing something or watching another person doing something. They seem to code for not only the action, but also the goal or intention of the action. Thus they may play an important role in interpretation of the meaning of another person’s behavior. The insula, and perhaps the mirror neurons as well, play a critical role in attunement and the sense of being understood by another person.
When these connections are not well developed, intense emotions are not well regulated. In the face of fear, for example, a person may be flooded with stress hormones. However, with a well-developed MPC, she will experience the feeling, but her hormonal response will be turned down so that she is not overwhelmed. If, on the other hand, she does not have a well- developed MPC, the amygdala will go off unrestrained, and she will be flooded with fear that she cannot manage. In the face of overwhelming distress, she cannot make use of the parts of her brain responsible for rational thinking. She may become completely overwhelmed and be unable to function. In fact, the amygdala is overactive in post-traumatic stress disorder (PTSD) and all anxiety disorders. 
When a parent gazes into her baby’s eyes, she literally promotes the growth of her baby’s brain, helping to wire it for a secure sense of self. The MPC has been referred to as the “observing brain.” It is where our sense of self lies. When a mother looks at a baby in a way that tells her, not with words but with feelings, “I understand you,” the baby begins to recognize herself, both physically and psychologically. This mutual gaze, in which the baby is literally and figuratively “seen,” actually encourages the development of the MPC and with it her sense of self. As her brain matures in this kind of secure, loving relationship, it becomes wired in a way that will serve her well for the rest of her life. She will be able to think clearly and to regulate feelings in the face of stressful experiences.

Friday, July 5, 2013

Obama Rallies for Babies to Grow America Stronger


President Obama is investing in our future by investing in early brain and child development.  The July 8th event, Rally4Babies, sponsored by Zero to Three, was organized to call attention to the importance of this investment. Obama's "Preschool for All" proposal in its entirety can be seen on the Grow America Stronger website that describes the research behind the Early Childhood Initiative. It includes a link to sign a petition in support.

I was very pleased to learn that while the main focus of the proposal is on preschool, it includes a good deal of funding for programs for infants and very young children. For example, the voluntary home visiting program allocates $15 billion over 10 years to expand home visiting services for families with very young children. The proposal speaks of "evidence-based home visiting programs [that] demonstrate improved maternal and child health in the early years, long-lasting positive impact on parental skills, and enhanced children's cognitive, language, and social-emotional development and school readiness." The Nurse-Family Partnership is one such evidence-based program.

In my book Keeping Your Child in Mind, essentially an argument for his proposal, I outline all of the contemporary research and knowledge at the interface of developmental psychology, neuroscience and genetics supporting this investment in early childhood (although I examine the issue from the perspective of health care, rather than education.) This excerpt offers an explanation for the success of home visiting programs.
John Bowlby, describing the essential role of attachment relationships in survival, spoke of a child’s need for what he called a “secure base” from which to explore the world and grow into a separate person. He also recognized the need for a mother to have a secure base of her own in order to provide this security for her child:
I have referred to the ordinary sensitive mother who is attuned to her child’s actions and signals, who responds to them more or less appropriately, and who is able to monitor the effects her behavior has on her child and to modify it accordingly. . . . This is where a parent, especially the mother who usually bears the brunt of parenting during the early months or years, needs all the help she can get—not in looking after her baby, which is her job, but in all the household chores. . . . In addition to practical help, a congenial female companion is likely to provide the new mother with emotional support or, in my terminology, to provide for her the kind of secure base we all need in conditions of stress and without which it is difficult to relax.
In some cultures an extended family can fill this role. A supportive grandmother can be very important. If a new mother holds in her mind a warm, loving relationship with her own mother, even if the grandmother is not nearby or is deceased, this relationship can provide the secure base she needs when she becomes a mother.
It is not uncommon in our culture for a mother to raise her children without benefit of her own secure base (and most do not have help with household chores!!). Families are fragmented by geography and/or divorce. A spouse may be relied upon both to be the breadwinner and sole emotional support, which can put significant strain on a marriage. Many new mothers I see describe highly troubled relationships with their own mothers, full of grief and loss.
A home visiting program provides such a secure base to at-risk families. In our society today, where many live in poverty and families are fragmented, many mothers are raising children without a secure base of her own.

When a parent herself has experienced abuse, providing such a secure base is especially difficult. The home visiting programs share much in common with Selma Fraiberg's original infant mental health program, described in this excerpt.
This way of thinking about and working with children and families is well described in a relatively new field known as “infant mental health.” The field grew out of the work of Selma Fraiberg, a child psychoanalyst who, in her groundbreaking 1974 article “Ghosts in the Nursery,” described the Infant Mental Health Program. A staff of experienced psychologists and social workers went into the homes of mothers who had been abused. By forming a close connection in a supportive and understanding way while these mothers were interacting with their children in their own homes, the staff were able to significantly improve the parenting capacities of these traumatized mothers. The most important part of this intervention turned out to be the relationship between the therapist and the mother. It was different from therapy with the mother. The aim of the intervention was to help the mother connect with her child in a meaningful way.
This intervention, and others modeled on Fraiberg's approach, actually serves to wire healthy brains, as described in this excerpt (stay tuned for more on this subject in my next post):
Contemporary research in neuroscience reveals that a child’s brain develops in relation to other people, not simply on its own. When parents are attuned to their child’s emotional experiences, new connections are formed that control the way that child regulates her experience. These relationships actually wire the brain. This is particularly true in the first year, when the volume of the brain doubles, but relationships can continue to shape the structure of the brain well into adulthood. 
Quality preschool is for all is a good thing. But equally, if not more important, is finding a way to provide a secure base for all new parents, with the aim of supporting their efforts to provide such a secure base for their children.  Currently the United States lags significantly behind many countries in the value we place on parents and young children (A lovely alternative example is Finland, where every expectant mother receives a box of baby goods-a baby box- from the Finnish state social services agency.) Fortunately, not only does Obama recognize this fact, but he also understands that remedying the situation is essential for the future of our country.