On Rising Disability Benefits for Children: Distribute Diapers, Not Drugs

Children who grow up in poverty are at risk for problems of emotional, behavioral and attentional regulation. Today's Globe reports that SSI (Supplemental Security Income) for disabilities has surpassed traditional welfare as a source of support for poor families. The vast majority of these disabilities are mental health problems such as ADHD ( attention deficit hyperactivity disorder.) In her brilliant three part series that led to this current study, Patricia Wen uncovered some complex questions.  What does it mean for children and families that in order to receive financial support, there is incentive to get children diagnosed with psychiatric disorders and medicated with psychiatric drugs?

Current research at the Yale Child Study Center offers a novel look at this problem, literally from the other end. In a study published in Pediatrics in 2013, researcher Megan Smith showed that 30 percent of families living in poverty report diaper need.

Extensive research has  shown that when parents are fully emotionally present with their infants, they support development of emotional regulation, cognitive resourcefulness and social adaptation. But what if her baby is screaming in a dirty diaper, uncomfortable or in pain, and a mother can't reliably have access to a clean one? The stress of this predicament may make emotional regulation, both for parent and child, impossible. Smith concludes:

Although a majority of studies have examined family socioeconomic status as income and educational and employment status, emerging research suggests that indicators of material hardship are increasingly important to child health. This study supports this premise with the suggestion that an adequate supply of diapers may prove a tangible way of reducing parenting stress, a critical factor influencing child health and development. 

Next weekend, Smith will be presenting her research at the Austen Riggs Center, in conjunction with a community diaper drive sponsored by the Berkshire Psychoanalytic Institute. 

Wen's current Globe piece quotes Rebecca Vallas of the Center for American Progress; "Cash is what actually matters for these families, as a baseline, before you can even start talking about supports and services."

The point of juxtaposing these two studies is not that we should distribute diapers in place of cash. Rather it raises the question of whether it makes sense to invest in infants, rather than waiting until problems of emotional and behavioral regulation are so great that children meet diagnostic criteria for a psychiatric disorder. 

The infant brain makes as many as 700 synaptic connections per second. By investing resources in infancy, not only with diapers, but also such things as quality child care, paid maternity and paternity leave, and identification and treatment of perinatal mental health problems such as postpartum depression and anxiety, we literally have the opportunity to grow healthy brains. 

The current SSI system seems to be an investment in illness. In contrast, concrete support with clean diapers, as well as the broader support of parents and young children, is an investment in prevention and health. 

Dancing Lessons: Metaphor for Healing Through Relationships

Dancing Lessons, a new play recently premiered at Barrington Stage Company, is ostensibly about an actual dancing lesson. An injured dancer reluctantly agrees to give a one-hour dance lesson to a young man with Asperger's syndrome who lives in her apartment building.

At first the two characters are cast in conventional roles, he awkwardly defining himself by DSM criteria and she drinking too much while spewing bitterness over her sudden unexpected disability. Over the course of the play's single act, as their relationship deepens, we appreciate the complexity of their characters. As they grow closer, sharing painful stories of loss from their past, they discover they are in many ways not that different from each other. In a wonderful fantasy sequence at the end, the two shed their respective disabilities and dance gracefully together.

The play, itself an act of creativity, can be seen as a metaphor for the value of play and creativity in healing. 

D.W. Winnicott, pediatrician turned psychoanalyst, is known for the playfulness he introduced to his work with children and families. I am not referring to "play therapy" but rather time and space to sit on the floor and see what unfolds.

Every summer the Austen Riggs Center in Stockbridge, MA hosts a creativity seminar in which mental health clinicians and a range of artists come together to explore the creative process. In the introduction to A Spirit That Impels, a collection of essays that grew out of the yearly seminar, editor M. Gerard Fromm shares a vignette told to him by a colleague who had the good fortune to observe Winnicott at work.  

Winnicott would see a family for one or two consultations; this one involved a young mother and her 3-year-old son.

He sat on the floor playing with the child, while also talking with the mother, who was sitting on the couch. She told Winnicott that her ordinarily sweet little boy had suddenly become quite ill-tempered and obstreperous. Worst of all, toilet training was completely set back, and the lad was now worrisomely constipated. The father in this working-class household spent long hours at two jobs, and the boys mother was at her wit’s end.

The trainee described to Fromm how she had no idea what was going on, but at the end of the visit Winnicott turned to the mother and said, “So how long have you been pregnant?” She revealed that she had not told anyone, but Winnicott suggested that the boy did in fact know and suggested she speak with him about it. When the mother returned a few weeks later, she reported that not only was her son “great fun again,” but his constipation had completely resolved.

In his book Playing and Reality, Winnicott writes:

This gives us some indication for therapeutic procedure- to afford opportunity for formless experience, and for creative impulses, motor and sensory, which are the stuff of playing.

This playfulness that Winnicott employed in his clinical work stands in start contrast to today’s system of mental health care replete with assessment tools and standardized forms.  Our reliance on DSM classification and medication may not leave room for this kind of creativity and healing through relationships.  

For example, in standard treatment of postpartum depression, the "problem" is seen as residing squarely in the mother, who may be offered nothing more than psychiatric medication. The role of the baby, the way fussiness, sleep and feeding difficulties affect the mother, may not be addressed. Similarly when we diagnose ADHD based on standard symptom checklists, and treat with "behavior management" or medication, there may be no room for creativity, either in making sense of or in treating the "problem." In the play space there is opportunity to understanding the meaning of behavior in the context of relationships.

Parent-child relationships are a complex intricate dance. At times this dance can be full of mismatches and stepped on toes. Sitting on the floor with parent and child together, rather than diagnosing disorders or managing problems, I prefer to think of my work as a form of dancing lessons.  Through playfulness and creativity, parent and child learn to dance gracefully, and as St. Germain’s characters discover in the final scene, to find beauty and joy in their relationship

Examining the Antidepressant:Suicide Link Ten Years After FDA Warning

When I hear debate over the association between SSRI’s (selective serotonin re-uptake inhibitors, a class of antidepressant medication) and suicidal behavior in children and adolescents, I am immediately brought back to a night in the early 2000's.  As the covering pediatrician I was called to the emergency room to see a young man, a patient of a pediatrician in a neighboring town, who had attempted suicide by taking a nearly lethal overdose. 

That night, as I watched over him in the intensive care unit, I learned that he was a high achieving student and athlete who, struggling under the pressures of the college application process, had been prescribed an SSRI by his pediatrician.  His parents described a transformation in his personality over the months preceding the suicide attempt that was so dramatic that I ordered a CT scan to see if he had a brain tumor. It was normal. When, in the coming years the data emerged about increasing suicidal behavior following use of SSRI's, I recognized in retrospect that his change in behavior was a result of the medication. But at the time I knew nothing of these serious side effects.

At that time, coinciding with pharmaceutical industry's aggressive marketing campaign directed at the public as well as a professional audience, these drugs were becoming increasingly popular with pediatricians.

As the possible serious side effects of these medications came increasingly in to awareness, the FDA issued the controversial "black box warning" that the drugs carried an increased risk of suicidal behavior. Following the black box warning, pediatricians, myself included, became reluctant to prescribe these medications. We did not have the time or experience to provide the recommended increased monitoring and close follow-up.

Recently the Boston Globe published an article reviewing the data addressing the concern that the warning, by discouraging prescribing, led to increased suicidal behavior. It includes this key finding.

Studies also found no increase in other treatments for depression, such as psychotherapy; leading to what Fritz called “a net decrease in the amount of treatment."

This finding offers evidence for more insidious and perhaps more dangerous side effect of antidepressant use in children. The fact that we as a society condone use of these medications in children in the absence of relationship based treatments- - CDC report from December 2013 indicated that 50% of adolescents who are on psychiatric medication have not seen a mental health professional - itself changes the landscape of mental health care.

When medications can be used alone, the professions who offer opportunity for listening and human connection are devalued, both culturally and monetarily.

This kind of devaluing sends qualified professionals away. Pediatricians, whose longstanding relationships with children and families makes them ideally suited for preventive interventions, are discouraged from using their time to listen. Social workers, psychologists and others who offer relationship based treatment in which feelings can be recognized and understood, when paid less and less while being required to jump through increasing number of hoops, are less likely to accept insurance.  The drug itself becomes inextricably linked with the shortage of quality mental health care.

A recent study, a survey of close to 2,000 people being prescribed antidepressants, showed a much higher than expected rate of serious psychological side effects. Almost half described, “feeling emotionally numb” and “caring less about others.” These findings occur in the context of a social acceptance of medicating away feelings, and in doing so, devaluing the “being with” that is necessary for growth and healing. The absence of opportunity for meaningful human connection where feelings are recognized and understood, in combination with these psychological side effects, may be what leads to increased risk of suicidal behavior.

I wonder if before we can change what we do, we need to change how we think. Prescribing psychiatric medication to a child without simultaneously offering time and space to listen to him and his family is unacceptable. A change in perspective and attitude is needed before we can to begin to repair our broken mental health care system.

Andrew Solomon, in his sweeping tome about depression, The Noonday Demon, respects the role of medication in treatment. But, recognizing that medication alone it is not sufficient, he writes, "Rebuilding the self in and after depression requires love, insight, work, and most of all, time."

Epigenetics, Psychoanalysis, and Listening to Parents

Psychoanalysts for over a hundred of years have recognized the significance of early relationships in health and development. Now the exploding science of early childhood offers evidence that early parental care regulates physiology, influences development of the stress response, and even affects the expression of genes and structure and function of the brain.

The latest issue of the journal Neuropsychoanalysis provides an integration of psychoanalytic thought and contemporary developmental and evolutionary science. The article by Myron Hofer, and the accompanying commentary contain an abundance of evidence for the significance of early relationships.

Michael Meaney, a father of the new and rapidly growing field of epigenetics, offers this comment.

As Hofer noted, “maternal- infant interactions ... regulate the basic physiology of developing infants (such as sleep states, body temperature, autonomic balance, level of general motoric activity, and adrenal and growth hormone levels)”. These studies also revealed that these same maternal regulators were a source of information that shaped long-term phenotypic adaptation [gene expression and individual charcteristics.]

But all the science in the world may fall on deaf ears if our culture does not support parents in being present with their infants in the way the research suggests is critically important. 

If we pass laws condoning 8-week maternity leave, how can we take in and apply this abundance of research pointing to the significance of the early weeks, months and years? If, rather than addressing the problem of parents feeling overwhelmed and alone, and offering meanignful support, we are quick to diagnose them (and their children) with ADHD and prescribe medication, opportunities to make use of this wealth of scientific evidence are lost.  

Beatrice Beebe, a leading researcher in infant development whose detailed videotapes of mothers and infants offer elegant evidence for the richness and complexity of early parent-child relationships, praises Hofer's integration of theory and research. But Beebe, in conversation with a colleague of mine who is a general pediatrician, suggested that video be used in every 4-month well child visit. This comment represents a kind of disconnect between science and reality. The science certainly supports this kind of investment in time and attention to parent-child relationships in infancy.  But in today's fast-paced world of primary care, where clinicians are under pressure to see more and more patients in less and less time, such a suggestion is almost laughable.

In his concluding remarks, Meaney points in the right direction:

Developmental psychobiology established the conceptual framework within which to better understand the biology of early experience. The challenge is to now translate the emerging scientific advances into psychiatry and clinical psychology.

It seems like a kind of chicken-egg phenomenon. If as a culture we can place value on parents caring for themselves in order to be present with their children; if we value time for listening to parents and children together in the setting of primary care as well as mental health care, we may be better able to hear what the science is (and has been) telling us. 

Rethinking the Meaning and Use of the Word "Autism"

In the course of working on my new book about listening to parents and children, I have had the pleasure of immersing myself in the writing of D.W.Winnicott, pediatrician turned psychoanalyst.  Winnicott's professional life included both caring for countless young children and families as a pediatrician, and psychoanalytic practice, where his adult patients "regressed to dependence," giving him an opportunity to interact with their infantile qualities, but with adult capacities for communication. This combination of experiences gave him a unique vantage point from which to make his many brilliant observations about children and the nature of the parent-child relationship.

A recent New York Times Magazine article on autism prompted me to share his words of wisdom on the subject, which, though written in 1966, still have relevance today.  The following is from a collection of papers, Thinking About Children:

From my point of view the invention of the term autism was a mixed blessing...I would like to say that once this term has been invented and applied, the stage was set for something which is slightly false, i.e. the discovery of a disease…Pediatricians and physically minded doctors as a whole like to think in terms of diseases which gives a tidy look to the textbooks…The unfortunate thing is that in matters psychological things are not like that. 

Winnicott implores the reader to instead understand the child in relational and developmental context. He writes:

The subject quickly becomes one not of autism and not of the early roots of a disorder that might develop in to autism, but rather one of the whole story of human emotional development and the relationship of the maturational process in the individual child to the environmental provision which may or may not in any one particular case facilitate the maturational process.

In my behavioral pediatrics practice, parents of a young child may wish for a diagnosis to relieve them of the feeling that they are "bad parents;" that their child's challenging behavior is their "fault." Yet when I give parents space and time to make sense of their child's behavior, and in doing so help him learn to manage his unique vulnerabilities- essentially doing what Winnicott suggests-I find that most parents prefer not to have their child diagnosed with a disorder.

A recent book on the subject, Autism Spectrum Disorder: Perspectives From Psychoanalysis and Neuroscience, while still referring to a "disorder," captures the tenor of Winnicott's approach. My blurb on the book's cover reads:

This book, with its central focus on the parent-child relationship, offers a unique and very important contribution. Parents struggle terribly in their efforts to make sense of the behavior of a child with a wide range of neuro-developmental challenges that currently fall under the heading of Autism Spectrum Disorders. Drawing on extensive evidence from the fields of genetics and neuroscience as well as in-depth clinical material, the authors show how a clinician can set these children on healthy developmental paths by supporting parents’ efforts to find meaning in their children’s behavior.

Many adults with autism now advocate for the idea that autism is not a disorder. But they come from a very different perspective, arguing that their unique way of interacting with the world is simply different, not abnormal. Certainly for an adult this is a valid perspective. However, when I work with parents and young children where the diagnosis is being entertained, the whole family is struggling terribly. It feels to me a great disservice to a young child to think of calling this situation "normal." 

An approach like that of Winnicott, Sherkow and Harrison may be fraught in the context of the history of "refrigerator mothers." While this theory has been widely discounted, any attempt to consider the child's relational and developmental context may be interpreted as "blaming the parent." That is why I love Winnnicott's approach. Rather than asking, "Is it or is it not autism?" we might be wise to discard the term completely.  Instead, if we offer space and time to learn, "the whole story of human emotional development," the very act of listening to the story becomes the cornerstone of treatment.