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.

Saturday, May 24, 2014

Quotidian Trauma, Quotidian Resilience: Boston Conference on Contemporary Developmental Neuroscience

When Frank was a young boy, and he committed some typical toddler transgression such as having a meltdown when it was time to leave the playground, his father would slap him across the face, hurting and humiliating him in a very public way.

When I spoke with Frank over 20 years later, in the context of helping him with his own son Leo's frequent tantrums in my behavioral pediatrics practice, he did not describe this experience as "trauma." Rather, he described it in a very matter-of-fact tone.

But when we explored in detail his response to his son's tantrums, we discovered that, flooded by the stress of his own memories, Frank in a sense would shut down. Normally a thoughtful and empathic person, he simply told Leo to "cut it out." As we spoke he recognized how he was emotionally absent during these moments, which were increasing in frequency. It seemed as if Leo was testing Frank, perhaps looking for a more appropriate response that would help him manage this normal behavior. Once this process was brought in to awareness, Frank was able to be present with Leo- to tolerate his tantrums and understand them from his 2-year-old perspective. Soon the frequency and intensity of the tantrums returned to a level typical for Leo's developmental stage. Frank, greatly relieved, once again found himself enjoying his son.

The upcoming Boston conference; Psychological Trauma: Neuroscience, Attachment, and Therapeutic Interventions, promises to offer insight in to the developmental neuroscience behind this story.

What Frank experienced as a young child might be termed "quotidian" or "everyday" trauma. It was not watching a relative get shot, or having his house washed away in an avalanche. It was a daily mismatch with his father- he was looking for reassurance and containment and instead got a slap across the face. It was what leading researcher Ed Tronick would term "unrepaired mismatch." Frank, in a way that is extremely common- termed "intergenerational transmission of trauma" was then repeating this cycle with his own child. When this dynamic was brought in to awareness, was able to "repair the mismatch," setting his relationship with his own son on a healthier path.

Tronick, who runs the Infant Parent Mental Health Postgraduate Certificate Program at UMass Boston, and will be presenting at next week's conference, describes this process in a paper entitled Quotidian resilience: Exploring mechanisms that drive resilience from a perspective of everyday stress and coping. Resilience is a capacity that develops over time through the typical misattunments that inevitably occur between parent and child. D. W. Winnicott, pediatrician turned psychoanalyst, coined the phrase "the good-enough mother" to describe this phenomenon.

Quotidian trauma, on the other hand, occurs when these mismatches are not repaired. Tronick's research as shown that even if they are only repaired 30% of the time, development still proceeds in a healthy direction.

Steven Porges, a professor of psychiatry at University of North Carolina Chapel Hill, another speaker at the conference, has developed through his research, a fascinating theory to explain this process on a neurobiological basis. Tronick dramatically demonstrates the effects on an infant of these misatunement, or mismatches, in his Still Face experiment. In it we see how a young infant becomes highly distressed and disorganized when his mother does not respond to him in the typical way.

Many are familiar with the term "fight-flight" response to describe how when the body is faced with extreme stress, the sympathetic nervous system kicks in. What Porges brilliantly identifies is that in the setting of parenting, the drive to protect one's child may override this response. So what happens when a parent, like Frank, is flooded with stress, but cannot fight or take flight? A more primitive stress response, mediated not by the sympathetic, but by the parasympathetic nervous system, takes over. This is the "freeze response" that leads an animal to play dead in the face of overwhelming threat.

The parasympathetic nervous system innervates the muscles of the face and voice, controlling on a neurobiological basis that attunement that is so important to healthy development. Putting this together with Tronick's research, we can understand what happened to Frank. In a way that was unconscious and so out of his control, flooded with stress but with his fight-flight reaction unavailable, his parasympathetic system took over. The result is a literal still face. Leo's increasing tantrums match the increasing distress seen in the infant in Tronick's experiment.

At this week's conference, organized by Bessel van der Kolk, whose work with psychological trauma is featured in the New York Times Magazine this weekend, there will be much more to learn. This exploding field of study, while often identified with "Trauma" with a capital "T," has much to teach us about prevention. From the research that will be presented, we are able to understand not only how to treat trauma, but also how to intervene in the earliest months and years to break the cycle of transmission of trauma and set development on a healthy path.

Thursday, May 15, 2014

Roz Chast on Parent-Child Relationships

Roz Chast's new book Can't we talk about something more pleasant?, a touching, funny, sad, and thought provoking graphic memoir, is primarily about her caregiving role as her elderly parents approach death. She makes her painful subject tolerable with humor. For example, at a point when Chast thinks her mother's death is imminent, she arrives at the "the Place" where her mother is under the care of a new nurse. She finds her sitting up, dressed, and eating lunch. Chast writes, "Where in the five Stages of Death, is EAT TUNA SANDWICH?!?!?"

Chast has a troubled, fraught relationship with both parents, though more so with her mother, right up to the end. Though the focus of the book is the final years, Chast gives some insights in to the origins of these difficulties.  Reading the memoir with an eye to understanding parent-child relationships, I found an interesting example of the way parent and child can dysregulate each other. Of how when things go wrong, the problem is not either exclusively in the parent or the child, but in the relationship.

Chast was born one month premature, delivered by cesarean section as a precaution because her mother's first baby, a girl, had died at 7 and 1/2 months. A family narrative suggested that the death was related to standing on a stool to change a lightbulb, something Chast's meek and fearful father refused to do. But the actual cause was placenta previa. An obstetrician had told Chast's mother that her "uterus would rupture" if she carried to term.

Chast describes herself as "probably not a fun baby." She had low tone, cried a lot, didn't like to eat or sleep. Likely some of these traits were related to her prematurity. Chast writes, "I had one cold after another, and from the time I could speak, one anxiety after another." Temperamentally she was much more like her father than her mother. While as an adult she writes of her mother, "I can sympathize with her desire to leave me in the care of someone else for a while," she follows with," who knows what I thought back then."

Chast's mother came from a history of trauma. Her father, Chast's maternal grandfather, was an engineer in Russia but came to the US, presumably following persecution of the Jews, to a life of extreme poverty that left him "bitter and angry."  It is possible that her mother's experience as a parent was colored not only by this history, but also her history of loss. Even today pregnancy loss may not be recognized as an experience with its own significant grieving process. Certainly in 1940 it is likely that one was expected to just carry on.

The aim of the book, I believe, is to call attention to the inherent challenges of caring for aging parents. But it is a rich and beautiful story, with other lessons as well. Chast, with her sparse details, offers us a picture of a parent-child relationship that got off on the wrong foot. I wonder if Chast's brilliant creativity is in part a result of having to cope with this difficult and painful family story. If so, her struggles become our gift.

Thursday, May 8, 2014

Keep Mothers in Mind for Mother's Day and Mental Health Month

In recognition of May as National Mental Health Awareness Month, President Obama made a proclamation that included this statement
My Administration is also investing in programs that promote mental health among young people. 
While he went on to speak of working with teachers and students, my hope is that Obama will recognize that prevention starts with parents and babies. A social and cultural valuing of parents, as occurs in countries like Australia and Finland, is the path to a truly preventive model.

A recent issue of the journal Current Problems in Pediatric and Adolescent Health Care identifies the following:
The presence of parental psychological problems, such as depression or anxiety, can lead to prolonged periods of disorganized parent-infant social interaction, compromising long-term infant outcomes. A wealth of studies has shown that maternal depression is a strong predictor of infants' social, emotional, and cognitive problems throughout the lifespan.
Representative Ellen Story and her Postpartum Depression Commission have recognized this fact. While the initial focus of the group had been on screening for postpartum depression, it has expanded to focus on the emotional well being of parents during pregnancy and in the postpartum period. This includes supporting of strong, healthy parent-child relationships.

One of the initiatives is a new program MCPAP for Moms. The aim of the program is to provide statewide support for pediatricians, obstetricians and other clinicians who have the opportunity to identify and treat new parents who may be struggling with a range of perinatal emotional complications. MCPAP for Moms is partnering with the wonderful organization, MotherWoman, to integrate the community based perinatal support model, as well as the important and valuable program at the Massachusetts School of Professional Psychology,  the MSPP Interface Referral Service, that connects people in need of help with appropriate care.

D.W.Winnicott observed in his work as a pediatrician and psychoanalyst what he termed the "ordinary devoted mother." In the early weeks and months, when the infant is completely helpless, he relies on this devotion. When his caregivers are present in this way, development proceeds in a healthy direction. But when a parent is, in the words of Winnicott's biographer Adam Phillips, "preoccupied by something else," in the face of such things as social isolation, depression, anxiety or even PTSD, containing the helpless baby can be very difficult. Add a fussy baby to the mix, and this is where development can first get off track.

I am happy to be part of the MCPAP for Moms initiative because its leaders recognize the need to the focus is on the relationship. It is not only about treating the mother, but also bringing in the baby- identifying stressed early relationships and finding ways to support those relationships.

The baby is an active participant from the start. Crying, sleep and feeding problems often affect the emotional well being of new parents. The baby's mood can affect the parents, and the parents' mood can affect the baby. Parent and baby can interact in a way that causes worsening of each other's distress. This is the point at which help is needed- for the parent, for the baby, for the relationship.

By valuing the role of parents, and investing resources in the early weeks, months, and years when the baby's brain is most rapidly developing, we will be engaging in promotion of mental health and primary prevention of mental illness.

Friday, May 2, 2014

Accepting Gratitude

How often, when someone thanks us for something, do we respond with some variation of, "don't worry about it," or, "it's nothing?"  My yoga teacher, a beautiful and inspirational person who starts every class with thoughts to guide our practice for the day, first brought this issue to my attention. She confessed to having difficulty accepting gratitude. She was making an effort to pause, check her natural reaction, and instead respond with a simple, "you're welcome." To remind herself, she would accompany the words with a gesture of hand to heart.

The subject again came up at a medical conference and really got me thinking. In the health care setting, thanking can have particularly great significance. For the person who is doing the thanking, it isn't "nothing."  Our natural inclination to be dismissive in the face of gratitude may feel, to the person expressing it, like a form of pushing away, a kind of rejection. Of course it isn't meant that way, and is more likely to come from an honest place of being humble or perhaps even self-effacing.

The person giving the conference suggested a response of thanks in return. But this didn't feel right to me. It may be away of getting the last word, and also may communicate rejection. Some form of "I'm glad I could help,"  seems closer to the mark. But perhaps the exact words don't matter as much as the feeling behind them.

There is much evidence that expressing gratitude is good for our mental health.  It can be a form of meaningful connection, a kind of expression of love. Perhaps we need to be more mindful of the benefits, on both sides, of graciously receiving it.