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.

Friday, July 25, 2014

How Yoga Informs Parenting: Value in Not Knowing

In yoga, a pose referred to by my teacher as "how wonderful" involves a lifting of the head and chest, and opening of the arms out to the side, with a bend in the elbows.

In her introductory words of wisdom to a class in which that pose was to be the theme of the day, she asked us, "Do you ever make up stories?" She shared that she may in response to a distracted expression from a friend think, "She's mad at me," or from her 3-year-old child who refuses to put on his shoes, "He's trying to drive me crazy!" She identified how this ability to try to make sense of other's behavior has evolutionary significance. It helps us navigate a complex social world- otherwise, she said, we would have no idea what was going on. But sometimes this kind of assuming of meaning, this making up stories, can get us in to trouble.

What if instead, we employ the open stance of  "I don't know?"-words she demonstrated fit perfectly with the pose of "how wonderful."

In my behavioral pediatric practice, I find parents often driven by a  need to know. "Is there something wrong with him?" they ask. There are tremendous pressures -from teachers, from family, from insurance companies, to name the problem. There is a kind of certainty in this approach, a kind of professional declaring of "I know whats wrong with you."

What if, rather than being guided by diagnostic instruments, that ask questions with the aim of getting an answer, we approach the situation with a stance of curiosity, of inquiry, of "not knowing."

I find if, in a way not dissimilar to the hour-long yoga class, I offer space and time to let the story unfold, we uncover complex meaning in "problem" behavior. There may be a number of relatives with similar traits, suggesting a genetic component. There may have been significant stresses in a family that, even with parents' best efforts to shield a child from the effects, have been noticed and absorbed. A child may have a range of sensory sensitivities that he can manage, but under the stress of separation, often at bedtime or in the process of getting out the door, these sensitivities are magnified. "Problem" behavior may be both cause of and result of family conflict between parents, among siblings, between generations.

There is courage in a stance of not knowing. In yoga, we trust our teacher to guide us in the backbends that evolve out of the "how wonderful/I don't know" pose. The work is hard.  She challenges us while taking care to protect us from harm.

Perhaps professionals who care for children with "behavior problems" -pediatricians, psychiatrists, teachers- could learn a lesson from my yoga teacher (support from the health care system that decided what is and is not "covered" would be essential to this kind of approach.) Rather than being guided by a need to make a "diagnosis," we would support parents in a safe, holding environment through a time of not knowing, on a journey to find the true meaning of behavior.

This kind of journey might not only serve to decrease the number of children receiving psychiatric diagnoses, but also help us to discover creative solutions. We would have the opportunity to uncover both weaknesses and strengths, and to support development of resilience.  In the words of pediatrician turned psychoanalyst D.W. Winnicott, we would be promoting development of a child's "true self."

How wonderful.

Tuesday, July 15, 2014

Why Depression is Not Like Diabetes

At the recent gubernatorial candidates forum on mental health, Martha Coakley repeated the oft-heard phrase that depression is like diabetes. Her motivation was good, the idea being to reduce the stigma of mental illness, and to offer "parity" or equal insurance coverage, for mental and physical illness. However, I am concerned that this phrase, and its companion, "ADHD is like diabetes," will, in fact, have the exact opposite effect.

A recent New York Times op ed, The Trouble with Brain Science, helped me to put my finger on what is troubling about these statements. Psychologist Gary Marcus identifies the need for a bridge between neuroscience and psychology that does not currently exist.

Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. The above analogies disregard the intimate intertwining of brain and mind. For the pancreas, there is no corresponding "mind" that exists in the realm of feelings and relationships.

While there is some emerging evidence of the brain structures involved in the collection of symptoms named by the DSM (Diagnostic and Statistical Manual of Mental Disorders,) there are no known biological processes corresponding to depression, ADHD or any other diagnosis in the DSM. There is, however, a wealth of new evidence showing how brain structure and function changes in relationships.

These collections of symptoms, intimately intertwined with feelings and relationships, are problems of behavioral and emotional regulation. The capacity for emotional regulation develops in relationships.  If DSM diagnoses can only be legitimized by comparing them to diabetes-and food allergies, as was recently done by the director of the NIMH (National Institute for Mental Health)- this comparison may increase, rather than decrease the stigma by de-valuing relationships and our basic human need for meaningful connection.

The primary treatment for diabetes is a drug. This analogy works if we accept that the primary treatment for mental illness is drugs. The pharmaceutical industry must be pleased with this approach.

But, in fact, the primary treatment for problems of emotional well-being is time. What is needed is time and space for listening, where individuals can have the opportunity to have their feelings recognized and understood. In this time and space, people can make sense of, and find meaning in, their experience.

A model that compares depression to diabetes is an illness model. It promotes a kind of "there is something wrong with you and I will fix it" approach.   It is not simply a question of "therapy vs. medication" as many "evidence based" research studies suggest. It is a question of a completely different model, a resilience model. Such a model, that values time and space for listening and being heard, seeks to help people re-connect with their most competent selves.

But we will only get there if we stop comparing depression to diabetes.

Thursday, July 3, 2014

Supporting Parent-Baby Pairs in the Wake of Infertility

A new study in Denmark demonstrated a 33% increased risk of a range of psychiatric disorders in children whose mothers were treated for infertility. The authors do not offer a cause, but postulate that the increased risk is related not to the treatments, but to the infertility itself.

These findings echo research showing increased risk of psychiatric problems in children whose mothers have struggled with perinatal emotional complications such as anxiety and depression.

How can we make sense of this?

Mental health, including the capacity for emotional regulation, empathy, resourceful thinking and resilience, develops in relationships. So the answer to this question lies in the way infertility impacts on parent-child relationships.

I recently came upon a beautiful expression in a work of literature that captures pediatrician D.W. Winnicott's concept of primary maternal preoccupation, that he identifies as central to a child's healthy emotional development.

The book is James Agee's A Death in the Family. In this early scene, the father is awakened during the night because his father is ill. As he dresses to leave the house, his wife, on her way downstairs to make him breakfast, whispers to him to bring his shoes in to the kitchen.

"He watched her disappear, wondering what in hell she meant by that, and was suddenly taken with a snort of silent amusement. She looked so deadly serious, about the shoes. God, the ten thousand little things every day that a woman kept thinking of, on account of children. Hardly even thinking, he thought to himself as he pulled on his other sock. Practically automatic. Like breathing."

The experience of infertility may get in the way of this breathing. Without appropriate support, a mother may feel that she is suffocating.

A mother, and also a father who, while not experiencing the physical assaults of infertility treatments, certainly shares in the emotional trauma, may come to the experience of parenthood with a range of significant vulnerabilities.

Anxiety over the well being of a new baby, no matter how much reassurance well meaning clinicians offer, may be unrelenting. In the face of repeated loss, as occurs in the process of infertility treatment, not only with every period, but sometimes with early pregnancy loss, may lead a parent to, in an adaptive effort to protect themselves from further loss, disengage emotionally. A parent may not fully surrender to the falling in love that accompanies the birth of a baby. And parents may be simply emotionally exhausted.

The baby also may have a role to play. There is evidence that stress in pregnancy, as is almost inevitable in a pregnancy that follows infertility treatments, is associated with what is termed "behavioral dysregulation" in the baby. That is, the baby may be more difficult to feed, may cry more or have irregular sleep patterns.

The good news is that, having identified infertility as a risk factor in development of mental illness, there is ample opportunity to set these vulnerable parent-baby pairs on a healthy path. One option is suggested in a recent article in the Atlantic, How Supportive Parenting Protects the Brain, where the possible role of the pediatrician is addressed.

What if every parent-baby pair, in the aftermath of infertility treatment, got some extra time and attention? An extra hour-long visit-with clinicians reimbursed for their time- to meet with parent and baby together, to listen to them both? Even better, as pediatricians have variable interest/expertise in this kind of work, have an infant mental health specialist, physically located in the pediatrician's office. The Newborn Behavioral Observation system is a wonderful tool for listening to parent and baby together in a way that sets development on a healthy path.

The idea is to normalize, rather than stigmatize.

This study might cause alarm for parents who are already stressed by the process of infertility treatment. I was alarmed myself by the statement by one of the study's authors that "this knowledge should be balanced against the physical and psychological benefits of pregnancy." To even entertain the idea of not getting pregnant because of this potential risk to the child is absurd, and feels almost punishing.

But if instead we use this study as further evidence of the value of protecting space and time to listen to parents and babies, then alarm could be transformed in to hope.