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.

Sunday, September 28, 2014

Days of Awe and the Certainty of Neuroscience

Just like the digital codes of replicating life held within DNA, the brain's fundamental secret will be laid open one day. But even when it has, the wonder will remain, that mere wet stuff can make this bright inward cinema of thought, of sight and sound and touch bound into a vivid illusion of instantaneous present, with a self, another brightly wrought illusion, hovering like a ghost at its centre. Could it ever be explained, how matter becomes conscious?
The actual words written by Ian McEwan, in his novel Saturday about a day in the life of a neurosurgeon, are worthy of awe of the human mind. In a recent blog post I referred to a piece by psychologist Gary Marcus in which he calls attention to "the trouble with brain science." Perhaps inspired by this very piece of writing, he refers to the lack of a bridge between neuroscience and psychology comparable to the bridge between genetics and living beings that discovery of the double helix provided.

I describe how absence of this bridge is the problem inherent in the oft-used comparison between depression, or ADHD, and diabetes. NIMH director Thomas Insel has called for a study of the neuroscience of mental illness in the same way we study cancer, food allergies, and diabetes.

Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. For the pancreas, there is no corresponding mind in the realm of thoughts and feelings. The pancreas does not love, does not grieve, does not produce great literature.

This wish to compare psychological experience to physical illness ostensibly comes from a wish to destigmatize emotional suffering. But in fact it may have the opposite effect, as it devalues the  human relationships. It is an effort to apply certainty to situations ripe with uncertainty.

There is a dark side to the certainty of neuroscience. Years ago I treated a young girl, Charlotte, who had been diagnosed with ADHD by a previous doctor.  I took over her care, following the standard practice in pediatrics for visits every 3 months for review of "symptoms" of hyperactivity and inattention and adjustment of medications. When she continued to struggle, her parents paid a large sum of money to have a brain scan done by a doctor who claimed to identify the exact location of her problem. Despite the alleged certainty of these results, her "symptoms" continued. I referred the family to a therapist, but lost touch with them when I left that practice.

Recently I learned from her mother, Jennifer, when I ran in to her on the street, that she was doing much better. "I know why," she told me. She had hidden from me, and from herself, that all along Charlotte's stepfather had been physically and emotionally abusing her. Only now, with this story brought to light, could she begin to heal.

Missing from treatment of this girl was not knowledge of brain science, but time for listening.  In 30-minute visits every three months, with Charlotte and Jennifer together in the room, neither she nor her mother felt safe enough to share what was really going on.

The week between Rosh Hashannah, the days of Awe, and Yom Kippur, the day of Atonement, seems an appropriate occasion for contemplating these issues. It offers an opportunity for awe at the wonder of the human mind. It might also offer opportunity to atone for not listening to children like Charlotte. When we make diagnoses, and use brain scans to verify them, we may miss the complexity of human experience. The essence of being human is the ability to find meaning in behavior. I hope that going forward, we can protect space and time to listen, to discover that meaning. We are not likely to find it on a brain scan.

Tuesday, September 9, 2014

Postpartum Mental Illness: Ability to Soothe Baby Helps Mothers Most

Fascinating research at the Yale School of Medicine shows that in poor families who are under-resourced and overburdened (a more meaningful phrase replacing "high-risk,") "diaper need" or lack of reliable access to clean diapers, is the factor that most impacts on mothers' mental health. In a study published in Pediatrics, lead researcher Megan Smith found that 30% of mothers living in poverty report diaper need.

When mothers were worried about when they would be able to get the next diaper, self esteem was diminished in the face of their inability to soothe their baby, in turn negatively impacting their relationship with their baby, setting the stage for a downward spiral.

One take home message of this research is the importance of providing clean diapers. The National Diaper Bank Network, along with many local organizations, is making efforts to meet this significant need.

A second broader implication is the remarkable finding of how much the baby's well being impacts on the mother's mental health.

The converse of the finding that diaper need negatively impacts a mother's mental health, is that reliable access to clean diapers can improve a mother's mental health.

Generalizing this observation to a broader population of mothers with mental illness, the ability to soothe a baby, to take care of a baby's basic needs, may be integral to that mother's emotional well being. For that reason, the baby's behavior, including excessive crying, feeding issues, sleep issues should be an integral part of treatment of postpartum mental illness.

Traditionally treatment of postpartum depression focuses on the mother, often in the form of medication, but also support groups and psychotherapy. The baby's behavior is addressed separately, usually by a pediatrician. Innovative programs such as the Infant Behavior, Cry and Sleep clinic in Rhode Island explore the relational nature of these problems.

In a recent talk at the Austen Riggs Center Smith described a brochure addressing the question that many mothers ask- how can I prevent my baby from experiencing the effects of mental illness? Much of Smith's audience laughed at the brochures recommendations: "establish good relationships," reduce conflict," help with anxiety."

For families struggling to obtain life's basic necessities, these suggestions are laughable but certainly not funny. But for any family where a mother is struggling with mental illness, these goals may be unattainable without significant help.

In the new MCPAP for Moms program, a statewide initiative to improve identification and treatment for mothers who are struggling with perinatal emotional complications, efforts are being made to incorporate treatment of the mother and infant together.  Supporting a mother's efforts to effectively soothe and feed her baby by helping her to make sense of her baby's unique qualities and communications, is an integral part of preventing the negative impact of maternal mental illness on child development. A positive cycle of interaction can be set in place. This innovative research on diaper need offers evidence for the wisdom of this direction.