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, November 22, 2014

Lessons from Adam Lanza: Listen Early and Listen Well

The just released report, Shooting at Sandy Hook Elementary School, from Connecticut's Office of the Child Advocate offers a searing account of the holes in our mental health care system. The report is careful to point out that no causative link exists between their findings and the events at Sandy Hook. However, this in-depth investigation offers an opportunity, if we are able to hear and take action on its recommendations, to begin to fix a system that without significant attention may lead to an ever growing epidemic of serious mental illness.

I highlight 4 key points addressed in the 114-page report:

1) Early means early.

When significant problems in social-emotional development are identified, the greatest investment of resources ideally should come well before age three. In this time period, when the brain is rapidly growing and changing,  opportunity exists to set development on a healthier path. The report states:
A review of information regarding AL’s early years with his family does not reveal any profound tragedies or traumas. However, records clearly indicate the presence of developmental challenges and opportunities to maximize therapeutic and intensive early intervention. These observations underscore the importance of parental and pediatric vigilance regarding children’s developmental well-being. AL was referred for early intervention late in his toddler years, when he was almost three. By this time, he presented with several developmental challenges, including significant speech and language delays, sensory integration challenges, motor difficulties, and perseverative behaviors.
I would also like to highlight the report's important statement:" Research-based intervention to support improved sensory processing through occupational therapy is a critical service for these children."

2) The problem is located not exclusively in the child, but in parent-child relationships.

The report describes significant ongoing marital conflict, with Adam's father described as a "weekend father" who was not involved in the emotional lives of his children. There is evidence that Adam's mother might have had significant emotional illness. She was preoccupied with her own health and mortality despite the fact that her doctors reports do not show signs of physical illness.  While these findings do not represent " profound tragedies or traumas," the story is one of a biologically vulnerable child with two parents preoccupied and emotionally unavailable.

When a problem is placed squarely in a child,  the relational nature of these problems may be missed. Perhaps by addressing the issues in the marriage and the mother's mental health, room could have been made in their minds for thinking about the meaning of Adam's increasingly disturbed behavior.

3) Need for collaborative care with adequate reimbursement. The report states:
Pediatricians’ offices must have resources to conduct comprehensive and ongoing
developmental and behavioral health screening for youth, with appropriate reimbursement strategies to support this work.
 Children and their families should have access to quality care coordination, often reserved only for children with complex medical needs, but beneficial for children with developmental challenges and mental health concerns. Care coordination should facilitate more effective information-sharing between medical, community, and educational providers.
When people are stressed and vulnerable, they will share what is important only when they feel safe. Parents may experience terrible shame in the face of a child who is struggling and a marriage that is collapsing. Clinicians need to be reimbursed for time spent listening to parents. Time spent in coordination of care, a critical part of comprehensive treatment, also should be reimbursed.

4) Listening, not placing blame, will lead to meaningful change.

The report concludes by emphasizing that it "in no way blames parents, educators or mental health professionals for AL's heinous acts." I remain hopeful that blame can stay out of the conversation. Already media coverage has focused on the one adversarial aspect of the report that suggests the school "appeased" his mother, perhaps because she was white and wealthy.

All the accumulated evidence points to extreme suffering in the Lanza home over many years; suffering that went unheard and unrecognized. Blaming the school or the mother is not only unhelpful but also diverts attention from the critically important recommendations in this report.

 We are in the midst of an epidemic of violence and mental illness. The recommendations, particularly those I have outlined above, may offer a way off that path. I hope that those in a position to effect these changes will be open to listening. If this comprehensive report can be used to make substantive changes in the education, health care and mental health care systems, then some meaning may be found in the senseless, tragic loss of life at Sandy Hook.

Tuesday, November 11, 2014

ADHD: The Role of Curiosity

3-year-old Cara smiles impishly in to the camera.” You see she’s standing on the kitchen table,” her proud yet concerned grandmother, my dental hygienist, Anne, says to me. She explains that Cara was standing on the table because she never listens, and runs away when her mother tries to take her picture.

She knows that I am a pediatrician and “expert” in behavior problems, so, after showing me the picture, as she cleans my teeth she shares with me that her granddaughter might have ADHD. “She won’t sit in the circle with the other kids for the whole story time. They’ve started an evaluation.”

I nod in shared concern while she works on my teeth, and she goes on. She’s known me for many years, so the conversation flows easily. “It’s hard,” she says, “because Mindy (her daughter) just broke up with her boyfriend. “So she’s a single Mom, “ I say after a rinse. “Yes, and she works nights and lets Cara stay up til 11 so she can be with her.” At the next pause I comment, “So Cara must be tired in school. That can lead to problems of attention.” As Cara’s grandmother resumes her work on my mouth, she agrees. Then she goes on to explain that Cara is the youngest in her class of mostly 4-year-olds.  She begins to wonder if all of these things she is telling me might be related to the problems Cara is having in school. Her tone shifts.

“She’s just so engaged and curious,” Anne explains. “Maybe we need to channel that energy and help her to find ways to use it in a positive way.” Then she reflects, “Actually Mindy was like that as a child. She was so smart that she got bored in class and sometimes got in to trouble. But after some struggles during those years she found her way.” She tells me that Mindy is passionate about her work as a neonatal nurse.

During my visit I feel a shift in Anne’s thinking. Simply by talking with me, a captive audience with whom she has a longstanding relationship, she goes from describing her granddaughter in terms of “disorders” and “evaluations” to a stance of curiosity.

As we both stand to schedule our next appointment, Anne again looks at the impish face of her granddaughter, trapped on the kitchen table. She sees the picture, cute as it is, as a kind of sign that things may feel out-of-control for Cara. She even begins to wonder if her daughter is too stressed, and perhaps needs more help from her. Maybe, she says, if Mindy had a bit of time to herself, she could be more patient with Cara. She decides to offer her daughter a day of babysitting.


Recent statistics indicate that diagnosis of ADHD has increased 42% in the past 8 years. 3-year-old Cara might be on her way to joining that statistic. I am hopeful that the system of care will offer space and time to listen to the whole story. When her grandmother was able to wonder about the meaning of that photo, Cara’s communication, in the form of behavior, was understood. Being heard and recognized in this way gives Cara the opportunity to become not another statistic, but instead to develop in to her own true self.