First in Gun Violence, Last in Paid Maternity Leave: Is There A Link?

In his remarks in the wake of the Charleston shootings, President Obama said, "At some point, we as a country will have to reckon with the fact that this type of mass violence does not happen in other advanced countries." 

When reading a recent article about Dylann Roof's early life history, I immediately thought of the Center for Disease Control (CDC) study on adverse childhood experiences (ACE.)   A massive long-term study, it provides extensive evidence that exposure to adverse childhood experiences, including not only frank abuse, but also such things as neglect, domestic violence, divorce, parental mental illness and substance abuse, dramatically increases the risk of a wide range of health problems both mental and physical. The study is located on the CDC website under a section entitled "Division of Violence Prevention."

 While I only know what I read in the paper, it seems that Roof had a very difficult childhood, with possible exposure to domestic violence. His step grandmother suggests that his parents may not have been available, either physically or emotionally, to care for him. She also indicates that he developed obsessive-compulsive behavior as a young child. In my experience with many young children with similar symptoms, this behavior often represents a solution to a problem, a way to manage overwhelming anxiety and emotional distress. 

Who was listening to this young child and family when things began to unravel? Who took the time to understand the source of his increasingly troubled behavior? Is it possible that he was drawn to the white supremacist group as a way of finding a family? Was it a place where he could be heard when no one was listening?

The United States is the only industrialized nation in the world without government supported paid maternity leave. This statistic reflects a lack of value of parents and young children. In stark contrast, in Finland, every new parent receives a “baby box” filled with clothes, diapers and other assorted baby needs. When the box is empty, it often serves as the baby’s first bed. While the items themselves are useful, the meaning of this box is of greater significance. It says “our society places value on new parents and babies.” Could there be link between the amount of violence in our country, in contrast to other developed countries, and the lack of support for young children and families?

Certainly the conversation about racism, and why such groups even exist, is critical. But going back to Roof's childhood may lead to the answer to the question President Obama raised. As the CDC wisely recognizes, supporting young children and families, and devoting resources early, before these adverse experiences can exert their harmful effects on the body, brain and mind, goes  under the heading of "prevention of violence." Paid parental leave, and with it a shift towards valuing young children and families, may be a necessary first step. 

Teen Bipolar Disorder and the Abnormal Brain: What Does the New Research Mean?

Two glaring omissions stand out in the recent widely publicized Yale study, titled in the Yale News  "Adolescent Brains Develop differently in Bipolar Disorder." Using MRI to compare a group of teens with the diagnosis of bipolar disorder according to DSM criteria with a group that did not have this disorder, they found volume decrease in the area of the brain cortex known to be involved in emotional regulation. 

The first omission is any mention of the possible effects of medication. While the newsletter does not even mention medication, the study itself does say that the teens carrying the bipolar were on medication but that "medication was not systematically studied." The long-term effects of psychiatric medication are unknown. A  study in the Archives of General Psychiatry suggested that one of group of drugs, the atypical antipsychotics, which are often used to treat bipolar disorder, may themselves be linked to decreased brain volume. 

But perhaps the more glaring omission is anything about the early history, or life story, of these teenagers. 

Elegant and compelling research by Harvard psychiatrist Martin Teicher and colleagues demonstrates that mental illness in the setting of what they term “maltreatment” is a very different entity, in terms of course of illness, response to stress, brain structure and gene expression, than the same DSM named “disorders” in the absence of these experiences.

Maltreatment is broadly defined as being “characterized by sustained or repeated exposure to events that usually involve a betrayal of trust.” 

It includes not only physical and sexual abuse, but also emotional abuse, including exposure to domestic violence, humiliation and shaming, as well as emotional and physical neglect. The incidence of childhood maltreatment ranges from about 14% in one-year prevalence to 42% in retrospective reviews covering the full 18 years of childhood.

The way maltreatment is defined has great significance in the way we think about the connection between childhood experiences and adult mental illness. The word “trauma” itself may convey a kind of “not me” response, but when the term is defined in this way, we see that these experiences are, in fact, ubiquitous.

This research shows that it is meaningless to talk about mental health disorders, as defined by the DSM system, without knowledge of this early life experience.

But perhaps more importantly, the language we use has great implication for treatment. The Yale study authors recognize that the brain is “plastic” so prevention is possible. But without recognizing the role of early life experience in development of the brain abnormalities, the treatment might very well end up being a drug.  Broadening our understanding of the cause of the brain abnormalities, as Teicher’s work demonstrates,  shows that true prevention lies in supporting young families, and intervening early in families where children are at risk for experiencing maltreatment.

Teicher recommends starting with the way we name these disorders:

We propose using the term ecophenotype to delineate these psychiatric conditions. We specifically recommend, as a first step, adding the specifier “with maltreatment history” or “with early life stress” to the disorders discussed here so that these populations can be studied separately or stratified within samples. This will lead to a richer understanding of differences in clinical presentation, genetic underpinnings, biological correlates, treatment response, and outcomes.

The Yale study, tellingly published in the journal “Biological Psychiatry” gives the impression that these “disorders” are biological in the way that, to use a frequent comparison, diabetes is. This view is a disservice to our humanity; to the way our lives have meaning because of our relationships with others and the stories we tell. The first and critical step in prevention of “bipolar disorder” is to recognize that these stories exist, and to make space and time to hear them.