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, February 13, 2015

The Place of Love in Child Therapy



4-year-old Ella climbed on to the couch, into Susan’s lap, wrapping her arms tightly around her mother as Susan lovingly stroked her hair. They sat together in quiet loving embrace before beginning to pick up the toys, as the hour-long visit was coming to an end.

Weeks earlier Susan had wept in my office in anger and frustration. “She never listens,” preceded descriptions of explosive scenes where Ella kicked her mother, and Susan, in a haze of agitation, grabbed her daughter by the shoulders and shook her. At this visit, while Ella played quietly on the floor, Susan described a scene when Ella had told her mother, “I get so sad when you yell at me.” Susan now spoke, both to me and to her daughter, about how they were both having a hard time. Susan understood that just as she was feeling out-of-control in those moments, Ella was similarly stressed, and needed help from her mother in managing her intense feelings. This new understanding led to the moment of loving connection.

At the end of her graphic memoir, Are You My Mother?, Alison Bechdel describes a scene from a well-known case of psychoanalyst D.W.Winnicott., The Piggle. Winnicott sits on the floor with his little patient, Gabrielle, with whom he had worked for almost three years, starting when she was two. “I know you are really shy, “Winnicott says, ”and what you really want to tell me is that you love me.” He writes, “She was very positive in her gesture of assent."

Bechdel, in her last session with her own therapist, who during the course of their years of work together had gotten analytic training, has a similar experience. Her therapist says, “A lot of what we’ve done here has to do with love.” And then, “I know that you love me.” Bechdel sits quietly for a frame, and then says, “I … I do. I love you.”

Ours is a culture of advice. When parents come to me with their young children, they implore me to “tell me what to do.”  Recently I was interviewed on the radio by a child psychiatrist at a well-known New York teaching hospital. He told me that he had written a manual of “parent training” that offers “behavioral tools.” He claimed that when parents struggle with their child’s behavior it is because they “haven’t been taught” and they “don’t know what to do.”

I told him that I begged to disagree. Instead, I adhere to the wisdom of Winnicott, who wrote, “ No theory is acceptable that does not allow for the fact that mothers have always performed this essential function well enough.” As with Susan and Ella, problems occur when parents, for a range of reasons, sometimes including a child’s innate temperament, are stressed, and lose touch with their natural intuition.

Classical psychoanalytic theory supported work with an analyst alone with the child, even as young as two. Contemporary developmental science, with abundant evidence showing that the brain grows in relationships, offers a different perspective. While much of the conceptual framework of a discipline known as infant mental health is founded in psychoanalytic thinking, with the relationship
 being central to growth and healing, it offers a different model of treatment.

In the case of the Piggle,  her mother stayed home, a train ride away, with her new baby while Gabrielle traveled with her father to meet with Winnicott. In contrast, this relatively new and growing discipline of infant mental health supports working with parent and child together. While the brain can change in relationships throughout the lifespan, working with parent and child in the earliest years of life offers the greatest opportunity for change, as the brain is most rapidly growing.

In adult therapy, expressions of love, by the patient for the therapist, can be transformative and healing. But the aim is different when working with young children. As with Susan and Ella, the aim is not for the patient to express love for the therapist, but rather for the child and parent to be re-connected in love.


As Valentine’s Day approaches, I think of the deep transformative feelings of love that occurred during the visit with Ella and her mother.  It occurs to me that the work I do, along with my colleagues in the field of infant mental health, is neither parent training nor classic psychoanalysis. It is about facilitating, in the words of Simon and Garfunkel, a mother and child reunion.

Monday, February 2, 2015

Vaccination, Parenting, and the Specter of Unbearable Loss

As the measles outbreak gathers worrisome steam in parallel to the explosion of passionate rants both pro and anti-vaccination, I find myself wondering; what is this really about? Rather than get bogged down in the myriad of issues on either side- though at the outset I will say that as a pediatrician I unequivocally recommend vaccination- I will aim to look at the bigger picture.

Is this issue really about trying to have control in a situation where we as parents do not have control? Is it an effort to deny the fact that when we become parents, we make ourselves vulnerable to the unlikely but real possibility of unbearable loss?

The intensity of the rage, strikingly evident in a blog post by a cardiologist opposing vaccination, makes me wonder if this is really all about something else. Perhaps beneath all the vitriol is really fear of loss. 

As a culture, we are not good at dealing with loss.  The myriad of baby monitoring devices exploding on to the market, offer a kind of illusion of control, are an example of this phenomenon. Putting a baby to sleep on his back will do more to insure his safety than any commercial monitoring device, none of which are indicated for medical reasons. 

The defining of grief as an illness offers yet another example. The latest version of the DSM eliminated what is called the "bereavement exclusion." What this translates to clinically is that if a person has depressive symptoms for over two weeks following a loss, he can be diagnosed with major depressive disorder. 

In contrast to this cultural denial of loss, Buddhism embraces suffering and loss as a normal part of living. Buddhist Thich Nhat Hahn writes
If there is someone capable of sitting calmly and listening with his or her heart for one hour, the other person will feel great relief from his suffering. If you suffer so much and no one has been able to listen to your suffering, your suffering will remain there. But if someone is able to listen to you and understand you, you will feel relief after one hour of being together…. That is called compassionate listening. 
I wonder if the mess we are in is in part due to our devaluing of space and time for listening, for holding through pain and loss. 

There is deep fear on the part of parents on both sides of the vaccine argument. Those against vaccination fear harm by the vaccine. Those in favor fear for their child's exposure to disease.

Science is clearly on the side of vaccination. Measles is a highly contagious illness. Before vaccination became widespread in the early 1960’s, hundreds died every year from the disease. There is massive scientific evidence discrediting the claim that MMR vaccine causes autism. Yet here we are, on the cusp of what may prove to be a major public health crisis.

Could making space for loss have averted this crisis? Loss is an inevitable part of parenting- when we put our child to bed in his own crib for the first time, when he gets on the bus to go to Kindergarten, when he gets his license and takes that first drive on his own out the driveway. If as parents we felt safe enough, held enough, to acknowledge this idea, would we let go of a desperate need for control in a situation where we really don’t have control?

If so, perhaps we could recognize that vaccination is not about our individual child. It is about being a responsible citizen.