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, June 17, 2016

Autism and Neuroscience Research: A Public Health Perspective

I vividly recall the emotional pain of a new mother in my pediatric practice many years ago as she described the stress she experienced bringing her infant son to meet her colleagues in her office. He screamed inconsolably the entire time. She was similarly unable to take him to social events, observing with deep envy the easy social interaction of other parents with their children. The low level depression she had struggled with much of her life returned in full force. Her son was later diagnosed with autism. 
Many parents of children subsequently diagnosed with autism describe this agonizing absence of the easy give-and-take they observe between other parents and their infants. A recent article,  An Integrative Model of Autism Spectrum Disorder by psychoanalyst William Singletary explores the latest research in neuroscience, genetics, and developmental psychology showing how this stressful experience of disconnection, while originally attributable to neurobiological vulnerabilities in the infant, itself plays a significant role in development of the disorder.  
It makes sense that my little patient too was stressed, but had limited ways of communicating his distress. Just as his mother was stressed and even depressed by the lack of intimacy with her child, so was this little boy likely stressed by the difficulty connecting. Evidence suggests that this disconnect may be at least in part due to variations in brain pathways responsible for sensory processing. Research shows that the stress of the disconnect itself may continue to exert a negative effect on the developing brain. 
Whenever we enter in to the realm of the infant-parent relationship in discussion of autism, there is a risk of echoes of the devastating "refrigerator mother" theory that placed blame for the disorder squarely on the mother. Research into the genetic and neurobiological underpinnings of autism offers evidence of the fallacy of this theory.  
Singletary identifies the significance of the relationship in a way that is healing rather than blaming.  Evidence of the brain's neuroplasticity shows us that by focusing on supporting the relationship, thus decreasing the stressful experience of lack of connection on the part of both parent and child, we may help to prevent progression and even reverse the genetic and structural brain abnormalities.
 The article addresses in depth a number of evidence-based treatments of autism that support parent-child relationship in this way, including the Early Start Denver ModelSingletary also offers case material from his psychoanalytic practice, explaining that his intensive treatment offers insight into the inner emotional life of the child with autism.  He finds evidence of the stress these children experience from the social isolation that results from their biological vulnerabilities. 
Reading his article, I found myself thinking about that mother and son so many years ago in my pediatric practice, and what I might have been able to do to help them.  Another article about a program in a pediatric practice in the Bronx offers an answer.
What if we had the opportunity to support all stressed parents and infants in the early weeks and months of life, when the brain is most plastic? The central issue is the absence of connection, made all the more painful with the cultural expectation that this should be a time of bliss and joy. Autism is but one cause of this loss of connection. 
The Bronx program integrates the Healthy Steps model in to a pediatric practice. When a pediatrician identifies a stressed parent-child pair, she asks her colleague down the hall to come and meet the family. A recent news article about the program describes a case of a young mother struggling with her two-year-old daughter around eating. The pediatrician, in her 15-minute visit, identifies the problem: 
It’s time to bring in an expert of childhood mental health. So Castalnuovo brings in Rahil Briggs, the child psychologist and introduces her personally to this family. It’s what’s called a “warm hand off” and makes it more likely they will actually see someone instead of disappearing down the rabbit hole of outside referrals.
A wide range of troubling behaviors that we see in young children are both cause and result of stressed relationships. When these issues can be addressed early we support healthy development of the rapidly growing brain.
If I had known what I know now, and had such a person in my office (thanks in part to the UMass Boston Infant-Parent Mental Health program I could now be that person), I might have said to that young mother, "I see that you are really struggling. I wonder if it might be helpful to take some time to make sense of this problem. My colleague down the the hall knows all about helping young children and their parents. Let me introduce you to her."
Would I have been able to change this course of that family's life? I don't know. But all the best science of our time suggests that the answer might be yes. 
The Healthy Steps model is not specifically about identification and treatment of autism. But it is one example of taking a broad public health approach to supporting early parent-child relationships.
If we are going to make a dent in the exponential rise in autism and other so-called mental health disorders in children, such a public health perspective is necessary. As I describe in my new book,The Silenced Child: From Labels, Medications, and Quick-Fix Solutions to Listening, Growth, and Lifelong Resilience, we need to look broadly at the way our culture supports, and fails to support, parents and children.  Paid parental leave programs and fostering a culture of postpartum care that recognizes the normal disorganization of the transition to parenthood are other examples of initiatives that offer opportunity to change the situation in significant ways. 
When we support these early relationships, intervening in situations of stress before things begin to derail, we have the opportunity to set development on a healthy path-at the level of behavior, genes and brains- for all children.


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