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, March 25, 2017

Did Mothers Save the Affordable Care Act?

In striking contrast to the happenings in the US congress on Thursday afternoon, Kate Middleton, future queen of England, spoke these words at London's Royal College of Obstetricians and Gynecologists on the occasion of a launch of educational films dealing with maternal mental health:
Nothing can really prepare you for you the sheer overwhelming experience of what it means to become a mother, It is full of complex emotions of joy, exhaustion, love and worry all mixed together. Your fundamental identity changes overnight. You go from thinking of yourself as primarily an individual, to suddenly being a mother, first and foremost.
Her normalization of the struggles of this transition, heightened by absence of the kind of support she acknowledges she, unlike many mothers, has in abundance, provided exactly what is needed to decrease stigma and shame. 

When after a tense day on Friday the House had to admit defeat and pull legislation to repeal the Affordable Care Act, it occurred to me that perhaps the late removal of 10 essential health benefits, including maternity and mental health care, done to appease the conservative Freedom Caucus, in fact contributed to the final demise of the American Health Care Act. 

Both maternity care and mental health care are exactly what we need in abundance to turn our country around. In his highly acclaimed book Hillbilly Elegy J.D. Vance comes to the conclusion that the problems afflicting the communities who feel unheard and unrecognized, and so voted in large numbers for President Trump, have their roots in Adverse Childhood Experiences

When parents feel heard and supported, they are available to be present with their children in a way that promotes healthy development, both physical and emotional. In contrast, when parents struggle- with things such as mental illness, substance abuse, marital conflict and domestic violence-it impacts upon their children's growing bodies and brains in ways that have long-term negative consequences. 

In my rural community in Western Massachusetts, we are bringing together clinicians who work with newborns and parents-including pediatricians, maternity nurses, early intervention specialists and home visitors- to insure that all babies and parents feel heard and supported from the moment of birth. An abundance of scientific evidence shows us that investment in the earliest days and weeks of life offers the greatest opportunity to promote development and prevent transmission of trauma to the next generation. 

I recognize that the politics are complicated. However, the idea that perhaps members of Congress, all of whom have mothers, could not bring themselves to vote against mothers in such an explicit way gives me hope. 

Perhaps we needed to come face-to-face with the importance of maternal and mental health care in a dramatic, high profile, and potentially dangerous way. Now that we are here, I am hopeful that momentum will move us forward to address this issue in ways that are broad and far-reaching. Kate Middleton, and her program Heads Together, serves as an excellent model.



Sunday, March 5, 2017

Rethinking Sensory Sensitivities: Why Music is Therapy



Towards the end of  our 2 day visit with neuroscientist Stephen Porges at the University of Massachusetts Boston Infant-Parent Mental Health program,  I asked about a young girl I treated a number of years ago with selective mutism.  Her parents described how during a large family gathering  she would shut down. But if they listened to classical music, she would join the gathering and begin to speak. This story, he replied, represents his theory in action.

In my 30 years practicing general and behavioral pediatrics and now specializing in early childhood mental health, I have increasingly come to recognize the central role of sensory processing in healthy emotional development. When I listen carefully to stories of parents, whether the child is 18 months, 5 years or even 17 years, with concerns ranging from a fussy baby, attention problems, behaviors associate with autism, anxiety, and explosive behavior, I invariably discover behaviors  suggestive of sensory processing sensitivities. A child could not ride in the car without screaming unless the same song was played over and over again. A visit to a butterfly museum ended in a meltdown as a child longed to have a butterfly land on his shirt but yet fell apart when it did. A newborn became completely disorganized and unable to feed when his father sneezed. These details I have collected over the years could fill several books.

Many have wondered about the central role of sensory processing in behaviors or "symptoms" we name as psychiatric disorders. Occupational therapy as a discipline has called for recognition of "Sensory Integration Disorder." Child psychiatrist Stanley Greenspan called attention to the way sensory  and affective experience are intimately intertwined.

In those two days, however, Stephen Porges fundamentally transformed my understanding of sensory processing and its role in emotional and behavioral disturbances.

The bones of the middle ear, it turns out, are a direct entry point, via the autonomic nervous system, to our social engagement system. He described how mammals are different from reptiles because two of these tiny bones are detached, allowing us to hear the low amplitude, high frequency sounds of the human voice.

Proper functioning of the middle ear muscles, along with the muscles of the face, particularly around the eyes, as well as the larynx that control intonation and prosody of voice, is essential for social engagement. When the way we take in sound is distorted, it disrupts the entire autonomic nervous system, interfering with this social engagement system.

Underlying this conceptualization is the Polyvagal Theory, founded on decades of detailed neurophysiology research. (The theory is very complex: I attempt to explain it more fully in my recently released book The Developmental Science of Early Childhood.)

Essentially Porges discovered that rather than the simple either-or of social engagement or fight flight, there is a third way that our body responds to the environment when we experience overwhelming threat. This response is under the influence of what he terms the "primitive vagus" and is closer in function to the reptilian brain.

When my patient with selective mutism listens to classical music, the sense of threat she is experiencing in the environment, that is paralyzing her social engagement system, subsides.

Porges has developed a model of treatment called The Safe and Sound Protocol, with body of evidence to support its efficacy in treating a range of difficulties. It is described as a "non-invasive intervention involves listening to music that has been processed specifically to retune the nervous system (regulating state) to introduce a sense of safety and the ability to socially engage."


Porges is calling on us to rethink static categories of "disorders" and rather to recognize the wide range of disturbances of emotion and behavior as distortions of the social engagement system via distortions in function of the autonomic nervous system. With this conceptualization, listening to music could be the primary treatment.

While Porges' theory and research resonate deeply with my clinical work, my profound understanding of his ideas actually comes from my son, who has given me permission to write about him. Sitting in a car in the parking lot with the windows closed while the rest of the family enjoyed fireworks, running in circles and not engaging with other children in preschool, gagging on foods other than the narrow range he could tolerate- these typical examples represent his early years. 

Unaware of Porges' theory, my son found his own treatment. In toy stores only the musical instruments interested him. At the age of 8 he took up the saxophone. His beautiful voice transformed to a deep bass in his adolescent years. Now in college, he performs regularly in two singing groups who are like second families.  Thriving academically,  his social engagement system is working. 

It is not often that someone comes along and profoundly alters the way we understand the world. In my view, Stephen Porges is one such person.