Child in Mind

Diagnosing vs Careful Listening

2012-01-27T07:44:00.021-05:00

"A diagnosis tells that there is a reason for that other than that they are bad."

This quote is from a blog post written in criticism of my most recent post about the controversy over the autism diagnosis. The intense and widely varied response to that post has prompted me to further explore this complex and highly emotionally charged issue.

The wish to be recognized and understood by those who love us is an essential human quality. We want to have our experience validated. In my work with parents, my main objective is to listen and validate their experience, with the hope that they will be more free to do the same for their child. For parents whose child is struggling in a variety of ways, a diagnosis may say to them "You are not a bad parent." In this way, I understand that a diagnosis is of value.

Speaking from the child's perspective, there is a similar wish to have his experience validated and understood. When, in that previous post, I describe an occupational therapist "giving words to his experience' I did not mean teaching the child to talk. I meant literally giving words to his experience, as in saying "I know its hard for you when its so loud and other kids are too close to you." This kind of giving voice can go a long way in helping a child make sense of his experience. The aim is to avoid having him feel that there is something "wrong with him."

The same blog post goes on to say:

"Dr. Gold simply does not understand that autism is not a psychiatric disorder."

It took me some time to wrap my mind around this criticism. The autism diagnosis or preschool depression or any other psychiatric diagnoses are in the DSM, the Diagnostic and Statistical Manual of Mental Disorders (italics mine.) In essence, you can't have a diagnosis without having a disorder, because it is by definition a diagnosis of a disorder.

So the question becomes: Can we validate a child's or a parent's experience, recognize that there is nothing "wrong with him," that his experiences are "real", without giving it a label?

Psychotherapists run in to a similar challenge when they work with adults whose primary caregivers had significant depression. These adults have often, over the years, internalized a sense that they are bad, that there is something wrong with them. Helping them to recognize that their caregiver was in some way emotionally unavailable to them can validate their experience. It can be enormously helpful in shaking that crippling sense of being damaged in some way. In this setting, the "diagnosis" may only be relevant for the insurance company, and has no real meaning in terms of helping the person to feel better about himself.

While I don't have an answer to this dilemma, I do, thanks to the responses of my readers, have a clearer sense of what the problem is. We don't listen to each other enough. Careful listening, and with that the ability to understand another perspective, is one of the qualities that makes us human. Cultivating this skill will be good for everyone.

The Autism Label Controversy: A Child's View

2012-01-22T07:15:00.033-05:00

Child's voice. " I am very smart and tuned in to everything happening around me. I get overwhelmed when there are a lot of people. I love music, but I hear every sound so intensely that I need to cover my ears. Sometimes I run around in circles to help myself calm down. When grown-ups make me go somewhere that is too loud or confusing, I lie down on the floor and scream. When people get too close I cant' stand it. Sometimes I hit the other kids when this happens and now I can't go to preschool. My parents fight all the time about what to do about my difficult behavior. My little sister is very quiet because she knows to get out of the way when I am having trouble"

Adult's voice. "He has Autism"

Certainly this child and his family need help. An occupational therapist consulting in the school setting would be able to help this child give words to his experience. She could support both the teachers' efforts to understand what environments are challenging and how to manage these challenges. She might even recommend a different school setting that is more compatible. A therapist working with parents and child together would similarly help them as a family to manage this child's unique biological vulnerabilities.

If the proposed changes to the diagnostic criteria for autism in DSM V, the newest version of Diagnostic and Statistical Manual of Mental Disorders, result in children like this not getting the help they need, as a recent article in the New York Times suggests, it will be a terrible loss for these families. It will result in increased costs to society when these unaddressed problems grow into bigger problems in later childhood and adulthood, as they inevitably will.

This fear was expressed by Lori Shery, president of the Asperger Syndrome Education Network, when she was quoted in the article saying “If clinicians say, ‘These kids don’t fit the criteria for an autism spectrum diagnosis,’ they are not going to get the supports and services they need, and they’re going to experience failure."

But the real question is this: Why have we created a health care system where the insurance industry, a for-profit business, is allowed to dictate our children's experience in this way?

The need for a diagnosis is primarily driven by the health insurance industry. Clinicians need to have something to bill for, so that services are "covered.". " As I state in my book Keeping Your Child in Mind," [This] is a dangerous example of the tail wagging the dog."

From the young child's perspective, there is a significant downside to receiving such a label. As my book states:

Parents who receive a label of a major psychiatric diagnosis for their child inevitably go through a period of mourning. The child they had is gone and has been replaced by a child with a “disorder.” As D. W. Winnicott so wisely observed, a child develops a healthy sense of self when the people who care for him recognize the meaning of his behavior, rather than substituting their own adult meaning. Parents often begin to regard behaviors as “symptoms” of the “disorder.” For a very young child whose development is unfolding, his “true self” might be lost in the face of such a frightening label. It is my hope that we can move from an emphasis on diagnosis and labeling to an emphasis on prevention. We need to ask not “what is the disorder?” but rather, “what is the experience of this particular child and family?” and “what can we do to move things in a better direction?”

From a young child's perspective, the diagnosis with a psychiatric disorder reduces the complexity of his experience to a label that by its very nature indicates that there is something "wrong with him."

I had a similar discussion with a child psychiatrist who is advocating for the diagnosis of "preschool depression." Certainly young children can struggle with disturbances of mood, and, as is the case with the above child, these families need help, and early intervention is essential to prevent more significant and deeply entrenched difficulties.

But as is the case with the diagnosis of autism, the diagnosis of depression in a young child reduces the complexity of his experience to a disorder, and clearly locates the problem within the child. Often there is a complex interaction between the child's unique biological vulnerabilities and his environment. Qualities that are problems in early childhood may, with the right help, be transformed into adaptive assets as he grows up.

In a previous post I wrote about a new book, Childism, that calls attention to a kind of prejudice against children that exists in our culture. In a sense this kind of labeling can be seen as a manifestation of that prejudice.

Many parents of children with the diagnosis of autism object to my perspective, describing relief that the things they were struggling with had a name. But what if teachers, friends, grandparents, and clinicians were respectful of their struggles and provided help without having to burden their child with a "disorder?" I suspect that these same parents would prefer the latter scenario.

By focusing the discussion on the question: "what are the diagnostic criteria for autism,", we are failing to see the forest for the trees. The real question is "Why are we as a society willing to give the insurance industry so much control over our children's lives?"

Mothers, Babies, Psychoanalysts, Pediatricians

2012-01-16T07:23:00.015-05:00

For many people the word "psychoanalyst" conjures up an image of a man sitting silent behind a patient lying on a couch. In stark contrast to this image, the National Meeting of the American Psychoanalytic Association(APsAA) this past week prominently featured women analysts presenting their work with mothers and infants.

Among the most striking presentations was a pair of videos shown as part of the main research symposium by Nancy Suchman, PhD of the Yale Child Study Center. Substance abusing mothers who had histories of significant emotional trauma received an intervention that specifically aimed to listen to the mother and support her efforts to listen to her child. This is known as "mentalization based therapy." In my book Keeping Your Child in Mind, I show what mentalization, or holding a child's mind in mind, looks like in everyday parenting moments as well as in the clinical setting of a pediatric practice.

In the first video, before treatment, the mother was tense and angry, describing her infant's clingy behavior and night wakings as his attempts to make life difficult for her. After the 6 week intervention, she was calm and thoughtful, wondering about the meaning of her baby's behavior. She recognized how much her baby needed and loved her. In a related study, part of the Minding the Baby program at Yale, children of mothers who were similarly at risk but without the history of substance abuse received this mentalization based treatment. Their children showed fewer behavior problems, and the mothers reported less parenting stress several years after the intervention. Another researcher, Dana Shai, PhD, spoke of how a parent's ability to hold her baby in mind is reflected in her body and the way she physically interacts with her baby. This "embodied mentalization" was clear in the second video, when not only the mother's words and tone of voice were different, but her whole body was relaxed and welcoming. This was "evidence based medicine" at its best -an intervention founded on a solid conceptual framework, used in a high quality research design, demonstrating meaningful and significant improvement in developmental outcome.

When I was being interviewed on the Diane Rehm show about the new AAP guidelines regarding diagnosis of ADHD in children under age six, one of the other participants, a professor of pediatrics who clearly supported the new guidelines, identified behavior modification followed by medication as an evidence based intervention. I responded that there were in fact other quality interventions, citing the Minding the Baby program as an evidence based practice. As they had not heard of it, and didn't have any idea what I was talking about, I'm afraid my comment got lost. Here is the actual exchange.

GOLD
I want to just address this issue of behavior therapy because, again, when you start with the much younger children when they're two or three, there are a number of very well-established interventions, such as the Minding the Baby program at Yale, Circle of Security, Promoting First Relationships, that work with parents and children together to promote the ability to self regulate, which is really what ADHD is a problem of, self regulation.

So there are other forms of intervention besides behavior therapy. And, again, that kind of undermines the parents' natural authority if you give them training. But there aren't that many services. The problem is if the AAP kind of endorses medication in very young children, it will decrease the motivation to improve access to other interventions. And that's my biggest worry in very young children.

REHM
What do you think, Dr. Ostrander?

OSTRANDER
Well, I think that, you know, by far measure, the behavioral therapies tend to be the ones that has the greatest empirical support. Now, I'm not to say -- that's not to say that there are not other interventions that are not effective. But, you know, if -- what you -- it seems to me, the most prudent course is to take the medications that have the greatest demonstrated efficacy and try those first.

In another APsAA program, two psychoanalysts from the Parent-Infant Psychotherapy Program at Columbia University, Talia Hatzor and Christine Anzieu-Premmereur, described beautiful individual work with mother-baby pairs. The settings included both private practice and an early head start program, with mothers dealing with poverty and their own abuse histories. The presenters bemoaned the fact that pediatricians do not refer to them. We talked about the gap between primary care clinicians, who are seeing mothers and young infants, and the wealth of knowledge coming out of the discipline of psychoanalysis.

I have been writing about the new AAP policy statement on Early Childhood Adversity and Toxic Stress which emphasizes the need for pediatricians to intervene early to support parent-infant relationships. As I have said, the policy statement is lacking in specifics what such intervention actually looks like. After being at this meeting, it is my wish (fantasy) that there be a combined meeting of pediatricians and psychoanalysts to share experiences and ideas. I would also include health care policy makers, for to do this important work clinicians need freedom from the current restrictive environment imposed by the health insurance industry. The pediatricians (as well as other primary care clinicians) are in the right place at the right time. The psychoanalysts have a great deal to teach us about how to make use of this privileged position.

Is Our Society Prejudiced Against Children?

2012-01-10T05:49:00.010-05:00

Tears ran down Elena’s cheeks as she described being so overwhelmed and full of rage that she forcefully held her fully clothed 4-year-old son, James, under the shower when he wouldn’t go to bed. Later in the same 50-minute visit she revealed that she had suffered years of physical and emotional abuse as a child. As is typical of visits to my behavioral pediatrics practice, she had brought James because he was “defiant.” “Something must be wrong with him,” was followed by, “Tell me what to do to make him listen.” James’ preschool teachers, who were having trouble managing his behavior, had suggested that he might have attention deficit hyperactivity disorder (ADHD.) They recommended to Elena that medication be considered. They knew nothing of this history. My wish in listening to this story is not to judge, but rather to understand the experience of both mother and child.

A great tragedy of 2011 was the sudden death of Elizabeth Young-Bruehl a month before the publication of her book, Childism: Confronting Prejudice Against Children, released January 10th. Not only was this the loss of a great mind, but also the opportunity for her to represent her very important ideas, ones that are likely to cause some controversy, in public discussion.

Young-Breuhl, an analyst, political theorist and biographer, calls attention to the way human rights of children are threatened. Childism is defined as “a prejudice against children on the ground of a belief that they are property and can (or even should) be controlled, enslaved, or removed to serve adult needs.”

Elena’s story offers a microscopic view of the macroscopic phenomenon Young-Breuhl so brilliantly articulates. Following the history of the field of Child Abuse and Neglect (CAN) studies, she finds that “from the start [this field] took attention away from abusers and their motivations; and it implied that children could be helped without their abusers being helped.” Furthermore, she describes Child Protective Services (CPS) as a “rescue service-a child saving service-not a family service supporting child development generally and helping parents…” Rather than setting up a system of treatment, CPS became "an investigative service...a situation in which bad families suspected of making their children bad will be invaded and infiltrated." Young- Breuhl has empathy for both parent and child, arguing that failure to support families is a manifestation of childism.

While Young-Breuhl does not write about ADHD, such as James is believed by his teachers to have, she writes of “a childism of the sort that is now fueling an epidemic of diagnoses of bipolar II disorder and the prescription of medications to children who are, in effect, being doped into acquiescence.”

I wonder if Young-Breuhl would have considered the new American Academy of Pediatrics (AAP) guidelines recommending the diagnosis of ADHD in children under age 6 (in contrast to the previous guidelines that covered age 6-12) to be a manifestation of childism.

According to the new AAP guidelines, if a child in this age group meets diagnostic criteria for ADHD, he is first treated with “behavior management techniques” and if these fail, medication is prescribed. The guidelines do not offer opportunity to explore the meaning, or motivations, of behavior, which is often due to a combination of biological vulnerability and environmental stress. One could argue that inherent in this approach is the phenomenon of childism; the idea that children are property of adults, who have the right to control them for their own self-interest.

Rather than blaming individual parents, my aim, as Young-Breuhl does, is to call attention to the way we as a society approach problems involving children and families. For childism is a societal phenomenon. Most individual parents, given the opportunity to be heard and supported, are not childist. They long to help their children, not merely control them.

Elena, once she had the chance to tell her story, was eager to address her own trauma. She wanted to learn to regulate her emotions and help her son to manage his. She did not want to medicate away his symptoms. But getting such help is not easy. There is a severe shortage of quality mental health care services. Pediatricians are under enormous time pressures in the current system of health care, in which a practice must accommodate demands of multiple different insurance carriers. Visits are on average 10 minutes in length, not offering a chance for a clinician to listen to a story like Elena’s.

The problem of improving access to care is a political one. Young-Breuhl describes an attempt in 1970 to pass the Comprehensive Child Development Act. Its creators were accused of being “anti-family.” Young-Breuhl writes, “To this kind of childism, in which trying to ensure that parents were responsive to their children’s developmental needs was seen as anti-family, the framers and supporters of the act could not reply, “this is childism.” They lacked the concept of childism to address the root of the controversy and so remained on the defensive, trying to win a “disinformation” propaganda war. A futile project.” Current efforts to provide services for young children and families similarly come up against “family values” propaganda.

Young-Bruehl compares the situation in our country with that of comparably developed countries that have lower rates of child abuse and neglect. There, “children have a range of preventative and development-oriented services: universal health care, health services, and parent support services in homes after the birth of a child; maternal and parental leaves for infant care; developmental preschool programs; after-school programs; and economic supports of various kinds.”

Young-Breuhl wisely recognizes that “children whose development is not being supported cannot be protected.” She proposes a new Comprehensive Child Development Act. I think she would be heartened by the recent policy statement of the AAP: Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health. This policy statement seeks to use the explosion of research at the interface of neuroscience, genetics and developmental psychology to support early parent-child relationships. It is a preventive model designed to promote healthy development.

Access to care is a significant obstacle to implementation. I believe Young- Bruehl would say that childism is the reason why pediatric primary care clinicians and mental health care workers are among the lowest paid professionals. She would point to childism to explain why the health insurance industry and pharmaceutical industry have together been able to create a system where children are more likely to be medicated than listened to. She would say that medicating James (or even using "behavior management") without addressing either his mother's history of abuse or his experience of her out-of-control behavior would be a manifestation of childism.

Atthe time of her death, Young-Breuhl was in the process of editing the complete works of D.W.Winnicott, pediatrician turned psychoanalyst. His notion of the need to recognize a child's "true self" to facilitate healthy development fits seamlessly with her ideas.

Pediatrician T. Berry Brazelton, whose work is featured as an antidote to childism, endorses the book, recommending that all who are involved with children and families should read it. This book has helped me, like nothing else I've read, to understand why it is so hard to get the kind of help for children that all the best science of our time is telling us they need. I hope everyone reads it. As Young-Breuhl states, “prejudice has to be recognized in order to be overcome.”

Yoga as Treatment for Colic?

2012-01-06T06:02:00.038-05:00

Just to clarify, I mean yoga for mom, not baby. In my book, Keeping Your Child in Mind, I tell a story of a mom who was struggling with both postpartum depression and a "colicky" baby. After one visit with me, she decided to take a yoga class rather than see a therapist. At a follow-up visit a couple of weeks later, their relationship seemed totally transformed. The baby smiled at her as she joyfully told me that she felt like he "had just been born." I attributed much of the transformation to having a chance to be heard both by me and by her husband. I wonder if, in fact, the yoga had an important role to play. I've been thinking about recommending yoga as part of treatment both for colic and postpartum depression, two problems which often go together.

Recently I had the pleasure of meeting Suzanne Zeedyk, a developmental psychologist in Scotland who is kind of my counterpart in the UK. She is trying to address a large audience regarding the implications of the explosion of research and knowledge at the interface of neuroscience and developmental psychology. She's had quite a bit of success-of course its different because Scotland is a small place that has socialized medicine. The departments of education, health care and finance all seem to be listening to her. She has even gotten the cooperation of law enforcement in understanding the connection between violence prevention and supporting early-parent child relationships. In a piece from an early education blog : Early Years the Key to Reducing Violence, a detective talks about how the "Violence Reduction Unit" is supporting early years initiatives and work with parents.

So what does this have to do with yoga? Earlier this week Suzanne sent me a link to a post she had written about the importance of emotional regulation for stressed parents. She asks the question: "Is there a child protection agency out there that includes yoga as a mandatory element of their parenting programmes?" She describes the multiple demands on mothers whose children are in foster care, mothers who themselves often have a history of trauma, with nothing being offered to support their efforts at emotional regulation. But, she wisely points out, emotional regulation is perhaps the most important and most difficult task for a mother. It is through self-regulation that a parent teaches this essential skill to a child. She says:

In other words, children’s brains and bodies can only learn what self-comfort and containment feel like when they have first experienced comfort and containment in the arms of a trusted adult. If the brain does not have the opportunity to know this state, then it will not build the synaptic connections that are able to easily facilitate emotional regulation, later on in life. If a child does not have such neural pathways in place within the first few years of his/her life, then the battle to gain control of intense feelings may forever be a losing one.

A child and mother in the child protective services system is an extreme example. But when a baby has colic, or a mother is depressed, or both, this task of emotional regulation, of staying calm in the face of your child's distress, is very challenging. Perhaps yoga should also be a routine intervention in this situation.

By coincidence, I had just come back from a yoga class when I read her post. My teacher, who is now pregnant herself with her second child, teaches a yoga class for pregnant moms (this is also a great idea, especially given what we are learning about the effects of stress during pregnancy on fetal development.) She then offers these moms the chance to come to her class after the baby is born. So while doing my down-dogs I listened to a cooing baby, who looked to be about 3 months old. He happily kicked his legs while he intently watched his mother. Interestingly, whenever her head was down ( they were right in front of me so I could easily observe, and as those who read my blog know, I am a professional baby observer!)) his cooing reached a crescendo. Then when she looked up and smiled at him he became quiet and gleefully smiled back- a great example of a young infant's terrific communication skills!!

Of course yoga is not for everyone, and yoga classes are extraordinarily variable. The point is that moms, particularly under the stress of colic and/or postpartum depression, need help with their own emotional regulation. Using the body to help the brain, through yoga, martial arts, swimming or even simply walking can be an important intervention that is good for the whole family!

Baby Docs Need Time to Listen to Parents

2011-12-30T08:31:00.003-05:00

The American Academy of Pediatrics(AAP), the major organization representing pediatricians in this country, has just issued an important policy statement: Early Childhood Adversity, Toxic Stress and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health.

Citing a large body of evidence on the long-term effects of "toxic stress" in early childhood, on not only psychological health but physical health, they address the pediatrician's role in promoting first relationships that can be protective against the effect of this stress. They write:

In contrast to positive or tolerable stress, toxic stress is defined as the excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships..toxic stress early in life plays a critical role by disrupting brain circuitry and other important regulatory systems in ways that continue to influence physiology, behavior, and health decades later.

It is the absence or insufficiency of protective relationships that reinforce healthy adaptations to stress, which, in the presence of significant adversity, leads to disruptive physiologic responses... that increase the risk of health- threatening behaviors and frank disease later in life.

Much of the evidence they site comes from what is referred to as the ACES study. On ongoing study begun in 1995, it documents the close correlation between adverse childhood experiences, including abuse and neglect, parental mental illness, substance abuse and family discord, and long term health outcomes, not only in the form of mental illness but also chronic illnesses such as obesity, diabetes and heart disease. The study is a collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente's Health Appraisal Clinic in San Diego.

Not to toot my own horn, but this is exactly what I have been writing about on my blog for the past two years and in my book Keeping Your Child in Mind.

For example, a post from March 20011, Early Relationships and Brain Development as the Core of Medical Practice describes an outstanding pediatric practice in California run by Dr. Nadine Burke, that incorporates the ACES study into the everyday care of children. I raise the issue of the emotionally challenging of this work for the doctor, who in the absence of a culture that values careful listening, may suffer from "burnout" taking in so many stories that often involve significant trauma. The beauty of Dr. Burke's program is not only that they take the time, but also that the culture of the practice supports collaborative care. Multidisciplinary team meetings give clinicians an opportunity to share not only ideas and insights, but also the burden of carrying these stories.

One place where the AAP policy falls short is in describing exactly what implementation would look like in a pediatric practice. This policy states

Because the essence of toxic stress is the absence of buffers needed to return the physiologic stress response to baseline, the primary prevention of its adverse consequences includes those aspects of routine anticipatory guidance that strengthen a family’s social supports, encourage a parent’s adoption of positive parenting techniques, and facilitate a child’s emerging social, emotional, and language skills

It then goes on to list some programs. But what does the pediatrician actually do? The bottom line is taking the time to listen. As I write in my book

Being understood by a person we love is one of our most powerful yearnings, for adults and children alike. The need for understanding is part of what makes us human. When our feelings are validated, we know that we’re not alone. For a young child, this understanding helps develop his mind and sense of himself. When the people who care for him can reflect back his experience, he learns to recognize and manage his emotions, think more clearly, and adapt to his complex social world.

The new policy statement recognizes the potential value of the relationships between pediatricians and the families they care for.

High expectations are grounded in the public’s deep respect for pediatricians as trusted guardians of child health.

As a culture we need to value the primary care clinician, not only in the form of payment equal to the more lucrative subspecialties, but in the form of recognizing the role of relationships in healing. It makes sense that if we are recognizing the importance of family relationships in preventing poor health outcomes, that we should recognize the importance of doctor-patient relationships in supporting these families.

When primary care clinicians take time to carefully listen to stressed parents, parents feel supported in their efforts to carefully listen to their children, thus promoting healthy development. In turn, our culture needs to support and value primary care clinicians ( and its not only pediatricians, the subject of this policy statement, but all those entrusted with primary care of children.) As the report wisely states:

Rather than continuing the current trend of “doing more with less,” as pediatricians take on a wide range of additional responsibilities, payment reforms should reflect the value of pediatricians’ time and knowledge, as well as the importance of a pediatrician-led medical home serving as a focal point for the reduction of toxic stress and for the support of child and family resiliency.

Early Relationships and Brain Development

2011-12-23T06:02:00.024-05:00

The research and knowledge about how early relationships shape brain development has been exploding in recent years. Three new studies caught my attention. The more we know about this area, the more we recognize how important it is to support parents and young children in the early years when the brain is most rapidly developing and so most "plastic," or able to change.

The first study, using neuroimaging techniques, showed that children exposed to severe maternal depression since birth had larger amygdalas at age 10. Much research has shown that postpartum depression can have long term impact on child development. In addition we know that the amygdala plays a critical role in emotional regulation. Trauma researcher Bessel van der Kolk has referred to it as "the smoke alarm of the brain." It makes sense that when mothers, because of their own emotional distress, are not able to be attuned with their babies as the would wish, the centers of the baby's brain responsible for emotional regulation may not develop as well. So the amygdala is, in a sense, unchecked.

The take home message is not that mothers should feel guilty if they are depressed, but that they should get help. I have written in a previous post about the dearth of services for women with PPD and new initiatives to address this problem. I have added my efforts to the cause by starting the Early Childhood Social Emotional Health Program at Newton Wellesley Hospital where mothers struggling with a range of perinatal emotional complications can be seen with their baby.

The second study, is also about the amygdala: Amygdalar Activation and Connectivity in Adolescents With Attention-Deficit/Hyperactivity Disorder. Also using neuroimaging, these researchers showed that the amygdala was overactive in a group of teenagers with the diagnosis of ADHD. I have written previously about ADHD as a problem of regulation of emotion, attention and behavior. The authors of the study link this finding to the difficulties with emotional reactivity seen in teenagers with ADHD. If we combine these findings with the previous study, it seems that treating mother-baby pairs in the setting of postpartum depression might in fact prevent ADHD! Such a study, known as an intervention study, is yet to be done, but certainly it seems to make sense to place our efforts in that direction.

The last study comes out of the Minnesota Longitudinal Study of Risk and Adaptation, which has followed a group of children from birth into adulthood. They showed a link between secure early attachment relationships and satisfying romantic relationships in young adults. The results were affected by quality of social skills in preschool and having a best friend in adolescence. The authors conclude that early relationships are very important, but other relationships along the way to adulthood can influence the effects.

While this study is not about neuroimaging, if we think about how being in a successful romantic relationship as an adult requires a good degree of emotional regulation, we can make a connection. Secure early attachment relationships are characterized by attunement between mother and infant. When something is amiss, as in the case of postpartum depression, these relationships may develop a quality of insecurity. This may show itself in the brain as an overactive amygdala, perhaps with relative underdevelopment of the centers of the brain responsible for regulating the amygdala. These studies together offer insight into how brain development may affect later adult relationships.

These studies span the developmental spectrum, from childhood to adolesence and on to adulthood. With such far reaching implications, it certainly makes sense to put our efforts into helping these young brains to grow in a healthy way from the start.

A Troubling Parenting Moment at the Airport

2011-12-18T07:12:00.026-05:00

The little boy, who looked to be about two, darted away in a fit of giggles. His young mother, who seemed thoroughly worn out and exasperated, ran after him, grabbed him by the arm and said in a harsh whisper, "You must stand here!"

We were on line waiting to board a Southwest Airlines flight. For those of you not familiar with the Southwest system, there are no assigned seats. Rather, when a passenger obtains a boarding pass, a number indicates a place in line. Then before boarding, passengers line up according to the number they have been given. It is a very well organized system, but doesn't necessarily work for a two-year-old.

I've been thinking a lot about what happened next. While I do not know anything about this mother-child pair, I have imagined many reasons why the situation unraveled as it did.

The above scene repeated itself two or three times. The mother had a companion, another young woman about her age, maybe a friend or her sister, who was fully absorbed with her phone for a few rounds of chasing before she looked up and said to the boy, "Do you want to watch a movie?" Immediately he stopped his darting and stood quietly looking at the phone, but the woman said, "You have to wait til we get on the plane." He screamed and ran off again. This time he threw himself on the ground in the middle of the two lines of people (interestingly right at my feet-perhaps he sensed a sympathetic observer.) At which point his mother said in a loud voice, "If you don't listen, all of these people are going to tell Santa you've been a bad boy!"

I was horrified, and might have even been tempted to intervene (probably not a good idea in the absence of frank abuse) but fortunately at that moment they began to board the plane.

So what went wrong? I start with the mother's perspective. Likely she was experiencing a flood of shame and humiliation, as parents of young children do when they "act out" in public. On every radio interview I've had, I am asked about the dreaded "supermarket scene," another place where a child must conform to the rules under the watchful eye of the general public.

The fact is that the "public eye" is generally either sympathetic or too involved in their own life to even notice. Yet shame pervades. In this situation it must have been particularly intense, as the mother passed this shame on to her son. She put the experience of humiliation directly in to him with her comment about Santa.

Next, I go on to the four aspects of holding a child in mind, as I describe in my book Keeping Your Child in Mind: Overcoming Defiance, Tantrums and Other Everyday Behavior Problems by Seeing the World Through Your Child's Eyes

The first is to be curious about the meaning of behavior. I wonder if this boy had some difficulties processing sensory input. As I mention in a previous post, a recent study showed that sensory over-responsiveness occurs in 25% of cases of problem behavior. An airport is a very difficult place for a child with sensory processing problems. Or perhaps he had just had a difficult separation- an event that may precede a trip on a plane. Or he may simply have been tired or hungry.

The second component is empathy. His mother, likely because of her own distress(see step four) was particularly unempathic, not recognizing how even in the absence of the above possible stressors, standing still can be a challenge for a two-year-old.

The third component is regulating and containing behavior. The little boy likely felt very stressed by this out of control situation. He needed help containing his experience. The mother's companion was on the right track in offering the phone. He needed something that would help him to regulate himself. Reading a book, offering a movie or game, or even a snack, might have helped him to feel less out of control.

The last, and most difficult, is to manage your own distress. This mother might have been tired herself, might have been angry with her companion for being so unhelpful, or any countless number of feelings, in addition to the shame I describe above, that can get in the way of seeing things from your child's perspective. When a person is flooded with stress, the higher centers of the brain responsible for rational thought do not work well. Had she been thinking more clearly, it might have occurred to her that her companion could hold the place in line. She could have let her son run around before being confined to the plane. Likely the other passengers would have been fine with that.

It's a lot to think about for such a tiny moment. But it deserves this kind of attention, because repeated experiences of shaming are not good for a young child. Who says being a parent isn't the hardest job there is?

Limit Setting as Containment of Feelings

2011-12-12T06:32:00.028-05:00

Two recent experiences have gotten me thinking about the concept of "containment." It is the third component of keeping your child in mind, an approach to supporting healthy emotional development that I describe in my book, Keeping Your Child in Mind. In its most concrete form it refers to the importance of setting limits on your child's behavior. For example, by giving a "time out" every time your child hits, you show him that this behavior will not be tolerated. In doing so, you protect him from the intensity of his feelings by making sure that things do not get out of control. When young children are so consumed with anger and frustration that they hit, they feel out of control, and clear limits help them learn to regulate and manage these difficult emotions. (Combining limits with empathy, as I describe in my previous post, is essential.)

The first experience was a radio interview I had last week on the program Radio 2 Women on WBCR in the Berkshires. My interviewer, Serene Mastrianni, was among the best I've encountered. She had read the book twice, the first time going right to the section corresponding to her own child's age, and then again from the beginning. She had given it some careful thought. She had begun to actively use the book, not only in her own family, but to support friends. She told me the following story.

One such friend, the mother of a 12-year-old boy, had called her in tears. Her son had just had an explosive tantrum and at its height, he screamed at her, " I know you hate me, but I didn't know Dad hates me too!" Her friend was devastated. Serene's response to her hysterical friend was (after, "you've go to to read this book") "sit with him find out what this is all about." So her friend, rather than reacting in anger or hurt, did just that. And with time, the story unfolded that he had been bullied at school. He was a very successful student, president of his class, and he had never had this experience. He was furious with his parents for having failed to protect him, even though in reality they knew nothing about it.

This story combined with the second experience, attending the Zero to Three conference,"the premier conference for professionals dedicated to promoting the health and well-being of infants and toddlers," this past week in Washinton, DC, led me to consider the deeper meaning of the term 'containment." At a lecture I attending on teaching therapists to work with parent-infant pairs, the speaker described containment as "tolerating and sitting with feelings until the meaning unfolds." This is exactly what Serene's friend had done.

Tolerating your child's feelings in this way can be very difficult for a parent, as your child's behavior, particularly when it involves either physical or verbal assault, may provoke intense reactions. But the rewards, as this story shows, are great. Containment requires that, for the moment, you put your own distress aside (the fourth component of keeping a child in mind.) The beauty of Serene's story is that she was able to help her friend with this challenging task. It points out that for parents to be able to keep their child in mind in this way, there must be someone keeping them in mind. That person could be a friend, spouse, family member, pediatrician, or therapist.

"What about positive feelings?" Serene asked. I love this question. Much attention is given in the parenting literature to negative feelings, such as anger, frustration and sadness. But meeting a child’s experience of excitement and joy is in many ways equally important in promoting healthy development. Failure recognize and contain joy may slip under parents' radar as the behavior that follows may not be disruptive. But a child brimming with excitement over an experience with a friend or teacher who is met by a distracted parent may feel unrecognized, as the above child would have been if rather than being listened to he were sent to his room for "talking back." A parent who is depressed may have particular difficulty meeting a child's joy. This is one of many reasons why it is critical for parents who are struggling with depression to get help.

Serene told of a time when her daughter came home in just such an excited state, and she busy with something and did not respond. Later that day, however, Serene recognized what had happened and said to her daughter, "you were really happy when you came home and I wasn't listening. I'm sorry. Come here now and tell me all about it."

In the everyday stress of life, there are many times when a parent will not be available to contain a child's feelings, whether positive or negative, in the way I have described. But this very process of recognizing such a moment of disruption, and subsequently repairing it, is, in itself, essential for promoting healthy emotional development.

Why "Defiant" Behavior Pushes Parents' Buttons

2011-12-06T09:18:00.005-05:00

Recently NPR had a story about temper tantrums, describing a new study showing that the sounds children make during a tantrum indicate that they are primarily sad rather than angry. The written version of the story opens with description of tantrums as " the cause of profound helplessness among parents."

I thought this was an interesting choice of words, as I have always thought of tantrums as representing a sense of helplessness in children. In fact, in my over 20 years of practicing pediatrics I have told parents that, for the most part, tantrums are a normal healthy phenomenon. They occur when young children emerge for a stage of omnipotence in the first year to recognize that they are relatively powerless. An excerpt from my book describes the phenomenon.

Imagine that your toddler sets his sight on your glasses and declares proudly, “mine.” In an appropriate way, you might calmly say, “No, those are Mommy’s. I need them to see.” Suddenly he is confronted with the fact of his relative smallness and powerlessness. If he happens to be in a particularly vulnerable state, such as before lunch or naptime, he might become enraged that you, his beloved mother, have burst the bubble of his omnipotence. Unable to contain his intense feelings, he might lash out and hit you.

The NPR piece got me thinking that we often describe children's behavior in negative terms, which immediately sets up a relationship of antagonism and confrontation. A colleague of mine, Suzanne Zeedyk, wisely has suggested that we reframe "challenging" behavior as "stressed" behavior. Then the language itself puts us in a position to empathize with the child's perspective.

The word"defiant" is a perfect example of this negative language. That word(as well as "tantrums") is actually in the title of my book Keeping Your Child in Mind: Overcoming Defiance, Tantrums and other Everyday Behavior Problems by Seeing the World Through Your Child's Eyes. The first part of the title was my doing, as it comes from an important concept in contemporary developmental science. The subtitle was my publisher's doing, but I understand why it was chosen, as this is a common language. Perhaps, however, it is time to rethink that language.

Recently I was asked to do an email interview for a parenting blog about defiance. The interviewer also used the word "impudence," another highly negative word. I suggested that this word projects intentions onto the child that are likely not there. In fact, "defiant" behavior almost always has its origins in a feeling of being out of control. From the child's perspective, his experience is not being recognized or understood. In a way he is not "seen."

Herein lies the explanation of why defiance pushes our buttons. In a sense a parent is having exactly the same experience as the child. He or she is not being "seen" or recognized as an adult deserving of respect. A parent might have had other experiences of not being "seen,” perhaps by a spouse, co-worker or by her own parents, that makes her particularly vulnerable to getting upset about not being “seen” by her child.

In almost every instance of “defiant" behavior, if one digs a bit below the surface, there is a way the child is also not being seen, or a way in which her experience is not recognized. For a particularly dramatic example, a six-year-old was brought to my practice with a chief complaint of “defiant behavior”. Further history revealed significant trauma in the child’s life. An alcoholic father who had abandoned the child as a toddler had recently been making visits, at which time he was often drunk and very loud. Yet her feelings about visits had not been discussed until they came to see me for “defiant” behavior,” which was worse around bedtime.

This child began sleeping all night in her bed after a couple of visits with me. We discussed this experience, recognizing her need for her mother's company at bedtime for stories, comfort and reassurance. Once a child feels that he is being seen, that his experience is recognized and understood, the "difficult" behavior often evaporates.

In general, if there is increasing “defiance” it is important to take a step back and try to understand what feels out of control for the child. It might be that he is very sensitive to loud noises or taste, and battles around "making a scene” at a family outing or being “picky eater” are related to these sensory sensitivities. It might be that there is a new baby and everyone is chronically sleep deprived. Or there may be financial stress or marital conflict. Simply recognizing that these things are difficult for a child and acknowledging his experience, even if the stressors are still there, goes a long way in having a child feel understood, and in turn decreasing “defiant” behavior.

Limits on behavior are essential, and my book goes on to say that the above toddler must be taught that hitting is never OK. But understanding, empathy and managing our own distress are all equally important. Reframing "difficult" behavior as "stressed" behavior is an important first step.

When Time and Space is the Treatment

2011-12-02T06:02:00.004-05:00

In my pediatric practice, it is not uncommon for a parent, given the space and time, to reveal a critical and unexpected piece of information. Consider these two stories, with details changed to protect privacy. Jennifer’s Mom was desperate for a change in her ADHD medication. A previous doctor had diagnosed her and now she was increasingly distracted in school. In telling me Jennifer’s story, Mom focused on all the different medications she had been on and how they had controlled her symptoms. Towards the very end of the 50 minute visit Mom almost casually dropped this information. “She’s wary of therapists because of what happened with DCF (Department of Children and Families.)” I asked why. Recently, Jennifer had told a therapist about her stepfather’s behavior and it had been reported as possible abuse.

Five year old Kevin’s Mom was distraught about his constant fighting with his younger sister. He always had to have everything first, his demands were escalating. They were having increasing difficulty getting out of the house in the morning. I saw them for 2 fifty minute visits. The first involved the whole family and we talked about some common approaches to managing behavior. I was struck by Mom’s level of distress, which seemed out of proportion to this fairly typical sibling rivalry. Towards the end of the second visit, when Mom was alone with Kevin, she quietly began to cry. I looked puzzled. She told me of the horrible accident that had taken the life of her older brother when she was a child. Her family had never mourned this loss. That trauma came flooding back now that she had two children of her own.

“If you ask questions you get answers-and hardly anything else.” This well know aphorism in medicine comes from a book, The Doctor, HIs Patient and the Illness by Hungarian psychiatrist Michael Balint. In this book he documents his experience running groups for primary care doctors. He writes of the “doctor as drug,” describing how doctors use themselves and their relationship with their patients as an important part of the care they offer.

Time and space, then, is the treatment. It gives patients a chance to say what is really important, the things that won’t come out if doctors just ask questions. For parents who feel stressed and alone, an opportunity to sit in a quiet room with respected and attentive listener for 50 minutes is invaluable. It gives them an opportunity to think about their child, rather than simply get advice about what to do. In both of these cases, telling their story was essential for effective treatment. For Jennifer, she needed an acknowledgement of the trauma of that experience with DCF, which now got in the way of her asking for help. Kevin’s mother recognized how her own unresolved loss interfered with her ability to respond effectively to her children. In a brief visit structured by questions, parents are unlikely to develop the comfort required to open up.

The world of business has its own saying: “Time is money.” For the private health insurance industry it is more profitable to cover a brief "medication check" than a 50 minute visit. Put this together with huge marketing efforts from the pharmaceutical industry and you have a big problem. Prescribing medication takes much less time than sitting with someone until they trust you enough to talk about what is important.

Primary care practices must have a large staff to manage the complexities of multiple different insurance plans. Office managers spend hours making calls and filling out forms to get insurance companies to give prior authorization for such things as MRIs and neuropsychological testing. In order for the practice to be viable and support this staff, the doctors are forced to see more patients in less time.

The interests of the private health insurance industry and the interests of children can stand in direct opposition to one another. As health care reform (I hope!) proceeds, the perspective of this non-voting population must be taken into account.

Sock Bump Anxiety Disorder? Understanding Children with Sensory Over-responsiveness

2011-11-25T07:10:00.040-05:00

In the December issue of the Journal of the American Academy of Child and Adolescent Psychiatry there is an article, with an accompanying commentary, that encourages me to think that perhaps the discipline of psychiatry is making moves from the "what" to the "why" of mental illness. Alice Carter, a brilliant researcher at UMass Boston, has an article entitled Sensory Over-Responsivity, Psychopathology, and Family Impairment in School-Aged Children.

In their editorial in the same issue Cynthia Rogers and Joan Luby write:

This work suggests that developmental scientists and mental health clinicians should recognize sensorimotor processing as an important independent developmental domain and key area of challenge in early childhood that has tangible implications for behavioral and emotional functioning.

Interestingly Joan Luby has written about the validity of diagnosing major depressive disorder in preschool children, an idea about which I have grave concerns. I wrote, in a response in the Boston Globe when her work on this subject was first published:

My sense is that these children process the world differently. One mother described carrying her screaming son for hours until she realized that he didn't want to be held. Another mother said her daughter was "not cuddly" and difficult to feed. As they become toddlers, the issues change. I hear about what I call "sock bump anxiety," where many changes of socks are required to find the one with the right seam in the toes. "Fun" family outings to a county fair can end in disaster as kids become overwhelmed by all of the sights and sounds. Intense tantrums and meltdowns are frequent.

Now I wonder if Luby an I are more on the same page than I had thought. The question, in my opinion, should be not "what is the disorder" but rather "what is the expereince of this particular child and family?" Unfortunately, as Dan Carlat states in his book Unhinged: the Trouble with Psychiatry

The tradition of psychological curiosity has been dying a gradual death, and the DSM is part cause, part consequence of this transformation of our profession. These days psychiatrists are less interested in ‘why’ and more interested in ‘what’.

My clinical experience is consistent with Dr. Carter's findings. I see young children with a wide range of behavioral concerns. Sometimes they have symptoms of anxiety. Others are "explosive" or "hyperactive and impulsive" Still others have rigid rituals, and teachers have raised concern about autism spectrum disorder. In almost every story, there are symptoms of sensory over-responsiveness. These symptoms are inevitably accomapied by problems of self-regulation and in fact have been called "regulatory disorders" in the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood–Revised(DC:0-3R). And as Dr. Carter describes, these symptoms are very disruptive to family functioning. Often siblings are the most dramatically affected when their needs are relegated to the back burner, as families struggle to avoid and then manage the frequent meltdowns that inevitably accompany these sensory difficulties.

I have wondered what it is that makes one child with sensory over-responsiveness and concurrent problems of self-regulation develop depressive symptoms, other autistic symptoms and yet another hyperactivity and attention problems. I suspect we will find that the gene(s) responsible for sensory processing are associated with different genetic vulnerabilities, and so the symptom takes a different path.

Occupational therapists have long recognized the significance of these problems, and many have advocated for adding a diagnosis of "sensory integration disorder" to the DSM list. Rather than debate whether sensory over-responsiveness is a disorder in and of itself, it is in my opinion, enough to recognize, as Dr. Carter has done, that it can be a significant problem for a child and family. Then primary care clinicians, mental health care providers as well as friends and family can offer the validation and support these families need. Waiting for a DSM defined diagnosis to emerge may narrow thinking and cloud our view of the complexity of the family's experience (Such a label maybe necessary, unfortunately, to bill insurance for services.) As I have said before on this blog, these "problems" of sensory over-responsiveness may be transformed into adaptive assets when children, validated and understood by their caregivers, develop the language skills and capacity for self-regulation that come with growing up.

A Small Town, A Little Boy, and a Terrible Disease

2011-11-22T11:31:00.003-05:00

(This post was written for a former patient from my days of doing general pediatrics, who turned 11 on 11/11/11)

Charley was with his mother in my office for his three-year-old check-up. Having taken care of Charley since he was born, I knew his family well. They had relocated from New York to our small New England town. As often happens in a small town, we shared many other connections. Tracy, Charley’s mother, taught at the school my children attended. We had many friends in common. Shortly before this visit, I ran into her outside the community center after dropping my kids at camp. Tracy was 5 months pregnant with a girl. “How’s your summer going?” I asked. Her smile was huge. “Great!” she replied. “Sam (her older son) is in camp so I get to spend all this special time with Charley.” She looked over at him as he ran around on the grass. “I fall more in love with him every day.”

Charley sat quietly on the exam table as our conversation flowed easily from social events to sleep habits. He was generally healthy, but was in early intervention for low muscle tone and mild language delay. His language was progressing, and the physical therapist, Tracy told me, was not concerned. “But he’s having some trouble climbing stairs,” she said. This struck me as odd, as Charley was a very active boy in an athletic family, and I made a mental note. Later that afternoon, I called our local pediatric neurologist. “I should see him,” he said. “And send him to the lab for a CPK (an enzyme made by muscles).” I called Tracy. She and her husband Benjy decided that they preferred to go to a neurologist in New York, and would schedule their own appointment, but agreed to pick up the lab slip for the blood test.

One evening several months later I was on call, the only doctor in the office with a sick child. I was on the phone with the ICU doctor at the hospital when my nurse handed me a slip of paper.

Charley S.
Critical Value
CPK 21,000

An hour later I was home, having somehow managed to transfer the little girl. I held the message in my hand. I had never seen a CPK this high, the normal number being under 100. After anxiously pacing around for a few minutes, I paged the neurologist I had originally spoken with. “He has muscular dystrophy,” he said without pause. I hung up the phone, trembling. I would have to tell a family that their son was going to die.

I needed to speak with the neurologist who had seen Charley. But I didn’t know who it was. So I had to call Tracy. I tried to be calm, explaining that the test results weren’t quite normal and that I wanted the name of the neurologist they had seen in New York. She gave me his number and asked, “How abnormal are they?” “They are high”, I replied. “I’ll speak with the neurologist tonight and meet you in the office first thing in the morning.” “OK”, she said. I hung up the phone and said to myself, “She knows.”

I spent the next hour on the phone with the New York neurologist. He said it was most likely Duchene’s muscular dystrophy (DMD). He described the current prognosis as “wheelchair by 10, death by 20”. But he suggested that I share with Charley’s parents that current research in gene therapy might offer a cure in the next 10-20 years. He wished me luck. During the few minutes that I slept that night, I had tormented dreams about telling them.

Tracy came alone. Years later she told me, “I purposefully kept quiet that morning as Benjy kissed the kids goodbye and went off to work just to give him one more morning of a normal life. ”

The nurse led her to an exam room and reported to me, “She’s a little shaky.” “That makes two of us,” I replied. I took a deep breath and walked in the room. I sat next to Tracy and held her, both of us sobbing. However, I was sure to reinforce that there was hope- that current research offered the possibility of a cure.

After a few weeks of living in shock, Tracy and Benjy took action. They started Charley’s Fund, whose sole aim is to raise money for research to find a cure for DMD. In seven years they have raised over $17 million. In the Fund’s most recent brochure, they write, ”All that “plugging away” has led to a very exciting moment in DMD history: first-ever human clinical trials for DMD boys.”

Tracy told me of a recent visit to the neurologist. “The doc examined Charley and just blurted out "Wow...this is epic!" He could barely believe that Charley can hold his head off a pillow when lying on his back for 60 seconds. The fact that he can even jump off the floor, let alone a considerable distance, is amazing and I know that is due to the fact that we received his diagnosis early and started steroids, supplements, night braces, and a nightly physical therapy routine. I know many, many parents of DMD kids who were not diagnosed until 6 years old or even later because teachers, physical therapists, friends, even pediatricians tell them that all kids develop at their own pace and your son will catch up in time.”

I think often of that moment I stood looking at the lab slip. It was a last moment of calm before a collision between the small town doc and the family whose life would be forever changed. I sometimes wonder if it was the intimacy of the small town life that in some way led to the early diagnosis, and to the explosion of energy now propelling Charley’s family, and all the other boys with this devastating diagnosis, forward toward a cure.

Parenting in China: Academic Achievement or Empathy and Resourcefulness?

2011-11-18T07:20:00.026-05:00

Recently I learned that a publishing company in China with the delightful name of "Good Morning Press" has purchased the rights to publish my book Keeping Your Child in Mind. I admit that China was the last country I expected to publish my book, which is in many ways the antithesis to the controversial book Battle Hymn of the Tiger Mother that received so much attention earlier this year. It made me wonder if, just as many Americans question the need to replicate the very rigid parenting methods espoused in the book in order to "compete with China," the Chinese (or at least some segment of the population) have recognized the value of instilling not high level skill, but rather empathy, flexibility, cognitive resourcefulness and social adaptation. The approach I describe in my book, based on over 40 years of developmental science research, points the way towards these qualities.

When Chua's book came out, I wrote the following post (I repeat it here, as it predated my Boston.com presence):

"All this talk about Amy Chua’s parenting techniques has me thinking about Brandon Fisher, the manufacturer of drilling equipment who President Obama recognized in the State of the Union Address for his critical role in the rescue of the Chilean miners. While I cannot claim to know anything about Fisher's upbringing, I do know a great deal about what qualities in a parent-child relationship lead to the characteristics he exhibited, namely empathy, flexibility and resourcefulness.

I wonder if the anxiety being experienced on a grand scale by American parents in the wake of Chua’s book is due to the fact that that while severe parenting techniques designed to achieve academic success may not be palatable, parents feel a void when it comes to finding an acceptable alternative model, as exemplified by the Boston globe op ed, The tiger mother roars, and slacker parents shudder.

John Bowlby, the father of attachment theory (no relation to “attachment parenting” as described by William Sears) describes the importance of a secure early relationships in raising a child who, in Bowlby’s words, is “self-reliant and bold in his explorations of the world, co-operative with others, and also-a very important point-sympathetic and helpful to others in distress.”

Contemporary research offers a close up view of a secure parent-child relationship that can instill these qualities. It involves a balance of empathy and limit setting. There are four key elements. The first is wondering about the meaning of a child’s behavior rather than responding to the behavior itself. The second is empathy. This is more than saying “I know how you feel.” It means actually feeling what your child is feeling, but reflecting it back to him in a way that says, “I know you’re upset, but we’ll manage.” The third is containing difficult emotions, often in the form of setting limits. Limit setting is about teaching the essential life skills of frustration tolerance, impulse control and emotional regulation. And forth, and perhaps most challenging, is doing all this without letting your own distress get in the way.

Lest this list cause a parent to feel overwhelmed by the enormity of the task, research of Ed Tronick, child development expert, offers hope. If parents are attuned with their child only 30% of the time, if 70% of the time you don’t connect with your child in the way I describe, as long as most disruptions are recognized and repaired, development moves forward in a healthy direction. In fact, disruptions and their subsequent repair are essential in instilling resilience, an important fourth attribute to add to Bowlby’s list. D.W.Winnicott, pediatrician turned psychoanalyst coined the phrase the “good-enough mother” to describe a mother who is not perfect, and in her very imperfection helps her child to manage life’s challenges in direct proportion to what he is capable of.

Chua’s book, in addition to creating mass unease in American parents, has raised fear regarding our ability to compete with China. Towards that end, raising a generation of Brandon Fishers, citizens with the qualities of empathy, flexibility, resourcefulness, and resilience, is essential. In order to accomplish this task, we must support parent-child relationships from the beginning. There is extensive evidence that children learn these skills in infancy, when the brain is making as many as 1.8 million neural connections per second.

Unfortunately our country does not value parents in this way. Our lack of support of early parent-child relationships is exemplified by our maternity leave policy that lags far behind other countries, as well as the rapid increase of prescribing of psychoactive medication to very young children. This second phenomenon is in turn inextricably linked with the very powerful health insurance industry and the lack of value placed on primary care and mental health care services.

Public policy to support early parent-child relationships is essential. For example, postpartum depression can negatively impact a mother's ability to be present with her child in a way that promotes healthy emotional development. Recently a new law was passed in Massachusetts that calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.

Contemporary research in child development offers an answer to the questions raised by Chua, both on a small scale: a model of parenting to follow, and on a large scale: a model of social policy to support parents in this task. I thank her for providing the motivation to address issues that are critical for the future of our children and of our country."

Perhaps this interest in my book implies that China (at least in some small way) has caught on to the importance of valuing parent-child relationships. If so, now more than ever is the time for our country to recognize the need to nurture these, in a sense, American qualities of empathy, flexibility, resourcefulness and resilience.

Antidepressants in Pregnancy and Autism: A Possible Link

2011-11-13T08:24:00.021-05:00

Studies abound that aim to answer both the question "What causes autism?" and "What is the reason for the increase in incidence and prevalence of autism?" A study published in the November issue of the Archives of General Psychiatry, Antidepressant Use During Pregnancy and Childhood Autism Spectrum Disorders caught my attention. As both the prevalence of autism and the use of SSRI's (selective serotonin reuptake inhibitors) have increased dramatically in recent years, and SSRI's are powerful medications that act on the brain, the findings do seem plausible.

Writing about research for a general audience, I want to say at the start that this is a preliminary investigation, one that simply raises a question. Pregnant women or those planning to conceive who are on these medications should not rush to go off them. The authors of the study are careful to say that, "The potential risk associated with exposure must be balanced with the risk to the mother or fetus of untreated mental health disorders." Untreated mental health disorders do pose a risk to mother and fetus. Women who are pregnant or of childbearing age and contemplating getting pregnant who have been on SSRI's may have a great difficulty getting off of them even if there is a question of risk to a fetus.

In this population based study done at the Kaiser Permanente Medical Care Program in Northern California, the researchers found

a 2-fold increased risk of ASD(autism spectrum disorder) associated with treatment with selective serotonin reuptake inhibitors by the mother during the year before delivery, with the strongest effect associated with treatment during the first trimester.

They found that there was no increase in risk for ASD if a mother had been treated for mental health problems but did not receive SSRI's. This finding attempts to answer the question of whether it is the depression or the drug that is associated with ASD. Their findings suggest that it is the drug.

The authors conclude:

Although the number of children exposed prenatally to selective serotonin reuptake inhibitors in this population was low, results suggest that exposure, especially during the first trimester, may modestly increase the risk of ASD. Further studies are needed to replicate and extend these findings.

My reaction to the study is not its implication for women who are pregnant now, but for young girls and adolescents who are being placed on these medications, often by pediatricians, for relatively mild symptoms. SSRI's have been shown to be effective for severe depression, and certainly in the setting of suicidal behavior, the urgent need for treatment may outweigh the potential long-term risk.

Recently I had the privilege to read an advance review copy of a book due to come out this April with the compelling title Dosed: The Medication Generation Grows Up. A well-researched book written by a journalist who has herself been on SSRI's since her teenage years, it shows how these drugs are often not a quick fix, but rather may be followed by a decades-long relationship with psychiatric medication. One particularly striking story is of a woman started on a SSRI at age 11 who, now pregnant in her thirties, is unable to get off them despite her strong desire to protect her unborn child from the potential risks of the drug.

Because these medications can cause such dramatic symptom relief, it is understandable how parents, physicians and teenagers themselves are drawn to them. Seeing your child in emotional pain is one of the greatest challenges of being a parent. However, in the absence of suicidality, holding them through these crises, with a combination of careful listening and quality psychotherapy, may in fact give them the tools to manage future crises they may encounter as they venture out into the world on their own. In my book, Keeping Your Child in Mind, the chapter on adolescence shows how these interventions can promote healthy emotional development.

Shortage of quality mental health care services, as well as lack of support for parents of teenagers, may make this kind of help difficult to attain. But now that this risk of SSRI's to a fetus is out there as a possibility, I believe it is more important than ever that we as a society make an effort to provide treatment for children and adolescents with mild to moderate depression that does not include prescribing psychiatric medication.

Supporting Fathers' Emotional Health is Essential for Children

2011-11-07T06:17:00.031-05:00

Sometimes in my behavioral pediatrics practice I have the privilege of doing in depth work with a mother and father together. Recently I saw a four-year-old girl with "explosive behavior." After a number of session spent focusing on a range of issues, her father began to speak about his alcoholic, emotionally abusive father. He found himself full of rage, rage that he now recognized was unfortunately often misdirected at his daughter. Perhaps because of the trust he had developed in our work together, he accepted a referral to therapist, with the hope of being able to put his feelings of anger in their rightful place.

More often that not, however, fathers do not come to these visits. I hear stories from mothers of their spouse's terrible emotional stress. Often there is intense conflict between mother and father over discipline techniques. Because the mother is in the room with me, I can listen in depth to her story . But when I encourage the father to come so I can hear about his experience, there are many obstacles. Most common is "he can't get off from work." A close second is "he doesn't believe in this kind of help," or "he doesn't like to talk about feelings."

I hope that a new study published in the December issue (online today) of Pediatrics, Paternal Depressive Symptoms and Child Behavioral or Emotional Problems in the United States will encourage fathers to seek help, and motivate clinicians to strive to include fathers in treatment of young children with emotional and behavior problems. The study shows, not surprisingly, that paternal depression and other mental health problems affect the emotional state and behavior of children.

The literature on postpartum depression in mothers, and its long term effect on child development, has exploded in recent years. Yet services for women struggling with perinatal emotional complications are often hard to come by. Many people, as I describe in a previous post are working hard to address these needs. Unfortunately fathers have not received this kind of attention.

This past weekend my local paper ran a story Swedish dads swap work for childcare about fathers making use of Sweden's very generous parental leave policy. Sweden has the right idea, not only in generous paid parental leave, but also in supporting fathers taking on the role as primary caregiver.

We need to take a good look at why we have lagged behind on this front, despite significant increased presence of fathers in the lives of their growing children. This latest study published in Pediatrics shows that the time has come to pay attention. I for one will continue to give fathers of my child patients careful thought, and encourage their participation in treatment. The vast majority of parents, when they see that getting help for themselves will help their children, are motivated to do this difficult and sometimes painful work.

Creativity Needed in Balancing Family and Career

2011-11-02T14:50:00.020-04:00

This past summer I wrote a post in response to a New York Times Op Ed that criticized women physicians who work part time. I concluded:

Being a mother is both an awesome privilege and an awesome responsibility. It is in a sense the greatest act of creativity. It makes sense that women who create in this way can also create their own professional lives. By embracing this creativity, both as mothers and as professionals, we can aim to find new and important ways to contribute to society, while at the same time being present in the lives of our children in ways that support the healthy development of the next generation

This idea holds particular relevance for me now, on the eve of starting a new job.

When I was in my late 20's, I had what in many ways was an ideal job. I was practicing pediatrics at Revere Community Health Center, an affiliate of Massachusetts General Hospital. I loved my colleagues and had a wonderful patient population. I was on staff at MGH and on the faculty at Harvard Medical School, where I had the opportunity to teach interviewing skills to first year medical students.

One of the best parts of the job was that I did supervision around my cases, a form of training usually reserved for mental health professionals, with Michael Jellinek, chief of child psychiatry at MGH. He helped me address the complex emotional needs of my most challenging patients and sort out my feelings when they got in the way.

One particularly memorable patient was a young teenager with poorly controlled diabetes who had experienced significant emotional trauma. As an example of enactment of my rescue fantasy, I always agreed to see her, even when she came very late for her appointment. On a couple of occasions, when she was on the verge of hypoglycemia, I gave her my lunch. Speaking with Dr. Jellinek allowed me to be a more effective doctor for her.

The only downside of that time in my life was that I was single. Then I met my husband, who lived in New York. As he had an established ophthalmology practice and a daughter from a previous marriage, in order to be with him I would have to move. As I was in love and wanted to start a family, it was an easy decision to make. But leaving my job, and in particular my work with Dr. Jellinek, was sad and painful.

To sum up the next 20 years- I had two children, worked part time, teaching and practicing general and behavioral pediatrics. In 2000 my family relocated to the Berkshires where I took a job in a busy small town practice. In 2004 I began to study as a scholar with the Berkshire Psychoanalytic Institute in Stockbridge. There I discovered, among others, the work of Winnicott and Fonagy, and the growing discipline of infant mental health. I stopped doing general pediatrics in order to be able to keep up with the increasingly busy lives of my then school age children. I began my writing career, first for the Boston Globe and then for my new book. Keeping Your Child in Mind. I enrolled, in the fall of 2010, in the UMass Boston Infant-Parent Mental Health Post-Graduate Certificate Program in which a group of fellows from a range of disciplines met for one 3-day weekend a month for 10 months.

On the Saturday of our February weekend there was an op ed in the New York Times about a mother's struggles with managing her rage toward her child. With my mind in high gear as a result of the intellectually stimulating environment of the weekend, I composed a letter to the editor, which was published the following weekend.

That night I received an email from a pediatrician on staff at Newton-Wellesley Hospital who I had met at a conference a few years earlier. He had read my letter and had an idea.

Dr Jellinek, who is still chief of child psychiatry at MGH, but now also president of Newton-Wellesley Hospital, was embarking on a major initiative to expand child psychiatry services. This pediatrician had followed my work through my writing, and knew that I had once worked with Dr. Jellinek. Perhaps, he thought, there would be a place for me in this new plan.

Nine months and many meetings later, plans have been finalized for me to start a program (one day a week for now, as I still live in the Berkshires) at Newton-Wellesley Hospital integrating services of OB, pediatrics and psychiatry to promote early childhood social and emotional health. It will focus on perinatal emotional complications and address the emotional needs of the 0-5 age group. Dr. Jellinek is as kind, smart and thoughtful as I remember him. The only difference is now I call him Mike.

Though I could not have recognized this as they were happening, the discontinuities in my professional life, made to accommodate family, have led me to a very good place!

Over-reliance on Psychiatric Medication in Children: A Pediatrician's View

2011-10-28T08:29:00.003-04:00

This weekend I was scheduled to speak at a conference in LA sponsored by the International Society for Ethical Psychology and Psychiatry entitled "Alternatives to Biological Psychiatry." Unfortunately, due to a family emergency, I was unable to attend. As I had already prepared my talk, I decided to translate it into a blog post.

Recent studies predict that treatment of mental illness and mood disorders will soon makeup 30-40% of a pediatrician’s office practice. A study that appeared in the journal Pediatrics revealed that 8% of pediatricians felt they had adequate training in prescribing antidepressants, 16% felt comfortable prescribing them, but 72% actually did. The cover of the October 2011 issue of Pediatric Annals reads: "Assessment of Pediatric Mental Health:Primary care providers are now on the front lines in the diagnosis of mental health issues". While this over-reliance on medication in children has complex social and political roots, the fact is that pediatricians are the ones putting prescriptions into parent's hands.

There are a number of realities of pediatric practice that have led to this situation. Clinicians in most communities are faced with severe shortage of quality mental health care services. The health insurance industry contributes to this poor access, as low reimbursement and complex administrative rules are disincentives for therapists to participate in these plans. In addition, primary care clinicians are under intense time pressures. Again the health insurance industry plays a role, as in order to maintain a staff to manage multiple insurances, clinicians must see more and more patients in less and less time. In addition, there is often great pressure from teachers, parents and other clinicians to prescribe medication. And last, the
AAP endorses the biological model of psychiatry, as evidenced by the recent recommendation to extend diagnosis of ADHD down to age 4. Prescribing psychiatric medication to young children is a common endpoint of all of these factors.

The growing discipline known as Infant Mental Health offers a different paradigm. Research at the interface of neuroscience, epigenetics and developmental psychology offers both a different way to understand the emotional and behavior problems of young children, as well as a different model of intervenion. While in pediatrics the term infant refers to the first year, this discipline addresses the 0-5 age group.

While it is not my intention to cover this topic in depth, there are some key concepts. First, it is infant-parent mental health, and interventions always involve working with parent and child together. Second, symptoms (or behaviors) have meaning and come from somewhere. And third, the developmental trajectory of any individual child is a result of a complex interplay of genes and environment.

This model is best illustrated with an example. Following my recent appearance on the Diane Rehm Show, I received many emails from parents describing their experiences. One mother gave me permission to use her story, provided she could not be identified. I have selected out key aspects of the detailed story she sent me to illustrate how these principles can be applied to help young children and their families. I have divided her experience into obstacles to care and paths to success.

Obstacles to care:
Dysregulated from birth, with severe colic and poor sleep.
Pediatricians did not recognize signs early
Structured preschool setting “stressed him out”
Frustrated teachers diagnosed ADHD
Previously happy boy now crying all the time
Parents depressed, marriage severely strained

Paths to success:
Parents discovered Stanley Greenspan’s book Overcoming ADHD
Recognize difficulties as problem of self-regulation
Adjust environment and alter expectations without using label
Play-based preschool
Occupational therapy to address sensory processing challenges, with parents in attendance
Minimize media exposure
Calm, happy child, happy parents
Excels at chess, top of his class

So how can we help more children and families find this path to success? Changes need to be made at a policy level, including improving access to primary care and mental health care, calling attention to impact of pharmaceutical industry, and addressing problems in the health insurance industry, perhaps with a single payer system. The second front is through education of professional who work with young children about the growing body of knowledge coming out of the discipline of infant mental health, and its application to their work. This includes primary care providers, mental health clinicians, teachers and child care workers

A wonderful piece in the November 2009 issue of Atlantic entitled The Science of Success describes the "orchid hypothesis." Children with genetic vulnerabilities, like many of these children who are dysregulated from birth and have multiple sensory processing challenges, who grow up in an environment where they are misunderstood, "bad behavior" is punished, or "symptoms" are medicated away, may develop more serious forms of mental illness. On the other hand, in an environment that helps them to make sense of and manage their experience, as the parents of this child above did, they can grow up to be society’s most creative, successful, and happy people.

I conclude with a number of quotes from Ralph Waldo Emerson, who my daughter is currently studying in high school.

Whoso would be a man [woman] must be a non-conformist
For non-conformity the world whips you with displeasure
Nothing can bring you peace but yourself. Nothing can bring you peace but the triumph of principle.
This time, like all times, is a very good one, if we but know what to do with it.

Learning from parents-a most important education

2011-10-22T09:25:00.036-04:00

Recently I had an "aha" moment of sorts. I was speaking to a group at the Pacella Parent Child Center in New York. I was explaining the path that had led me to write my book, Keeping Your Child in Mind. I was telling the group how in 2006, when my own kids were both school age, I stopped doing primary care and began doing exclusively behavioral pediatrics. I was still working within a general pediatrics practice. The major change was that I started scheduling all my patients for 50 minute visits. Where previously an "ADHD evaluation" had been, at most, one 50 minute visit, and many visits for behavior problems only 30 minutes in length, I began insisting on a minimum of two 50 minute visits for any behavior problem, preferably the first with parents alone.

Many practitioners might now dismiss what I am about to say, insisting that this is not a financially viable plan. But the fact is that I have been reimbursed for these visits on average $150. It is possible for a practice to have one or two clinicians devote several 50 minutes a week to addressing "behavior problems," especially given the potential gain. As I describe in my book, when parents are simply given advice about "what to do" both clinician and parent often experience failure. In contrast, giving a parent time and space to be heard often results in dramatic improvements in behavior.

With this change in my practice, I began to listen more carefully to my patients, specifically to parents. I heard stories of struggles with infertility, newborns who were difficult to soothe from day one, parents who struggled with depression when their children were infants, among many other things. But I also learned about what made things better. Once parents were given the time and space to tell their story, they came up with many resourceful solutions to address their children's difficulties.

Certainly the ideas I have developed over the years come in large part from studying contemporary research from leaders in the field of child development. I am a graduate of the Scholar's program of the Berkshire Psychoanalytic Institute and of the UMass Boston Infant-Parent Mental Health Post-Graduate Certificate Program. But perhaps my most important education has been in carefully listening to the experience of parents.

Last week I had the privilege to be on the Diane Rehm Show speaking about the new guidelines from the American Academy of Pediatrics extending age of diagnosis of ADHD down to age four. To sum up the position I presented on the hour- long show, I advised using caution before prescribing medications to kids under six. I advocated for early intervention, even in infancy when problems of self regulation can present. I argued for validating parent's experience without using a major psychiatric diagnosis, and for recognizing the meaning of behavior rather than focusing exclusively on symptoms.

A mother who had listened to the show emailed me, thanking me for being "the voice of reason." She shared in detail her experience with her now six-year-old child. She described terrible struggles for the first five years until she and her husband discovered Stanley Greenspan's book about ADHD (his ideas and approach are very similar to mine) and everything "clicked." They took matters into their own hands in advocating for their son, who is now thriving. There were many details in her story- both the obstacles to help and the elements of the path to success.

Recently I have seen myself referred to in the media as a "child mental health expert." I appreciate this description, as it affords an opportunity for recognition of this important perspective that my infant mental health colleagues and I bring to the conversation. But reading what this mother wrote reminded me again that parents are always the experts with their child, and that there is still much that I can learn.

Diagnosing ADHD Under Age 6: A Mistaken Idea

2011-10-16T08:02:00.004-04:00

Once again ADHD is in the news. At the American Academy of Pediatrics National Conference and Exhibition this weekend in Boston, the new guidelines for diagnosis and treatment of ADHD were unveiled with much fanfare. The most significant change is that the AAP now endorses diagnosing the disorder from age 4-18, a change from the previous guidelines which recommended diagnosis from age 6-12. I take no issue with extending the age of diagnosis upward. But the new recommendation to extend the diagnosis down to age 4 is very worrisome.

As I describe in a previous post, what is now called ADHD is a constellation of symptoms that represent problems of regulation of behavior, attention and emotions. These problems have complex causes. There may be a biological vulnerabilities, which often have a genetic component. Often there are associated sensory processing problems. Family conflict, including parent-child conflict as well as marital conflict, is clearly associated with problems of self regulation. Sleep and eating problems often occur within the context of family conflict and can exacerbate problems of self-regulation.

Children who are struggling in a variety of ways are scheduled in pediatric practices for an "ADHD evaluation." The question asked is: "Do symptoms meet diagnostic criteria?" The more appropriate question should be "What is the experience of this particular child and what can we do to set things in a better direction?" By invoking the label of ADHD, thinking may stop. Curiosity about the meaning of behavior ends. However, years of longitudinal research, as I describe in my book, Keeping Your Child in Mind, has shown that children develop the capacity for empathy, flexible thinking and emotional regulation when parents respond to the meaning of behavior rather than simply the behavior itself.

A press release regarding the new guidelines describes the recommendations for children under 6 as follows.

According to the AAP guidelines, in preschool children (ages 4 and 5) with ADHD, doctors should first try behavioral interventions, such as group or individual parent training in behavior management techniques. Methylphenidate may be considered for preschool children with moderate to severe symptoms who do not see significant improvement after behavior therapy, starting with a lower dose.

Certainly children with problems of self-regulation are struggling, and they absolutely should receive treatment. But receiving a diagnosis of ADHD should not be the only route to receiving treatment, particularly if that treatment consist primarily of "parent training" "behavior management" or medication. There are a whole range of other interventions that can be very helpful to these struggling children and families. These include parent-child psychotherapy and occupational therapy that aim specifically to improve a child's capacity for self-regulation. Getting a label should not be a prerequisite for getting help.

Addressing "comorbidities" does not solve the problem. What this means is simply adding more letters to the child's diagnosis such as ODD (oppositional defiant disorder) CD(conduct disorder) that represent meaningless descriptions of symptoms without any consideration of underlying cause. In my experience, almost all children who have the diagnosis of ADHD are oppositional and defiant. But there are as many variations to the causes of this behavior as there are families.

Under age six children can get the greatest benefit from alternative interventions. This is the time when the brain is most plastic. Changing relationships can change the brain. In addition there are not, or at least should not be, the academic concerns that begin in first grade. Once kids begin to fall behind academically it can affect their self-esteem, and so the pressures to treat with medication increase.

A study done last year showed that kids who are the youngest in their class are 60 percent more likely to be diagnosed with ADHD than kids who are the oldest. There is a wide range of maturity rate. A four or five-year- old who is among the youngest in the class is at particular risk for being diagnosed with ADHD for what is in fact a normal developmental variation.

Recent reports show a dramatic rise in both diagnosis of ADHD and prescribing of stimulant medication for ADHD. We can be sure that with the implementation of these new guidelines, this trend will continue.

What is infant mental health? A case of a hitting toddler

2011-10-13T07:32:00.009-04:00

In a few weeks I will launch a new program in the Boston area (more information to follow when the details are ironed out) where I will see children under the age of five. The working name is "Early Childhood Social-Emotional Health" program (ECSH) It is an infant mental health program, drawing on the explosion of knowledge coming out of this growing discipline. I had the privilege of learning about the most current research first-hand from leaders in the field in an excellent a yearlong program at UMass Boston: The Infant-Parent Mental Health Post-Graduate Certificate Program.

There are two major problems with the term "infant mental health." First of all, it implies that there is such a thing as infant mental illness, which is, in my opinion, not the case. Second, when say that I am a pediatrician who treats behavior problems in children under age five, most people are puzzled. I tell them that I give parents space and time to reflect, and to be curious about the meaning of behavior, with the aim of getting development back on a healthy path. Still the blank look. I have found that the best way to explain it is through stories, as I do in my book Keeping Your Child in Mind. As always, I protect privacy by changing identifying details.

"She always hits! I don't know what's wrong with her!" Jane despaired at the start of her visit with me. She came with her three-month-old son, who slept in his carrier. She was horrified that her 18-month-old daughter Callie (who did not come to this visit, so Jane and I could talk freely) was behaving this way. She and her husband never hit. She couldn't understand where this behavior came from. The worst time, she said, was when she was trying to nurse the baby. Callie would try to climb up on her, and when told to get down she would hit her mother, the baby or both. Jane felt tense and angry. Her husband worked long hours and she was alone with the two kids most of the day. "What can I do to make her stop?" she asked.

This is not an uncommon occurrence. I frequently hear parents describe "visions of Columbine" when they see aggressive behavior in their toddlers. Rather than jumping right in with what to do, I took some time to listen to Jane's story. She told me of a difficult pregnancy and how hard it had been when she was alone much of the time when Callie was an infant.

Then she began to talk about her own family. Her father was an alcoholic who was verbally and sometimes physically abusive to her mother. There was constant yelling. She told me that she "hated aggression." When she saw Callie hitting she had an immediate physical sensation of stress. Jane just wanted her to stop.

We began to wonder together about why Callie might be hitting. Jane described how close she and Callie had been before the baby was born. With her husband gone much of the time she rarely had time alone with Callie anymore. "Perhaps she misses me," Jane said. She was surprised when I suggested that while clearly hitting was not acceptable, aggression in a toddler could be seen as a healthy thing. It was not the same as adult aggression, which carried a whole host of complex meanings. We might reframe Callie's behavior as claiming what she felt was her rightful place. We talked about how toddlers are asserting their emerging sense of self . Yet they recognize that they are in fact powerless in many situations. "Wow!" Jane exclaimed. "I feel that way sometimes, but I have words to express my feelings!"

We talked very little about what to do. I was careful to frame the issue of her childhood trauma and its relation to the current situation. This history did not mean that Callie's hitting was her "fault." Rather Jane needed to move her issues out of the way so she could see the situation from Callie's perspective. I was confident that she would then know what to do.

Sure enough, when she returned two weeks later, this time with Callie, the hitting had almost completely resolved. "I give her a bottle," Jane said. She had thought that she was "supposed to" get rid of the bottle by a year. But when the baby was born, Callie had become interested in the bottle again. So the three of them now sat quietly while Jane nursed the baby. Callie would drink an ounce or two and then lose interest in the bottle. She would play at her mother's feet until Jane was finished nursing.

Callie was a delightful little girl who played quietly while Jane and I spoke. Then we got to see the essence of toddlerhood in action. Callie went to her mother's purse and said "passie." Jane explained to me that as with the bottle, Callie had a renewed interest in the pacifier. "I decided to just let her have it." Jane rummaged in her bag and pulled it out, handing it to Callie, who took it, looked it over and gave it back. She returned to her play. A few minutes later she again said, "passie. " Again her mother gave it to her, and again she gave it back. This, I said, is the ambivalence of toddlerhood. Part of her wants to be a baby, but she also wants to grow up and be a big girl. Jane, by being respectful of Callie's perspective, was enabling her to sort this through naturally, Had Jane refused to let her have the pacifier, it is likely that, as an assertion of her wish to control the situation, Callie would have insisted on having it, and a battle would have ensued. She might have started using the pacifier again.

Jane, through her natural intuition about her daughter, figured out what to do. I simply offered her the space and time to think and to be heard. I hope that this small intervention has set the whole family on a different path. The baby now can nurse in peace. Jane is less worried that there is something wrong with Callie, who is in turn free to express her emerging self. For a young family, a little reflection goes a long way.

ADHD: The role of diet and sleep

2011-10-07T08:05:00.008-04:00

I recently had a guest post published on the CNN news blog, The Charts, entitled Calming your child's ADHD symptoms. The subject clearly needs a fresh look, given the startling statistic from a recent CDC report that diagnosis of ADHD was up by 29% from 2000 to 2009, and evidence that medication use for ADHD increased at an average yearly rate of 3.4% from 1996 to 2008.

In a nutshell, I describe ADHD as a problem of regulation of emotion, behavior and attention. I offer three points of approach. The first is to address family relationships. This is because children learn self-regulation in context of relationships with primary caregivers, and family conflict is clearly associated with increased risk for ADHD. Second, I recommend involving kids in activities that promote self-regulation including, but not limited to, horseback riding, swimming, martial arts and drumming. And last I recommend careful use of medication when a child's symptoms interfere with learning and social relationships.

A number of people commented that I had not addressed the issues of diet or sleep, both of which have been associated with symptoms of inattention and hyperactivity. I gave some careful thought to why I had not included these issues among the top three. The reason is that, in my experience, problems around sleep and diet are usually embedded in problems in relationships (the major exception is obstructive sleep apnea, a sometimes overlooked condition that can cause of hyperactivity in children. This topic is well covered in a recent post by an ENT specialist on the blog KevinMD.)

For example, I took care of one teenage girl with symptoms of inattention who met diagnostic criteria for ADHD. I learned that up until her thirteenth birthday, her mother lay in bed with her every night until she fell asleep. Then on the day of her birthday, her mother decided that her daughter was too old for this habit, and abruptly stopped, insisting that she fall asleep on her own. Not surprisingly, her brain and body had no idea how to fall asleep independently, so she was staying up until two or three o'clock every morning, sneaking her laptop into bed with her.

Many children with a range of behavior problems crave sweets. Parents describe constant battles around food choices. It is likely that these problems have complex causes: sweets may be used to reduce stress, and food is a place where children can exert absolute control by simply closing their mouths.

Certainly it is important for growth, development, and learning that children eat a healthy diet. Ideally they should have three meals a day with sufficient fresh fruits, vegetables, and protein and a minimum of processed foods. However, if all attention in management of ADHD is focused on diet, to the exclusion of relationships, then the intervention is off the mark. In addition, evidence for more specific food restrictions, such as dairy, wheat or food dyes, is more anecdotal, and some of these diets can be quite restrictive.

Similarly, getting enough sleep is essential to healthy brain function and regulation of behavior, emotions and attention. But, with the exception of obstructive sleep apnea, most sleep problems develop in the context of relationships. In my work with the teenager I describe above, we needed to understand what about family relationships, between mother and father as well as between mother and daughter, led to this problematic situation. Only then could we could begin to solve the "sleep problem." Many children I see with a diagnosis of ADHD have been engaging in battles with their parents for years around sleep, but almost always in the setting of a range of conflicts within the family.

My answer to those who question the omission of sleep and diet from my discussion of ADHD is that yes, these issues are important. In my CNN piece I describe inattention, impulsivity and hyperactivity as symptoms, and urge parents and clinicians who treat ADHD to not simply treat symptoms, but rather to address the underlying cause. Similarly, problems with sleep and diet are often symptoms of problems in relationships. Many parents describe being overwhelmed by the volume of information coming at them about this complex entity known as ADHD. I believe both parents and professional would do well to be open to a variety of ideas while maintaining a focus on supporting relationships and repairing disruptions in relationships.

Prevention and Primary Care

2011-10-03T06:44:00.003-04:00

One main objective of the Affordable Care Act, or health care reform, is to focus on prevention. This has been translated into requiring insurance companies to cover annual physicals and a variety of screening tests. Of course primary prevention is done in the setting of primary care. Unfortunately the government is, in a sense, working against itself because of the current system for determining reimbursement for medical services. Pauline Chen documents this well in her recent piece in the New York Times: How One Small Group Sets Doctors' Pay She writes:

Why are there so many medical specialists in a time when we need more primary care doctors? Meet the RUC, a committee of 29 men and women who play a critical role in dividing the Medicare pie.

She describes the close connection between the RUC and the Centers for Medicare and Medicaid Services, or C.M.S.

First, C.M.S. historically has approved 90 percent or more of the recommendations from the RUC. Second, while the RUC makes its recommendations based on an anonymous two-thirds majority vote, about 80 percent of those voting to begin with — accounting for 23 of the 29 seats — are physicians representing professional societies. Third, almost all of those physicians are specialists (currently only five RUC members are doctors from primary care fields).

Prevention happens through the relationships that develop over time in the primary care setting. Consider this story from my pediatric practice( details, as always, have been changed to protect privacy) Six year old Kevin’s mom, Robin, was upset about his constant fighting with his younger sister. I had taken care of both children since they were infants.

Robin was distraught over Kevin's need to always have everything first, and his demands were escalating. They were having increasing difficulty getting out of the house in the morning. I saw them for 2 fifty-minute visits. The first involved the whole family and we talked about some common approaches to managing behavior. I was struck by Mom’s level of distress, which seemed out of proportion to this fairly typical sibling rivalry. Towards the end of the second visit, when Mom was alone with Kevin, she quietly began to cry. I looked puzzled. She told me of the horrible accident that had taken the life of her older brother when she was a child. Her family never spoke about it. That trauma came flooding back now that she had two children of her own. She recognized that she had to mourn this loss in order to be present with her children in the way she wanted to be.

This was 10 years ago. Recently I ran into Kevin. He is now a talented musician as well as an excellent student. I saw him in town with his arm around a girl. He gave me a big smile and a friendly "hello." Of course I can't say what path his life would have taken had this trauma of his mother's not been addressed. But I suspect that it had a role in freeing him to develop into the person he is today.

Prevention can only happen in a meaningful way if the value of primary care is recognized. This involves not only monetary value. Certainly with the burden of loan repayment, financial issues are paramount in determining what field doctors-in-training chose to go in to. But in addition we as a society need to recognize that listening, particularly listening that occurs in the context of a relationship that develops over time, is an important form of treatment. Prevention is not only about screening tests.

Parenting Toddlers and Teenagers: Much in Common

2011-09-28T10:13:00.013-04:00

Psychoanalyst Peter Blos describes the "second individuation process of adolescence," referring to the way in which adolescence shares many qualities with toddlerhood in terms of developmental tasks. Sometimes when I listen to parents describe their struggles with their teenage children, I have an image of trying to contain a person, often bigger than themselves, who has advanced thinking skills. The tantrums of adolescence involve not thrashing arms and legs, but words, and often cruel and vicious words.

D. W.Winnicott, pediatrician turned psychoanalyst, offers some words of wisdom that can guide a parent through this challenging period. He writes, in his book Playing and Reality

If you do all you can to promote personal growth in your offspring, you will need to be able to deal with startling results. If your children find themselves at all they will not be contented to find anything but the whole of themselves, and that will include the aggression and destructive elements in themselves as well as the elements that can be labeled loving. There will be this long tussle which you will need to survive.

This idea resonated with Pam, mother of 16 year old Eva, who had come to see me for a consultation. She described the following scene. Pam and Eva had planned to have a nice lunch together. Eva was busy at school and had developed an increasingly serious relationship with her boyfriend, Chris. Eva and Pam had always been close and both eagerly anticipated this opportunity to spend a bit of time together. Things started off well enough. Eva excitedly told her mother about the latest social happenings at school and about a paper she was working on.

But then over some little thing, Pam couldn’t even remember what it was when she told me the story in my office, Eva had exploded with a burst of venomous rage. “You never think about my feelings,” she’d started with, calmly enough. But when Pam tried to get her to explain what she meant, Eva’s anger only increased. Vicious insults started flying at her. Caught off guard, Pam found herself becoming defensive.

Their discussion escalated into a shouting match as they quickly paid their bill and left the restaurant. Pam, in an effort to get home without being in an accident, stopped talking to Eva, who, she felt, was becoming increasingly irrational in her verbal assault on her mother. Pam’s silence only further enraged Eva and she screamed at her mother, who held tight to the wheel, hands shaking.

They made it home and immediately went their separate ways. Pam called her husband. As he was not the recipient of the full intensity of Eva’s distress he was able to support his wife and help her to calm down. Eva closed the door to her room and called her boyfriend. Several hours later Eva emerged from her room. “I’m sorry, Mom, she said. I’ve been feeling so much stress trying to balance work and friends and Chris.” “I understand that this is a very difficult time for you,” Pam had replied. “But," she went on to say, "it is not acceptable for you to speak to me the way you did.”

Pam was feeling beaten down by these repeated interactions with her daughter. While she had been able to negotiate the prior stages of development with Eva, the intensity of feelings directed at her from her teenage daughter sometimes was too much to bear. I told Pam that she was doing just what she needed to do, namely withstand the full intensity of her daughters feelings , both the negative and positive ones, yet set limits on her behavior. Pam needed to show Eva that she loved and supported her daughter, but would not allow her destroy her mother.

A toddler needs similar kinds of limits as he tries to make sense of who he is as a person separate from his parents. While two-year-olds will not say "thank you for setting limits," when parents contain both their behavior and their intense feelings, it helps them to feel safe and secure. This safety and security is needed just as much for teenagers as they begin to separate and develop their emerging identity. Ironically just when a teenager is most actively and aggressively pushing you away, she most need you to be there.

Winnicott offers a hopeful look at the future if a parent has withstood the “long tussle” of adolescence. He writes:

Your rewards come in the richness that may gradually appear in the personal potential of this or that boy or girl. And if you succeed you must be prepared to be jealous of your children who are getting better opportunities for personal development than you had yourselves. You will feel rewarded if one day your daughter asks you to do some baby-sitting for her, indicating thereby that she thinks you may be able to do this satisfactorily; or if your son wants to be like you in some way, or falls in love with a girl you would have liked yourself, if you had been younger. Rewards come indirectly. And of course you know you will not be thanked.

Music Therapy

2011-09-23T08:29:00.005-04:00

Recently in my behavioral pediatrics practice I saw James, a 5-year-old boy (details, as always, have been changed to protect privacy) who struggled with severe social anxiety. The lunchroom and gym were particularly difficult, and he would retreat into silence. In a visit with his parents we were discussing how to approach the teachers about making him comfortable in school. We had a full 50 minute appointment so we were, in a sense, free to let ideas emerge. That's when his father observed, "You know, he loves classical music." His mother described a recent outing where there had been a lot going on and James was quite agitated. But when someone put on some classical music, James became completely calm and seemed at peace.

It was an important detail. We began to brainstorm about how they might make use of this observation in the school setting in addition to social experiences outside of the classroom.

This story led me to wonder how this piece of information might help us to understand James' brain. For some reason he couldn't process all the sensory information coming at him in a busy social scene. But with the help of classical music, it was as if the neurons, the cells of his brain, lined up and began to work properly.

This visit got me thinking about a movie I recently saw The Music Never Stopped. It is based on the story of an actual patient as described by neurologist and writer Oliver Sacks in his essay "The Last Hippie." The movie's main character is a young man who suffered severe brain injury, and was socially disconnected even from his immediate family. But he had been a passionate musician, and when when he listened to music he loved from the time before his injury he became completely clear thinking and engaged. Like my young patient, his brain was a place of confusion and disorganization until the music allowed things to, in a sense, fall into place.

Interestingly, while working on this post I received an email from the publicist at Berklee College of Music alerting me to an upcoming program (October 5th-6th) about music therapy for autism spectrum disorders. The press release for the program states:

There is scientific evidence that music therapy influences children on the autism spectrum in several ways, like enhancing skills in communication, interpersonal relationships, self-regulation, coping strategies, stress management, and focusing attention,” says Berklee’s Music Therapy Department Chair Dr. Suzanne Hanser.

Similar to my young patient with social anxiety, children diagnosed with autism spectrum disorders are often overwhelmed by sensory input. It makes perfect sense to me that music would help them to organize their experience and engage with the world around them.

There is currently an explosion of research at the intersection of neuroscience, genetics, and developmental psychology to help us understand young children who are struggling with a range of what are usually referred to as "behavior problems." I am a clinician, not a researcher. However, I listen carefully to my young patients. I encourage their parents, as James' parents clearly were, to be curious about what the world is like for them. If we listen and observe in this way, these children can be our greatest teachers.

Postpartum Depression: Listening to Mothers

2011-09-18T07:45:00.006-04:00

When I see children in my pediatric practice for behavior problems, I often hear stories from mothers who struggled terribly when their children were very young infants. Among the most dramatic example of this was a mother with severe postpartum depression whose father died suddenly when her baby was four months old. Much to my astonishment, she described being relieved by this event. It wasn't because she didn’t love her father. Rather, in sharing the grief with her siblings and extended family, she no longer felt so completely alone.

A Massachusetts law passed last summer calls attention to the public health problem of postpartum depression (PPD). The most common complication of pregnancy, extensive research has demonstrated its significant long term effects on a child’s development, with increased risk for behavior problems in childhood and depression in adolescence.

The new law requires Massachusetts health insurers to submit annual reports on their efforts to screen for postpartum depression. The department of Public Health will develop regulations and policies to address postpartum depression. In addition the law calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.

The Boston Globe editorial board endorsed this legislation with the following statement: "Early detection could stave off far more serious problems for mothers and their babies, whose well-being is deeply linked to the first few months of care. And universal screening would ensure that no woman falls through the cracks. The sooner new mothers can be diagnosed, the sooner they will recover."

This legislation is an important first step. A lot of work needs to be done, however, to turn the Globe's very optimistic statement into a reality. This summer I became involved with two organizations who are working towards this goal. One is a working group of the Massachusetts Chapter of the American Academy of Pediatrics. One of the biggest problems with mandatory screening, which is done primarily by obstetricians and pediatricians, is that the people doing the screening may not know what to do with a positive screen.

Interestingly, a study of women struggling with PPD ( which I prefer to call "perinatal emotional complications" thus avoiding the stigma associated with major mental illness- I must give credit to Liz Friedman-see below-for coining this phrase) shows that mothers may not want a referral or medication but simply for their clinician, a person with whom they have an established relationship, to listen to them. Primary care clinicians need to feel comfortable with what our group called "engagement," - to stay in the room with a distraught mother before jumping to a referral.

Perhaps equally importantly, the health insurance industry need to recognize that time and space, offering a mother, who may feel so terribly alone, a chance to be heard in a non-judgemental way by a respected caregiver, is an essential part of treatment.

The second organization I connected with is called MotherWoman. This organization seeks to educate clinicians and to create referral networks of people in communities who can offer a variety of interventions for these mothers. It is run by a remarkably energetic and enthusiastic woman, Liz Friedman. She describes her program as follows:

The Community-based Perinatal Support Model (CPSM) has been developed to address the gap between screening and services for mothers. CPSM aims to prevent, identify and facilitate treatment of PMD(perinatal mood disorders) by creating a comprehensive, community-based, multi-disciplinary safety net for women.

These two organizations are starting the hard work necessary to translate the new legislation into a form that is useful and meaningful for mothers struggling with perinatal emotional complications.

When I speak with mothers like the one above, I wish that I had seen them when their children were infants. This is not to say that their child's behavior problems is their fault. But the research clearly shows that when mothers are emotionally available to their young infants, development proceeds in a healthy direction. By working to address perinatal emotional complications, we have the opportunity not only to ease these mothers' suffering, but also to help them to be fully present with their babies. We can help transform these early months from a time of stress and pain into a time of joy and love.

Creativity in the Age of Psychiatric Medication

2011-09-12T05:30:00.019-04:00

Recently I attended a reception at the Austen Riggs Center in Stockbridge, MA for the new medical director. Austen Riggs is an inpatient psychiatric hospital where intensive psychotherapy remains the core of treatment( thought certainly medication is used as well.) At the reception I met the new Erikson scholar, an art historian who is writing a biography of a woman, one of the first patients at Riggs, who shortly after her stay went on to become a world famous violinist. We spoke about the connection between mental illness and creativity. We wondered what this woman's fate might have been had she lived today when she most surely would have been medicated.

In the last chapter of my new book Keeping Your Child in Mind: Overcoming Defiance, Tantrums, and Other Everyday Behavior Problems by Seeing the World through Your Child's Eyes I discuss the problems associated with the exponential rise in prescribing of psychiatric medication for children. While I am not against medication per se, I have a number of concerns about what I consider to be an over-reliance on medication to treat complex problems. Not only are there side effects and unknown effects on the developing brain, but medication is often the focus of treatment to the exclusion of important family issues. Significant events in a child's life may go unaddressed. Usually a child does not have an opportunity to talk about what it means to him to be taking a pill to manage his behavior.

Following this conversation at Riggs it occurred to me that I should add yet another concern- potential loss of creative talent.

Several weeks ago there was an op ed in the New York Times: “Words Failed, Then Saved Me, “ that offers a beautiful example of turning a biological vulnerability into an adaptive asset. The author, Philip Schultz, now a Pulitzer Prize winning poet, struggled terribly as a child with what is today recognized as dyslexia. Schultz describes how his mother would read his favorite comics over and over again with the hope that this would help him to make sense of words. I wonder if this kind of tolerance and patience gave Schultz the space to, as he says, “invent a new way of reading” that was adapted to his particular form of dyslexia.

Schultz describes not only his academic struggles but also how he was kicked out of one school for hitting other children when they called him "stupid.' I wonder if he had been child today, he might have been described as "impulsive" and "distracted," classic symptoms of what now is called "ADHD." He might have been diagnosed and medicated. Had his symptoms been medicated away, he might not have invented his new way of reading, a method he now uses to teach others with similar difficulties to write fiction and poetry. He might not have become poet, much less win the Pulitzer Prize.

As a behavioral pediatrician, I often hear parents ask if there “something wrong" with their child. I help them to reframe the question, asking instead “what is his experience of the world, and how can we help him to make sense of and manage that unique experience?” I have seen kids who were "explosive" and "inflexible" as very young children. They were easily overwhelmed by a variety of sensory experiences. But in the setting of an understanding and supportive environment, they have gone on to be talented actors, musicians and artists.

Supporting children in this way involves investment of time and energy from parents, teachers, and clinicians. In our culture treatment of a child with "behavior problems" usually focuses on resolution of symptoms, often with medication, rather than understanding the meaning of behavior. Medication may more quickly control a child's symptoms. But at what cost?

Keeping Children in Mind on 9/11/11

2011-09-07T06:54:00.008-04:00

When I first learned of the planes hitting the twin towers, my initial thought was that I wanted my children, then three and six, home with me. This is despite the fact that I live in a rural community 125 miles north of New York City that was in no way physically affected by the trauma. As the 10th anniversary of 9/11 approaches, I have been thinking of reaction, of how in the face of overwhelming fear our first instinct is to be near our children.

Children, in fact, have a similar reaction. This behavior was initially termed "attachment behavior" by John Bowlby, a British psychoanalyst who developed his theories in England during World War II, when he saw the devastating effects on children who were routinely separated from their parents and moved to the countryside, ostensibly to "keep them safe." Heavily influenced by Charles Darwin, he recognized this behavior, this drive to seek out primary caregivers in the face of fear, as essential to the survival of our species. Over 50 years of subsequent research based on his original theories has shown that in order for a child to feel secure in this attachment, a parent needs to be reliably available, both physically and emotionally. It is this sense of safety and security that gives children the freedom to explore, grow and develop.

In other words, in order for them to be OK, they need first and foremost for us to be OK. Certainly it is important include children in conversations about 9/11, to listen carefully to what they are thinking and feeling, and to clarify any misperceptions they may have. But this listening cannot happen effectively if parents do not first take care of themselves.

I once saw a mother in my behavioral pediatrics practice who's family had experienced a different mass trauma (to protect privacy I will omit details) She wanted me to meet with her two school age girls to "make sure they're OK," a perfect example of that instinct to protect the children first. I suggested instead that I meet with the parents. The mother came by herself- the father was still back at the site of the trauma. She had relocated to my town to stay with family. We spent an hour talking mostly about what the experience had been like for her.

She was suffering from anxiety not only about the effects of the initial trauma on her children but also the massive uncertainly of their future and such basic questions as where they would live. But we also talked about other things. One was her relationship with her own parents. Her father, who had died recently, was an incredibly stoic man who had himself survived unimaginable trauma. We talked about how she thought of him often and tried to emulate him. But she recognized that she was shouldering in a lot in trying so hard to be brave. At the end of the hour, she smiled, let out a big sigh, and said, " I really needed to talk about this. I feel so much better!" She recognized that her children were doing well, as evidenced by the fact that they were doing their schoolwork and participating in all of their usual activities. More than anything they needed for her to be fully present with them. And to do that, she herself needed to be heard .

Immediately following the terrorist attacks of September 11, 2001, leading trauma researcher Susan Coates provided critical mental health services to children and their parents at the Family Assistance Center set up by Disaster Psychiatry Outreach in New York City. In an interview Dr. Coates said, "Parents are often surprised by how much their children have taken in. And sometimes we find that we need to shift our attention to parents who are so overwhelmed already that they cannot take in what their children are communicating and find that their own posttraumatic stress is triggered by what their children are communicating."

As pediatrician, I often have parents ask me "what to do" in a range of situations. I understand this wish to have some kind of instruction manual, especially in the face of this upcoming anniversary. But in fact parents are the experts regarding their child, and if I tell them what to do I am undermining their natural authority. What I do instead, as I did with this mother, is offer them a place to be heard, with the hope that this will free them to be with their child both physically and emotionally- to be, in Bowlby's words "a secure base." From this place, "what to do" will follow naturally.

Promoting Healthy Emotional Development in Children: Social Media Helps the Cause

2011-08-31T08:06:00.021-04:00

In 2006-2008, years I hope will turn out to have been the peak of the bipolar diagnosis in young children, it was not uncommon for parents to bring a child as young as 18 months to my behavioral pediatrics practice asking if he had the disorder. During the same time period, I had the good fortune to be a scholar with the Berkshire Psychoanalytic Institute. There I was exposed to a wealth of research and knowledge at the interface of developmental psychology, genetics and neuroscience, coming out of the growing discipline referred to as infant mental health (in this discipline "infant" refers to age zero to five.)*

The research I was learning about, particularly the work of Peter Fonagy, offered me the tools to help families in dramatic and meaningful ways. He and his colleagues have shown how children develop a healthy sense of self, and with that a capacity for empathy, emotional regulation and resourceful thinking, when the people who care for them respond to the meaning of their behavior, that is, motivations and intentions, rather than the behavior itself. This kind of reflection, referred to as holding a child's mind in mind, actually promotes healthy development of the regulatory centers of the brain.

Being a responsive caregiver in this way, particularly in the face of a biologically vulnerable child, is very hard work.
In my office, guided by this model, I aim to listen to the whole of caregiver’s experience in order to fortify their efforts to be fully present with their child. In doing so, I aim not only to change behavior but also to support relationships and to get the rapidly moving train of development back on track.

I longed to communicate to my pediatric colleagues, who are on the front lines with young children and families, not only this new knowledge, but also the way I was able to use these ideas everyday in my pediatric practice with such powerful results. The model of psychiatric diagnosis, often followed by psychiatric medication, needed to be counterbalanced by this alternative paradigm. But I felt that I was living in two completely separate worlds. How could I bring them together? This is where social media comes in.

At first my plan was to develop a curriculum for pediatricians in training. But as a small town doc with no academic appointment, it was hard to break in to this world. Then in June of 2008 the story broke about leading psychiatrists receiving, but failing to disclose, large amounts of money from the drug companies who manufacture the medications used to treat childhood bipolar disorder(they were subsequently found to have violated conflict of interest rules.) I was moved to write an op ed for the Boston Globe entitled Mind Altering Drugs and the Problem Child. The overwhelmingly positive response led to the decision to write a book (That book Keeping Your Child in Mind was released August 30th.) My thinking was that writing for a general audience, important in its own right, might also give me a way in to the world of academic medicine. In addition to embarking on the book project, I started writing this blog.

This past March, a follower of my blog emailed me a link to an article in the New Yorker. The article The Poverty Clinic, described the practice of Nadine Burke, a pediatrician who was incorporating principles of Infant Mental Health in her inner city clinic. I was thrilled to find another like minded pediatrician, particularly one who was so successful, and I subsequently wrote a blog post, Early Relationships and Brain Development as the Core of Medical Practice, about Dr. Burke and her work.

Shortly after this post went up, a pediatrician in Seattle, doing a search for information about Dr. Burke, found my blog. She emailed me to say that she had been up all night reading it. She too had discovered the wealth of knowledge in the world of Infant Mental Health and she too was overjoyed to find a like minded pediatrician. She told me how these ideas, as I describe above, had completely transformed her practice. Rather than "giving advice" and telling parents "what to do" from the stance of an "expert" she found herself listening to parents in a new way. By shifting her task from "fixing problems" to "supporting relationships," she had seen dramatic changes in her her ability to help young children and families. She invited me to speak this coming April at a conference she was organizing for general pediatricians on Infant Mental Health.

About a month later I received an email from a new fellow in Developmental and Behavioral Pediatrics at Boston Medical Center. She was from Seattle, and had worked with the same pediatrician who had discovered my blog via Dr. Burke. That pediatrician had suggested to this new fellow that she seek me out. She, in turn, approached the director of her program, with the suggestion that they read my book and invite me to come and speak about it. So here is my foot in the door of academic medicine in the Boston community, thanks to social media, via San Francisco and Seattle. (I will soon have an opportunity for both practice and teaching in the Boston area-stay tuned to my blog for news about this in the coming months!)

So here I am writing about what I am doing, namely using social media to bring new knowledge to a larger community. As a country doc, I fully embrace this model of shared information as a powerful tool to make the world a better place for children and families.

* Note to my regular readers: this is an introductory post for the new direct feed of my blog posts on the Boston.com website

Pharmaceutical And Health Insurance Industries May Harm Children's Mental Health

2011-08-23T08:07:00.023-04:00

This will be a brief post (I'm on vacation with my family) just to call attention to two important and related items published yesterday. First, in the New York Times, an Op Ed entitled "The Kids Are Not Alright about how "corporate interests threaten children's welfare." As one example, the author states:

Another area of concern: we medicate increasing numbers of children with potentially harmful psychotropic drugs, a trend fueled in part by questionable and under-regulated pharmaceutical industry practices. In the early 2000s, for example, drug companies withheld data suggesting that such drugs were more dangerous and less effective for children and teenagers than parents had been led to believe. The law now requires “black box” warnings on those drugs’ labels, but regulators have done little more to protect children from sometimes unneeded and dangerous drug treatments.

Another related piece published on Kevin MD refers to the Wall Street Journal article describing the fact that over 25% of children in the United States are on some form of chronic medication. The author, Maggie Kozel, is a pediatrician who has written a book entitled The Color of Atmosphere: One Physician's Journey In and Out of Medicine about the effects of managed care on the practice of primary care medicine, that I will be sure to read when I get home. In her recent piece she writes:

Our system of private, fee-for-service insurance is basically a business model that focuses on the top of the health care pyramid (the doctor) and pays for quick fixes (prescriptions) with immediately observable (short term) results. That works great for bacterial pneumonia; not so much for a kid bouncing off the walls, or gaining too much weight, or who is sad. Nowhere is this more glaring than in the realm of mental health.

Health insurance companies have determined, by virtue of their reimbursement strategies, that the work of treating serious mental illness would shift to primary care providers. A recent study by the AAP predicts that treatment of mental illness and mood disorders will soon makeup 30-40% of a pediatrician’s office practice. To put this trend in perspective, an earlier study that appeared in the journal Pediatrics revealed that 8% of pediatricians felt they had adequate training in prescribing antidepressants, 16% felt comfortable prescribing them, but 72% actually did. If they don’t, who will? This is just one example of the growing disconnect between rational medical practice and the way we deliver healthcare. Furthermore, where do both pediatricians and psychiatrists get most of their information about these psychotropic medications that are now flying off prescription pads? The pharmaceutical companies that produce them, through the hundreds of millions of dollars they spend each year on marketing and the clinical studies they fund. The insurers and pharmaceutical companies aren’t necessarily the bad guys here. They are doing what they are tasked to do: run a business.

I am pleased to be joined by these intelligent voices in calling attention to the very serious problem of over-reliance on psychiatric medication to address complex problems in children's lives.

Having Empathy for Parents: An Essential First Step

2011-08-18T12:32:00.022-04:00

I continue here with the theme of my previous post. I was inspired to write by a conversation over dinner last night with a friend who is a prominent psychoanalyst. He was describing a case that had been discussed at a conference. Yet another well respected psychoanalyst presented an analysis of a five year old boy. Already my bristles were up, but I tried to listen with an open mind. As a kind of an aside to the main story about the child and his analyst, my friend relayed that the parents "were awful in some way." The analyst had described to the group how the little boy had become fixated on the whereabouts of his wife, to the point where he could not stay in the room and had to go and look for her. The idea, my friend explained, was that a five year old child needs to hold in his mind a relationship not only with each parent, but with the parents in relation to each other, in order to feel emotionally at ease. Fair enough, I said (though this classical model needs some careful rethinking in the face of many different family constellations seen today.)

But however important this analyst's observation may be, this case felt to me more like a use of the child as a lab specimen in the study of child development than an effective form of treatment. As I have said in multiple blog posts, and describe in detail in my new book Keeping Your in Child in Mind(in stock at Amazon now!) what is most important for a child's healthy development is that he feel understood by the people he loves. At the age of five, being understood by a therapist, should, in my opinion be part of the larger goal of supporting the parents in their understanding of their child. For this to happen, as Dr. Ornstein so wisely describes (see previous post), the parents must be an integral part of the treatment of a young child.

When a therapist judgmentally dismisses parents as, "awful in some way," it precludes any meaningful participation. Having worked with countless young children and families, I do understand where this reaction comes from. Recently I saw a four year old girl with her parents. Her fathers rage at this young child was barely contained. He spoke of her in highly negative terms while she sat playing on the floor. It was painful to listen to. But when I met with the parents alone, he broke down and cried, telling of his own abusive father and how he struggled daily with his own internal rage. He hated himself for directing it at his young daughter, who he loved more than anyone in the world. When he recognized that I was not judging him but rather was empathically listening to his struggles, he could accept a recommendation for his own therapy without becoming defensive. While the parents had come to me for advice about how to manage their daughter's behavior, now they could think about her perspective. They could ponder her experience as the recipient of her fathers displaced rage.

On my Psychology today blog, I received an interesting comment in response to my post Dyadic Therapy: Working with the Parent-Child Relationship This writer questioned my position of empathy. He had been abandoned by his mother at birth, his father died when he was nine and he was raised by a member of the Hitler youth who fled war torn Germany. She had threatened him with being sent to an orphanage for any bad behavior and admonished him not to cry at his father's funeral. He concluded his comment with "Dyadic therapy with the long-dead Nazi warlord is not likely gonna work?"

My first response was that, in the absence of frank abuse or severe mental illness, I believe one can always work with parents to support efforts to think about their child's mind and subjective experience. In another post I refer to the beautiful work of psychoanalyst Carole Gammer, who works with parents and children together in the face of with significant parental mental health problems. Not a treatment for the parents, it is instead a focal intervention whose aim is to, in a sense, support the parents' efforts to hold their child in mind. She has amazing results under highly adverse circumstances.

However, I had to rethink my response to his comment. On second thought, I wrote, "Unfortunately one could argue that, at that time in history, large segments of German society were exhibiting behavior consistent with abuse, severe mental illness, or both." The empathy I am advocating for assumes a certain level of sanity in society. Respect for parents, offering help for those who, like the father in my story, are struggling, and valuing this critical yet highly challenging task of raising the next generation, is part of that sanity.

Parenting and Empathy: An Essential Partnership

2011-08-13T05:32:00.035-04:00

Last week I had the privilege of reconnecting with Anna Ornstein, a brilliant child psychiatrist and one of my original mentors. In preparation for our meeting, I re-read a paper she had given me back in 2004* (written with her husband Paul Ornstein, MD about 20 years before that), when I was just beginning to develop the ideas now described in my new book, Keeping Your Child in Mind. While I do not reference the paper in my book, it is filled with such wisdom that I felt compelled to quote large segments of it in this blog post. Interestingly, much of what she says is similar to what in the current world of developmental psychology is referred to as "reflective functioning, " or what I refer to in my book as "holding a child's mind in mind." While in that language, empathy is included as one component of the more complex task of reflective functioning, in Dr. Ornstein's language "empathy" encompasses the many components of reflective functioning. She writes:

The parent who is capable of parental attunement is one who developed an adult form of empathy-a capacity in which an adult man or woman can immerse him or herself into the inner life of a child without this threatening his or her own sense of separateness and without the parent injecting his or her needs into the interaction with the child. This is a more complex and difficult task than is generally acknowledged.

She goes on to be more specific:

In other words, empathy involves the recognition of the child's motives for the behavior. Since in the case of a young child only the behavior is available for observation, it is more likely that this will be interpreted in terms of meaning that it has for the caretaker rather than the meaning the behavior has for the child. This is particularly true once the child's motive has been partially or completely ignored and the behavior has been responded to only in terms of its meaning to the caretaker. By the time the child becomes demanding, hits or bites because his intent has been originally misinterpreted or ignored, an interaction has been set in motion that precludes the possibility of recognizing and responding to the child's original motives.

But the beauty of Dr. Ornstein's paper is that not only does she capture this idea so clearly, but then goes on to articulate why this happens and how to work empathically with parents to help them to change these unhealthy patterns of interaction. She writes, " we consider parenting as on of the most important challenges in the consolidation and esteem of the adult's self." She gives an example of a toddler:

Toddlers experience themselves as the center of the universe; they are now filled with a sense of initiative and healthy vigor. They want those around them to see, recognize, and acknowledge their intoxicating sense of what they discover to be their own powers and abilities. To an environment[parent] that is fearful of losing its control over the toddler's developmentally exaggerated sense of power, this behavior will be threatening. Under these circumstances, the environment[parent] attempts to reinforce its control, battles ensue, and a child's self assertion disintegrates into the aimless and frequently destructive forms of aggression...In terms of overt symptoms, we witness an increase in the intensity of separation anxiety; the toddler becomes clingy and whiny and develops nightmares and other forms of sleep disturbances.

Dr. Ornstein then goes on to brilliantly address the implication for child therapy.

As a brief aside, Dr. Ornstein told me, over our glass of wine, that she was fired from her job for writing a paper that espoused similar ideas in the mid 1970's. In the heyday of psychoanalysis, children were treated without involvement of the parent, and Dr. Ornstein's assertion that one could not treat the child without including the parent was considered heresy. She writes:

Listening to case conferences in which families and their troubled children are being discussed, it appears extremely difficult for the professional not to create or reinforce guilt in the parents for their child's emotional difficulties...we would suggest that therapists of children of all ages, but certainly those of young children, focus their attention on the specific features in the parents' personalities that have made the parenting of this particular child at this particular time in the child's and parent's lives, difficult for them.

She goes on to say:

Parental dysfunctions are symptoms that require exploration as do other psychological symptoms...When the therapist does not appreciate the narcissistic mortification that parents experience [narcissism in relation to a child is a healthy thing in-as-much as one views the child as a part of oneself] that parents experience for having a troubled child and when parents feel further reduced in their self-esteem because they are not included in the therapeutic effort, it is then that they are likely to remove the child from treatment or look for an explanation other than a psychological one for the child's difficulties.

I believe Dr. Ornstein's elegant words speak for themselves. The contemporary world of developmental psychology, as I have said, espouses the same ideas but with two differences. One is that Dr. Ornstein's paper is filled with psychoanalytic language that can be hard to relate to. Second, and perhaps most important, is that the significance of "reflective functioning" or "holding a child in mind," in facilitating healthy emotional development, has been demonstrated by years of high quality longitudinal research. Dr. Ornstein's ideas, however eloquent, are, in contrast, based on clinical experience alone. Going back to read her paper after all these years made me recognize the importance of not only including clinical experience in development of new ideas, but also addressing the poetry and passion of parent-child relationships, which can be diluted out in pursuit of "evidence" in the research setting.

*The paper is a chapter in a book entitled Parental Influences in Health and Disease, eds James Anthony and George Pollack

Supporting A Parent's Natural Intuition

2011-08-06T06:55:00.010-04:00

Yesterday I had my first radio interview about my new book Keeping Your Child in Mind, which will be released this coming Tuesday. I welcome the opportunity to talk about my book, not only because it helps spread the work about ideas important to the future of our children, but because these discussions offer the opportunity for new thinking. In the interview yesterday, I was asked the question: "Do parents need to read books to be able to understand their child?" A particularly interesting question to ask a person who has just written a book for parents! I began my response by saying that I was not in general a fan of parenting books. They run the risk of trying to apply a one size fits all approach when in fact each family situation is unique. But perhaps more importantly they can undermine a parent's natural authority.

Rising to the challenge of thinking while I'm talking, I then said that the problem is that things get in the way of a parent's natural intuition, and that my book in a sense supports parents in recognizing and addressing these obstacles. I had actually never thought of it this way before. "What can get in the way," I went on to say, "includes such things as depression and marital conflict." And just stress in general," my wise interviewer added. "Yes," I agreed. "when parents are free from external stress, they have a natural intuition and understanding about their child." As I say in my book, in reference to the work of D.W. Winnicott, pediatrician turned psychoanalyst: "A mother knows what her baby feels through her intense identification with him. He is part of her."

My interviewer was particularly drawn to the title of the second chapter: "Strengthening the Secure Base: Listening to Parents." I had an image as we were talking of clearing the brush, made up of the multitude of stresses of life, to be able to gain a clear view of your child. Obviously there is more to this task than reading a book, but my hope is that parents will recognize themselves in the stories in my book, feel understood themselves and in turn be better able to access their own natural understanding of their child. Then they won't need to read any parenting books!

Infant-Parent Mental Health: Getting the Word Out

2011-08-02T07:30:00.024-04:00

I was so enthralled by the movie Page One that I saw it twice in one weekend. It is a behind-the-scenes look at the New York Times. It addresses the question of how people receive information: the relative roles of traditional journalism and new media, and how things are so rapidly changing. While it may seem a bit off topic for my blog, I thought to write a post about it when yesterday I received the latest issue of Zero to Three (not published on line), the journal of the organization Zero to Three National Center for Infants, Toddlers, and Families. It is jam packed with a wealth of important information. There are articles about, among others, healing from postpartum depression, a program designed to strengthen relationships between parents and children, and a case of selective mutism, all from the perspective of the discipline of infant mental health.

Over this past year as a fellow in the U Mass Boston Infant-Parent Mental Health Post-Graduate Certificate Program, the other fellows and I had many conversations about what a treat it was to spend intensive time with like-minded colleagues, but how frustrating it could be when we returned to the "real world" and people didn't know what we were talking about. One woman, who was about to graduate from law school and plans to be a child advocate, told of speaking with judges about how early relationships shape the brain and being looked at like she had three heads. There was no support for her lawyer colleagues to encourage them to address the more complex and often painful issues involved in dealing with suspected abuse and placing children in foster care.

Tying these ideas together, I recently was referred, in my behavioral pediatrics practice, a seven-year-old girl with selective mutism. She had gone through two years at school without talking. Now her parents came to me with the question, "Should we do something or give it another year?" With a full hour to talk with her parents, I heard a story of a girl who had struggled with severe separation anxiety since infancy. The family was dealing with multiple stresses, and there were generations of similar difficulties (selective mutism is now understood as being a manifestation of social anxiety, which often occurs in multiple generations). None of this had ever been discussed until our visit. The school had had a number of meeting with the parents in which they said to give it more time, but now were telling the parents that if she did not start talking, she would have to be placed in a special education class. This is despite the fact that the girl was clearly of normal intelligence and spoke well and frequently at home.

Somehow the wealth of knowledge coming out of the growing discipline of infant mental health must find its way to the larger community. At the back of this issue of Zero to Three, there are reprints in English and Spanish of handouts "designed as tools to spark discussion on important child development topics and to support parents in developing the skills of self-awareness, careful observation, and flexible response." It has a section with the heading "Behavior Has Meaning" stating:

All behavior has a purpose. Babies and toddlers are not able to put their thoughts and feelings into words very well, so they communicate by using actions. A baby may cling and cry because she is fearful of new places. A toddler may bite to keep another child from interrupting her play. Understanding what your child's behavior is telling you helps you find supportive ways to respond to her and teach her better ways to express herself.

I wanted to bring these parents of the girl with selective mutism to place where they would ask not "what can we do to make her talk?" but "why is she behaving this way? and "what does it feel like for her to struggle in this way?" These kinds of questions would naturally lead them to "what to do" to help her and support her with these struggles. Our visit was a start. I introduced a new way to think about the problem. I can only hope that it sunk in. Having the Zero to Three handout might have helped, but certainly seeing her at four, three or even two would have been preferable.

So here I am, writing about what I am doing, namely using social media to bring new knowledge to a larger community. In the very near future (perhaps this week) I will have a direct feed of my blog on the newly designed Boston.com website (the Globe is following the lead of the New York Times in offering a separate free and subscription site) As Page One clearly shows, both traditional journalism and new media have an important role to play!

Pediatricians Prescribing Psychiatric Medication: A Dose of Reality

2011-07-22T08:01:00.002-04:00

Recently I attended a meeting of a working group of the Massachusetts Chapter of the American Academy of
Pediatrics(MCAAP) The task of this working group, a subgroup of the MCAAP task force on mental health care in pediatrics, was to address the need for collaboration between pediatricians and mental health professionals in caring for children. At the meeting individuals described different models.

One pediatrician, a man who has been in practice for over 30 years in a large group with 15 pediatricians and 10 nurse practitioners, was invited to present his model, held up as an example of an innovative and workable model. This is what he said.

First, clinicians went in groups of 4 to attend conferences run by Joseph Biederman, who, this doctor stated, "runs one of the best research programs in the country." (This is the same Biederman recently found guilty of violating conflict of interest rules in accepting, and not reporting, millions of dollars from the pharmaceutical companies that make psychiatric medication- see previous post.) Then a child psychiatrist, a close colleague of Biederman"s, started bi-weekly phone consultation with the group as a whole.

Now, this pediatrician said with pride, the clinicians in his practice are comfortable " treating 80% of ADHD, anxiety and depression." They were hiring a social worker, whose job it would be not to do therapy, but rather to "make sure patients are taking their medications and refilling prescriptions."

In other words, mental health care, at least for this doctor and his large group, is equivalent to prescribing psychiatric medication.

This practice is paid by Blue Cross Blue Shield under the new model of AQC(alternative quality care) global budget. If the practice overspends they pay the insurance company and if they underspend they split the profit. In addition, if they practice "quality care" as defined by the insurance company, they receive more money. One measure of quality is follow up every four month for ADHD and compliance with psychiatric medication.

Another pediatrician offered an alternative model of collaborative care. She described a close personal relationship with a psychologist, who was also at the meeting. She described how, through confidential voicemail and email, they spoke frequently about their most challenging patients, working closely to provide care, and in doing so keeping a number of patients out of the hospital.

Until this point, I had been silent, taking this all in, trying to find some solid ground to stand on. In a sense the people who presented these two models were speaking completely different languages, one in which mental health care equals medication and another in which mental health care equals providing a holding environment through relationships. I volunteered that providing a setting in which mental health professionals and pediatricians in a community could develop relationships, such as a monthly collaborative case conference, might be the best model. Fortunately the leader of the group was intrigued by this idea as a model to implement and study.

Unfortunately this point of view is at risk of being overpowered, under the influence of the pharmaceutical and health insurance industries, by the first doctor's model. Our best hope for fighting this trend, I believe, lies in maintaining a focus on prevention, and on promotion of healthy social -emotional development in early childhood through relationship based interventions. I will continue to focus my efforts, as I have written about at length on this blog, both on working with young children and their families and teaching pediatricians about the world of research and knowledge coming from the discipline of infant mental health.

I left the meeting feeling a combination of horrified and hopeful, but certainly energized to forge ahead, even if at times it really feels like swimming against the tide!

The Antidepressant Debate: A Pediatrician's View

2011-07-17T13:29:00.016-04:00

In 2002, when I was practicing general pediatrics, I was called to our local emergency room to see a teenager who had attempted suicide by ingesting a variety of pills. She was a patient of a pediatrician who did not have admitting privileges at our hospital, so I did not have a prior relationship with her. After she had been medically stabilized, I took a detailed history.

She was an athlete and top student who had been struggling under the pressure of college applications when her pediatrician, several weeks before this incident, had placed her on the antidepressant paxil. Both the girl and her mother described behavior that was totally different from her usual self. She had gone out drinking with kids who she hardly knew. She was impulsive and agitated. I was alarmed by this sudden change in behavior, so alarmed that I ordered a CT scan to be sure that her symptoms were not caused by a brain tumor.

I now understand that she was experiencing a side effect of paxil. While there had been growing evidence that these drugs had the potential to cause suicidal ideation and behavior, as is well documented in Side Effects: A Prosecutor, a Whistleblower, and a Bestselling Antidepressant on Trial by Alison Bass, it was not until 2004 that the "black box " warning describing the risk of suicidality in pediatric patients was instituted. in 2002 I was unaware of these findings, and had in fact prescribed these medications to a number of teenagers in a way that in retrospect seems cavalier and risky.

In today's New York Times Sunday Dialogue Seeking a Path Through Depression's Landscape there is minimal mention of children. Marcia Angell, in her letter in response to Warren Procci's letter (which was written in response to last Sunday's op ed In Defense of Antidepressants) states:

Many have devastating side effects, especially in children and when used long term. Studies generally show that the benefits are small.

I follow these discussions with interest, but I believe the problems of psychiatric medication use in children is of a different magnitude. It is not simply a question of the relative merits of psychotherapy or medication, or of the potentially serious side effects. Rather it is a question of what is not done when psychiatric medication is used to treat symptoms in children.

Last summer I attended a wonderful course entitled "Keeping The Brain in Mind." Teacher Francine Lapides referred to psychotherapists as "neuroarchitects." In the course of a long-term trusting relationship with a patient, one in which a therapist is attuned to the patient's experience, often in a way that the patient's own parents were not, the brain may actually change. This kind of a relationship can change the way a person manages and responds to stress. The patient may learn, at the level of biochemistry of the brain, to think about feelings and regulate and manage difficult experiences.

Listening to this material as a pediatrician, I thought about parents as the original neuroarchitects. When a child is struggling, whether with sadness, anxiety or explosive behavior, supporting parents efforts to understand and manage their child's experience can offer parents the opportunity to help their child in safe and meaningful ways. This is not to say that the problem is the parent's fault. But when parents themselves have the chance to tell their story in a supportive non-judgmental environment, I have found that this fortifies them to be present with their child in a way that helps the child manage his or her particular vulnerabilities. This kind of emotional presence with a troubled child is very hard work, and parents need the time and space to be heard.

In a sense, psychiatric drugs can deprive parents of this opportunity. Drugs place the problem squarely in the child. In my pediatric practice, I meet with parents and bill under the child's name. It is not therapy for the parents or the child, but rather support for the relationship. Certainly many excellent child therapists work with parents in this way. But when symptoms are treated with medication, it may be difficult to find the motivation to do this hard work. Thus the opportunity to use the loving caregiving relationship to help a child learn to manage his or her own feelings may be lost.

Without this opportunity, I wonder how many of these children will end up ten, twenty or thirty years from now telling a therapist about how their parents didn't understand what they were feeling. This missed opportunity is, in my opinion, a potentially tragic side effect of prescribing psychiatric drugs to young children.

Beyond Biederman and Antipsychotics for Young Children

2011-07-12T18:13:00.033-04:00

In the blogging world there is a lot of understandable outrage about this issue (though surprisingly little in the press-nothing in the New York times and one holiday weekend piece in the Boston Globe.) There is outrage both about the finding that Biederman and his colleagues had, in fact, failed to disclose enormous consulting fees from the pharmaceutical companies, and that the punishment was fairly mild, considering that as a result of his work huge numbers of young children were placed on atypical antipsychotics, powerful mind-altering drugs with serious side effects. In addition, there seems to be quite a bit of evidence that Biederman and his colleagues were actually working in collaboration with the pharmaceutical companies to promote both these drugs and the diagnosis of bipolar disorder in children. This issue is thoroughly covered on a blog called Boring Old Man.

Reading about this subject causes me a great deal of agitation as well. But outrage is not enough. The questions that need to be answered are one: how did we allow this to happen? And two, what path can we take as an alternative to this misguided one? Without addressing these questions the outrage simply causes hypertension.

Yesterday morning I was feeling rising agitation as I delved into this selection of blog posts, when fortunately my 10 AM patient arrived. I think her story offers some answer to these questions. As always, I will change details to protect privacy while maintaining the essence of the story.

3-year-old Anna was adopted by her parents, John and Diane, about 4 months prior to this, our second visit. At our fist visit, I met for an hour with her parents. Anna had experienced significant loss and physical trauma in her early years and had been adopted out of foster care after a number of different placements. When she first came home with John and Diane, she had little language, but now after just 4 months in many ways she was thriving. But both both parents were being undone by her almost daily severe explosive tantrums. Their marriage was severely strained as they fought over how to manage these outbursts. had called me in desperation one day to say that she needed to come in sooner, despite the fact that our appointment was only two days away.

After I listened for about 45 minutes, while they told me the story of what they knew of Anna's previous life, as well as about their lives and how they came to adopt, I asked for them to describe to me in detail what these tantrums looked like. At some seemingly minor frustration, Anna would first clench her fists in frustration. When her parents intervened, this would escalate to uncontrollable kicking, biting and spitting. Diane described feeling full of anger when her otherwise sweet child behaved in this way, and John insisted that Anna needed to "learn to listen to them." Sometimes they would give her a time out, sending her to her room, or threatening to take away some beloved toy. Or they would ignore her, letting her run around. With either approach the episode ended when she eventually simply collapsed from exhaustion.

Just before our visit I had been reading the work of psychiatrist Bruce Perry, who I referred to in my previous blog post, who has written some wonderful handouts about the effects of early trauma on brain development and behavior. I had his model in my mind when Diane said to me, "Its as if she's in survival mode."

"I think you're exactly right," I said to them. "When Anna acts like this, the thinking parts of her brain are not working. In many ways she's like a helpless infant, able to use only the more primitive parts of her brain. She needs you to help her manage and contain her feelings. At that moment, likely in some way because of her earlier trauma, she is unable to do it herself." Then I said "You need to be your most generous just at the time when you feel the most angry."

Diane and John were quiet for a moment as they thought this over. For some reason, perhaps because they had a quiet time together to tell their story. they really took this idea in. In fact Diane repeated the phrase a few times, nodding in thoughtful understanding. Our time was up, and we scheduled a follow up appointment the next week, when I would meet Anna. This was the appointment following my blog reading session.

Anna gave me a charming smile as she came into the room and began to explore the toys. We all sat on the floor and I watched her easy interaction with her Mom and Dad. Then after a while we spoke about our previous visit. Diane said, " I thought about that a lot- we need to be most generous when we feel most angry." She described observing Anna begin to escalate and saying softly,"do you need a hug?" Diane described how this would sometimes cause Anna to pause, kind of stunned out of the direction she was taking. Both John and Diane were learning how to identify, and thus avoid, some of the things that triggered her meltdowns, both by diverting her attention and giving her more love and attention at these vulnerable moments.

We all acknowledged that this kind of thoughtful attention was very hard work, and that clearly they had a long and challenging road ahead. But both parents were fortified, and had an idea of what they were working towards. We planned to meet again in a few weeks.

So what does this story have to say about the Biederman issue? First of all, parents are desperate when they are struggling with a child in this way. When a clinician sees such a family, he feels that desperation and of course wants to help. The combined forces of the health insurance industry, with poor reimbursement for mental health care and thus lack of access to quality care, aggressive marketing by the pharmaceutical industry and cultural expectation of a quick fix together with this Biederman et al fiasco, allowed the "bipolar" diagnosis and atypical antipsychotics to, in a sense, fill a void. As I state in the last chapter of my forthcoming book Keeping Your Child in Mind,

Infant mental health services, unfortunately, are not well covered by third-party payers and are not marketed as widely as prescription drugs. And as we have seen, they require hard work and do not offer the “quick fix” of medication. As such, they are less available as a form of intervention for struggling young children and families.

Yet it is just the discipline of infant mental health, as exemplified by the work of Dr. Perry and others I have written about over the past year, that offers the answer to the second question: what is an alternative path to that offered by Biederman and colleagues? That same morning of the blog reading and this visit, I had been communicating with colleagues about developing a new program that integrates care among obstetricians, pediatricians and psychiatrists to address perinatal emotional complications. It has been well established that explosive behavior problems in children are often associated with postpartum depression. It is this kind of preventive work that offers a meaningful alternative approach.

Now that it has, I hope, been clearly established that this explosion of "bipolar disorder" diagnosis and antipsychotic use in young children was the wrong path, we need to move on. We need to fully invest in making the changes necessary to out health care system to enable us to go down a different path towards meaningful help for these struggling families and children.

Achieving Emotional Regulation: Using the Body to Help the Brain

2011-07-07T06:31:00.015-04:00

I recently heard a great story from a parent in my behavioral pediatrics practice. Their son was very active and had a hard time settling down to learn, and so, before an early morning tutoring session, a very resourceful teacher suggested he ride a scooter down the empty halls to the room where a group of kids with reading difficulties met. To make it fair, the teacher allowed all of the students in the group to ride scooters to class. The kids lay on their stomachs and used their arms to propel them down the long hall. Interestingly, not only this boy, but all of the kids in the class began to do better!

One of the best weekends of the Infant-Parent Mental Health Post-Graduate Certificate Program which I have been attending and writing about over the past year, was with child psychiatrist Bruce Perry. He spoke of the importance of what he referred to as "rapid alternating movements' in achieving emotional regulation. Dr. Perry's ideas grew out of his frustration with the traditional model of psychiatric care, where children who have experienced significant trauma are expected to sit and talk with a therapist about their experience( and of course are also medicated.) HIs model of intervention is based on knowledge of brain development and is termed the "Neurosequential Model of Therapeutics.'

While it is not my intention to describe the model in detail, one of the main messages, which has relevance not only to traumatized children, is that in order to think, learn and process experience, one must first feel calm. A range of activities can achieve this calm. Dr. Perry does therapy sessions with very troubled children while going on walks. Horseback riding, martial arts, drumming and dance are other activities that can serve to achieve this kind of calm. A group of fellows from the program got to try out the theory. After a long, very stimulating (and also somewhat dysregulating) day of learning with Dr. Perry, we went ice skating. Not only was it a lot of fun, but it worked wonders in helping us to process the experience.

Often when kids are struggling in school, teachers express concern that they are "over-scheduled." But if extracurricular activities are carefully planned and well thought out, they can be considered an essential part of treatment. It is best to have some kind of a calming activity interspersed with homework, tutoring or therapy. These can be tailored to a child's particular talents and interests. Many know the story that Michael Phelps struggled terribly with ADHD. Swimming can be a very regulating activity, but some kids with learning and behavior problems also have sensory processing difficulties and can't stand to have their head under water. Clearly swimming isn't the right choice for them.

The more children I see with a range of "behavior problems," the more I recognize the importance of using the body to help the brain. Occupational therapy for young children can accomplish this goal. But as children get older, and can learn to express their feelings, parents can help them identify what works for them. This same boy on the scooter, several years later, learned to recognize that when he was feeling overwhelmed, going down to the basement to play his drums helped him to regroup. This kind of awareness, both of mind and body, can serve kids well not only in childhood, but over the course of a lifetime as they learn to adapt to their particular vulnerabilities.

Value Primary Care Clinicians, Not Psychiatric Drugs for Children

2011-07-03T07:20:00.046-04:00

As I sat down to write this blog post, I was torn between two stories. One, in yesterday's Boston Globe Harvard Doctors Punished Over Pay, refers to the child psychiatrists who advocate for atypical antipsychotics for children and who received, but did not report, large sums of money from the drug companies that make these medications. The article stated:

Concluding a three-year investigation, Massachusetts General Hospital and Harvard Medical School sanctioned renowned child psychiatrist Dr. Joseph Biederman and two colleagues after finding they violated conflict of interest rule.

The other was last weeks pair of stories about the government's plan to essentially spy on primary care clinicians. The original New York Times article U.S. Plans Stealth Survey on Access to Doctors stated

Alarmed by a shortage of primary care doctors, Obama administration officials are recruiting a team of “mystery shoppers” to pose as patients, call doctors’ offices and request appointments to see how difficult it is for people to get care when they need it.

Two days later, the Times ran another story entitled Administration Halts Survey of Making Doctors Visits describing how the Obama administration had "shelved plans" for the survey.

I decided to address them both, as I see them as linked. They both speak to the value this country places on individuals listening to and understanding each other.

Prescribing powerful mind-altering drugs to preschoolers with emotional and behavioral problems is the antithesis of listening, both to children and to parents. As I have observed frequently both on this blog and in my forthcoming book, Keeping Your Child in Mind

Being understood by a person we love is one of our most powerful yearnings, for adults and children alike. The need for understanding is part of what makes us human. When our feelings are validated, we know that we’re not alone. For a young child, this understanding helps develop his mind and sense of himself. When the people who care for him can reflect back his experience, he learns to recognize and manage his emotions, think more clearly, and adapt to his complex social world

Yet the combined forces of the health insurance industry and pharmaceutical industry have led to a situation in which listening to desperate parents who are struggling with their troubled children often is translated into prescribing a drug (one with very serious side effects) to control their behavior. A March 2009 Times article Drug Makers Told Studies Would Aid It, Papers Say refers to the same psychiatrist now found two years later to have violated conflict of interest rules.

The psychiatrist, Dr. Joseph Biederman, outlined plans to test Johnson & Johnson’s drugs in presentations to company executives. One slide referred to a proposed trial in preschool children of risperidone, an antipsychotic drug made by the drug company. The trial, the slide stated, “will support the safety and effectiveness of risperidone in this age group."

Primary care clinicians, in conjunction with mental health clinicians, have the opportunity in relationships with families over time, to support parents efforts to promote their children's healthy emotional development. Parents themselves need to be heard and understood. They may be struggling with financial stress, a strained marriage or single parenthood, conflicted relationships with their own parents as well as a temperamentally challenging and inflexible child. In my book I place these two paradigms, effective listening, and prescribing psychiatric drugs, side by side.

Those who advocate use of medication in young children with a range of behavior problems argue that stress hurts the brain and that these medications can protect the brain from this stress. When children and parents feel out of control, when there is sleep deprivation and explosive behavior, both parents and children experience a great deal of stress. It is not surprising that giving a powerful drug that acts on the brain would calm a child down.

But medication is not the only way to reduce stress. As I describe in chapter two, being understood by people who love you also reduces stress at the level of brain biochemistry. Reducing stress and changing the brain in this way is hard work. It requires sustained effort and a lot of support for parents. But the changes are safe and may last a lifetime.

Much as I am an ardent supporter of President Obama, the proposed, "spying" on primary care clinicians to evaluate the primary care shortage has me concerned that he doesn't fully understand what good primary care clinicians do.

Effective listening is very hard work. A good primary care clinician values and nurtures relationships with families over time. She holds the health and well being of the family, supporting and guiding them through the myriad of challenges both emotional and physical that come their way. She spends hours on the phone, both with insurance companies, advocating for coverage for procedures and medications that require"prior authorization," as well as with patients and their worried family members.

I know that President Obama values, and is a master of, this kind of effective listening. I hope that he applies these listening skills to the primary care clinicians, and listen to their stories. Perhaps then the administration will come up with a policy to address the shortage of primary care clinicians (sure to worsen as millions join the ranks of the insured) that, unlike the spying plan, makes sense.

Teaching Your Teenager To Drive: How Contemporary Developmental Theory Can Help

2011-06-26T11:20:00.001-04:00

Can I practice what I preach? I was asking myself just that question when last week, my 16-year-old daughter decided that a trip to the mall was the time for her to learn how to drive on the Turnpike. She's had her permit for about two months, and so far I've found the experience of driving with her to be much less stressful than I anticipated(she did take Drivers Ed through school, which was a big help in taking the learning out of the realm of the mother-daughter relationship!)

My forthcoming book "Keeping Your Child in Mind," is organized around one idea, an idea that comes out of contemporary developmental research at the interface of psychology and neuroscience. In a nutshell, by understanding your child's behavior, empathizing with her experience, managing difficult feelings by containing them and setting appropriate limits, all while managing your own distress, you will help facilitate her healthy emotional development. The question I asked myself that morning was, can I do this while hurling past trucks at 70 miles per hour on a busy turnpike?

Most of my book is based on stories from my pediatrics practice, but some of the stories in the book are drawn from my experience as a mother. Now that the book is done, this was a chance to see what it would be like to use the ideas in the book in a moment potentially fraught with multiple levels of difficulty.

Number one, understanding her behavior. She is capable of doing this and feels confident in her abilities. Intellectually I understand that, even though I still see her as my baby, for child of her age it is developmentally appropriate to drive on a major highway. Number two, empathize with her feelings. I think of one of my favorite phrases that I learned from a social worker many years ago; "Face your fears and watch them disappear." My daugher is probably terrified, but she knows that she needs to just do it. Third, set appropriate limits. In this context, I need to calmly yet firmly tell her that she cannot drive at 65 in the left lane. As soon as she can safely do so, she must shift back into the right lane. No discussion, no negotiating this point. And last, I must master my own distress, so that I can be fully present with my daughter and help her to manage this challenging experience. I must tuck away that fleeting thought when I said good-bye to my son in the morning that he might never see me again. I must set aside the fears that I can't even bring myself to write in this post. She successfully navigates not only passing these huge trucks and shifting back into the right lane, but exiting from the turnpike and entering the Interstate for a short distance. " You need to slow down," I say as calmly as I can a manage when, towards the end of the hour-long trip, she attempts to negotiate the exit at 40 miles per hour.

At last, she pulls into a spot in the mall parking lot. "Thank you for helping me." she says. "And for staying calm." I tell l her that
I'm glad we did it together. I would much rather she learn the nuances of turnpike driving from me than have to figure it out on her own when she gets her license.

During the trip I actually held the image of the cover of my book in my mind while taking deep breaths and working to stay calm. Certainly there have been many moments when I have lost my cool with my children. But for this critical developmental milestone, the idea of holding my child in mind really came through. I go into the mall and buy myself a new pair of shoes. I deserve it. This is hard work!

Storytelling As Treatment for Common Childhood "Behavior Problems": A Clinical Example

2011-06-21T11:15:00.001-04:00

I am most grateful to my patients, who are often my best teachers. I am moved to write about them, to spread the knowledge they have given me to a larger audience. Of course confidentiality is my top priority, so I aim to protect my patients' privacy while staying true to their story. This past week in the KevinMD newsletter, there was a piece about the new discipline of narrative medicine, which looks to literature and the power of stories to enhance the practice of medicine. The following encounter, from my behavioral pediatrics practice, is a perfect example of the power of storytelling.

Eighteen-month-old Joe was drinking up to 5 six ounce bottles a day. "He won't eat anything else, but when I say no to the bottle, he screams. It's just easier to give in." Joe's mother, Sandra, had been advised at multiple visits to the pediatrician that she needed to stop. He was at risk for nutritional problems including iron deficiency anemia, and his teeth were being damaged when he fell asleep with the bottle in his mouth. Yet despite having this information, Sandra was unable to set limits with Joe. Her pediatrician referred her to me.

I met with Joe and his mother for one 50 minute visit. We sat on the floor and talked while Joe played. He was a delightful boy who was very curious and quickly got absorbed with the selection of toys. He looked healthy and robust. His mother started the visit telling me that she knew she just needed to get rid of the bottles, but that she couldn't bring herself to do it. Rather than focus on what to do, I asked her to tell me about her pregnancy and Joe's infancy. Sandra was from Ecuador, and she had met her American husband when she came to the US as a student. They had gotten pregnant much sooner than they planned. Sandra's mother was unable to get a visa and had never met Joe. I asked Sandra what it was like to have a new baby without her mother nearby. "It's terrible," she said. Her husband worked long hours and she had only recently begun to make friends. She spoke with her mother on skype, but, she said, "for Joe she's not a real person." This made her very sad because her mother so much wanted to be involved as a grandmother. In contrast, her mother-in-law, who lived nearby, did not show much interest in helping her with the baby.

Sandra spoke of great difficulty nursing in the first days, when Joe did not latch on well. "He never would have survived in the wild," Sandra told me. She conveyed sense that both she and Joe had failed in some way. I pointed out that "in the wild" she would never have been alone without extended family.

Sandra began to talk about how things were so different in Ecuador. Parents were in charge of what their kids ate, and there was none of this "offering choices" that so many had advised her to do. In addition, a fat baby was a sign of a healthy baby. Sandra felt that to fail to feed you child was to be a failure as a mother.

Then Sandra remembered that she herself had been a very skinny child. In fact, she recalled her mother telling her stories about when Sandra was an infant and the other mothers would say to her mother, "What's wrong with you that you starve your baby?" Yet Sandra recalled that she was a very busy active child, very much like Joe, who often didn't want to be bothered with eating.

"It sounds like you are having s similar experience with Joe to what your mother experienced with you," I said. Sandra was quiet as she seemed to be thinking this over. "You're right," she said. "Maybe this is more about me than about Joe."

We spoke some more about Joe's behavior around eating and the differences between American and Ecuadorian ideas about raising children. I said that she would have to decide what she wanted to do, but that I thought that if she continued to battle with Joe around eating, this would likely continue to be a problem. My only "advice" was that she consider giving Joe more independence to feed himself. We made a follow up appointment in a few days, when her husband would be able to come.

"I got rid of the bottles," Sandra told me as soon as we were settled on the floor. Joe once again was contentedly playing. "How did he do?" I asked, surprised by this rapid development. "Well he cried at night, but he seems OK during the day." Then she told me that he had eaten some new foods, and was interested in what another child was eating at a play date. "I knew everything we talked about last time. I just didn't want to do it." "What made the difference?" I asked. She claimed that she had realized she needed to protect his teeth.

We talked some more about bedtime and some other parenting issues that they had been struggling with. I asked if she wanted to schedule another appointment. "Well, we solved the problem," she said. She told me that she would call if things did not continue to go well.

In this age of "evidence-based medicine" I wonder how I would design a study to show if telling her story to a supportive non-judgmental person was the reason Sandra was finally able to follow through with what she knew she needed to do. Would one group get standard "advice" while the other had the opportunity to sit on the floor and tell their story? I'm not a researcher, but from what I know about research, designing such study to have statistical significance would be very difficult. All I can say is, "I was there." I am pretty sure that having her story heard was what enabled her to act. I'll leave it to the researchers to prove it.

On "Composing a Life": Women Physicians Who Work Part Time

2011-06-15T13:54:00.031-04:00

I admit I was almost stunned into silence by this past Sunday's Op Ed in the New York Times entitled Don't Quit this Day Job. A woman anesthesiologist argued that the current shortage of primary care physicians is due to women who take residency slots and then chose to work part time. She concludes her piece by saying that:

Patients need doctors to take care of them. Medicine shouldn’t be a part-time interest to be set aside if it becomes inconvenient; it deserves to be a life’s work.

I was heartened to read the array of wise letters to the editor written in response. They all identify important issues and I highly recommend reading all of them. One that I particularly admired was from a woman ER physician who wrote;

Dr. Sibert claims that “medicine shouldn’t be a part-time interest to be set aside if it becomes inconvenient.” I would argue that the same holds true for my child.

I was encouraged to formulate my own response.

About ten years ago I read a book Composing a Life by Mary Catherine Bateson, daughter of Margaret Mead. Bateson follows the lives of 7 women, including Joan Erikson, wife of Erik Erikson, who had significant careers that were shaped around their roles as spouse and mother. In the introduction she writes:

This is a book about life as improvisatory art, about the ways we combine familiar and unfamiliar components in response to new situations, following an underlying grammar and an evolving aesthetic.

As my professional life has taken many twists and turns to accommodate the needs of spouse and children, I have found it comforting and inspiring to think of this not as a burden, but rather as creation of a work of art.

As many readers of my blog know, I have just written a book, Keeping Your Child in Mind. My hope is that this book will offer validation and support to a large number of families, more than I could ever reach in my practice. Yet had I not taken these twists and turns to accommodate the needs of my family, this book would never have been written.

I have worked part time since my children were born, and took my first break from primary care to start a parenting center when my second child was born. Then when my children reached school age, my husband and I recognized that to meet the demands of swim practice, play rehearsals, dance performances and all the other things that go along with of having school age children, one of us would have to be more available. My husband is an eye doctor who runs his own practice, so it made sense that I would be the one to change.

Much as I loved doing primary care, the inflexibility and time demands of taking call were not compatible with the way we wanted to raise our children. Reluctantly I gave it up, focusing on building a behavioral pediatrics practice that did not require taking call. It was that experience that led to my writing a column for the Boston Globe entitled Mind-Altering Drugs and the Problem Child. The overwhelmingly positive response, from parents and professionals around the world, in turn led to the writing of the book.

Being a mother is both an awesome privilege and an awesome responsibility. It is in a sense the greatest act of creativity. It makes sense that women who create in this way can also create their own professional lives. By embracing this creativity, both as mothers and as professionals, we can aim to find new and important ways to contribute to society, while at the same time being present in the lives of our children in ways that support the healthy development of the next generation.

Rise in Autism or Simply Autism Diagnosis?

2011-06-08T14:58:00.023-04:00

A mother brings her two year old son, Evan, for an evaluation through the Massachusetts Early Intervention Program(EI). She and her husband are at their wits end, fighting constantly over this very challenging child. An older sister is neglected in the face of the intense demands of of her brother. He screams in the face of any transition, cannot tolerate loud noises, eats only a very narrow range of foods. He has frequent meltdowns and is difficult to comfort physically, resisting efforts of his parents to hold him. When he goes to playgroup, he runs around in circles rather than interact with the other children.

A study published in the June issue of Pediatrics, Early Autism Spectrum Disorder Diagnoses in Massachusetts, shows that more young children in Massachusetts are receiving treatment for autism spectrum disorders, with the proportion of those 3 and younger being treated rising by 66% from 2001 to 2005. A summary of the study states "Researchers did not determine whether the increase was because of improved awareness, better diagnosis or an increase in the prevalence of the disorder, but said a combination of factors was likely."

There is yet another reason for the increase in diagnosis, perhaps even the major reason . If the above child is diagnosed with an autism spectrum disorder, he will receive a whole range of services through EI including developmental specialists coming into the home on a regular basis to help the family make sense of and manage Evan's difficulties. On the other hand, if he does not get the diagnosis, this family, which is most certainly struggling, may get ZERO. Nothing. No help at all.

Evan may have some significant biologically based vulnerabilities, with a low frustration tolerance, inflexibility and number of sensory processing difficulties. But if he and his family can get the support they need, he may learn to manage these vulnerabilities. He may even be able to transform them in to an asset, becoming a musician or a professional chef.

Perhaps the rise in diagnosis is not because of a rise in autism, but because of limited access to mental health and community based support services for children like Evan and their families. The health insurance industry and managed care have contributed to this problem through prohibitively complex administrative costs for private practitioners. Many of the best mental health practitioners are therefore not on insurance plans and quality services may be inaccessible to families who most need them. Early Intervention is a superb program that is available to anyone in need. But the catch is that a child usually needs to have a diagnosis to be eligible.

Autism is a highly charged subject. Parents of children who are severely impaired understandably bristle to questions about the legitimacy of the diagnosis. I suspect that what is now called autism represents a very wide range of difficulties that we will come to learn are actually a number of different and distinct problems. While early identification and intervention is essential. I believe there is a need for caution regarding diagnosis.

Parents who receive a label of a major psychiatric diagnosis for their child inevitably go through a period of mourning. The child they had is gone and has been replaced by a child with a “disorder.” As D. W.Winnicott, pediatrician turned psychoanalyst, so wisely observed, a child develops a healthy sense of self when the people who care for him recognize the meaning of his behavior, rather than substituting their own adult meaning. Parents often begin to regard behaviors as “symptoms” of the “disorder.” For a very young child whose development is unfolding, his “true self”(again in Winnicott's words) might be lost in the face of such a frightening label.

It is my hope that we can move from an emphasis on diagnosis and labeling to an emphasis on prevention. We need to ask not “what is the disorder?” but rather, “what is the experience of this particular child and family?” and “what can we do to set things in a better direction?” This current situation, where a diagnosis is needed in order to get help, is a dangerous example of the tail wagging the dog.

Why Pediatricians Need to Know About Infant Mental Health

2011-06-04T06:04:00.028-04:00

I recently became recertified by the American Board of Pediatrics. My certification was due to expire at the end of this year. In order to accomplish this task I had to do two things. One was to complete an assessment of my knowledge base. The other was to complete an approved "quality improvement activity." I chose one referred to as the "Attention Deficit Hyperactivity Disorder (ADHD) Performance Improvement Module" Clinicians who are currently seeing very few patients(the case for me due to the book writing) are able to use simulated patients for this online activity. By giving data for patients over three time points, this "performance improvement module" scored me in the high range of improvement of care because I gave the Vanderbilt( a standardized assessment tool for ADHD evaluation with a parent and a teacher version that assesses symptoms and academic performance) to every patient, discussed the option of medication, and if they were on medication, measured weight and blood pressure at every visit. That and pay $1,000 and I am now recertified until 2016.

This experience brought to mind a case of a seven-year-old boy who was referred to me for evaluation of ADHD. He arrived with the completed parent and teacher Vanderbilt forms on which he scored in the high range for inattentive and hyperactive ADHD. His mother had a high expectation that I would put him on medication. In our first visit, when I met with the mother alone, the following story emerged (details have, as always, been changed to protect privacy.)

For the first six years of his life this boy lived with his father, who was an actively drinking alcoholic. His mother lived in a different state and was intermittently involved in his life. When his father became ill with advanced liver disease, his mother moved closer to him and began to be more involved in his care. His father continued to drink despite his rapidly declining health, and though his mother was at first reluctant to share details, her son had witnessed his father's rather gruesome death at home about 6 months prior to our visit. He was now living with his mother and was struggling in school. He was receiving no psychotherapy or intervention of any kind. His teachers, who knew little of this story, had recommended the "ADHD evaluation" and had suggested strongly that he might benefit from stimulant medication.

The work of psychiatrist Bruce Perry, who taught one of the weekends of the Infant-Parent Mental Health Post Graduate Certificate program of which I have been writing for the past year, helped me to understand what was likely happening for this boy in school (for the sake of this blog post his work is simplified. For further information see the Child Trauma Academy website.) For most of his life this boy lived with an unreliable caregiver, who, when he was drinking likely was unrecognizable. The same person who he relied on for safety and security was frightening and unpredictable. The subsequent witnessing of his father's death adds a level of trauma that is almost unimaginable.

When children experience this kind of trauma from an early age, it affects the areas of the brain responsible for regulation of the most basic functions. A child may in a constant state of "hyper-arousal" in which he is constantly vigilant for possible danger. He does not have a normal sense of time and may exist only in the present. In the face of any kind of stimulation, he may experience either a fight-flight response or alternatively what is referred to as a dissociative response, in which his mind in a sense shuts down. In either state the brain does not function well and a person is unable to think, much less to learn.

In order to treat this kind of early trauma, one must start at these lower centers of the brain in order to help a child develop the basic capacity for self regulation. This may involve such activities as massage, walking, or martial arts. In essence, one needs to rebuild the brain from the bottom up. Only in this way can one hope to engage the higher centers of the brain and help a child make sense of his experience and begin to use his brain to learn.

Yet the standard of care in pediatrics, as reflected in my successful recertification experience, is to document symptoms of inattention and hyperactivity and then treat with stimulant medication. And the fact is that in the short term, stimulants may help a traumatized child to calm down. But the benefits are short lived, and often there is an escalation to higher and higher doses of medication over time.

A teacher of mine who is a leader in the discipline of infant mental health recently asked me why pediatricians should do this work, and not "a new front line practitioner trained in well child medicine and developmental mental health." The fact is that pediatricians, who are on the front lines and see children and parents early and often, do treat behavioral and developmental problems as a huge part of their practice. A 2001 policy statement The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care by the American Academy of Pediatrics reflects this fact.

As is clear from the above story, pediatricians are doing this work under the influence of a powerful pharmaceutical industry and pervasive culture of medication. Therefore, if we are to "do no harm" it is imperative that pediatricians are exposed to the wealth of knowledge and research generated in the discipline of infant mental health. This research offers a different model for understanding and treating behavior problems from the "advice giving", "parent training", "behavior management" and medication prescribing that is currently the standard of care in pediatrics. In my experience, as well as that of as small but growing number of pediatricians who are learning about infant mental health, these ideas have great relevance to our practice, and offer the opportunity to help young children and families in profoundly meaningful ways.

President Obama, Parenting and Personal Responsibility

2011-05-31T10:02:00.023-04:00

When President Obama was interviewed on 60 Minutes following the capture and killing of Osama bin Laden, he compared the wait while the Navy SEALs were in the compound and he didn't know what was happening with the wait to hear if his sick young daughter had meningitis. What struck me about this was the ease with which he, in front of an audience of millions, equated in value his role as father with his role as leader of the free world.

I am currently making my way through David Remnick's brilliant book The Bridge: The Life and Rise of Barack Obama. Remnick quotes Obama, describing what Remnick refers to as Obama's "credo for his career:"

What if a politician were to see his job as that of an organizer, as part teacher and part advocate, one who does not sell voters short but who educates them about the real choices before them?...The right wing, the Christian right, has done a good job of building these organizations of accountability, much better than the left or progressive forces have. But it's always easier to organize around intolerance, narrow-mindedness, and false nostalgia. And they also have hijacked the higher moral ground with this language of family values and moral responsibility.

Now we have to take this same language-these same values that are encouraged within our families-of looking out for one another, of sharing,of sacrificing for each other-and apply them to a larger society. Let's talk about creating a society, not just individual families, based on these values. Right now we have a society that talks about the irresponsibility of teens getting pregnant, not the irresponsibility of a society that fails to educate them to aspire for more.

Obama's version of family values clearly includes both personal and social responsibility.

In the last chapter of my forthcoming book Keeping Your Child in Mind I address the changes that need to be made to our society in order to apply the explosion of knowledge about the importance of supporting early parent-child relationships to promote children's healthy development. There are many obstacles. These include lack of value we place on primary care and mental health care services, need from more emphasis on prevention, need for changes to our medical education system to attract more primary care clinicians, and a modification of the influence of the powerful health insurance and pharmaceutical industries. The last chapter states:

If parents are to embrace this challenging yet highly rewarding task, they need to feel valued themselves. Just as a parent needs to hold a child in mind, we as a society need to hold parents in mind.

At times when the obstacles seem overwhelming, President Obama has been my inspiration. He forged ahead, despite what may at times have seemed overwhelming obstacles, because he believed he had something important to do. To again quote from Remnick's book:

Before embarking on the story of the political rise of Barack Obama, it may be useful to take time out for a mental exercise. Here it is:
Name your state senator.
No, not the two legislative titans who represent your state in Washington, D.C. The question is, who represents your district in your state capital?
Fine. Now that you have Googled the name and are trying to wrap your mind around the pronunciation and other such details, imagine that this undoubtedly decent, if generally anonymous, man or woman emerges in a very few years from Trenton or Harrisburg, Tallahassee or Lansing to become, as if in a reality television show, President of the United States.

I feel that I have an ally in President Obama. While of course I don't personally know him (though our birthdays are 2 months apart- me June 8th 1961 and him August 4th 1961-yes we will both be 50 soon-, and we got married and had kids within a few years of each other, both have University of Chicago ties, and lived just blocks apart in Hyde Park when he was a community organizer and I was in medical school!!) I know that he will understand what I am trying to do. I hope he reads my book.

Continuing Medical Education (CME) Cost and Over-Reliance on Psychiatric Drugs for Children: A Possible Link

2011-05-22T11:53:00.007-04:00

On the day I began to formulate the idea for this piece, I received an email announcing a continuing medical education (CME) course in psychiatry. Number one on the list of course objectives was: "Implement recent developments in psychopharmacology in clinical practice." I was mulling over the issue of CME after having been recently informed that offering CME credits for the intensive program in Infant-Parent Mental Health at University of Massachusetts Boston in which I am a fellow might be prohibitively expensive. In contrast, my colleagues in psychology, social work, and counseling will be able to get CEU’s (continuing education units).

There are four MDs in my group of 25(three pediatricians and one psychiatrist.) For us CME is necessary for maintaining professional licensing as well as obtaining hospital admitting privileges and being credentialed with insurance companies. Staying up-to-date with important new research and knowledge is certainly an essential part of practicing medicine. Yet given the already massive time pressures on physicians, MD's are unlikely to take a course that does not offer CME credit. We are a distinct minority.

Not having any knowledge about this subject, I did some research. Apparently the cost of offering CME is regulated by an organization called the Accreditation Council for Continuing Medical Education (ACCME.) If a person or organization wants to offer CME for a course, they must apply to the ACCME. According to their website the cost for "pre-application"(I'm not sure what that is) is $1000. The initial accreditation fee is $7,500 and the annual fee is $3,000. The reaccreditation fee is also $7,500. The International Association for Continuing Education and Training(IACET) in contrast, charges an application fee of $450 and an overall fee of $2,300 for CEU accreditation.

In the Infant-Parent Mental Health Post-Graduate Certificate Program(IPMHPCP), in ten intensive three-day weekends over the course of a year, we learn from leading researchers and clinicians from a range of disciplines about how early relationships shape the brain and influence healthy emotional development. The same program is run in Napa, California. The program’s website states:

“The IPMHPCP goals are to prepare individual professionals who:
Are highly skilled and invested in infant-parent work;
Have an integrated understanding of infant-parent relationships, regulatory, and social-emotional/mental health concepts and theories;
Have an understanding of the major theorists, researchers, and clinicians in the area of social-emotional development, infant-parent mental health, and infant-caregiver relationships;
Are invested in an interdisciplinary approach to promotion, prevention, screening, assessment, treatment, monitoring, and policy development; and,
Are able, within their scope of practice, to provide promotion, prevention, screening, assessment, treatment, and monitoring of children age 0-5, their parents and other caregivers.”

How very relevant is this work both to pediatricians who see families early and often, and to child psychiatrists who treat young children. Yet if this program is unable to provide CME it is less likely that these disciplines will have access to this important information.

Instead pediatricians and psychiatrists learn primarily about how drugs shape the brain. I recently attended a full day CME course on “Child Psychiatry in Primary Care.” While we learned a great deal about medication, including the use of atypical antipsychotics for explosive behavior in young children, there was not one mention of the word "relationship."

In contrast, a pediatrician colleague of mine took a course last week given by leading childhood trauma researcher Bessel van der Kolk, (who I refer to in my two previous posts.) He offers a different model for understanding explosive behavior that is very much tied relationships, and he is critical of over-relaince on psychiatric medication. My colleague found the course extremely helpful and relevant, but CME was not offered.

I do not know why CME credits are so much more expensive than CEUs. But I do wonder if this system, which seems to have a good deal of control over who knows what, contributes to how we understand and treat emotional problems in young children.

I have no doubt that the IPMHPCP has left me well qualified to do the work I do, namely treat a range of behavior issues in young children within the setting of a pediatric practice. I have sought out the kind of educational opportunities I believe have most relevance for this kind of work. When it comes time to renew my license, I can only hope that the Board of Registration in Medicine will recognize this fact.

Helping a Traumatized Child: A Hopeful Follow-Up

2011-05-17T11:17:00.009-04:00

I live in a small town, so I often have the opportunity to get follow-up on the children I cared for in my previous job. Walking down the street this morning I heard a voice call out "Hi Dr.Gold!!" I turned to see the mother of a child I had seen for a number of years. Similar to the child I described in the previous post, this child had experienced significant trauma in her early years. To protect privacy I will not go into detail. This family had come to me for medication for ADHD. While the child clearly met diagnostic criteria, and ADHD medication helped her to stay in school and not fail completely, it was obvious from the start that she needed more intensive help than I could offer. Yet her parents resisted. There were many reasons for this, ranging from transportation issues to a wish not to address some very painful subjects.

My leaving that practice actually forced the issue. The only person who would prescribe medication was a psychiatrist in a nearby town. She has a practice policy that anyone on medication must be in therapy.

When I run into families I know in public, I am hesitant to talk about our work in order to protect their privacy. But this mother seemed positively joyful, so I was moved to ask, How's Jane? (not her real name) ""She's thriving!" was her response. "We have her in therapy and she's on some new medications. I don't know why I resisted for so long!!"

This morning I also received an email from a pediatrician colleague bemoaning the fact that so many pediatricians have become simply drug prescribers. She asked: "Can we wipe the slate clean and start again? - maybe by listening and telling the stories over and over again; perhaps. Slow and steady." I like this cautious optimism, and believe strongly that it is the only way. We cannot give up on these kids!!

Preserve Important Childhood Trauma Treatment Program

2011-05-13T13:54:00.009-04:00

In a powerful recent New York Times op ed, Post-Traumatic Childhood, leading trauma researcher Bessel van der Kolk writes about the possible of loss of funding for the National Child Traumatic Stress Network, an organization developed in 2001 to evaluate and develop treatments for traumatized children nationwide. He writes:

 Most traumatized children now do not even receive a proper mental health assessment. Moreover, hundreds of thousands of them are numbed by powerful drugs that help control their "bad behavior," but that don't deal with the imprint of terror and helplessness on their minds and brains. Drugs can sedate, but they do not help children deal with trauma - in fact, they may prevent recovery by interfering with learning and the formation of relationships, essential preconditions for becoming functioning adults.

This paragraph brought to mind a particularly distressing case from my previous job as a behavioral pediatrician in a busy small town practice. This eight year old boy(details have been changed to protect privacy) had recently moved to a new foster home in my town and his foster parents brought him to see me to prescribe medication for attention deficit hyperactivity disorder(ADHD), which had been diagnosed by a psychiatrist in another town about 40 minutes away.

This little boy had not only been physically and sexually abused starting at a very young age, but he had been removed from another foster home where he had allegedly sexually assaulted another young child. He was impulsive and distracted in school, symptoms which, according to his new foster mother, were helped by his medication. She wanted me to prescribe the medication because the trip to the psychiatrist was too long. At the time I saw him, he was receiving no other treatment besides monthly visits to the psychiatrist for his medication.

When I resisted, saying in as gentle a way as possible that his problems needed much more intensive intervention than I could offer as a pediatrician, his foster mother was indignant. "But his psychiatrist said I should come to you. It's only to refill the medication, and I just can't drive that far." When I called the psychiatrist, horrified to learn that she had endorsed this plan, she reluctantly agreed to continue seeing the patient, but made it clear that she felt I was just making this foster mother's life more difficult.

I don't know if I made things any better for this boy by insisting that he at least be treated by a trained mental health professional. I spoke with the psychiatrist about the need for more intensive help, but given the lack of resources and lack of motivation, both on the part of the foster mother and psychiatrist, this probably didn't happen. Yet I felt that I could not collude with the system in sedating away this child's symptoms rather than addressing the underlying trauma, the "imprint of terror and helplessness" so eloquently and dramatically described by Dr. van der Kolk.

Soon after this incident I left that job. I had begun to feel increasingly uncomfortable prescribing medication to children in this way. The standard of care for ADHD treatment, where similarly traumatized children are often treated by pediatricians who prescribe medication at visits every 3 months, did not seem right. Instead I am writing to call attention to the problem, as well as developing, within a pediatric practice, an infant mental health program that focuses on prevention.

Many others in the areas of childhood trauma research, as well as the growing discipline of infant mental health, are speaking out about the need for changes in the way we treat these most vulnerable members of our society. I hope that our combined voices will be sufficient to call attention to the problem, and reverse the proposed 70 percent reduction in funding for the National Child Traumatic Stress Network.

Supporting Successful Communication Between Parent and Child

2011-05-08T07:23:00.006-04:00

Recently, at the UMass Boston Infant Parent Mental Health Post Graduate Certificate Program in which I have been participating for the past year, we heard a wonderful talk by Carole Gammer, a family therapist who lives in Paris, France. She has written a book entitled, The Child's Voice in Family Therapy. Among the more remarkable things about her presentation was that she spoke to us in English while showing video tapes of observed therapy sessions conducted in French and German.

In one case, a young single mother who struggled with serious depression was having constant battles with her five year old daughter. In a way typical of many families I see, she asked Dr. Gammer "what to do to make her listen." Dr. Gammer works with child and parent together in a very focal way to help develop more healthy ways of relating. I found her work similar to mine but rather than have parents tell their story, she has parent and child act it out with puppets. In the segment she showed us, she asked them to act out a typical morning. It was remarkable that despite the fact that they were being observed by psychology students, both became absorbed in the play and really showed what it was like. The mother made repeated demands of her daughter-get out of be, get dressed-which her daughter did not do. The mother finally ended up threatening to abandon her child if she did not get up and get ready for school. It left us thinking that it was no wonder the child also had severe separation anxiety.

Then Dr. Gammer did her intervention, which involved selecting one very specific interaction to work on. The one they chose was eating breakfast. After some discussion with Dr. Gammer, the mother offered a couple of choices and she and her daughter eventually agreed on cornflakes. It was the first moment of successful communication between mother and child. By chance, Dr. Gammer stopped the video at this point to answer some questions, so we got a good long look. The mother had up until this point looked very tense and angry, but in this moment of cooperation her body seemed to relax. She was smiling, and her pleasure at her success was evident. Her daughter looked directly at her, smiling at her as she agreed, "OK, cornflakes( a word that is shared by all three languages!)

This was a lovely example of supporting parents by helping them" be" with a child rather than telling them "what to do." When things are out of control as was the case for this mother-daughter pair, both parent and child are angry and sad, yet they are longing to connect. I have found that meaningful change happens in my behavioral pediatrics practice when we share these powerful moments of re-connection. One can imagine that the levels of stress hormones in this mother, likely at a constant high level as she battles with her child over every little thing, decreased in that instant. In turn, the same probably happened for her daughter.

It is only a tiny moment, but at least they both know what is possible and what to work for. This focal intervention, along with others like it in the context of the supportive, non-judgemental relationship Dr. Gammer has with this family, is likely to transform the unhealthy dance of mutual dysregulation, in which these two have been engaged, into one of mutual regulation, as they accumulate successes like the one we saw in this video. In my opinion, while it is clearly more work, this is a far better approach than giving a parent advice about "what to do."

National Children's Mental Health Awareness Day

2011-05-03T15:28:00.018-04:00

My posts have been less frequent as I am down to the wire with the final proofreading of my forthcoming book, Keeping Your Child in Mind, which will be available on August 30th. However I did not want this day to go unacknowledged, so I will reference and quote from the bulletin Promoting Resilience in Young Children created for the occasion by the State of Massachusetts, which includes multiple resources.

The future prosperity of our nation depends on the healthy growth, development and school success of each and every one of our young children. Yet, it is estimated that one quarter of the children in our state are at risk for “toxic” or emotionally costly stress caused by domestic violence, child abuse/neglect, family substance abuse and parental depression (Boston Thrive in Five research review, 2009)1. Young children can also be strongly affected by a range of issues such as a death in the family, a car accident, or long- term separation from a parent.
Because young children’s brains are still developing, trauma and stress can have long-term effects on the developing architecture of their brains. Without supports to promote resilience as they grow, children may take with them the effects of traumatic events, and be more likely to experience problems with substance abuse, depression, and stress management.
A strong relationship with a caring adult who responds sensitively to a child is the first line of defense in protecting against stress or trauma. Due to their own stressors, sometimes a parent or caregiver may need to support to help children cope appropriately.

1 National Scientific Council on the Developing Child, 2005 ibid

Why is this Post Different From All Other Posts?

2011-04-23T13:40:00.024-04:00

My son's bar mitzvah is this September (yes-two weeks after my book comes out!!) and so despite the fact that we are not a particularly observant family, we found ourselves at Shabbat services on Saturday morning of Passover. The Rabbi has members of the congregation take turns reading parts of the service. By total random chance, it was my turn to read when we got to the translation of the day's Torah portion. And this is what I read:

A God, compassionate and gracious, slow to anger, abounding in kindness and faithfulness, extending kindness to the thousandth generation, forgiving iniquity, transgression, and sins. Yet He does not remit all punishment, but visits the iniquity of parents upon children and children's children, upon the third and fourth generations.

So there it is in the Torah, what in the world of child development is referred to as "intergenerational transmission of trauma," or "intergenerational transmission of attachment." This can take many forms. Parents who have been abused are more likely, without adequate help, to abuse their own children. Most parents I see in my office who are struggling with their child’s challenging behavior tell me some variation of the statement "Í don’t want to do to Charlie what my parents did to me.” Yet they are horrified to find that they are in fact behaving in exactly the same way as their parents. They find themselves distracted and emotionally unavailable, or explosive and full of rage. In the book History Beyond Trauma two French psychoanalysts describe how psychiatric symptoms can represent trauma of war that has not been expressed, sometimes for generations.

"So why is this in the Torah?" the Rabbi asked. One member of the congregation said that it was about taking responsibility for your behavior as a parent. I thought this was a good answer. When this question of how parents behavior affects their children comes up, it is often heard as blaming parents for their children's problems. In the first chapter of my book I have a section entitled "Guilt, Blame and Responsibility" (also a previous blog post of the same title) because I think is is important to address this problem up front. When people feel blamed, they may become defensive and shut down. Here's an excerpt

Guilt and blame are negative words, and responsibility is a positive one. People generally feel good about themselves when they take responsibility for their lives. They feel empowered. But taking on the responsibility for raising a child in a meaningful and effective way is not an easy task. In the setting of
fragmented families, financial stress or a parental history of abuse or neglect, it is especially difficult. Add to this a child with a challenging temperament, and the responsibility can easily feel overwhelming.

As I've said many times before, supporting parents in this essential task of raising the next generation is critical. The flip side of recognizing our society's responsibility to support parents is for parents to recognize their responsibility for facilitating their child's healthy development. For what its worth, the Torah seems to support this point of view.

A Beautiful Parenting Moment at the Local Coffee Shop

2011-04-18T08:10:00.017-04:00

It was a peaceful Saturday morning at Fuel, a local coffee shop in Great Barrington. People sat quietly murmuring with friends over coffee and muffins, or intently working at their laptops. I was doing the final edits for my forthcoming book Keeping Your Child in Mind, when I looked up to see a small boy of about two years tottering down the narrow aisle holding a plate with an enormous cinnamon bun almost the size of his head. His father followed close behind and they sat down at a table right next to me. The boy was proudly surveying his prize when his father innocently reached over and asked "May I share?" Instantaneously the peace was shattered."NO!!! MINE!!! NO SHARE!!!" His father made a hasty retreat but it was too late. The boy quickly descended into an all out tantrum despite his father's attempts to soothe him.

His mother, who had been at the cash register, rushed back to try to help. While she joined the efforts to quiet his screams, now transformed into sobs of “no share!”, she and the boy’s father looked to be deciding whether to abandon their outing or try to repair the situation. Fuel is a friendly place, and the other customers, including myself, smiled at them knowingly. This, together with a gradual decline in the intensity of their son's crying, seemed to lead to a decision to stay. His mother sat with him while his father went to finish the transaction at the register. He returned with breakfast for the grown-ups and after a bit more time, the boy's crying slowed to a quiet whimper. Calm once again descended, and the three of them were quietly eating their breakfast when the boy took a piece of his cinnamon roll, reached across the table to his father and said, “Share?”

Mine is a favorite word of most toddlers. This word doesn’t represent greed, but rather the toddler’s great joy in his newly emerging sense of self. Certainly limits must be set, and a toddler must learn over time that everything is not in fact, "mine." Just how to impart this sense of limits while at the same time facilitating a healthy sense of self is one of the great challenges of being a parent of a toddler. Sometimes a child might feel particularly vulnerable, such as when he is hungry or tired, and can collapse in the face of a parent who shatters the illusion of his omnipotence. I imagine this was the case with this little boy and his cinnamon bun.

His parents, clearly attuned to the emotional state of their child despite the pressure of a public scene, sensed that this was not a moment to set a limit. He had his two-year-old reason for feeling that sole possession of this prize was essential. They were all rewarded by a happy repair of the disrupted morning. And with their respect for his autonomy, he was able to take in the idea of sharing, though for the time being, he needed to share at his own initiative.

This was a tiny moment, yet full of such richness and complexity. Strung together, such moments, when parents respond to the meaning of a child's behavior rather than simply the behavior itself, serve to set a child on a path of healthy emotional development.

Early Relationships and Brain Development as the Core of Medical Practice

2011-03-23T10:30:00.014-04:00

Given the current explosion of knowledge about the effects of early relationships on brain development, I believe that research at the interface of developmental psychology, neuroscience and genetics will soon need to be at the center of our medical education system. Thus I was excited and heartened to read about the Bayview Child Health Center and its medical director Nadine Burke in this week's New Yorker. An article entitled The Poverty Clinic describes a practice in a poor inner city neighborhood that applies this research to their daily care of patients.

Burke was most heavily influences by what is referred to as the ACE study, a retrospective review that showed a strong connection between adverse childhood experiences(including such parental divorce, abuse and neglect, being raised by a family member with mental illness) and many long term health outcomes. These include chronic medical conditions as emphysema and heart disease illness, substance abuse and other mental illness. She is also influenced by research in neuroendocrinology and behavioral genetics, including work of Michael Meaney and Bruce McEwen.

Burke's idea, drawing on the evidence that adverse experiences affect the brain and body on a molecular level, is to treat early childhood trauma as a medical problem. She describes "multidisciplinary rounds" modeled on treatment of cancer where care is coordinated among surgeons and other specialists. The article states:

At Bayview clinic, having the patient's ACE data, and a theoretical framework for discussion the effects of trauma, has inspired Burke and her colleagues to be more vigilant about abuse and neglect. It also makes them more likely to help children get the social services they need, and better prepared to talk to parents early about the importance of secure attachment.

Treatment interventions may include one or more psychological interventions and alternative therapies including yoga and medication. Alicia Lieberman, a leader in the field of infant parent mental health, is collaborating with Burke.

I wonder if Dr. Burke's medical model is successful in part because it allows clinicians to put the emotional component of this very difficult work at a distance. Bruce Perry, a brilliant psychiatrist at the Child Trauma Academy who has written extensively about working with traumatized children, describes very similar interventions. It may be that for clinicians who have not chosen a mental health profession, such as internists and pediatricians, viewing early trauma as a biological problem may be adaptive. It may allow them to do the work without being overwhelmed by feelings that the emotional suffering of their patients may bring up. This form of defense may be particularly important for clinicians who themselves have experienced some kind of early trauma, and for whom their patient's experiences are a bit too close to home. In the mental health professions, there are opportunities to discuss these types of reactions to the work. However, training in medicine and pediatrics rarely offers such opportunities.

In a sense analogous to testing for iron deficiency because of our knowledge about its importance in brain development, primary care clinicians on the front lines with young children and families will need to know about and apply our knowledge of the importance of early relationships on brain development. Dr Burke's clinic is an important step in the right direction. As this model makes its way into medical practice, however, it will be important to find a place for recognizing the emotional piece of the work. Not only will this avoid clinician "burn out" but it will give value to the relationship between clinician and patient. It can be the clinician him or herself who is the most important part of the treatment.

Psychiatric "Disorders" in Young Children: Proceed With Caution

2011-03-06T07:48:00.020-05:00

"Mental Health Disorder" are big words to put on a small person. Sensory processing disorder, major depressive disorder, anxiety disorder, to name a few, are being given to preschoolers, toddlers and even infants. Certainly young children and their families can suffer terribly with the symptoms that characterize these "disorders." Yet I worry that a child's "true self," to quote pediatrician turned psychiatrist D.W.Winnicott, can be lost under the weight of such a label.

Based on my years of clinical experience as a pediatrician, together with evidence offered by contemporary research in developmental psychology, genetics and neuroscience, I believe that supporting parents efforts to understand their child's experience of the world, to help him or her to make sense of whatever particular vulnerabilities he or she has, without labelling him or her with a disorder, is a better approach.

An article just published in The American Psychologist, Developmentally Sensitive Diagnostic Criteria for Mental Health Disorders in Early Childhood, a comment on my new Psychology Today blog and a family I recently saw has got me thinking further about this controversial issue.

I met with Joanne and Peter, parents of five-year- old Andrew, in my behavioral pediatrics practice (details,as always, have been changed to protect privacy) He was having increasingly inflexible and explosive behavior. They wanted to know "what to do" so he would stop getting upset about "little things." They described him as challenging since birth, a picky eater who had difficulty with loud noises. He could take hours to put on his socks because he hated the bumps.

Recently, he and his parents were at the playground and his younger sister fell and hurt herself. It wasn't anything major, but they had to leave suddenly without giving him usual warnings that made transitions less difficult for him. The result was that he was inconsolable for hours-unable to stop repeating, "Its not fair! I didn't get to go down the slide!" His parents tried to be patient and understanding, while simultaneously tending to their other child, but eventually Peter lost his cool. He yelled at Andrew and sent him to his room.

What prompted them to call me, after months of increasing frequency of similar scenes, was what happened next. Andrew kicked the wall and threw his toys. Then he began to call out,"I'm so sad!! I'm a bad person" I'm so sorry." It was his words that most frightened them. Joanne admitted to being worried that he might intentionally hurt himself. After a while, when she felt more comfortable with me, Joanne spoke of her own longstanding struggle with depression. There were other family members with similar difficulties. Both parents confessed their fear that Andrew was depressed.

Drawing on the research of Peter Fonagy and others, I sought to help Joanne and Peter in their efforts to help Andrew make sense of the world, to manage his inflexibility and sensory difficulties. It seemed to me, based on his history, that he had some biologically based genetic vulnerabilities. To them it seemed that he got upset about "little things." But it sounded from their description that at times for Andrew the world felt like an overwhelming and incomprehensible place. Joanne and Peter needed to help him learn to manage himself in the face of his particular challenges. Trying to reason with him when he was out of control did not work. I explained that at moments such as the playground incident, the higher centers of his brain were likely temporarily not working, and so Peter and Joanne hit a brick wall. They needed, in the heat of the moment, to find other means to help Andrew to regulate himself, even something as simple as going for a walk. Talking about what happened could come after he calmed down. Eventually their repeated efforts would give him the tools and language to regulate himself in these difficult moments.

Andrew's mother had a vivid memory of being taken to the psychiatrist as a child and given medication. She did not want Andrew to come to my office-to get the feeling that there was "something wrong with him." We agreed that they would try this new way of being with Andrew, and come back and see me in a few weeks to talk about what happened. Within a week or so of simply thinking differently about Andrew, he was more calm. Joanne and Peter felt more relaxed and sure of themselves. They found it easier to be with him and help him manage these moments of frustration.

Several weeks after this visit, I received the following comment on a blog post questioning the use of antipsychotics for young children. As a pediatrician I don't have the opportunity, other than stories from parents like Joanne, to hear adults describe their experience of being diagnosed and/or medicated, and I find these comments to be helpful. I quote him in full:

I was a so called HFA when I was a kid, "Aspergers Syndrome" they called it and was tortured on Risperdal.
Dropped out of school when I was 13 and finished my education on the
internet. Looking back I never fail to notice that 100% of my problem was not
that I was sick but that other people considered me so.I say leave them alone. I once bit myself and screamed cause someone was chewing paper (Couldn't stand paper, pencils, chalk, people bending their
hands and about 10 other things) and so what? Get me out of the room for a
minute and I'm fine. Any kid should have the right to take that over
permanent drug induced damage.

While I can't claim to know anything about this person, his wish to be recognized and understood, rather than labeled and medicated, comes through loud and clear. I wonder how many others have a similar experience without the opportunity to give voice to it until many years later.

Those who advocate for a new system of diagnostic criteria for mental health disorders in early childhood are not advocating for use of medication in this age group. It is a reasonable concern, however, that a consequence of psychiatric diagnosis, in the age of intense marketing efforts of the pharmaceutical industry and limited access to quality mental health services, will be an increase in prescribing of psychoactive medications to young children. In fact, an article in today's New York Times Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy offers a close up look of the realities of the practice of psychiatry today.

Even putting the issue of medication aside, the label of mental health "disorder" may obscure parents efforts to truly understand their child's experience. It is this kind of understanding that Peter and Joanne are working towards. In the setting of such recognition and understanding, children, even those with Andrew's quirks and vulnerabilities, have the opportunity to develop a strong, healthy sense of self.

Protecting infants from the ill effects of mental illness

2011-03-01T15:14:00.001-05:00

Three-month-old Jenna sleeps peacefully in her mother’s lap. The cards seem stacked against her. Cara at 17 is struggling to finish high school. She has been diagnosed in the past with depression and anxiety, but currently is receiving no treatment. Her primary care doctor, who referred her to me, has been prescribing an anti-anxiety medication as a temporizing measure. Cara has been playing phone tag for over a month with the therapist at the community mental health center, whom she needs to see in order to get an appointment with a psychiatrist.

Cara is scheduled as my patient in my behavioral pediatric practice. I put anxiety as the diagnosis on the billing form. But in truth the aim of my work with this mother-infant pair is to protect her daughter’s developing brain from the well-documented ill effects of maternal mental illness on child development.

Cara talks in a rambling manner about a range of subjects- her older sister at 20 pregnant with her second child, but neglectful of the first, her father who abandoned the family when she was two. She is particularly focused on her difficult relationship with James’ father, Ed. She tells of his drug use, his neediness and his difficulty accepting his role as father.

An infant’s brain makes as many as 1.8 million neural connections per second. The way in which these connections are formed is highly influenced by human relationships. As Cara responds to Jenna’s face and voice, is attuned with her rhythms and needs, both physical and emotional, she is literally growing her brain.

Important research has shown that when a mother can think about her baby’s mind and attribute meaning to his behavior, she helps him to develop a secure sense of himself and of his relationship with her. This security helps him to regulate himself in the face of difficult emotions. As he grows older he will have the capacity to think clearly and flexibly and manage himself in a complex social environment.

When I work with mother-baby pairs like Cara and Jenna, I focus on one simple thing. I listen to these mothers with the aim of helping them to reflect on their baby’s experience of the world and the meaning of their behavior. It never ceases to amaze me that with this singular focus, meaningful communication happens even in what appears to be chaotic and dismal circumstances.

As I listen to Cara’s rambling story, I know I need to help her start thinking about how all of this affects her relationship with Jenna. I use a technique I learned from leading researcher and clinician Peter Fonagy to help a person who is stuck in this kind of non-reflective thinking. I hold up my two hands. “Wait, I say. “I want you to help me understand how you think these problems with Ed connect with your relationship with Jenna.”

She pauses for a moment and then begins to cry. “When Jenna is so needy of me, it makes me think she’s just like her father, and I get so mad. Then I feel terrible for getting angry at her.” It’s a remarkable insight. But she isn’t done. She looks down at Jenna. “See how relaxed she is when I am calm. But when I get upset, she starts to cry.” Then she tells me of a time when she felt about to lose control, but somehow had managed to make Jenna laugh. “We were having a conversation,” she says joyfully, “even though she doesn’t say any words!”

It is a small moment in one 50-minute visit. I am confident, however, that with a string of moments like this, where Cara is fully present with her daughter, there is hope that she may break the cycle of intergenerational transmission of mental illness and help to grow a healthy brain.

The New York Times Thinks About Parents

2011-02-20T07:08:00.012-05:00

I felt that I was in very good company yesterday when my letter to New York Times was published in reference to last weeks op ed piece The Parent Trapped. In that piece, Katherine Ellison, responding to indictment of a mother in the murder of her two teenagers, describes her own journey from the brink in her relationship with her son. She describes feelings of barely controlled rage and her realization that she needed to get help.

While there was much that could be said about this piece, I picked up on the way in which Ms. Ellison, with the support of family, friends and professionals, took ownership of her role in the conflict. She wrote:

I spent much of the year learning about A.D.H.D., a condition I soon realized that I shared with my then 12-year-old son. Among its classic symptoms are conflict-seeking and hot-headedness. Humbling as it was, I ultimately heeded friends and professionals who encouraged me to shed my fantasy of being the victim of a raging, impossible child, and own up to the ways I was contributing to our fights.

In my response I wrote:

In the safety of my pediatric office, countless parents have revealed that they are startled by the intense rage they feel for a child whom they also have such powerful love. Katherine Ellison bravely and honestly addresses this issue in her article.

The fact is that intense opposing feelings are a normal part of any passionate relationship. But as she points out, when parents feel out of control, if they are unable to manage their own rage, it is essential to get help.

The beauty of her article is that it identifies the relational nature of the problem. All too often, a “behavior problem” is viewed as residing exclusively in the child. When parents feel recognized and understood, as Ms. Ellison seems to have felt, they are better able to be fully present with their child, in turn helping the child to manage his or her particular vulnerabilities.

Another letter identified the critical role of emotional regulation in development and the need for parents to "push the pause button" in the heat of the moment and reflect on whats going on. Yet another addressed the wrongness of corporal punishment and the need to find effective alternative measures. A third spoke of the need for friends, communities and professionals to be available to parents when they reach out for help.

What was most encouraging to me was that the majority of the letters in Saturday's paper were devoted to this subject. As the Times represents in some significant ways the cultural trends in this country, this fact gives me hope that we are seriously considering the essential role parents play, and our need as a society to support them in this very challenging yet highly rewarding task.

A Third Front in the War on Obesity

2011-02-16T13:28:00.004-05:00

Recently I watched the Academy Award winning film Monster’s Ball. A morbidly obese young boy whose father is about to be executed sneaks a chocolate bar while his mother is out, only to be verbally and physically assaulted by her when she returns and discovers a smudge of chocolate on his face. This is an extreme example, but it highlights the complex relationship children and parents can have with food and eating.

There is no doubt that childhood obesity is a huge public health problem with complex causes and far reaching effects. Michelle Obama’s efforts, now entering their second year, are admirable. The identified culprits that she has targeted; a sedentary lifestyle and aggressive marketing efforts of unhealthy foods by the food industry, play a significant role.

However, in addition to targeting interventions focused on the food industry and physical activity, it is critical to recognize the meaning of food and eating in parent-child relationships. An example from my behavioral pediatrics practice illustrates this point.

Sylvia brought her four-year-old son Andrew to see me because “he’s always eating”(details have been changed to protect privacy.) An engaging, plump little boy, he was enthralled by the Dunkin Donuts across the street from my office. Sylvia described constant battles around his demands for sweets.

But over the course of our 60-minute visit, other important issues emerged. Andrew’s father, Richard, had lost his job and the family had moved three times in the past year. Richard struggled with severe depression. In addition to the battles around foods, Andrew was having increasing numbers of temper outbursts, and his mother revealed to me that she was at times unable to contain her own rage. She had even on occasion beaten him with a belt. As Sylvia became more relaxed and began to open up, she shared that she had been physically abused as a child.

In helping to manage Andrew’s out of control heating habits, it was essential to recognize the connection between Andrew’s insatiable appetite and the stress he was experiencing in his relationships with both his mother and father. Supporting these relationships was the aim of my work with this family.

If the child in Monster’s Ball is one end of the continuum of disordered eating, and Andrew in the middle, in my general pediatric practice I see, at the other end of the continuum, the relatively minor everyday challenges of parenting that are inextricably linked to later eating habits.

A mother whose child has sensitivity to textures of foods may feel inadequate in the face of her child’s picky eating. This in turn may lead her, at moments of desperation, to force food into her child’s mouth, setting the stage for a lifelong distorted relationship with food. The primary care setting offers an opportunity for early intervention and repair of these types of difficulties. In addition, disordered sleep patterns are closely tied to risk of obesity. These patterns develop in the first few years of life, and a primary care clinician can play an important role in both development of healthy sleep habits and in setting patterns in a healthy direction when they go off course.

Supporting parent-child relationships is a critical element to add to this “war” on obesity. Investment in primary care and mental health care, as well as in programs that have been shown to support parent-child relationships that are at risk is essential. For example, the Yale based Minding the Baby program is a preventive home visiting program that aims to support parent-child relationships in young families stressed by limited economic resources.

Research by Jack P. Shonkoff, MD founding director of the Center on the Developing Child at Harvard University, has demonstrated that safe, stable, and nurturing relationships may protect children against poor health later in life. Children who develop a strong sense of self in the context of these secure relationships are more likely to make healthy lifestyle choices.

And a word of caution regarding the language of the “war” on childhood obesity. I wonder about the experience of an overweight child who is exposed to this news. Shame, confusion, and fear- these powerful emotions may go unprocessed. At the very least, these headlines should offer an opportunity for conversation among adults and children about diet and lifestyle choices.

Proposed Ban on Antipsychotic Use in Children Five and Under

2011-02-09T18:10:00.016-05:00

A study published in February issue of the Archives of General Psychiatry, written by Nancy Andreasen, former editor-in-chief of the American Journal of Psychiatry, provides evidence that long term use of antipsychotic medication results in loss of brain volume. She concludes that

Viewed together with data from animal studies, our study suggests that antipsychotics have a subtle but measurable influence on brain tissue loss over time, suggesting the importance of careful risk-benefit review of dosage and duration of treatment as well as their off-label use.

I propose that based on these findings, there be a ban on use of antipsychotic medication in children age five and under, the period of time when the brain is undergoing the most rapid growth and development.I specify this age group not only because they are the most vulnerable, but also because beyond age six the brain is less plastic, and so alternative interventions that aim to change the structure of the brain may be less effective. Also, it is a reasonable goal. If more evidence about damaging effects emerges it may be necessary to extend the ban to all children.

Those who advocate for use of antipsychotics in young children with a range of behavior problems argue that stress hurts the brain and that these medications can protect the brain from this stress. When children and parents feel out of control, when there is sleep deprivation and explosive behavior, both parents and children experience a great deal of stress. It is not surprising that giving a powerful drug that acts on the brain would calm a child down.

Medication, however, is not the only way to reduce stress. Being understood by people who love you also reduces stress at the level of brain biochemistry. Reducing stress and changing the brain in this way is not easy. It requires sustained effort and a lot of support for parents. But the changes are safe, and may last a lifetime.

The growing field of parent-infant mental health offers quality research and a wealth of effective interventions to support troubled children and their parents.These interventions , unfortunately, are not well covered by third party payers and are not marketed as widely as prescription drugs. , They require hard work and do not offer the “quick fix” of medication. As such, they are less available for struggling children and families.

As long as a drug is available (and the preferred mode of treatment according to the health insurance industry), motivation to do this more difficult work will be lost. In addition, there is a severe shortage of quality mental health care services. This is due to many factors, including poor reimbursement and prohibitively complex administrative costs for private practitioners. Just as motivation may be lost on an individual level, as long as the drug is available, there is little motivation to change the health care system to more effectively provide these alternative interventions.

All of this is reason enough not to use these medications in very young children. Add to this the solid evidence that these drugs damage the brains of adults, and using them in children whose brains are rapidly growing is, in my opinion, unconscionable.

Amy Chua and the role of empathy in parenting

2011-02-03T12:01:00.027-05:00

All this talk about Amy Chua’s parenting techniques has me thinking about Brandon Fisher, the manufacturer of drilling equipment who president Obama recognized in the State of the Union Address for his critical role in the rescue of the Chilean miners. While I cannot claim to know anything about Fisher's upbringing, I do know a great deal about what qualities in a parent-child relationship lead to the characteristics he exhibited, namely empathy, flexibility and resourcefulness.

I wonder if the anxiety being experienced on a grand scale by American parents in the wake of Chua’s book is due to the fact that that while severe parenting techniques designed to achieve academic success may not be palatable, parents feel a void when it comes to finding an acceptable alternative model, as exemplified by the Boston globe op ed, The tiger mother roars, and the slacker mother shudders.

John Bowlby, the father of attachment theory (no relation to “attachment parenting” as described by William Sears) describes the importance of a secure early relationships in raising a child who, in Bowlby’s words, is “self-reliant and bold in his explorations of the world, co-operative with others, and also-a very important point-sympathetic and helpful to others in distress.”

Contemporary research offers a close up view of a secure parent-child relationship that can instill these qualities. It involves a balance of empathy and limit setting. There are four key elements. The first is wondering about the meaning of a child’s behavior rather than responding to the behavior itself. The second is empathy. This is more than saying “I know how you feel.” It means actually feeling what your child is feeling, but reflecting it back to him in a way that says, “I know you’re upset, but we’ll manage.” The third is containing difficult emotions, often in the form of setting limits. Limit setting is about teaching the essential life skills of frustration tolerance, impulse control and emotional regulation. And forth, and perhaps most challenging, is doing all this without letting your own distress get in the way.

Lest this list cause a parent to feel overwhelmed by the enormity of the task, research of Ed Tronick, chief of the child development unit at Children’s Hospital Boston, offers hope. If parents are attuned with their child only 30% of the time, if 70% of the time you don’t connect with your child in the way I describe, as long as most disruptions are recognized and repaired, development moves forward in a healthy direction. In fact, disruptions and their subsequent repair are essential in instilling resilience, an important fourth attribute to add to Bowlby’s list. D.W.Winnicott, pediatrician turned psychoanalyst coined the phrase the “good-enough mother” to describe a mother who is not perfect, and in her very imperfection helps her child to manage life’s challenges in direct proportion to what he is capable of.

Chua’s book, in addition to creating mass unease in American parents, has raised fear regarding our ability to compete with China. Towards that end, raising a generation of Brandon Fishers, citizens with the qualities of empathy, flexibility, resourcefulness, and resilience, is essential. In order to accomplish this task, we must support parent-child relationships from the beginning. There is extensive evidence that children learn these skills in infancy, when the brain is making as many as 1.8 million neural connections per second.

Unfortunately our country does not recognize parents in this way. As I have said in previous posts repeating, our lack of support of early parent-child relationships is exemplified by our maternity leave policy that lags far behind other countries, as well as the rapid increase of prescribing of psychoactive medication to very young children. This second phenomenon is in turn inextricably linked with the very powerful health insurance industry and the lack of value placed on primary care and mental health care services.

Public policy to support early parent-child relationships is essential. For example, postpartum depression can negatively impact a mother's ability to be present with her child in a way that promotes healthy emotional development. This past summer a new law was passed in Massachusetts that calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.

Contemporary research in child development offers an answer to the questions raised by Chua, both on a small scale: a model of parenting to follow, and on a large scale: a model of social policy to support parents in this task. I thank her for providing the motivation to address issues that are critical for the future of our children and of our country.

Infant-parent mental health care-where does it fit in?

2011-01-27T13:41:00.021-05:00

When I tell friends, office staff and even some colleagues in pediatrics that I am building a behavioral pediatrics practice that is focused on infants, they sometimes give me a puzzled look. I was recently asked to write a guest post for a blog called "FreelanceMD:the cure for the common physician." The blog advertises itself as being for doctors taking charge of their own practice of medicine,and even has a section entitled "non-traditional medical careers". As the way I practice pediatrics doesn't fit into any defined category, I thought this might be a good community to join. I invite you to take a look at my guest post today, Inside Infant-Parent Mental Health Care. It has some similar themes to what I have written about elsewhere on this blog, and offers a specific example of what a pediatrician who follows the principles of the discipline of infant mental health actually does.

Extensive research has shown the long term negative effects of maternal depression and anxiety on child development. Untoward effects on development occur even when symptoms are below the level to qualify for a diagnosis, as is common in today's culture where new mothers are often struggling with minimal help and/or emotional support. We need to intervene early, when these brains are rapidly growing, when an infant’s brain is making as many as 1.8 million neural connections per second.

This kind of work fits very well in a primary care practice, where mothers and babies are seen early and often. Many programs that implement the principles of parent-infant mental health care are in university settings, or in large cities or specifically target high-risk groups. Being seen in a primary care practice avoids the stigma that still may be associated with a referral to a mental health care practitioner. It also offers the opportunity to help families that might not fit into an identified high risk category, but are struggling nonetheless.This is a model that could be applied in practices of any size in any location.The first step would be to integrate the growing ranks of mental health professionals who practice parent-infant psychotherapy into primary care practices. Next would be a large scale effort to teach these principals and practices to primary care providers themselves.

This model has worked well for me for many years. At first I did both primary care and behavioral pediatrics, but when my children reached school age and I could not meet the needs of my family if I were to continue taking call, I switched to doing exclusively behavioral pediatrics, but within a primary care practice. As far as the insurance companies are concerned I am credentialed as general pediatrician. I have always been well reimbursed for my services even when I see patients often and for 50 minute visits.

I hope that many pediatricians will follow a similar path.

A Vote for Repeal of Health Care Reform is a Vote Against Children (and so our country's future)

2011-01-19T11:20:00.025-05:00

My forthcoming book, that has a publication date of September 2011, offers over 150 pages of evidence, based on more than 30 years of research as well as my 25 years of experience as a pediatrician, that supporting parents' efforts to be fully emotionally present with their children, to be curious about their children's minds and the meaning of their behavior, will lead to a generation of citizens who are emotionally healthy, resourceful, and adaptive to a complex social world.

The last chapter, entitled "Beyond Medication" places this view up next to an alternative paradigm offered by the combined forces of the health insurance industry and pharmaceutical industry. I am currently in the final stages of editing this last chapter. This morning I came upon this sentence, that occurs following a section in which I describe obstacles to quality care for children and families. The sentence reads:

Often when I see a family in my office [with a mental health concern] we can clearly see what is needed but cannot get from here to there. I believe there is hope, however, in this age of health care reform.

As I write this, repeal of health care reform is being debated in the House. Fortunately repeal is unlikely to happen, given its support in the Senate and Obama's veto powers. So I probably won't have to take that sentence out of my book. Still, the fact that repeal is even being discussed makes me very uneasy.

Health care reform as it stands does not directly address these obstacles to care, but is, in my opinion, a critical beginning. Next must come a renewed value on prevention, primary care and mental health care. These changes will serve to promote our children's healthy emotional development.

A vote against health care reform is a vote for the insurance companies. The powerful health insurance industry together with the pharmaceutical industry obstruct true progress in promoting children's healthy emotional development, because both support the quick fix over more difficult, yet safer and more lasting relationship-based interventions.

In this last chapter of my book, I also describe the 40 fold increase in the diagnosis of bipolar disorder in children and the exponential increase in prescribing of atypical antipsychotics, a highly profitable class of drugs, to very young children. I put the issue in perspective by including a sentence about the influence of the pharmaceutical industry on Joseph Biederman, the child psychiatrist at Harvard who is primarily responsible for this phenomenon. Here is the sentence I added this morning.

Further complicating this story is the fact that Biederman was found to have earned at least $1.6 million in consulting fees from companies that make these drugs, while reporting only $200,000 of this income to his employer, Harvard University. He is currently under investigation for possible violation of federal and university research rules designed to police potential conflicts of interest.

The health insurance industry and the pharmaceutical industry often seem not to have our children's best interests in mind. Yet as Nobel Prize winning economist James Heckman has argued, an investment in young children is an investment in our country's future. Health care reform as it stands is an essential first step in the right direction.

An Epidemic of Uncontained Aggression

2011-01-11T10:37:00.027-05:00

Josh Marshall, a guest of Keith Olberman's news program Countdown, made a brilliant analogy when discussing the recent assassination attempt on congresswoman Gabrielle Giffords. He compared the current climate of incitement and violent rhetoric to a flu epidemic in which, while many are affected, the weak and infirm are the most vulnerable. Similarly, the mentally ill, like Jared Loughner appears to be, are most vulnerable to act on the inflammatory and hateful words so rampant in our culture today. But what is the cause of this epidemic? What is the "virus" responsible for this "illness?" Many blame the political situation which has become increasingly polarized and divisive. Others point to the media and the talk show hosts who promote the free expression of rage and hate.

I propose that while these may be proximate causes, the true cause may have much deeper roots. Extensive research has shown that children learn to regulate emotions, including aggression, at a young age, in relationships with their caregivers. This learning takes place at the level of gene expression and biochemistry of the brain. The centers of our brain responsible for observing and monitoring our behavior actually grow fibers that control lower centers of the brain responsible for fear and the fight-flight response. This growth takes place in the context of attuned loving relationships in which children feel understood.

We as a society now seem to be failing at this task of regulating aggression. I wonder if this failure is in some way connected to our culture's failure to nurture and support early parent-child relationships, as exemplified by our maternity leave policy that lags so far behind other countries, as well as the rapid increase of prescribing of psychoactive medication to very young children. The second phenomenon is in turn inextricably linked with the very powerful health insurance industry and the lack of value placed on primary care and mental health care services.

Aggression is a normal healthy emotion, which, if all goes well, children learn to regulate and contain. It then may be transformed into assertiveness, which is considered a positive trait. When children lack close secure relationships that help them to think about and understand their feelings, these aggressive feelings don't go away. Without the ability to think about feelings, a person is more likely to impulsively act them out.

This weekend I will have the privilege, as part of the UMass Boston Infant Parent Mental Health Post Graduate Certificate Program
to hear leading researcher Peter Fonagy present the most current research demonstrating the critical role of understanding children's minds and helping them to contain intense feelings in promoting their healthy emotional development.

Public policy to support early parent-child relationships is essential. For example, postpartum depression can negatively impact a mother's ability to be present with her child in a way that teaches him to regulate intense feelings. Program leader Ed Tronick has been instrumental in calling attention to this very important issue, and this past summer a new law was passed that requires Massachusetts health insurers to submit annual reports on their efforts to screen for postpartum depression and calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.

Certainly there are other angles for intervention in the aftermath of this horrific event, in the political realm as well as in the media. It may also inspire those strive to support these early relationships to, in the words of Dr. Tronick, "Press on with our work for children and families."

A Baby's Intuition

2010-12-28T13:30:00.031-05:00

2-month old Max sat comfortably on his mother's lap and intently studied his hand. "He discovered them a few weeks ago. He's working hard to get his thumb in his mouth," Ellen told me." Ah ooh," Max cooed to me when I smiled at him and commented on his new skill. "He's talking a lot too," Ellen said proudly. We wore huge grins of delight with Max's obvious talents.

Our visit three weeks earlier, in contrast, was painful and difficult. Max slept the whole time, but Ellen wept as she spoke of debilitating anxiety and periods of inexplicable sadness. "I sometimes feel so lost, she had said." We spoke about her strained relationship with her husband, John. She described an intrusive ever present mother-in-law who always managed to make her feel bad. Arguments between her and John were escalating. She felt increasingly that he didn't support her when she was overwhelmed. I was worried about the degree of her emotional distress, and asked if she wanted the name of a therapist to talk with about her sadness and anxiety. She said yes. I gave her some names, and also made a follow up visit to see her with the baby.

Ellen hadn't called the therapist, and explained that she was having longer periods where she felt better. Max was becoming such a delight that he was pulling her along. "I have three or four good days, but then the bad feelings return." I followed Ellen's lead, focusing on all the positive changes she had made. She was learning to take care of herself and was excitedly thinking about going back to work. As she described these good feelings, Max's little body was relaxed and content in her arms. After the trauma of the last visit, she seemed to delight in telling me the good parts. I wanted to give her the space, yet wondered to myself if the anxiety had indeed passed.

Then in the middle of telling me about the holiday it happened. She started calmly enough to describe a visit to her in-laws. But quickly her distress escalated. Her voice became tense, her face contorted with anger. I tried to follow the details of the story, but noticed that Max had begun to squirm on Ellen's lap. He pushed his head back and his legs extended. She distractedly held him up against her shoulder, increasingly agitated by her rage at her husband's behavior. But Max would not be calmed, and soon his fussing escalated to an all out cry. I sensed that Ellen was asking me to validate her position in the argument with her husband. But this was not my role, and I took a different approach.

"This anger you experience seems to be making you feel bad." She paused. "Yes-I'm really a nice person and I don't like to feel so mean." "I bet if I took your blood pressure right now it would be sky high." She readily agreed. As she shifted her focus from her rage, Max's fussing decreased. Ever mindful of not wanting to make her feel blamed, I commented on how Max was reacting to her mood. Fortunately she did not respond defensively, but rather observed, "He's very intuitive. He can tell exactly what I'm feeling."

Extensive literature, much of which I have discussed on this blog, describes the negative effects of a mother's depression and anxiety on a baby's development. My visits with Max an Ellen offer a close up snapshot of what this can look like and what might be done to help.

Elizabeth Meins, PhD and colleagues have shown in their research that a mother's capacity to think about her baby's mind is a associated with secure attachment. Secure attachment, in turn, is linked to many positive outcomes including emotional regulation, cognitive resourcefulness and social adaptation. Ellen's noting of her son's intuitiveness represents a perfect example of thinking about her baby's mind. She showed a non-defensive willingness to reflect on his experience. She could think about what might be going on in is 2-month-old mind when her anxiety took over.

Ed Tronick,PhD and colleagues have shown that if parents and infants are attuned 30% of the time, but disruptions occur in up to 70% of interactions, as long as most of these disruptions are recognized and repaired, development proceeds in a healthy direction. Ellen was able to repair the disruption caused by her momentary agitation, and to help Max to calm down.

Ellen, Max and I will meet again in a few weeks. Perhaps Ellen will need more intensive treatment for depression and anxiety. She still has the number of the therapist. Perhaps she and John will need support for their marriage. But I feel hopeful about Max and Ellen. She has seen how Max thrives when she is feeling good. This knowledge I believe, will motivate her to take care of herself so that she can continue to be emotionally available for Max in the way he needs and loves.

Promoting children's healthy development: An inspirational poem

2010-12-19T07:38:00.011-05:00

Below is a poem written and read by Chris Corrigan at the conclusion of a conference entitled "Applying the Science of Early Childhood Development to State Policy and Practice: a Case for Action and a Call for Innovation." The still face refers to Dr.Ed Tronick's paradigm that he articulates and demonstrates in this three minute video. The ACE in the poem refers to Adverse Childhood Events.

No more still face
a poetic harvest of the conference on science and early learning
by Chris Corrigan

November 4, 2010
Seattle, WA

Face it – relationships
language and emotion
700 synapses
babies are an ocean of potential for growth.
Reach out -
read and react
serve and return
the simplest skills for any parent to learn
ACEs are wild
don't poker face that child
ACEs are wild
don't poker face that child.

We need traction for action
no more funding for reactions
but positive interventions
systemic reinvention
health promotion and prevention
well placed intention.

Founders and funders
get this under your skin
When society is the still face
we create the ACE
When society is the still face
we create the ACE

So what do we do?

We partner early and often
And surely that softens
the hard blows of a cold world
a banner unfurled
a revolution of solutions
of iLabs and Head Start
exposure to the reading arts
bring parents together
to talk and train each other
raise kids in community
and pursue a unity of purpose
and hope and inspiration
for this nation can be
the demonstration project of population in relation
and information dissemination.

For a world of compassion
can fashion its future
synapse by synapse
and not relapse into a state
of comatose siloitis.

Because you know what?
We are the ACE
when society is the still face
we are the ACE
when society is the still face.

So let's get on the continuum
and at a minimum
shout out for Thrive by Five
Bring partnerships to life
Reach out and read
Everywhere plant seeds
Base policy on science
increase community self-reliance
reach parents where they are
at home and in their cars
at salons in Central Park
on the streets after dark
supporting healthy choices
hearing a diversity of voices.

Bring it to schools
deposit all the tools that every family needs
common methods that lead us
to children at the center
parents as mentors
resilience enters through doors
pried open by relationships
the community is the trajectory
the way to connectivity
cafés and conversation and new forms of evaluation
spark the realization
that T.X.T 4 B.A.B
Educare, P3 and all the rest we see
is about relationality.

Fusion makes change
the core is rearranged
fusion makes change
the core is rearranged

So people in this State
we can no longer wait for fate to have its day
here are the ways
we get traction for action:

One science fits all

So tear down the walls
that keep parents from all
the riches that help them call
the future to their kids
open up learning, cultivate a yearning
for society's embrace

A bill of rights that rights political will
that allocates the resources to relationships

This is STILL public health – why the stealth
approach to early learning? Let's be turning
this science to common sense
and then let's invest this sense to finance a dense campaign
to build better brains
better babies
break the chains that hold us back
keep us from conceiving
of new tender maybes...

Because in every single case
There is only this to chase:

No more ACE
No more still face
No more ACE
No more still face
No more ACE
No more

still

face.

This poem offers a hopeful antidote to the depressing yet powerful Boston Globe piece about the SSI system that I wrote about in my previous post. That post concluded with the words "this piece demonstrates with disturbing clarity how much we need to intervene early to support parents and their young children, before they get to such a point of desperation that they are willing to label a child as disabled in order to survive." The website of the Harvard University Center on the Developing Child offers a wealth of information about why and how to intervene early to promote healthy development.

Rising SSI benefits for young children and marketing of atypical antipsychotics: a possible link

2010-12-14T06:49:00.016-05:00

A legacy of unintended side effects, a powerful piece of investigative reporting in Sunday's Boston Globe, offers a view of the desperation of poverty. Parents speak to reporter Patricia Wen of seeking diagnoses and psychiatric medication for their young children in order to receive SSI(Supplemental Security Income)benefits. In order to qualify for SSI a child must have a recognized disability. In 1990 8% of children qualified because of mental, learning or behavioral issues. In 2009, that number had jumped nationwide to 53 percent. Wen writes:

In New England, the numbers are even higher — 63 percent of children qualify for SSI based on such mental disabilities. That is the highest percentage for any region in the country. And here and across the nation, the SSI trend line is up, with children under 5 the fastest-growing group. Once diagnosed, these children often bring in close to half their family’s income.

There are many alarming issues raised by this piece, and Ms. Wen is brave to tackle the subject, given that questioning benefits for troubled children is likely not to be a popular position among Globe readers.

One particular statistic jumped out at me. Wen outlines the historical shift in the program, from its inception in 1972, to the spike in mental disability cases following a legal ruling in favor of a boy whose disability payments had been cut off, through the identified abuses of the system in the 1990's followed by cracking down by federal law makers. Wen writes:

The children’s SSI disability rolls instantly shrunk — but the decline would be short-lived. Families and clinicians began to adjust to the new rules, which emphasized extensive medical records for any claimed disability. From 1997 to 2007, the number of children who qualified under behavioral, mental, and learning disorders more than tripled from 180,000 to 562,000.

What else happened in exactly that time period of significance for children's mental health? In June of 2001 I took a course sponsored by Harvard Medical School on Major Psychiatric Illnesses in Children and Adolescents. I attended a lecture given by Janet Wosniak entitled "Juvenile Bipolar Disorder: An Overlooked Condition in Treatment Resistant Depressed Children."

Little did any of us at the lecture know at the time that, largely as a result of Dr Wosniak her close colleague Joseph Biederman's ideas, we would over the next nine years see a 4000 percent increase in diagnosis of this "overlooked condition." These children were described as irritable with prolonged, aggressive temper outbursts that she called "affect storms." Some children were as young as 3 and over 60% were under age 12. In a previous blog post on the subject I wrote;

So here we have a perfect storm. A new disease with no clearly identified treatment. A new drug. Between 2000 and 2010 six atypical antipsychotics, Clozaril, Seroquel, Zyprexa, Risperdol, Abilify and Geodon were approved for treatment of pediatric bipolar disorder. The number of prescriptions for atypical antipsychotics for children and adolescents doubled to 4.4 million between 2003 and 2006. Prescribing of antipsychotics for two to five year olds has doubled in the past several years. Atypical antipsychotics are among the most profitable class of drugs in the United States.

I can't help but wonder if these events- rapid increase in SSI benefits for children under five for a mental health disability, and the rapid rise in diagnosis of bipolar disorder in young children in parallel with the explosion of development and marketing of atypical antipsychotics, are closely linked.

We urgently need a different paradigm for understanding emotional and behavioral problems in young children from that offered by the pharmaceutical industry. Money needs to be redirected to supporting parents in their ability to be physically and emotionally present with their very young children at times of most rapid brain development. Many interventions, such as Yale's Minding the Baby program, have been successful in setting children on a healthy path of development even in the context of significant economic and psychosocial risk. A wealth of high quality research is showing that children learn to regulate emotions in the context of relationships, and that this learning takes place at the level of gene expression and biochemistry of the brain.

Wen writes, "This abrupt climb in cases is a sign, some researchers say, that the SSI program has veered far from its original purpose." Aid for children with true disabilities, whether physical or mental, is extremely important, and the take home message should not be that the program is a bad one. Rather this piece demonstrates with disturbing clarity how much we need to intervene early to support parents and their young children, before they get to such a point of desperation that they are willing to label a child as disabled in order to survive.

How Parents and Children Regulate(and Dysregulate) Each Other

2010-12-10T11:56:00.014-05:00

When parents and children come to see me in my behavioral pediatric practice, they are angry, disconnected and sad. In moments of explosive behavior, both parent and child feel terribly out of control. My aim it to help them reconnect and in doing so, to calm down and find pleasure again in their relationship.

Recently I saw a 4 year old boy,David, whose mother, Alice, described him as "explosive." She told of a typical scene- a request to get ready for bed was met with a firm "no," and soon mother and child were head to head in battle. An hour later, David was kicking and screaming on the floor and Alice was crying, horrified at herself for having threatened to hit him.

Rather than launching right in to "what to do" I took some time to listen to Alice's story while David played on the floor. Many things emerged, but most striking was the fact that the family had moved three times in the past year after David's father,Ron, lost his business, leaving the family in financial ruin. Ron had been severely depressed, but according to Alice, they were settled now and he had a good job. When I commented that it sounded like a very stressful year, she immediately responded with," Yes, but we didn't let it affect David."

From my position, this clearly seemed impossible. Such an experience is inevitably stressful for a four year old child. But for some reason, Alice, who was an intelligent woman, did not see it. Perhaps she felt so much guilt, or even shame, about what had happened to her family that could not let herself recognize this truth.

I saw my task at that moment as helping Alice to understand David's experience, to recognize that his increasingly frequent battles for control were likely in part due to feeling things were out of control for whole past year. But I needed help Alice recognize this without increasing her guilt and shame. It was a difficult and sensitive procedure.

When I saw them two weeks later, the explosive episodes had significantly decreased. Alice told me that his behavior no longer seemed so bewildering to her. Rather than getting angry, she listened to him, yet set more firm limits. She was delighted with the results and felt proud of her ability to regain a sense of joy and stability in her relationship with her son.

In recent blog posts, I have written about my experience as a fellow with the Infant Parent Mental Health Post Graduate Certificate Program at U Mass Boston, which is lead by Ed Tronick. At our first weekend Dr. Tronick, who is perhaps best known for developing the still face paradigm, talked to us about his mutual regulation model. In a paper we read for that weekend, Dr. Tronick writes:

"The MRM(mutual regulation model) stipulates that caregivers/mothers and infants/children are linked subsystems of a dyadic system and each component, infant and caregiver/mother, regulate disorganization and its costs by a bidirectional process of behavioral signaling and receiving."

The still face paradigm, in which a mother interacts face to face with her infant as she usually would, then for a two minute period presents a completely still face, followed by a reunion episode of resumed face to face interaction, in Dr. Tronick's words "demonstrates the costliness of an experimental disruption of the mutual regulatory process...as it serves as a model for the stress inherent in normal interactions." Dr. Tronick's model is compelling and very complex. I admit that while I was fascinated, I had a difficult time connecting this construct with the daily interactions I have with children and families in my office.That is until my "aha" moment this week.

I have recently been in contact with another leading researcher in the field, Arietta Slade. She has written extensively about what is referred to as parental reflective functioning. This is also described as "holding a child's mind in mind."It essentially refers to a parent's capacity to reflect on the meaning of her child's behavior. Slade, along with other researchers, has shown how enhancing a parent's capacity for reflective functioning is associated with many positive outcomes for a child's emotional development, including flexibility, cognitive resourcesfulness and the ability to manage complex social situation. I have been heavily influence by her work in my practice, and have written about the concept of holding a child in mind on this blog and in my forthcoming book.

In this "aha" moment, I suddenly understood that when things go well in my office, it is not only because a parent increases her capacity for reflective functioning. Supporting her in her efforts to her to reflect upon the meaning of her child's behavior is simply the point of entry. Once the child feels understood, or held in mind, he becomes calm. As I have written about elsewhere on this blog,it is likely that this change is on a neurobiological basis, occurring at the level of the structures of the brain that produce stress hormones. When a child is calm, a mother begins to feel better about herself. In fact, often a child's out of control behavior itself produces a feeling of shame in a parent. When parent and child are more in control, this sense of shame decreases. In turn, when a parent feels less shame, and less stress, she can think more clearly. She is better able to reflect on the meaning of her child's behavior. In turn a child feels even more calm and in control. Voila! Mutual Regulation! This is where we aim to be.

The Pharmaceutical Industry, Psychiatric Drugs and Primary Care

2010-12-05T13:39:00.019-05:00

An article last week in the New York Times, entitled Drug makers wrote book under 2 doctors names reported on a book that was written by two psychiatrists for an audience of primary care clinicians. The book, whose aim was to teach these clinicians about how to treat psychiatric disorders, was in fact ghostwritten by the drug company then known as SmithKline Beecham.

Robert Whitaker, author of Anatomy of an Epidemic, comments on his blog in a post entitled Ghostwritten book hints at much larger problem He offers a larger context, stating that

In fact, this ghostwriting revelation simply hints at a much larger, pervasive problem, which is that financial bias profoundly affects the authorship of psychiatric textbooks at every turn. And it is quite easy to document that this is so.

Most concerning to me, as a pediatrician, was a comment on Mr. Whitaker's blog from an MD who states

The Amer. Acad Child and Adolescent Psychiatry Psychopharm conference this November seemed to me to reflect commercial bias in a level I found unsettling -given that AACAP has long been a refuge where quality of care has tended to come first.

Last week, I wrote in a blog post about the possible influence of the pharmaceutical industry on the recommendations child psychiatrists give to primary care clinicians. I describe a supposedly successful program that aims to increase access to mental health care. The program in fact simply supports primary care clinicians in prescribing psychiatric medication to children.

The New York Times article, Whitaker's post, and the comment on it all confirm my fears of the heavy influence of the pharmaceutical industry on how psychiatry is guiding primary care clinicians in treatment of of psychiatric problems, in both adults and children.

An alternative paradigm is urgently needed. A primary care clinician has a long standing relationship with a family than can be put to great use in addressing mental health problems in a preventive model. With the enormous financial influence of the pharmaceutical industry moving the ship of mental health care in one direction, getting it to move in a different direction will take an enormous effort. Add to this a cultural expectation of a quick fix, and this seems an almost impossible task. But when it comes to supporting children's healthy emotional development, I believe we have no choice but to make the effort to change direction.

Understanding Behavioral Epigenetics vs Increasing Access to Psychiatric Drugs for Children

2010-11-26T08:15:00.013-05:00

These two topics could be two different blogs posts, but I decided to put them together because, in considering the larger question of where we invest our resources in promoting children's mental health, the two are subjects are linked. The first fills me with excitement and optimism, the second with despair.

My blog posts have been less frequent because I have been hard at work, under the guidance of the brilliant behavioral geneticist David Reiss, revising the section of my book that covers the critically important topic of epigenetics. Knowledge in this discipline is exploding, and he generously offered me the most up to date references. I am eager to see how this complex information translates for a general audience. Any comments to that effect will be much appreciated.

Epigenetics puts a whole new spin on the “nature vs. nurture” debate, which has historically viewed genes and environment as separate independent factors in determining the course of an individual’s development. Rare genetic disorders that result from a single change in the gene sequence have strengthened this misconception that one’s genetic makeup inevitably determines one’s future. Epigenetics refers to changes in DNA structure which alter gene expression, and hence individual characteristics, that do not involve changes to the sequence of DNA. According to leading researcher Michael Meaney, behavioral epigenetics specifically refers to the way environment, or life experience, influences gene expression and subsequent behavior and development.

The significance of this research for parenting is that that a child may be born with a particular gene for some problematic trait. But the effects of that gene on behavior will vary according to the environment. If parents do not respond negatively to difficult behavior, the effects of that gene may be altered and the problematic behavior may not occur. Conversely, negative response to challenging behavior will lead to expression of behavior associated with the problematic gene. These genes directly affect the development of the structure and biochemistry brain.

(For those readers who interpret this material as blaming parents when things go wrong, I refer you to an earlier blog post Guilt, Blame and Responsibility)

The importance of family environment on moderating genetic influence have been demonstrated widely in infants, children and adolescents. One particularly striking example is research on the (S) or short allele of the serotonin transporter gene . This gene is associated with stress responsivity and also with structure and function of the amygdala and medial prefrontal cortex, brain structures which are critical in emotional regulation. A person may have the short allele, but its expression, or its effect on behavior, is strongly affected by life experience. For example a person with the short allele has an increased risk of depression if he experiences stressful life events. Frances Champagne, a major figure in the field, writes in her paper, How social experiences influence the brain

Although these examples of interactions between genotypes and early environment are striking, we are only starting to fully appreciate the complex interplay between genetic backgrounds, social environments and brain development. Indeed, it is likely that such interactions[between genes and environment} will be found to be common and significant in development of most behavioral phenotypes[individual characteristics].

While hard at work wrapping my mind around these important research findings, I received, in AAP smartbriefs, a daily email about pediatric related news stories, an item about a recently published study in Pediatrics about a Massachusetts based program designed to improve access to child psychiatry services, known as MCPAP. Internal Medicine News sums up the study as follows;

A state-funded initiative to offer free mental health consultations to pediatric primary care physicians increased the proportion of pediatricians who said they were able to meet the needs of their psychiatric patients from 8% to 63% in 3.5 years.

Translation: Primary care doctors significantly increased their prescribing of psychiatric medication to children. In my opinion, this is not a statistic to be proud of. From 2005 to 2010 I was part a pediatric practice receiving the services of the MCPAP program. In May 2009 I heard Barry Sarvet, the lead author on the current study, speak at the 5th Annual Child Psychiatry in Primary Care Conference. At this conference he clearly and unequivocally supported the prescribing of psychoactive medication by pediatricians to young children, including atypical antipsychotics. Granted, this prescribing is under the guidance of a MCPAP psychiatrist. Some of these children are seen for a one time consultation, but in many cases the psychiatrist simply speaks with the pediatrician on the telephone.

In March of 2009 I wrote an op ed for the Boston Globe entitled Backed into a Treatment Corner. In the article I describe two very troubled patients for whom who I felt forced into prescribing psychiatric medication. I made the analogy to expecting a primary care clinican to treat a brain tumor.The article made no mention of the MCPAP program. It was widely praised, and many of the letters to the editor spoke to the importance of exposing this widespread problem. A few days after it was published,however, I received a call from Dr. Sarvet. He was furious. Apparently he had gotten in trouble with the powers that be that provide funding for MCPAP. My piece apparently made them look bad. I found this interesting, because in fact one of the patients was from New York State and thus not under the jurisdiction of MCPAP. Yet Dr. Sarvet experienced my piece as a condemnation of his program. When I explained that this had been far from my intention in writing the piece, his response was,"Well, its too late to take it back."

Certainly MCPAP was successful in accomplishing what it set out to do. My individual experience was that the participating psychiatrists were very helpful. They responded to my questions, which almost exclusively were about prescribing medication to older children with a diagnosis of ADHD, in a timely manner. But read the fine print in the current Pediatrics article:

FINANCIAL DISCLOSURE: Dr Prince serves as a consultant to
Astra-Zeneca, is a member of the speakers bureau for McNeil
Pharmaceutical, and has received a speaker’s honorarium from
Shire, and Dr Bostic serves as a consultant to Forest
Laboratories and GlaxoSmithKline; the other authors have
indicated they have no financial relationships relevant to this
article to disclose.

I can't help but wonder if all of the MCPAP psychiatrists have at some point in their career,if not specifically in relation to this article, had significant associations with the pharmaceutical companies who profit from prescribing of psychiatric medication to children. Has this relationship affected their recommendations regarding prescribing practices? I am hard pressed to believe that it has not.

So how to fit these two seemingly disparate topics together? Rather than channelling money into programs that increase use of psychiatric medication for young children, wouldn't it make more sense to turn our attention to prevention, and to supporting families in promoting children's healthy emotional development? If the research in epigenetics is showing that with such interventions we might actually impact on gene expression, and in turn grow and development of the brain, this seems a far better path to pursue than changing young developing brains with powerful psychiatric medications.

If health care providers on the front lines have the time to develop relationships with young families, if there is a strong system of mental health care to support families who are struggling, and a medical education system that supports clinicians in their efforts to listen to parent’s stories, we will be well on our way. The image comes to mind of a set of Russian dolls. The highly valued primary care clinician, reimbursed by the health care system, listening to the whole of parent’s experience, can help bring out their basic wisdom and inherent intuition. Then we as a society could be said to be holding all children in mind.

High Tech Baby Monitors Prey on Parent's Vulnerabilities

2010-11-12T03:47:00.022-05:00

Recently I was interviewed by a reporter about the effects of the newest baby monitors on parent-child relationships. A teddy bear with a camera in its nose hooks up to a TV, allowing parents to watch their baby's every move. One product called an exmobaby is actually worn against the baby's skin and measures heart rate and respirations. A CEO of the company is quoted a saying, presumably as a selling point, “This continuous monitoring in realtime will allow for an ‘emotional umbilical cord’ between mother and child.” My conversation with this reporter got me thinking.

When we become parents we have the opportunity to open our hearts to a love unlike any other. This love may begin at the moment a mother learns she is pregnant. But in opening ourselves to this love, we take a risk. Though the idea is mostly out of our conscious awareness, in becoming parents we make ourselves vulnerable to an unlikely but real possibility of unbearable loss.

A central task of parenting is to manage our anxiety around this possibility. Not only when we put our children to bed, but when we let them go down a slide, go to preschool, go skiing in Europe. We allow them to separate and grow up. All along we must learn to manage our anxiety.

When I was pregnant with my son, we were told that he might have a very serious heart condition. He was followed with yearly tests and then last spring, when he was 12, we were told that he and his heart had grown to the point where the doctors felt we didn't need to worry about it. Even now, every night when I say "Goodnight, I love you, see you in the morning," I remember the gripping fear of loss. But when at the age of eight he begged to go to sleep away camp like his big sister, we let him go.

Now along come these baby monitors which, in my opinion, abuse this vulnerability for profit. Certainly if a baby has an identified medical condition, monitoring of heart rate and respirations may be indicated. But these monitors need to be used carefully and under supervision of a health care provider. For a baby who has no such identified risk, there is no reason to monitor him. Putting a child under the age of six months to sleep on his back does more to protect him than any baby monitor ever could. A simple audio monitor that allows parents to hear a baby if he cries during the night many be helpful. But unless you have a huge house, or are having a party, you will generally be able to hear your baby's cry during the night, and even that may not be necessary.

Another drawback of these monitors is that they send parents a message that it is not OK to leave your baby to do adult activities. What about watching a movie instead of your baby on TV? I read a recent blog post with the title"Attachment Parenting-Is It a Prison for Moms? "Attachment parenting is a style of parenting described by William Sears that advocates for a mother to be with her child as much as possible, including carrying and cosleeping. (It is distinct from and unrelated to John Bowlby's attachment theory.) These are fine choices if parents wish to make them. But it is important to recognize that solid relationship between parents, one that is often fostered by having adult time together, can contribute significantly to a child's healthy emotional development. It helps both parents and child negotiate the challenging task of separation.

As I approach the age of 50, I am aware that I need to work hard to be open minded to new technologies. But to high tech baby monitors, I give it an unequivocal thumbs down.

Diagnosing Autism in Infancy?

2010-11-05T06:41:00.029-04:00

Two juxtaposed slides presented at a talk by William Singletary on autism at last years annual American Psychoanalytic Association's meetings capture, in my opinion, the essence of the disorder. In one, a baby is held in the soft embrace of mother's arms, gazing back into her adoring face. In another, a baby screams as he looks into the wide open mouth of a fang bearing snake. These photographs vividly demonstrate that these children experience the world not as as soft and loving, but rather as harsh and frightening.

When the gene for autism is finally discovered, I believe it will be closely linked to the processing of sensory input. While non-autistic newborns experience touch and a loving face as comforting, autistic children are overwhelmed, and so retreat to the world of inanimate objects.

A New York Times article this past week At the Age of Peekaboo, in Therapy to Fight Autism describes current research into diagnosis and treatment in infancy, using an intervention based on the Early Start Denver Model. I referred to this intervention in my Boston Globe op ed about the limits of medication in treatment of autism.

An intervention, the Early Start Denver Model, was offered in the homes of families, with parent, child, and therapist playing together. In the two-year study period, toddlers diagnosed with autism showed significant improvement in behavior, language, and IQ. The authors attribute the success of their intervention to the fact that it is “delivered within an affectively rich, relationship-focused context.’’

While I have some concerns about diagnosing autism in infancy (more about that below) I feel strongly that a relationship based intervention is the way to go. If I am correct, and the primary problem lies in the way an infant experiences his environment,it is a quality with which he enters the world. But immediately after birth, this genetic vulnerability begins to wreak havoc on the environment.

Holding, feeding, comforting-these are the actions that give a new mother not only pleasure, but growing confidence in her mothering capacities. When she fails at even one of these, such as with a spitty baby who has difficulty tolerating feeds, a sense of inadequacy can follow. But if you multiply that to cover all the senses-if being held is not comforting, if singing provokes screaming,smiles are too much, that inadequacy can be devastating. Mothers may become depressed. Marriages are severely strained. Siblings may be neglected, become resentful and act out. For these reasons, it is essential that from the very beginning these problems are treated in the context of relationships.

Another study published this past week described in a Reuters article Autism risk gene may rewire brain looks at the brains of children with autism using functional MRI.

The team measured the strength of brain connections as the children worked. They found children with the version of the gene linked with autism called contactin associated protein-like 2 or CNTNAP2 had strong brain connections within the frontal lobe, but weaker connections to the rest of the brain."In children who carry the risk gene, the front of the brain appears to talk mostly with itself," Ashley Scott-Van Zeeland, now at Scripps Translational Science Institute, said in a statement.

In a previous blog post, I have describe the way in which early mother infant interactions wire the brain.

When a parent gazes into her baby’s eyes, she literally promotes the growth of her baby’s brain, helping it to be wired for a secure sense of self. The medial prefrontal cortex(MPC) has been referred to as the “observing brain.” It is where our sense of self lies. When a mother looks at a baby in a way that communicates with him, not with words but with feelings, “I understand you,” he begins to recognize himself, both physically and psychologically. This mutual gaze, literally and figuratively being “seen,” actually facilitates the development of the baby’s brain. As the MPC matures in this kind of secure loving relationship, the brain is wired in a way that will serve him well for the rest of his life. He will be able to think clearly and to regulate feelings in the face of stressful experiences.

It makes perfect sense that if this mutual gaze process goes awry from the start, the projections from the frontal lobe to the rest of the brain would not develop properly. Again this leads back to the critical importance of relationship based treatments.

All of which leads to my concern with the labeling of young infants with a devastating psychiatric disorder. I wish there were a way to recognize the infant's experience of the world, and to support parents efforts to interact with their infants in a way that reflects this understanding, without pathologizing it from the start. This would mean acknowledging that there is something different about these children that makes caring for them extremely challenging. It would mean offering services to families, such as the Early Start Denver Model, but without necessarily labeling infants as autistic.

Some parents may find comfort in a label. It demystifies their difficulties and relieves alot of the guilt and sense of inadequacy. But there is a process of mourning that goes along with receiving such a label and may affect the way parents see their child for the rest of his life. Also there is a risk that the family context of the problem is overlooked when the problem is seen as residing exclusively in the child.

I don't have an easy answer for this dilemma. But these news stories have motivated me to put the ideas out there, and I hope start a discussion about these challenging questions. Of one thing I am certain. The answer lies in continuing to devote resources to identifying these problems early, and supporting early parent-child relationships, with the long term goal of facilitating the healthy emotional development of the next generation.

Ode to Grandmothers

2010-11-02T09:30:00.029-04:00

Last week, a friend told me a story that motivated me to recognize the important role of grandmothers, not specifically for their grandchildren, but for their adult daughters who are now mothers.

My friend, mother to a fifteen year old boy in the throes of adolescent turmoil, did not have a close relationship with her mother when her children were young. Her mother preferred "not to meddle," despite her daughter's clear requests for her involvement. My friend struggled with this for years, seeking help and support from others, particularly her husband and close friends. Still she very much longed to connect with her mother. So she continued into her forties to put a lot of effort into this relationship. The other day, she told me, the effort seemed to have paid off.

She was having a particularly bad moment with her son, who chose an afternoon when she was feeling tired and stressed by her own work, to regale her with all of her faults and accuse her of being the cause of all his misery. The more she tried to talk to him, the more the conversation degenerated, to the point where she couldn't stand it anymore and got in her car and drove off. Much to her surprise, she found herself driving to her parents house, something she never spontaneously did, despite the fact that they lived close by.

Both her mother and father were overjoyed at her unexpected appearance. They made her tea and listened while she unloaded her distress. Then her mother, in a most uncharacteristic way said to her, "I know I might not have done all the right things when you were a kid, but I do remember that sometimes the only option was to keep a sense of humor."

My friend, who had been so caught up in her conflict with her son, suddenly saw that she had been fighting with him like she herself was a teenager. In the heat of the moment she forgot, though at saner moments certainly knew well, that teenagers are at times incapable of rational discussion. But until her mother heard her and reflected back what was happening, she had been unable to see it herself.

Dan Stern, in his book The Motherhood Constellation that outlines the basic principles of parent-infant psychotherapy, refers to the “good grandmother transference” to describe the kind of relationship a parent develops with the therapist who is working with a parent and child together. Transference is a psychoanalytic term that refers to the way people tend to transfer feelings from one relationship, often from childhood, to another current relationship. He writes:

The transference that evolves in this situation involves a desire to be valued, supported, aided,taught, and appreciated by a maternal figure.This desire for such a maternal figure is evidenced in many situations outside of the therapeutic one. Beginning in the hospital with the birth of the baby, mothers frequently find someone to fill this role or part of it. It is often a nurse, a nurses aide, the cleaning lady, or someone else who takes a moment to share personal experience and give heartfelt encouragement. It is amazing how important these short encounters can be. They are overwhelmingly with other mothers more experienced in motherhood...Later other mothers met in the park may fill this role, to say nothing of the mother's actual mother, grandmother, older sisters, and experienced friends.

Berry Brazelton, in his book Touchpoints: Birth to Three, in the section devoted to grandparents writes:

The best thing that has happened to me as a grandparent has been the chance for my children and me to have a whole new relationship...Each grandchild is a miracle, but a new relationship with your own children is an even greater one.

My forthcoming book, now in the final editing stages, speaks to the importance of supporting parents' efforts to be fully emotionally available for their children. Many of the mothers I describe in the book, mothers who have come to see me in my pediatric practice because of struggles with their children, have strained relationships with their own mothers. In effect they develop a kind of "good grandmother transference" with me. This is often very helpful to them in the task of raising their children. Though perhaps not within the scope of my role as pediatrician, I certainly wish for these mothers, and support them in any way I can, that they find peace, as my friend seems to have achieved, with their own mothers.

American Academy of Pediatrics Endorses Management of Postpartum Depression in Pediatric Practice

2010-10-26T12:24:00.022-04:00

Its nice to know I'm on the cutting edge. After no fewer than four recent posts about the importance of identification and management of postpartum depression, I learned yesterday that in the November issue of Pediatrics, the official Journal of the American Academy of Pediatrics, there is an article entitled: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice It is an excellent, thorough article that speaks to the many issues I have raised. A couple of sample quotes are:

Maternal postpartum depression threatens the mother-child (dyad) relationship(attachment and bonding)and, as such, creates an environment for the infant that adversely affects the infant’s development. The processes for early brain development—neuronal migration, synapse formation,and pruning—are responsive to and directed by environment as well as genetics. For example, it is known that an infant living in a neglectful environment,which is common with depressed mothers, can have adverse changes visible on MRI of the brain.

and

The primary care pediatrician, by virtue of having a longitudinal relationship with families, has a unique opportunity to identify maternal depression and help prevent untoward developmental and mental health outcomes for the infant and family.

The article addresses the associated problems of, among many others, marital discord, breast feeding issues and difficulty managing chronic health conditions.

In addressing what pediatricians have to offer, the article speaks to the roles of screening and referral as well as support of the parent-child relationship within the context of a pediatric practice.

It is in this last role that I think pediatricians may have more to offer than is generally recognized, even by pediatricians themselves. This morning I was thinking about a successful intervention for PPD Peter Cooper described at the course I recently attended(see previous posts). The intervention was done in a South African peri-urban settlement with marked adverse socioeconomic circumstances. In this study:

Women were visited in their homes by previously untrained lay
community workers who provided support and guidance in parenting. The purpose of the intervention was to promote sensitive and responsive parenting and secure infant attachment to the mother.

The intervention was successful in that it:

had a significant positive impact on the quality of the mother-infant relationship and on security of infant attachment, factors known to predict favourable child development.

I was wondering to myself if the therapeutic action in this intervention was actually the relationship between these workers and the mothers. The mothers became very attached to these women, viewing them as a kind of grandmother figure. I think it likely that this relationship in turn fortified them in their efforts to be more fully emotionally available for their infants.

If this is in fact correct, then a pediatrician, by virtue of a long standing relationship with parents that is usually one of trust and respect, is in an ideal position to promote the mother-infant relationship.

I hope that with the AAP endorsement of this important issue will also come a recognition, cultivation and valuing of this role. This would involve changes not only in how pediatricians think about themselves, but also in more global changes in such areas as reimbursement and medical education. But that's for another blog post!!

Research and stories: both have a role to play in advancing knowledge

2010-10-25T07:23:00.019-04:00

Last weekend, as I listened to leading researchers grapple with the question of how to design a feasible study of intervention for postpartum depression, I held in my mind an image of a particular moment in my office.

I was sitting on the floor with 10 month old Madison and her mother Nancy, who was struggling with postpartum depression. Nancy spoke of the strain Madison's refusal to take a bottle and her frequent night wakings were placing on her marriage. Madison contentedly played with the toy her mother had brought and then began to expand her exploration to the other toys in the office. We proceeded through the history, beginning with Nancy telling me about her pregnancy. Then I asked about her family. “My mother was severely depressed and frequently suicidal,” she said. Tears welled up in her eyes. “I don’t want Madison to go through what I did.” As she spoke, Nancy was freely crying.

Madison stopped her exploration of the toys. At first she sat completely still, observing her mother. This only made Nancy cry harder, as she saw the effect of her tears on Madison. Then Madison crawled up on to her mother and help on tight. They were both quiet for a bit. Madison began to fuss and reach for Nancy’s breast. Nancy got her settled to nurse, and very soon Madison fell fast asleep.

I understand the need for what is known as "evidence based medicine" to advance our knowledge of effective treatment. But given the constraints of research design, I could not help but wonder how to capture the complexity of this tiny moment. The researchers who spoke that weekend were trying to design interventions that would affect not only the mother's depression, but also the mother-child relationship.

In that moment I was literally inside in the mother-child relationship and witness to its enormous richness. I saw how Nancy was using the nursing to protect Madison from her depression. I understood that if I were to help Nancy her find time for herself and her marriage, I would need to help her find an alternative way to comfort Madison when her depression threatened to overwhelm her. I could only understand this by actually being in the moment of interaction between Nancy and Madison. By listening to Nancy and recognizing her experience as a mother, I could support her efforts to think about Madison's experience and how she could help Madison manage these difficult moments.

I struggled that weekend with the question of the relative role of research and clinical experience in advancing knowledge and promoting the healthy emotional development of children and parents. Upon my return home, my sixteen year old daughter handed me a paper she had written. The assignment was to write a daily theme on a subject of her choosing. That day she chose to write about the power of books. In her conclusion, she said:

Reading has power. A good author has the ability to craft words from his thoughts and change lives without even leaving his desk. A book is timeless, and can be read over and over by generation after generation and never lose its charm. A book is timely, and can erupt a change in the thoughts and opinions of people in the time period.

I believe she is right-that a book, or stories, have the power to change the way people think. Interestingly the Infant-Parent Mental Health Post Graduate Certificate Program, that I have written about in previous blog posts, brings together leading researchers with a group of fellows who are primarily clinicians immersed on a daily basis in the complexities of struggling families. I hope together we can join forces to make the world a better place for children.

Postpartum depression: A well recognized problem, but what is the treatment??

2010-10-19T17:03:00.012-04:00

When I see children in my pediatric practice for behavior problems, I often hear stories from mothers who struggled terribly when their children were very young infants. A most dramatic example of this was a mother with severe postpartum depression whose father died suddenly when her baby was four months old. Much to my astonishment, she described being relieved by this event. It wasn't because she didn’t love her father. Rather, in sharing the grief with her siblings, mother and extended family, she no longer felt so completely alone.

A Massachusetts law passed this summer calls attention to the public health problem of postpartum depression (PPD). The most common complication of pregnancy, extensive research has demonstrated its significant long term effects on a child’s development, with increased risk for behavior problems in childhood and depression in adolescence.

The new law requires Massachusetts health insurers to submit annual reports on their efforts to screen for postpartum depression. The department of Public Health will develop regulations and policies to address postpartum depression. In addition the law calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.

The Boston Globe editorial board endorsed this legislation with the following statement: "Early detection could stave off far more serious problems for mothers and their babies, whose well-being is deeply linked to the first few months of care. And universal screening would ensure that no woman falls through the cracks. The sooner new mothers can be diagnosed, the sooner they will recover."

The critical step in bringing this last statement from a wish to a reality is to find effective treatment for PPD. Ideally an intervention would both improve a mother’s depression and positively impact on her child’s development. Unfortunately is it far from clear exactly how to accomplish this goal.

Last weekend, I learned all about the latest research on the subject of postpartum depression as part of the Infant-Parent Mental Health Post-Graduate Certificate Program that I have described in previous posts. I was eager to learn from these world experts about effective treatment. These researchers, however, described difficulty defining, in a way that would be feasible for a well designed research study, what an effective intervention for PPD would look like.

Perhaps the mother I described above offers a clue. Being understood by a person you love is one of our most powerful yearnings. The need for understanding is part of what makes us human. When our feelings are validated, we know that we’re not alone. The truth of this statement is reflected by such sources as literature, philosophy and religion.

The necessary intervention, therefore, is perhaps more of a societal intervention. The most important component of an effective treatment for PPD may be that a new mother have an opportunity to be understood. She needs to feel supported over time in relationships that are of value to her. When partner, family members and friends are not sufficient for this role, or when there are enormous strains on these other relationships, the disciplines are available to support a mother include social workers, educators and primary care clinicians. These are among the lowest paid professionals in our society.

The law promoting PPD screening is a small step in the right direction. But in addition to focusing on the specifics of treatment interventions, it is critical to maintain a larger focus on the value we as a society place on the role of mother.

An Exquisite Parenting Moment at the General Store

2010-10-14T14:41:00.022-04:00

As I stood at the counter of our little general store waiting to buy my newspaper, I turned suddenly, along with all the other customers, to find the source of a loud, insistent voice coming from below the counter. "I want candy now!" We looked down to see a little boy who was about three years old. He tugged at his father's arm. His father calmly replied."Lunch first. Then you can have your candy." "NO! CANDY NOW!" said the not so little voice. The other people in the store, including myself, shared knowing smiles. After several exchanges like this, his father, seemingly unperturbed by his fellow town members listening in, said firmly "OK, then you can't have the candy." "Noooo! I want candy!!!" he cried. His mother, who had been quietly standing behind them chimed in. "Now you're really mad," she observed in a respectful tone. With this he began to stomp around the store, wearing an intense scowl on his face. His father, a rather large man, began to stomp around after him. After passing by the grocery aisle a couple of times, the little boy dissolved in a fit of giggles. I paid for my paper and went home, thankful for the inspiration for a blog post.

It was such a small moment. One of millions that make up the day to day challenges of being a parent. Yet such grace under pressure!! His parents were calm and sure of themselves. They were willing to face the consequences of setting a limit with their son, even if it precipitated this public display of three-year-old outrage. His mother conveyed, simply with the tone of her voice, that she accepted his reaction and understood his feelings, but she and his father were not going to change their minds. His father playfully showed him that they both could survive this disruption and move on.

This interaction has all the elements of holding a child in mind, the central theme of my book, which is due to be published in the fall of 2011. These are: 1) understanding a child's behavior from the perspective of his stage of development, 2) empathizing with a child's feelings, 3) containing and regulating both the feeling and behavior, and 4) and perhaps most difficult, staying present with a child without letting one's own distress get in the way. When parents do this repeatedly a child learns to understand his own mind. He develops the ability to regulate intense emotions, think clearly and manage himself in a complex social world.

Those parents in the general store likely thought they were simply saving their son's appetite for a good lunch. They were actually taking one more small but important step in the direction of promoting their son's healthy emotional development.

Supporting Infant-Parent Relationships: The Right Choice

2010-10-09T12:30:00.023-04:00

Though not the major aim of this blog, it turns out that it is also serving to document the trajectory of my professional life. I am certain now that where I have landed is the right place.

My earlier posts documented my sense of frustration seeing many patients for "ADHD evaluation." I listened to story after story of mothers alone and depressed with their fussy, "difficult" infant. This infant then became an "explosive" toddler. Child and parents continued to struggle until now at the age of seven, ten or even fifteen, they came to see me in search of a diagnosis and medication. More often than not their symptoms did meet DSM criteria for some diagnosis, usually ADHD. Between imminent failure in school, intense pressure from teachers and a severe shortage of quality mental health services, medication often seemed to be the only option.

It caused me great pain to see a child's life experience reduced in this way, and, as is also documented on this blog, I decided that I needed to focus my efforts on prevention.

Next weekend is my second installment of the Infant-Parent Mental Health Post Graduate Certificate Program I have referred to in the two previous blog posts. As I review the material in advance, I am learning about research providing evidence that postpartum depression, particularly if the depression is chronic, affects a child's cognitive development, and is associated with behavior regulation problems and depression.

Last week, I saw a mother and her 3 month old daughter. A single mother struggling with depression and anxiety, she hadn't slept in a long time. Her baby fussed and squirmed on her lap. I held the baby, walking her around the room to quiet her while her mother talked of feelings of helplessness and frustration. The other doctors in my practice, who had been called almost daily by this mother with problems of feeding, sleep and crying, didn't know what to do for her. Pediatricians, who are seeing these mother-baby pairs on a regular basis, are mostly unaware of this important field of study.

I am well aware that there are many other professionals who have been doing this work for a long time. One social worker in my program does home visits with high risk pregnant women and then together with their newborns for a year after delivery. Sadly, they are paid practically nothing for this critical work.

John Bowlby, the father of attachment theory, in a 1980 lecture said:

Successful parenting is a principal key to the mental health of the next generation. In most societies throughout the world these facts have been and still are, taken for granted and the societies organized accordingly. Paradoxically it has taken the world’s richest societies to ignore these basic facts. Man and woman power devoted to production of material goods counts as a plus in all our economic indices. Man and woman power devoted to the production of happy, healthy, and self-reliant children in their own homes does not count at all. We have created a topsy turvy world.

Next weekend I will learn more about effective interventions for these mother-baby pairs. I am very much looking forward to it. For now, sitting in a room with this mother and her young infant, at least I know I am in the right place to start.

Postpartum Depression: A View From the Front Lines

2010-09-30T15:14:00.039-04:00

My town is home to Fairview hospital, the smallest land based hospital in Massachusetts. With its 24 beds and about 170 newborn deliveries a year, Fairview is a wonderful place. For years as a primary care pediatrician I examined newborns and attended many a delivery in the middle of the night. So after deciding(for reasons I have described elsewhere in this blog) to focus my behavioral pediatrics practice on the 0-5 age population, I went to pay my friends the maternity nurses a visit. What better place for a preventive intervention than the newborn nursery? I wanted to hear about the problems they were seeing and their assessment of what the needs were.

Recently I have been reading the most current research on the impact of postpartum depression on infant development. This reading is in the setting of the The Infant-Parent Mental Health Post-Graduate Certificate Program that I referred to in my last blog post. Quoting from the program's website:

This program is based on the award-winning Napa Infant-Parent Mental Health Fellowship Program developed by Dr. Ed Tronick, Chief of the Child Development Unit at Children’s Hospital Boston...Dr. Kristie Brandt, Director of the Parent-Infant & Child Institute in Napa, California...the present program is designed to address the increasing need for skilled, interested and appropriately trained professionals to provide infant-parent mental health services for families with children ages birth to five years.

Given what I am learning, the stories I heard from the nurses were alarming. I will diverge slightly to describe the research I am referring to before returning to my visit to Fairview. Much of the contemporary research has been done by Peter Cooper and Lynne Murray and is described in their book, Postpartum Depression and Child Development. In a more recent paper they write that considerable evidence exists indicating that postpartum depression (PPD) limits a mother’s capacity to engage positively with her infant. Several studies have shown that PPD compromises child cognitive, behavioral and emotional development. To quote them directly:

PPD is now recognized, by virtue of the distress caused to mothers, as well as the wider adverse impact on the family, as a significant public health issue...Since adverse child outcomes associated with PPD are more likely to occur in the context of chronic or recurrent depression, it is particularly important that this group be identified and targeted for intervention...It is crucial that attention be given in the treatment to the quality of the mother-child relationship and that specific therapeutic measures be introduced to help mothers engage optimally with their infants.

Back to Fairview. The maternity nurses estimate that 15 to 25 percent (and perhaps as high as 50%) of mothers delivering at Fairview have major mental health problems. These range from mothers carrying multiple psychiatric diagnoses such as bipolar disorder and depression, to those without a specific diagnosis but with multiple psychosocial risk factors. For this group of patients, nurses feel that 100% do not have adequate follow up after delivery. Mothers may have one home visit with a nurse. A part time social worker sees some of them prenatally, but there may no plan for follow up.

The distress in the room was palpable. The nurses worried for these babies, feeling that they often sent them home "on a wing and a prayer." They described one mother with a diagnosis of depression who gave birth to her third child. A two year old with no shoes sat strapped in a stroller , while a ten year old who was on multiple antipsychotic medications wreaked havoc in the hallway.

What would happen, I wondered with them, if I were to meet for one or two sixty minute visits with these high risk mother-infant pairs in the hospital?(more time than is usually available for an in-hospital visit by a pediatrician) My aim would be to forge a relationship between myself and the parents as well support the new relationship between the parent and her infant. In my pediatric practice I could continue to follow them when the almost inevitable challenges of crying, feeding and sleep problems arise. "When can you start?" they asked.

It would be a small intervention in a small hospital in a small town(to put it in place, the complex questions of diagnosis and insurance coverage must be ironed out.) One can only hope, however, that it would help to put a dent in what is potentially a very big problem.

Dyadic Therapy: Working with the Parent-Child Relationship

2010-09-25T05:31:00.013-04:00

One of the things of which I am most certain, based on my years of practicing pediatrics together with my years of being a mother (and also just my experience as a human being) is that what children need most is for the people who love and care for them to understand them, and to be with them in a way that communicates that understanding.

For this reason, I have never understood why a young child would be ever seen in psychotherapy without his or her primary caregiver. Psychoanalytic theory contends that a young child has hidden conflict and fantasies that can be brought to light through imaginary play. This may well be true, but given the limited time and resources, is it really important?

This weekend I have begun what will be an intensive year long training in Infant-Parent Mental Health. Already I can see that perhaps the two most valuable piece of this experience will be one, to have this viewpoint validated by the world leaders in this newly emerging discipline and two, to be learning with a group of like minded clinicians from a wide range of disciplines, including social work, early intervention, infant massage, psychology, psychiatry and pediatrics.

This point was brought home for me yesterday when in our first full day we heard a case presentation and watched a video. Being ever mindful of confidentiality issues, I will describe only the basic points. The identified patient was a young child who had experienced significant neglect, with multiple losses and disruptions. This "dyadic therapy" we watched in the video was conducted with the child and adoptive parent together. The way in which both the setting and the therapist served to connect this mother with her very troubled child was magnificent.

Some of the most painful cases I have seen in my practice are those of children adopted out of situations of severe abuse and neglect. Parents come to me for medication when the children have been diagnosed with ADHD. When I hear these stories of terrible trauma, I work hard to convey to the parents that while medication may be helpful in controlling the symptoms, it is not sufficient.

Yet I immediately come up against intense resistance. The assumption is that I will recommend therapy. and the parents, for good reason, do not understand the purpose of individual therapy for such a young person. Yet a recommendation to work together with their child in therapy is also met with resistance. The difficult behavior is not their fault, and their loving and safe home should eventually cure the problems.

Here in lies the beauty of this program. My biggest challenge is a paucity of colleagues to refer to. In my community there is not only a shortage of child therapists, but even fewer who work from a conceptual framework that supports treatment of parent and child together.

My fantasy is that one day, when I see such a family, I will have a group of colleagues, all on the patient's insurance plan, who I trust to work to bring a parent and child together in the way I watched in that video yesterday. I know it's a dream, but at least as I sit with all of these colleagues who will one day be leaders in the field, I am hopeful that perhaps mental health care for children is moving in the right direction.

True Empathy: A Physical Sensation

2010-09-19T09:27:00.033-04:00

Emily brought her son Micheal to see me when he was 3 and 1/2 months old. He had been born one month premature, but it was clear from a first glance that he was doing well. I remember noticing that his mother was so close, physically close. She hovered over his carriage, reluctant to let me pick him up. She stood inches from him while I examined him.

He was robust little boy who gave a big smile as he intently followed his mother's face. Emily felt he was doing well. So well, in fact, that she was attributing qualities to him for which he seemed to young. "It's good for him to comfort himself, right? I should let him cry, right?" She seemed very anxious.

About a year earlier, Emily had lost a baby, Christopher she called him, in her ninth month of pregnancy, when she was in a car accident. She conceived again almost immediately. And here was this miracle baby. I watched Michael sleeping in his blue jumper. He seemed so small and vulnerable.

"He's doing great," I said. Emily continued to wear that uncertain look as I tried to reassure her. She asked about sleep. "Is it OK if he is still in our bed? Is it good for bonding?" she asked. I was puzzled by this question and paused, asking her to tell me what she meant.

"Is he bonded to me?" she asked. I started to attempt an answer when she interrupted me. "Can you bond in utero? I mean I bonded to Christopher, but he died. I didn't let myself bond to Michael when I was carrying him."

I felt a tingling in my arms and a clutching in my chest. Tears came to my eyes as I watched them run freely down her cheeks. We sat this way for a while, living in the unbearable pain of her loss.

I thought of this moment when listening to Francine Lapides, in her terrific course "Keeping the Brain in Mind," explain the neurophysiology of empathy. It was an "aha" moment for me. Empathy is a commonly used word in mental health, and I admit to having used it for years without really appreciating its meaning.

Empathy, she explained, is largely mediated by a structure called the insula. It is predominantly a right brain structure that connects to the visceral organs-the heart and intestine. It also connects the brain with the skin and mediates sensations of touch and temperature. It is responsible for what is commonly referred to as a "gut feeling." Empathy, then, in its truest form, means to literally feel what another person is feeling.

Daniel Siegel, in his paper Mindful Awareness, Mindsight, and Neural Integration defines empathy as "the capacity to put yourself in the mental perspective of another person." It is not an intellectual understanding, as in "I understand how you feel," which is primarily a left brain activity.

True empathy, an actual physical experience, is somewhat rare. Empathy has healing power, both for the listener and the person being heard. It represents a profound attunement between two human beings. It is something to strive for in all relationships.

With Emily I wondered aloud if getting pregnant so quickly had prevented her from doing the difficult work of grieving the loss of her first child. She said to me, "I feel like I can't give all of myself to Michael. I have to hold back to protect myself."

At that visit with me, perhaps fortified by our moment of connection, of true empathy, she found the courage to face this task of grieving. She recognized it was critically important not only for herself, but for her relationship with her infant son.