When a "Problem" Child Hides A Troubled Marriage

A piece in today's New York Times "Seeking to Pre-empt Marital Strife" states that only 19% of married couples take part in marital counselling. The article quotes Brian D. Doss, an assistant psychology professor at the University of Miami, “There’s a strong disincentive to think about your relationship as being in trouble — that’s almost admitting failure by admitting that something isn’t right.”

This article got me thinking about a six year boy named Mark. When he came to see me in my pediatric practice, his mother Dana’s face was tense and angry as she sat perched on the edge on the couch. Her son came easily into my office and was friendly and well related. He immediately settled in to play. I sat on the floor with him while I spoke with Dana. She had come to see me because he “never listens”. She said, her tone harsh and exasperated, “Tell me what to do so that I can make him listen.”

At the first visit when Dana came alone, she had given me a very detailed history of Mark’s difficulties and described frequent explosive scenes at home around such daily tasks as getting dressed. She had been to several pediatricians and specialists, none of whom had been able to help significantly with Mark’s behavior.

In reviewing his medical chart and all the previous evaluations, I noticed that Mark’s father had never been present. There was practically no mention of him. When I inquired, she said he traveled frequently and that yes, he had the same troubles dealing with Mark, perhaps even worse than her, as he tended to get angry more easily. When I scheduled our next appointment, I was sure to make it at a time when he could come. But she showed up without him, saying he had unexpectedly been called away on business.

This is often a warning sign to me. It may be easier to focus on one’s child’s behavior than to begin to acknowledge other large and seemingly unsolvable problems in a marriage. While Mark played quietly with the trains, Dana described his refusal that morning to come down for breakfast. Despite my best efforts to listen from a neutral place, I found myself feeling protective of Mark. There was so much aggression directed at him. I said to her, “It seems that this interaction was very upsetting to you.” “Oh no,” she replied, defensively backing away, “but I’m glad his father wasn’t home, because he really would have been furious.” I asked her to tell me more about this.

Perhaps it was the quiet room on the second floor, nestled in the trees. A brief respite from the constant challenge of Mark, who, for the moment, was content. But this small question unleashed a flood. I learned that much of the anger I felt in the room that day was actually directed towards her absent husband. She described years of conflict between them. He could fly into an explosive rage at the littlest provocation. She attributed her husband's behavior to his abusive father and his lack of a positive role model for managing anger. She revealed her suspicion that Mark was only reflecting in his behavior the rage that he experienced at home.

Now Dana could clearly see what needed to be done. With my encouragement, the next time she came with Mark’s father, Peter. The trust Dana had developed with me seemed to carry over to him. He spoke openly about his own abusive father. He became tearful as he described his difficulties controlling his feelings of anger. Once Dana and Peter acknowledged these problems, motivated by their desire to protect their son, they were able to get help for their troubled relationship.

In my experience, parents are often willing to locate a problem in their child rather than face the possibility of problems in their marriage. Perhaps this is because a spouse is, in a way, a primary attachment figure. A spouse is the person an adult most relies on for a sense of security and well being. Parents fill this role of primary attachment figure for a child. An adult may bring qualities from those original attachment relationships, some of which may have been less than healthy, to their relationship with their spouse.

Certainly marriage counselling takes time, money and a qualified therapist, three things that may be hard to come by. But perhaps the fear of loss of the person who provides a sense of safety and security may be an equal, if not larger, obstacle.

It is important for clinicians who evaluate children for "behavior problems" to recognize that couples are very reluctant to acknowledge difficulties in a marriage. Yet as was so clearly demonstrated with Mark, it is unfair to a child to locate the "problem" in a child when in fact it is in the marriage. We owe it to these children to support their parents efforts both to acknowledge marital conflict and to seek appropriate help.

Psychoanalysis, Buddhism and Jewish Theology

A delightful benefit to get my ideas out into the world via the Internet is that people send me their books. This week I received a book written by a person who describes himself as having been "awakened to the tradition of Zen Buddhism." I found the idea that someone thinks my work is related to Buddhism appealing.

When families come to see me in my pediatrics practice for “behavior problems”, both parents and children feel out of control. They are disconnected, angry and sad. I help them to recognize each other. Meaningful change happens in my office when we share these moments of re-connection.

Being understood by a person you love is one of the most powerful feelings, for adults and children alike. The need for understanding is what makes us human. When our feelings are validated, we know that we are not alone. For a young child, this understanding facilitates the development of his mind and his sense of himself. I aim to support parents' efforts to be fully present with their child.

Martin Buber, a Jewish philosopher and contemporary of Sigmund Freud, wrote of a concept he referred to as “I-Thou.” In contrast to “I-it” exchanges, which are typical of our day to day human interactions, in an “I-Thou” moment there is a true meeting of minds, a profound feeling of human connectedness. He felt that these moments indicated the presence of God. Not being an especially religious person, I would not put it in those terms. However, I would describe being in the room with a parent and child when they connect in a meaningful way as a spiritual experience.

I learned about Buber from the Rabbi at our local synagogue. Interestingly, however, I recently found this quote from Donald Cohen, former director of the Yale Child Study Center, who, had his life not been tragically cut short by cancer, likely would still be working today with Linda Mayes developing the ideas about parent-child relationships upon much of my writing and clinical work is based.

What fascinated me most was how intimate relationships and the desire for being with the other precede the rest of cognitive development, and that this social motivation moves these other achievements forward, including meta-representation and theories about other minds. This intuitive, deeply encoded social orientation is first expressed in the mother's arms and then forms the basis for all future I-Thou relationships.

D.W.Winnicott, I think, was referring to a similar phenomenon when he wrote about how a parent's recognition of a child's "true self" facilitates healthy emotional development. Whether through Buddhism, Jewish theology or psychoanalysis, it is important, in this age of advice, medication and 15 minute psychiatry visits, to stay focused on the value and healing power of true human connection.

Childhood Bipolar Disorder: Witness to the Onset of a Perfect Storm

Today while cleaning out my office in anticipation of my new job, I discovered that I had unknowingly been witness to to an historic moment in child psychiatry. I found a binder from a course I had taken in June of 2001 sponsored by Harvard Medical School on Major Psychiatric Illnesses in Children and Adolescents. Though I did not remember until I looked at my scrawled notes in the margins, on Saturday June 9th 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.

As this was in a sense a new disease, there were no controlled treatment trials. Wozniak described how she and Biederman reviewed charts of children seen with this constellation of symptoms in a psychopharmacology unit from 1991-1995. Patients received tricylics, stimulants, SSRI's, and mood stabilizers. Neuroleptics were used in 10% of visits. Mood stabilizers seemed to be the most effective, SSRI's seemed to be associated with risk of inducing mania. Wozniak did not mention atypical antipsychotics.

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.

It is not surprising that these powerful drugs are effective at controlling the explosive behavior associated with what Drs Wozniak and Biederman labeled as bipolar disorder(and is currently being redefined as Temper Dysregulation Disorder in an attempt to undo some of the damage of the storm). But this perfect storm may have prevented us from understanding these children in a way that leads to meaningful interventions.

While this storm was brewing, across the ocean in London, Peter Fonagy, Miriam Steele and colleagues were discovering, in the London Parent Child Project, that a parents capacity to reflect upon and understand her child's experience helps that child learn to regulate strong emotions. Subsequent research has shown that child may be born with a genetic vulnerability for emotional dysregulation, but interventions that address family conflict and support relationships protect against this vulnerability and facilitate emotional regulation at the level of gene expression and biochemistry of the brain.

My hope is that this storm is clearing. Our culture, realizing the potential harm of medicating so many young children with powerful drugs that have serious side effects, may now be open to new ways of thinking about these "irritable" children Dr. Wosniak described that June day 9 years ago.

Mental Health and the Media

How do mental health professionals, including both clinicians and researchers, effectively communicate their ideas to a lay audience in a way that is meaningful and can facilitate change?

This was the question raised in a fascinating event I attended at the Austen Riggs Center in Stockbridge, MA this weekend. The occasion was the presenting of the first Erickson Prize for Excellence in Mental Health Media The award winners, Alix Spiegel of NPR; Erica Goode of The New York Times; and Richard Simon of The Psychotherapy Networker, spoke about their work. The aim of the prize is twofold, both to reward journalists who have made major contributions to public understanding of mental health issues, and to educate mental health clinicians on how they might better communicate their important ideas to a larger community.

Effective communication of contemporary research in mental health is, in my opinion, a very important goal to work towards. As I have written about at length in this blog and elsewhere, my exposure to both the front lines of primary care pediatrics and the most contemporary research in child development, motivates me to get these ideas out to a lay audience, with the aim of facilitating a paradigm shift in how we as a culture think about "problem behavior" in children.

To that end, I have a piece in today's Boston Globe entitled Distracted parenting: hang up and see your baby. Drawing from a recent blog post, it and asks the question about the possible effect on early development of excessive use of cell phones by parents. I hope it will generate some thoughtful discussion.

With Psychiatric Drugs as an Option, Motivation may be Lost

Today I received a call from a mother that made me both want to cry and scream out in frustration. Several months ago I wrote a post entitled Drugs for Children May Silence Stories, in which I described a young boy who had suffered severe neglect as an infant. His adoptive parents had sought help from me when he was four, but when I recommended intervention for the whole family to address both his behavior problems and the effects of his early trauma, then did not follow through. Whenther it was lack of access to care, a wish not to deal with the problem, logistical difficulties, or some combination of these I do not know.

Then when he was in first grade, psychological testing revealed a likely diagnosis of ADHD and it was recommended that the parents consult with their pediatrician to consider a medication trial. His mother called me to set up an appointment. That was when I wrote the blog post.

I also returned his mother's phone call, but she again did not follow through, and I did not hear from her again until last week, nearly three months later. She left me a message saying that things were much worse and she wanted to see me right away to put her son on ADHD medication.

When I finally was able to speak with her today, she shared with me a story of a child clearly out of control. Her son had run away from teachers several times. He often crawled under his desk and curled up on the floor during class. He was disruptive and at times totally unapproachable. His mother again repeated her wish to see me right away so that I could prescribe medication for his ADHD because "they want to put him in a class for emotionally disturbed children."

My inclination was to stare at the phone in disbelief. How is it that this mother, a reasonable person, could expect that a pediatrician could effectively treat this problem simply by prescribing a pill? Clearly she was supported in this idea by the school. In fact our culture as a whole tends to disregard the impact of early trauma on development and relies heavily on medication to treat children once they reach an age when they are a problem in the school setting.

I explained to her that I was leaving the practice in a few weeks but that in any case, I felt that given the severity of the problem her son needed to have a comprehensive psychiatric evaluation, and, as I had recommended 3 years earlier, the whole family would need intensive help to manage this very challenging situation.

With Medicaid as the child's insurance, their only option was the local mental health clinic. I knew that the wait for a visit with a psychiatrist could be as long as three months,and a wait for a therapist could be almost as long. I worried for the boy's safety. I told her about the crisis team, and explained that if at any time she felt the situation was unsafe, she call that number and they would be seen right away.

This exchange left me with a feeling of despair. But it is stories like this that are the driving force behind the writing of my forthcoming book. It is imperative that our culture as a whole recognize the value of early parent-child relationships in promoting healthy emotional development and the importance of early intervention when things go wrong. With powerful medications to fall back on when children reach an age that they are a trouble to society, as was the case with this little boy, there may be little incentive to provide or obtain meaningful help.

Prevent Bullying and Violence by Nurturing Parents and Supporting Families

“Momma, have you ever felt like there’s a puzzle and there’s a piece missing and you find the piece and it fits? When I’m with the Maasai all the pieces fit.” This is a quote from my friend Roland, a seven year old boy, on a trip to Tanzania with his mother. He was on a safari and, using a stick, he was learning how the Maasai use spears to protect them from lions. His mother told me how at home in the United States, she always feels like she is apologizing for his aggression.

Her story made me think of many 2 year olds who I see in my pediatric practice. They come because they hit and are “too aggressive.” Their parents want help controlling the behavior. Once they feel comfortable talking with me, these parents frequently confess that when they see their child hit another child or throw a toy they have “visions of Colombine.”

We as a culture seem to be on a road to outlaw aggression. The fact is, however, that aggression is a normal, healthy feeling. Assertiveness, a quality generally considered to be a positive one, actually has a similar meaning, but looks different in a two year old than in an adult. Lacking the verbal skills to express intense emotion, Johnny, wanting the red truck another child just took out of his hands, may not have a calm discussion, but rather might grab the truck and whack the other child on the head.

Parents clearly have the responsibility to teach a child that such behavior is unacceptable. But, in order to avoid having a child grow up like Roland, with a sense that a piece of him is missing, it is essential that not only parents, but our culture, is accepting of the feeling behind the behavior.

In fact, the latest research at the intersection of neuroscience, behavioral genetics and developmental psychology is demonstrating that a parents’ ability to reflect and contain a child’s feelings will help that child learn to manage these feelings, and may change the way his brain handles strong emotions. He may be less likely to behave aggressively in the future. If, on the other hand, a child gets the idea that his feelings are “bad” and “wrong”, these feelings don’t go away. They just become disconnected from the child’s sense of who he is, like Roland’s missing puzzle piece.

If a child does not have a way to think about his feelings, he is likely to simply act them out. Children who continue, as they grow up, to behave in aggressive ways that are inappropriate for their age are often describes as “impulsive.” Impulsive literally means to act without thinking. A child needs to learn from the adults around him how to think about his feelings.

So where does this difficulty thinking about aggression come from? Many mothers and fathers reveal that they have experienced violence somewhere in their past. When Johnny whacks another kid with a truck, or hits them, it brings back a surge of feelings of intense stress and even rage. These feelings are completely unrelated to Johnny, but make it very difficult to think about Johnny’s experience from his two year old perspective. Other parents, like Roland’s mom, tell of having a sense from extended family and/or their social environment that aggressive feelings are bad.

Just as it is important for parents reflect and contain their toddler’s aggressive feelings, when children go to school and are behaving in unacceptably aggressive way it is essential to recognize the meaning of the behavior. Simply enforcing “bully –free zones” will not work. Often bullying reflects children’s experience of stress and violence at home. It may be more intense if as young children they did not learn to contain their aggressive feelings.

All of which points to two very specific needs. Our society must support parents in the challenging task of being fully present emotionally with their young children. We must provide a high quality and accessible mental healthcare system to support families in their efforts to help children who are struggling to contain and manage their aggression in the school setting. An acceptance of and respect for healthy aggression may in the long run decrease the risk of another Columbine.

Cell Phones and "Primary Maternal Preoccupation"

Recently I was on vacation at a pool with my kids. I noticed a father with his infant daughter who looked to be about 3 months old. Perched on a table in her car seat, she sat kicking and smiling. Her father faced her, but was talking on his cell phone. He distractedly shook the rattle hanging in front of her as he spoke in an animated way with the person on the other end of the line. His daughter continued to smile and kick for a while. Gradually, however, she slowed down. She became quiet. Then she began to fuss. Still on the phone, he made more intense efforts to engage her with the rattle. But he was not successful. Her crying escalated. Finally he had to abandon the cell phone as he needed two hands to take her out of the car seat. Then he picked her up and held her, walking around the pool in an effort to quiet her, which eventually he did.

I was thinking about this scene when re-reading about D.W. Winnicott's notion of what he called "Primary Maternal Preoccupation'(One shortcoming of Winnicott is that he essentially ignored fathers, so when referring to his work I only refer to mothers. To compensate for this inequality I refer to babies as "he"). This idea captures the way in which parents in a healthy way are completely absorbed with their young infant and attentive to his every nuance of expression. It is through this kind of mirror role that an infant begins to make sense of who he is.

Linda Mayes and colleagues, in fascinating research at the Yale Child Study Center, are examining the neurobiology of this maternal behavior and its effect on the developing infant brain. For example they have shown that oxytocin, which is present in high levels in a new mother, is connected to what under other circumstances might be called obsessive compulsive behavior, but in the setting of having a new baby is not only normal but highly adaptive both for mother and baby.

So what does this have to do with cell phones, which are now ubiquitous in our culture? Adam Phillips , in his biography of Winnicott writes:

When the infant looks at the mother's face, he can see himself, how he feels reflected back in her expression. If she is preoccupied by something else, when he looks at her he will only see how she feels. He will not be able to get 'something of himself back from the environment.' He can only discover what he feels by seeing it reflected back. If the infant is seen in a way that makes him feel that he exists, in a way that confirms him, he is free to go on looking.

When a parent is on a cell phone, he or she is "preoccupied with something else." It is certainly understandable that a person, who may have previously been absorbed with a successful career and is suddenly in the role of spending most of her time with a being that does not talk and requires enormous amounts of care 24 hours a day, would be drawn to the possibility of adult conversation. But I wonder if new parents are aware of the importance to a baby's development of that 'primary maternal preoccupation.' Perhaps if they were, they would consider spending a little less time on the phone.