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

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

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??

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

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

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

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

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.