Engaging Our Right Brains to Support Parents and Children

"People have to feel something in order to change the way they think and behave." This is a quote from my book Keeping Your Child in Mind. The right brain is the seat of emotional regulation. Most, if not all, emotional and behavioral problems are intrinsically tied to the ability to regulate emotions. Changes in the brain can occur only if the right brain centers that regulate emotion are actually firing.

I was thinking about this idea when I attended an amazing conference at the Picower Institute for Learning and Memory at MIT, New Insights on Early Life Stress and Mental Health. Leaders from a range of disciplines presented the explosion of scientific evidence showing that early caregiving relationships have a significant long term impact on both mental and physical health.

MIT is a particularly left brain place, and there was a lot of hard core science at this talk. One speaker, Robert Anda, did inject a bit of right brain experience. Anda is one of the main authors of the ACES study, a powerful longitudinal research project that shows the cumulative effect of adverse childhood experiences, including parental mental illness, divorce, neglect and abuse, on many outcomes related to physical and emotional health. He used art to make our right brains fire. In a painting he showed, a little boy of about seven sat at the dinner table as his parents engaged in an argument, his father holding a knife and his mother's face distorted by rage. The terror on the boy's face was palpable.

The conference was very much framed around the concept of adversity. Anda kept apologizing for making us depressed. Consider the conference description:

Within the last two decades, scientists have begun to examine the biological repercussions of early childhood stress, and have uncovered clues as to how these early life experiences cause lasting changes in DNA and the brain that predispose individuals to disabling behavioral and psychiatric disorders in adolescence and adulthood.

The whole day I found myself thinking that what was missing was a right brain experience of what it feels like when things go well. We know it is bad for kids when they do not have a secure safe relationship. But what does it feel like when parents and children do connect in a way that makes a child feel safe and secure? Earlier in the day I had had the opportunity to share just such a right brain experience.

I had given Pediatric Grand Rounds at Newton-Wellesley Hospital, where I was introducing the scientific basis of my new Social Emotional Health program, where I see families of children under age six. When families come to see me, parents and children feel sad, angry, and out-of-control. By carefully listening to parents' own experience I help them to reflect on the meaning of their child's behavior, rather than responding to the behavior itself. This approach is founded in decades of longitudinal research at the intersection of developmental psychology, neuroscience and genetics that I describe in my book.

I told my audience the story of a visit with a mother who experienced her 3-year-old son's behavior as an assault. I had reframed the child's behavior in these out-of-control moments as helpless rather than defiant. She said, "I know what you mean." She described one moment when, rather than getting angry, she had held her son firmly on her lap and said gently "What's wrong?" She told me how her son "melted in my arms" and replied softly, "I don't know."

This mother felt this change not only in her brain, but in her body. It is not uncommon for parents to have themselves experienced trauma in early relationships. They react to their child's provocative behavior on a physical level that is related to their own history, not to the child. By carefully listening to parents, in a visit that is not fifteen minutes but an hour, I help them to make these connections. Once their own issues are in a sense moved out of the way, they are free to reflect on their child's experience in a way that is not encumbered by their own trauma history. When a child feels understood in this way, his behavior improves. A positive cycle of interaction is set in place.

When I told this story during Grand Rounds, I felt a tingling in my arms as I spoke of this mother's transformation in my office. The visit with that family had been a powerful experience for me. The fact that I felt something in the telling makes me hopeful that I was able to convey this to my audience. Maybe they understood how this kind of careful listening may actually change brains.

My book is full of stories like this one. If we are going to change this path that was described at MIT, of early childhood stress leading to terrible outcomes, these conferences need to include stories of what goes right; when clinician-parent-child connect in a meaningful way. Once we know what this feels like, we will be closer to understanding what we need to do to set children and families on a better path.

Psychiatric Medication For Children? Important New Book Gives Pause

Two things most stood out for me in Kaitlin Bell Barnett's new book Dosed: The Medication Generation Grows Up. The first is the stories of women struggling to get off of SSRI's (selective serotonin re-uptake inhibitors), started in early adolescence, when they decide to get pregnant. The second is Bell Barnett's review of the literature regarding sexual dysfunction as a side effect of SSRIs in adolescence.

The book as a whole has much to say that is very important. As I write in my blurb for the cover:

Dosed is a fascinating, well-researched, and very important book. After reading it, I hope that no parent, pediatrician or psychiatrist will give psychiatric medication to a child or adolescent without very careful consideration of the potential long-term consequences. Bell Barnett shows that these medications are often not a ‘quick fix,’ but rather have deep, lasting impact, not only on physical and emotional health, but also on a person’s core sense of self.

Bell Barnett is a journalist who was herself started on SSRIs as a teenager. Her book intertwines in depth interviews with people who were started on psychiatric medication in childhood and are now young adults, with a journalistic study of the history of psychiatric medication use in children. I could probably write several posts covering all the important issues she addresses, but have chosen to focus on these two.

I first learned of the emerging evidence that SSRIs may cause long term sexual dysfunction last fall when I attended a talk by Robert Whitaker, author of the controversial book about psychiatric illness and medication Anatomy of an Epidemic. I was so alarmed about this data that I wanted to immediately write a blog post about it. But shortly after that talk I received the galleys of Bell Barnett's book. I discovered that she has a through review of the rather scant literature on the subject along with some very poignant stories, so I decided to wait until her book came out. I recommend that anyone who is concerned about this issue (as anyone who takes or prescribes these drugs should be) read her book. The subject is covered in the chapter entitled "Side Effects." Here are a few sample quotes.

A comprehensive review of the literature conducted in 2004 found just one clinical trial that reported erectile dysfunction in a teenager; most clinical guidelines and reviews of SSRIs didn't mention sexual side effects at all.

This is pretty shocking since, as the authors of the study cited above noted, anywhere from 30-40 percent of adults experience some kind of SSRI induced problems with libido, arousal, or orgasm.

And this important point:

Despite the lack of formal studies involving young people, anecdotal evidence suggests that drugs causing decreased libido and sexual dysfunction do sometimes pose a real problem, psychologically and socially, both for teenagers who are in the process of developing a sexual identity and for young adults testing out long-term intimate relationships.

And this from Elizabeth, who started taking SSRIs in 9th grade:

I am not sure I can [over]state the extent to which it impacted things. I didn't grow up with a normal sex drive, and that was obviously due to a combination of factors, but being on and off antidepressants whose impact I really couldn't understand back when I didn't have any real understanding of my sex drive or sex in relationships to begin with means I basically went through adolescence without experiencing anything in that realm in a "normal' way.

There's more, but the bottom line is that this issue is not well studied and yet of major significance in adolescent development.

Bell-Barnett poignantly captures the challenges faced by her interviewees who were started on SSRIs in childhood and now want to have children. Aware of the potential effects on the developing fetus, they try to get off the medication, but rebound with debilitating symptoms of depression. SSRIs are one of the most common medications prescribed in pregnancy. Yet we really do not know what the effects are on the developing fetus. A policy statement put out by the American Academy of Pediatrics earlier this year points to evidence that SSRI use in the third trimester is linked to a constellation of neonatal signs and symptoms. We do know that maternal depression itself can have a negative impact on the developing fetus. So if a woman is already on SSRIs and develops symptoms of depression without them, it may be best to stay on them during pregnancy.

The take home point of Bell Barnett's book, however, is that this issue needs to be considered by parents and clinicians when girls are prescribed these medications in childhood and adolescence well before having children is on their minds. These medications have a great allure as they may very quickly resolve symptoms. But one thing that Bell Barnett makes clear, and that is also supported by the literature, is that getting off these medications is very difficult.

Certainly these children and teenager should get help if they are struggling with depression. But other forms of intervention, including psychodynamic psychotherapy combined with self-regulating activities such as yoga, offer an alternative to medication. There is a severe shortage of quality mental health services due in part to the influence of the health insurance industry. It is a complex issue that must be addressed at the level of health care policy.

Large-scale use of these medications has major life-long impact on identity and sense of self of the current generation, referred to as "Generation Rx." Considering the complex issue of SSRIs in pregnancy, there is also potential for significant impact on the next generation. The time to pay attention to this problem is now. Reading Bell Barnett's book is a good place to start.

Relationships: The Fourth Vital Sign

Respiratory rate, heart rate, blood pressure- these are the three vital signs that those on the front lines of health care are well trained to measure as initial assessment of a patient. Given the explosion of knowledge emerging at the intersection of neuroscience, genetics and developmental psychology about the essential role of early caregiver-child relationships on lifelong health, it is time to add a fourth vital sign- relationships. I first learned of this idea from a colleague, David Willis who is Chair of the American Academy of Pediatrics (AAP) Early Brain and Child Development Initiative. He in turn learned it from Colleen Kraft. Adding this fourth vital sign puts assessment and support of early relationships front and center.

The AAP policy statement Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health captures the critical role of relationships in healthy development.

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.

A remarkable study coming out of the Yale Child Study Center and described in the New York Times  shows the wisdom of this focus on relationships. It was a randomized control study of the Child and Family Traumatic Stress Intervention(CFTSI). Children who received the intervention were 65 percent less likely than those in the comparison group to have developed full-blown post-traumatic stress disorder and 73 percent less likely to experience partial post-traumatic stress disorder. These are the kind of numbers that make one stand up and take notice.

What makes this intervention different is that it specifically works with caregiver and child together to support the caregiver's efforts to understand the meaning of the child's behavior.

Unlike traditional counseling, which is often unstructured and prolonged and may not involve both child and caregiver, this program follows a proven pattern: first a session with the caregiver, then one with the child, then two sessions with them together.

Steve Marans, lead author on the study, explains the results.

When children are alone with and don’t have words to describe their traumatic reactions, symptoms and symptomatic behaviors are their only means of expression. And caregivers are often unable to understand the connection between the traumatic event and their children’s symptoms and behaviors. To heal, children need recognition and understanding from their caregivers.

These remarkable results make perfect sense to me. Children want to be understood by their parents, not their therapist. This is the model I have been using for years in my pediatric practice to address any behavioral symptom, not only those associated with trauma, and I too have had remarkable results. It is wonderful to see this approach validated by a high quality randomized control study. As I write in my 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

This concept of supporting parent's efforts to reflect on the meaning of a child's behavior comes out of decades of research showing how this kind of understanding promotes health development at the level of gene expression and biochemistry of the brain.

When baby is born, if heart rate, respiratory rate and blood pressure are OK, our next priority is to support the primary relationships by carefully listening to both caregiver and baby. One way to accomplish this is to use a wonderful tool the Newborn Behavioral Observation system, developed by J.Kevin Nugent, colleague of T. Berry Brazelton. If problems are identified, such as a biologically vulnerable child whose cues are hard to read, or postpartum depression, or lack of social support for mother, we can address them. We will then be setting this new life out on a course of healthy development from the start.

Animal Therapy for Children (and Parents)

Recently there was a beautiful article, Wonder Dog , in the New York Times magazine about an emotionally troubled boy who was helped significantly by a devoted dog. I thought about this story this past week when my beloved dog, a lab-border collie mix who we adopted 9 years ago at the age of two , died rather suddenly. It turns out he had a tumor on his spleen and bled internally-at least it was quick and painless.

The thing is- he really helped me out with my emotional regulation, especially in my role as mother to my daughter, who as a young teenager had an incredible capacity to push my buttons. In the interests of full disclosure, I also had a lot of help from a wonderful therapist in understanding the roots of this issue. But Jasper was there with us on the front lines.

Whenever we would get into any kind of conflict and I would start to raise my voice, Jasper would immediately get up from his dog bed and come and lie right next to me. At once I would feel calm. My breathing slowed and I am quite sure my blood pressure went down. Rather than continue to butt heads with her, I would be able to think more clearly about what was happening and to reflect on the meaning of her behavior. Often I could identify some event in her life that was causing her stress and anxiety that she was now taking out on me. I was able to remain calm in the face of assault. Jasper helped me to much more rapidly defuse these encounters.

Now that he is gone, I think of his beautiful soulful eyes and his oh-so soft head, and I hope that I have internalized his presence enough that I can just think of him to gain that calm feeling. My daughter is older now and she herself has learned to regulate her own emotions. Part of this is simply development and maturation. But to some degree I believe she has learned this from me, and I in turn learned it in part from Jasper.

In my book, Keeping Your Child in Mind, I talk about how parents themselves need to find ways to manage their own emotions in order to be present with their children in a way that promotes healthy development. This involves having someone to hold them in mind, be it a spouse, friend, family member or therapist. I should add animals to that list.

The therapeutic value of animals for children is well known. I often recommend horseback riding as an activity for children with problems of emotional regulation. Child psychiatrist Bruce Perry, in his description of the Neurosequential Model of Therapeutics that he developed for working with traumatized children, writes:

Dogs have the capacity to provide the unconditional accepting and repetitive nurturing experiences required to help some of these children.

The wonderful documentary film Buck, clearly demonstrates how Buck's close relationship with horses has helped him to recover from the severe physical and emotional abuse he experienced as a child. He now uses this experience to help others. In training workshops he runs all over the country he shows the importance of managing your own emotions in order to be present with your horse in a way that helps him to manage his. It's an amazingly similar concept to my book!

If your child wants a dog, and you worry that you will "get stuck" taking care of it, remember that the dog can be a wonderful asset for the whole family. I know it will take our family a long time to heal from this terrible loss. I would often say to Jasper, "You are truly a good person ( as dog)." I hope that in writing this I can to some degree immortalize his gifts to us.

Possible Lessons From a Teenage Suicide

About three years ago an eighteen-year-old girl committed suicide several days after being admitted to a Boston area psychiatric hospital. A year later her family filed suit against her psychiatrist, who had seen her for one and one half sessions. The case went to trial this winter, and he was exonerated. Recently I was speaking with his wife about the case. "Nothing good came of it," she said. The girl is still dead, huge amounts of money were spent, and three years were taken from the life of my friend and her young family.

The case became public record once the suit was filed. My friend, a minister, spoke about the experience in her sermon at the time of the trial, hoping perhaps to find some life lesson in the experience. As I listened to her describe the event, her emotional pain still so fresh in her telling, I, too, was moved to try to capture it in writing.

I start by borrowing from her sermon. She poignantly describes her husband two days after the girl killed herself. He was at a party, "surrounded by friends and holding our newborn son and nonetheless looking stricken." The real tragedy of the story is, of course, the death itself. But unfortunately it became a story about other things, namely guilt, blame and responsibility.

In her sermon my friend vividly portrays her efforts to find empathy for the girl's mother.

I spent most of this past week in court with Jim, and I’ve searched my heart for the gesture Jesus hands down to us, a gesture of compassion: “My heart goes out to you.” It was there early on, but following her testimony, by which it’s become clear (at least to me) that Jim was not the problem, I can only muster such compassion when I’m removed from the situation, physically out of that courtroom: “My heart goes out to you.” But when I’m there, sitting close enough to touch her, where she sits in front of me, shoulder-to-shoulder with her gentle-faced second husband (her first having himself died from self-hanging), I haven’t got it. I haven’t got it to offer.

My friend told me of her sense that this mother was unable to think about her daughter. The mother seemed to have an image of what her daughter was or should be that did not consider her child's perspective. As an example, my friend told of the mother's insistence that her daughter's private journal be admitted as evidence in the trial.

Even though I don't know any of these people, I felt this overwhelming wish to have had time with this mother before her daughter died. Would empathy then have helped her to hold her child's mind in mind ? What in her life had caused her such pain that she was unable to do this?

For I am certain that mothers never want to hurt their children. No matter how horribly a mother speaks about or behaves towards her child, given the time and space to be heard, I believe it is possible to uncover the hurt in her own life that is making this task of holding her child in mind so difficult. But the staff at the hospital didn't have time to even try. As my friend said, "They didn't know they were working on a deadline."

But now it was too late. The girl was dead. And because the mother was on the attack, specifically attacking my friend's husband, empathy was not an option. If blame must be laid for this sad situation, I would place it on the lawyer who took the case. How could someone who saw her for less that two hours possibly be responsible for a eighteen year life?

My friend described the cross-examination of her husband. The girl had missed her last session. She had also missed the previous session, and he had gone to find her. The second time he chose not to go after her, because, as he explained to the court, she had said she didn't trust him. She probably wouldn't feel comfortable being actively chased down by a man she didn't trust.

The plaintiff's attorney asked him what he had done during that time. He answered that he had reviewed her chart and thought about her. The lawyer asked, with a sneer that my friend vividly conveyed, "You thought about her?' Her husband calmly looked him in the eye and said simply, "Yes."

Taylor Swift Captures Secure Attachment Relationship

If my book, Keeping Your Child In Mind, were to have a theme song/video, it would be Taylor Swift's The Best Day. I have included the lyrics below, but suggest watching and listening (with tissues!) It offers a "right brain" emotional experience of what D.W. Winnicott termed the "holding environment." As I write in my book:

Winnicott describes this way of being with a baby as the “holding environment.” The mother’s ability to tolerate and contain her baby’s distress helps him to make sense of and learn to manage his experiences. Even though holding a baby may seem to be simply a physical act, it is her emotional presence that is important to the baby.

The video speaks for itself, but here are a few points that stood out for me.

As a young child Taylor's mother physically contains her after a long day playing outside: "I hug your legs and fall asleep/
on the way home" She feels safe and secure with her mother who is "not scared of anything at all."

The video captures the way in which she was included in the arrival of her baby brother. Her love for him is clear in the later lyrics, "Inside and out, he's better than me."

At thirteen she experiences inevitable social trauma, with her friends being "so mean.". Her mother does not try to fix it. Rather, Taylor receives her mother's undivided and playful attention as they go for a ride in the car. One feels confident that though, as she says, "Don't know how long it's gonna take to feel okay," Taylor, refueled and fortified by mother's love, will work it out herself.

While the song is primarily about her mother, Swift brings in her father "whose strength is making me stronger."

Overall, the video perfectly captures the great value of simply being present with our children. In our culture of "advice" about "what to do" about any range of problems, this is a breath of fresh air. The challenge is clear our own minds and lives enough to offer our children this kind of holding. If we can, we are setting the foundation for their healthy emotional development and future success, in every sense of the word.

The Best Day

I'm five years old
It's getting cold
I've got my big coat on

I hear your laugh
And look up smiling at you
I run and run

Past the pumpkin patch
And the tractor rides
Look now -- the sky is gold
I hug your legs and fall asleep
On the way home

I don't know why all the trees change in the fall
I know you're not scared of anything at all
Don't know if Snow White's house is near or far away
But I know I had the best day
With you today

I'm thirteen now
And don't know how my friends
Could be so mean

I come home crying and you hold me tight and grab the keys

And we drive and drive
Until we've found a town
Far enough away

And we talk and window-shop
Until I've forgotten all their names

I don't know who I'm gonna talk to
Now at school
I know I'm laughing on the car ride home with you
Don't know how long it's gonna take to feel okay
But I know I had the best day
With you today

I have an excellent father
His strength is making me stronger
God smiles on my little brother
Inside and out
He's better than I am

I grew up in a pretty house
And I had space to run
And I had the best days with you

There is a video
I found from back when I was three
You set up a paint set in the kitchen
And you're talking to me

It's the age of princesses and pirate ships
And the seven dwarfs
Daddy's smart
And you're the prettiest lady in the whole wide world

Now I know why all the trees change in the fall
I know you were on my side
Even when I was wrong
And I love you for giving me your eyes
Staying back and watching me shine

And I didn't know if you knew
So I'm taking this chance to say
That I had the best day
With you today

Behind the Scenes Look at ADHD Treatment

Recently I went to a talk given by a local "ADHD (attention deficit hyperactivity disorder) expert" to a group of primary care pediatricians. The aim of the talk was to guide these practitioners in doing "ADHD evals" given the time constraints of primary care practice.

"Its all about the rating scales," he said. "You need to train your staff to give out the right scales. The key to working kids up is getting the scales done ahead of time. Nothing happens in the office."

This doctor proudly displayed his version of the main rating scale, the Vanderbilt, which he has divided into two time slots, because "kids have different symptoms at different times of day." Evaluation and treatment of ADHD consists primarily of scoring rating scales, making a decision to use medication, and once the decision is made, having follow-up visits every three months to adjust medication dose according to symptoms and side effects.

One pediatrician, someone for whom I have great respect as a clinician, was alarmed about a 5-year-old who was placed on a very high dose of medication by another doctor. When I asked her what was going on in the child's life that might cause him to have so much trouble, she didn't know. She had changed the medication, which did in fact improve the child's symptoms. Her approach is the standard of care in pediatrics.

In other areas of medicine, we treat the underlying cause, not just the symptom. In treating bacterial pneumonia, for example, we use an antibiotic, not a cough suppressant. The Vanderbilt lists symptoms of problems with regulation of behavior, emotions, and attention, which together may be labeled as ADHD. The question should be not “How do we control the symptoms?” but rather “What is making self-regulation difficult for this particular child?” followed by “What can we do to help promote self-regulation?”

Recently I saw several children who had been diagnosed with ADHD but medication "didn't work". One mother told me about her own struggles with untreated depression. Another child spent weekends with an actively drinking alcoholic father. A third child quietly spoke with her mother of being frightened when she pulled her hair and hit her.

Nowhere on these rating scales does it ask about family history or life stressors. According to the current standard of care it is possible to diagnose and treat ADHD without ever learning about any of this history. Detailed family history (see previous post), as is well described in the book A Lethal Inheritence, is essential to diagnostic evaluation. In addition, detailed early developmental history may reveal significant sensory processing problems that have been unrecognized.

When I have written about ADHD in the past, I usually get a number of angry responses from parents who say everything is fine in their family and I shouldn't blame them for the problem. In my experience, about 10 % of kids seen for "ADHD eval" have what I refer to as "straightforward ADHD." They have symptoms and an extensive family history of inattention and/or hyperactivity with no other issues. If you are in that 10%, this blog post is not about you.

Giving a list of therapists does not solve the problem, because the child is usually the "identified patient." Family therapy can be an important component of treatment when a child struggling with self-regulation, as is well described in the recent book, Suffer the Children: The Case against Labeling and Medicating and an Effective Alternative. Furthermore, once a child is placed on medication, his behavior is "better" for the short term and the motivation to do the more challenging, time intensive work to uncover the cause is lost.

The term "ADHD eval" implies only two options- a child does or does not have ADHD. It leaves no room for curiousity about the meaning of behavior. Then there is the term "co-morbidity." This simply offers the opportunity for more labels without exploring the cause of symptoms.

There is a reason why, as one of the pediatricians at this presentation bemoaned, a parent may say, "by the way" just when when a doctor has his hand on the doorknob to leave. It takes time to develop sense of safety and trust to be able to say what's really important.

Fortunately I work in a practice that is open to a different approach. Here are some initial changes I propose:

1) Schedule the visit as "evaluation of problem of attention, behavior and emotion," or more simply "behavior problem,"rather than "ADHD eval"

2) Have a minimum of two 50 minute visits for an evaluation

3) See parents alone without the child for the first visit. Aim to include both parents whenever possible

4) Goal of initial evaluation is to get detailed family and social history, and to offer parents an opportunity to be heard. Very often the parent and/or couple need support and possibly referral

5) Medication may be considered for an older child if he is unable to learn or function in a social environment without it. Equal attention must be given to other interventions, including addressing diet, sleep, and physical activity

Such an approach involves a change in expectation on the part of parents, teachers and clinicians. Parents are often under tremendous pressure from teachers to get a prescription for medication.

Stanley Greenspan's book Overcoming ADHD: Helping Your Child Become Calm, Engaged, and Focused--Without a Pill offers an excellent holistic approach that is founded in quality scientific research. One key component of his treatment is to support "reflective thinking." This involves helping a child to recognize both his strengths and challenges, and to develop strategies to manage his own unique vulnerabilities.

"We don"t have time" is not an acceptable answer. Changes must be made in our healthcare system to insure better reimursement for time spent listening in this way, and to improve access to quality mental health care services.

This is child's life we are talking about. If the root cause of the problem is not addressed, there may be years of medication adjustment until something bad happens- car accident, school failure, violent crime, prison. If I sound alarmist, it is because I am alarmed. The current standard of care of ADHD treatment, particularly now that diagnosis is extended down to age 4, effectively silences huge numbers of children. We need to give these children a voice.