Yale lab calls babies bigots- a worrisome interpretation

A CBS 60 minutes segment: Born good? Babies help unlock the origins of morality is getting a lot of attention. The opening observation that babies are in fact not blobs is certainly apt. Pediatrician T. Berry Brazelton has been telling us this for over 40 years, since he developed the Neonatal Behavioral Assessment Scale that clearly shows babies as young as a few hours having complex capacities for communication. When I teach pediatric residents I show them a 2-minute video clip of a three-day-old baby following my gaze and moving his mouth as if in conversation with me. Clearly not a "blob."

However, when the researchers at Yale went on to interpret their findings as indicating an innate capacity for bigotry, I became alarmed. Certainly their research results are robust in showing a baby's preference for stuffed toys that exhibit behavior that is "like them." Researcher Paul Bloom states in the program:

If you want to eradicate racism, for instance, you really are going to want to know to what extent babies are little bigots, to what extent is racism a natural part of humanity.

Here is Webster's definition of bigot:

A person who is obstinately or intolerantly devoted to his or her own opinions and prejudices. 

Using such a negative word to describe a baby feels a bit like a prejudice itself.  Elizabeth Young Breuhl in her book Childism: Confronting Prejudice Against Children, describes prejudice as projection of bad feelings from inside out on to another person.

At another point in the interview Bloom suggests that there might be sets of genes and areas of the brain responsible for such things as resilience and morality.  This rings of the approach of "biological psychiatry" with its history of placing complex developmental/relational problems squarely within a child.

I wonder if another interpretation of the results is in order. I immediately thought of Daniel Stern, a brilliant child psychoanalyst who recently passed away. In his book The Interpersonal World of the Infant he points to the explosion of infant research as evidence of an emerging sense of self in early infancy. He writes:

Recent findings about infants...support the view that the infant's first order of business, in creating an interpersonal world, is to form the sense of core self and core others. The evidence supports the notion that this task is largely accomplished during the period between two and seven months.

So these 3-5 month old babies in the Yale lab, shown out of relational context in interaction with a toy, are in the heart of this process of developing a sense of self in relation to others. An adult, who has a fully developed sense of self, must exercise extreme caution in interpreting their behavior using negatively charged words such as bigot and racist. The behavior must be interpreted in the context of this complex developmental task.

In keeping with the subject of sameness and difference,  the day that I learned of the CBS program I read a review of the new book Far From the Tree: Parents, Children, and the Search for Identity.  The book explores the issue of individual differences, and the complex interplay of genes and environment, through extensive interviews with families of children with various forms of difference or disability. Author Andrew Solomon is not a scientist, but a father and a writer who has done an enormous amount of research.  Though I have only read the first few pages of the over 900-page tome, I am already captivated. On page one he writes:

Our children are not us: they carry throwback genes and recessive traits and are subject right from the start to environmental stimuli beyond our control. And yet we are our children; the reality of being a parent never leaves those who have braved the metamorphosis. The psychoanalyst D. W. Winnicott once said, "There is no such thing as a baby, you will find you are describing a baby and someone. A baby cannot exist alone but is essentially part of a relationship."

 New York Times reviewer Julie Myerson writes of the book:

 This is a passionate and affecting work that will shake up your preconceptions and leave you in a better place.

This book seems an appropriate bookend to the Yale research, with all of the extensive research at the interface of neuroscience, developmental psychology and genetics on how a person develops a healthy sense of self in relation with other people in between.

Massage and music for mothers and babies

One of the best things about the work I do is that I get to meet great people and learn about wonderful programs that support parents and children.

Last week I was away in New Jersey speaking at the ICDL conference (Interdisciplinary Council for Learning and Development) In the afternoon, after giving my presentation, I attended another workshop. In the minutes before it started, a woman sitting in front of me turned to me and commented that she had enjoyed my presentation. I asked her what she did.

I learned that that she works at Newark Beth Israel Medical Center where she does massage in the Pediatric Intensive Care Unit and Hematology/Oncology unit. When I commented that this must be a very progressive hospital, she said that if she had come with the program fully formed, it was unlikely they would have used it. But she started out just doing a consult here and there, and when the doctors saw the value of her work, they expanded the program to what it is today.

In addition, she told me, in her program Nurturing Touch she does massage with drug addicted moms and their babies who are being treated for withdrawal symptoms. She explained that at first she just worked with the babies, and held what she soon recognized were incorrect assumptions about the mothers. She observed that "we rip the mothers and babies apart" when there is a positive tox screen (drugs found in the urine.)  When she actually met the mothers, she found that they were in deep pain over being separated from their babies and longed to reconnect with them. She began to use her massage techniques on the mothers as well, recognizing that many of them had histories of abuse, and might never have experienced touch in a positive and caring way. She did this simply with gentle hand massage. Her aim was to begin to relax their bodies enough to enable them to hold their own very dysregulated babies;  providing comfort both mother and baby so desperately needed.

Earlier that day I had received an email from someone who had been referred to my website by her pediatrician. She wanted to share her work with me. She is a musician and music therapist who began studying clinical psychology after the birth of her first child. But rather than complete her PhD, she produced an album for mothers and babies, Good Morning My Love, that won the Parent's Choice Gold Award. I found the following on her website:

The benefits of music are intuitive to most people. Music is a natural endorphin that bypasses intellectual thought and directly connects you to emotions. It can simultaneously engage both your playful, spontaneous side and your soulful, tender side. For many reasons it is one of the best ways to connect to your baby: Music, with its inherent melody, rhythm, and repetition, is a language that babies can understand from day one. It also has a way of organizing experience and enhancing it. Both you and your baby can use music to create routine, develop reliable patterns of expectations, and foster a sense of security - all of which help to create a familiar and loving environment. 

As a lover of folk music, I was captivated. One song that is excerpted on her website perfectly captures the ambivalence of toddlerhood with the lyrics, "Mama leave me be but don't leave me." In groups she runs for moms and babies, she uses music to address the anxiety and isolation that new moms often feel.

On my return home, these experiences came together in my mind when I read a study in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry suggesting that ADHD and Autism Spectrum Disorder (ASD) may actually represent one overarching diagnosis. Interestingly, at the conference I had been speaking with a colleague, an occupational therapist, about the overlap in symptoms not only of of ADHD and ASD, but also anxiety.

Stanley Greenspan, founder of ICDL, eloquently described the very close link between sensory and affective experience. He recognized these "disorders" as variations of ways in which these systems have been derailed, and created the DIR floortime model as a way to help children and their families to address problems of sensory and affective experience.

I suspect that as we learn more about the biology and genetics of these problems, we will find that the diagnostic categories as described in the DSM system represent artificial constructs.

Rather than figuring out what diagnostic category a child fits in to, we need to focus on supporting parents' efforts to understand their child's experience and to help him to manage his unique vulnerabilities.  The research that I describe in my book Keeping Your Child in Mind offers evidence for this model as a way to promote healthy emotional development.

At the conference, in collaboration with Dana Johnson, an occupational therapist who reached out to me after reading my work, we advocated for integrating the two models in our presentation: Development of the Parent: the Child's Contribution.

I hope that "alternative" therapies, as represented by music and massage, will someday be considered primary therapies, as they address the primary problem. Even better, offering these kinds of interventions for stressed mother-baby pairs may go a long way in preventing the development of more complex problems of sensory and affective experience, problems that we now label "psychiatric disorders."

Infant Mental Health and Child Protection: an Essential Partnership

Michael Bush, a bright, open-minded third-year student at West Virginia University College of Law, contacted me this past summer when, in his role as an editor of the Law Review, he was organizing a symposium on Child Protection in the 21st Century. In our subsequent email conversation he wisely observed that those in the legal profession are often in a position to decide what is "in the best interest of the child" with little substantive understanding of what exactly is in the best interest of the child.  He invited me to share my knowledge as an expert in infant mental health.

This week, his efforts and those of his fellow law review editors-a remarkable group of intelligent and thoughtful young people-came to fruition. It was an extraordinary experience that opened up many opportunities for meaningful collaboration.

 In my presentation I contrasted the historical view of Child Protection as a child-saving service designed to prosecute parents with the model of relationship-focused preventive intervention promoted by the field of infant mental health (those who are interested may see the talk in its entirety on the webcast.)


Rather than giving specific ideas about what to do, I offered a different way to think about work with very troubled families.  While many in the legal profession view their task as "proving what the parent has done wrong," (this is a direct quote from a CPS social worker) I encouraged them to think about creating a "holding environment" where there is room for non-judgmental curiosity about the meaning of behavior. I presented an overview of the research that supports this paradigm.

Many very important things came out of this trip. A number of people from CASA, a non-profit organization in Virginia that supports volunteer advocacy for abused and neglected children, attended my talk. Amber Moore, the editor-in-chief of the Law Review, told me that they had requested my PowerPoint because "they couldn't write fast enough." They want to use what I was teaching to train their volunteer workers. I discovered that people were starved for knowledge about contemporary research in child development in a form that they could understand.

I quoted from my book Keeping Your Child in Mind, explaining that while it was being marketed as a parenting book, it is actually a book about infant mental health written for a general audience. I wrote it with my pediatric and mental health colleagues in mind, but now I see how useful it could be to the legal profession, specifically those working in the area of child protection.

One of my co-presenters was a delightful judge from central West Virginia who has been doing child protection work for over 20 years. He openly admitted to his lack of knowledge on the subject of contemporary child development research and bought 5 copies of my book.

I met a remarkable young woman who, in addition to attending law school, works at the Industrial Home for Youth in Salem, where prior to a recent lawsuit, children as young as 13 were routinely placed in solitary confinement. As part of a law school class, she is drafting a bill to require multidisciplinary meetings every three months for these young offenders, who currently may not meet with anyone who is advocating for them for their entire stay. Because WVU is the only law school in West Virginia, the students' bills are presented to the state legislature, and a percentage of them actually become law. I am hopeful that she and I will keep in touch and that I can support her in her efforts.

As Keynote speaker of the symposium, I have been invited to write a paper for the West Virginia Law Review that will then be available for citation in legal work.  Another of my co-presenters, who spoke about the legal challenges of adolescent parents, already told me that she intends to cite my work.

This trip was well outside my comfort zone. I had never been to West Virginia (or even Pittsburgh-where I had to fly to get there) and certainly had never spoken with an audience of lawyers. My infant mental health colleagues are "my peeps." In a few weeks they will gather in Los Angeles at the wonderful Zero to Three National Training Institute. Sadly, I will miss it, in part because of this trip.

I have often said to my infant mental health colleagues that we need to work on communicating the wealth of ideas that will be presented at that conference widely beyond our borders.  It was like a dream come true to have the opportunity to speak to a group of bright young law students- the future lawmakers and policy makers of our country. The experience left me hungry for more.

A happy story in stressful times

It was quiet on the mountain. My husband and I were on an early morning hike with our dog up Monument Mountain. As we approached Inscription Rock, a landmark near the top, we saw a man and woman who looked to be in their late 60's, healthy outdoorsy types. The man was asking the woman to sit on the rock so he could take her picture.

As we passed by, the man walked towards me and asked me to take their picture. "Sure," I replied, taking his camera. Then, as the woman got settled on the rock, he whispered to me, "I'm about to ask this woman to marry me." Signaling to my husband to stay back with the dog, I began clicking away. He approached her and got down on one knee, pulling a small box out of his jacket pocket. There was much laughter and embracing. When the deed was done, they turned to face me, arms around each other, and asked me to take their picture together.

"It was meant to be," I said, referring both to our arrival at this spot at the exact moment of the proposal, as well as, I hope, their marriage. My husband and I continued over the top of the mountain and down the other side, exhillarated by this chance encounter with new love.

( Between the elections, hurricane Sandy and my preparations for two major presentations in the next two weeks-more about those soon- a relevant and meaningful blog post has not been forthcoming. I hope readers enjoy this little tale instead!)

Preventive mental health care for children falls through the cracks

The current issue of the Journal of the American Academy of Child and Adolescent Psychiatry has an excellent article, Integrating Mental Health Care Into Pediatric Primary Care Settings, identifying the causes of this problem.

Pediatric training provides limited experience in screening or intervening for mental disorders. In contrast, child psychiatry training emphasizes the treatment of children with established psychiatric diagnoses and typically offers limited experience with children at risk for mental disorders or children whose symptoms do not reach the threshold for diagnosis. 

In other words, the current structure of the health care system does not have room for prevention. Primary care clinicians, who have the main contact with young children and families, do not have adequate education in prevention, and specialists who children are referred to when problems arise only know how to treat identified "disorders." The article further elaborates on the reasons for this situation:

Current financing structures reward treating established diagnoses, not providing preventive services, because payment for visits, with few exceptions, requires a DSM-IV diagnosis.

This problem is currently being addressed in the refinement of the DC: 0-3, a classification of disorders of infancy and early childhood that recognizes the significant role of relationships in problems in this age group. If the DC:0-3 is "cross-walked" with a DSM diagnosis, then reimbursement is possible.  That word "disorder" is still part of the conversation, but it is a step in the right direction.

Another problem intrinsic to the system is that for billing purposes the child is the identified patient, making work with the family challenging.

Research on the treatment of child mental health conditions has strongly indicated the benefit of treating the child and the caregiver as “the patient,” but public and private plans frequently do not pay for family-focused treatment... the need to identify the child as the patient makes family-focused interventions difficult to support financially; likewise, payment for caregiver-only or collateral sessions is lacking.

Another problem identified is the lack of financial support for collaborative care. In my work with families in the Early Childhood Social Emotional Health program at Newton Wellesley Hospital I speak regularly with a child's primary care doctor. This is an essential part of care, as that person often has a longstanding ongoing relationship with the child and family and knows them well. In addition, if I refer a family on to more specialized care, such as with a psychiatrist, it is important that I fill them in on the work I have been doing with the family. Working as a team we can hold the family through a difficult time, and get development going in a healthy direction. I spend a lot of time on the phone because it is good care, and I know that many of my pediatrician and child psychiatry colleagues do the same. Yet none of this care is reimbursed.

The article offers this ray of hope:

The Affordable Care Act (Public Law 111-148) requires mental and behavioral health coverage in an essential benefit package at parity with medical benefits. This could incentivize the integration of care.

Of course for this to happen, President Obama must be reelected.

Yoga for autism, movement for learning

When I listen to parents of young children (under 5) in my behavioral pediatrics practice, they often describe a child who is very overwhelmed by sensory input, inflexible and easily dysregulated. They worry that their child is "on the spectrum." We talk about how their child does not feel calm in his body, and work together to help him find ways to feel calm. With this approach, there can be significant improvement in behavior.

Thus I was pleased, though not surprised, to learn of two studies validating this approach in children who have been diagnosed with autism. One, published in the current issue of the American Journal of Occupational Therapy, demonstrated that a 17 minute yoga program, called "Get Ready to Learn," significantly decreased anxiety, social withdrawal and aggression.

The second, published last year in The Journal of Alternative and Complementary Medicine demonstrated significant improvement in core features of autism in a group of children age 3-16 who participated in an 8 week multimodal yoga, dance and music therapy program.

In a related story, this morning on NPR's Only a Game, a program entitled Does Exercise Help Kids Learn? referred to the research of neurologist Majid Fotuhi showing that exercise improves learning efficiency. He stated:

I am also in favor of shorter teaching sessions which are intermittent with 20 minutes of P.E. or some kind of physical activity that’s somewhat structured.

In a previous post I refer to psychiatrist Bruce Perry, whose neurosequential model of therapeutics, primarily applied to work with traumatized children, uses self regulating activities interspersed between both learning and therapy. I conclude:

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.

Whether a child has symptoms associated with autism, has experienced trauma, or is struggling to learn, promoting self-regulation by using the body to help the brain is important. If we can incorporate this approach into treatment and education of young children, we will support healthy development of regulation of emotion, attention and behavior,  perhaps even avoiding the need to label them with a disorder.

New study asks; what happens to the dysregulated infant?

When I see children in my behavioral pediatrics practice, whether they are 2, 5 or 15 it is very common to hear from parents that as a baby their child "cried all the time" never slept" had "terrible feeding problems" or some variation of this. Therefore I was not surprised by the findings of a large longitudinal study published this week in Pediatrics: Long-term Outcomes of  Infant Behavioral Dysregulation. The researchers in Australia had information about over 5000 babies starting at 6 months, and found that when mother's reported symptoms of "dysregulation" at this age, they were significantly more likely to report of behavior problems at age 5 and age 14. This association was affected by such things as mother's level of education, marital status and presence of anxiety and/or depression. The authors conclude that:

By facilitating early referral to appropriate professionals, such as public health nurses, family therapists, psychologists, and social workers, clinicians may aim to improve not only behavioral out- comes in childhood and adolescence, but also parents’ perceptions of their children and the needs of the parents themselves.

While I am pleased that this conclusion is reached in a prestigious journal, what is lacking in this study, is understanding of how infant dysregulation and later behavior problems are linked, and so in how to treat these problems. Here are three points that speak to this issue.

1) This model places the "dysregulation" squarely in the baby. However, any new mother (I refer to mothers because that is what the study does- see below for thoughts about fathers) will tell you that the baby's behavior has a huge influence on a mother's behavior and emotional wellbeing.  The mother and baby regulate and dysregulate each other. For example, if a baby has difficulty settling to sleep, a parent will likely be severely sleep deprived. This in turn may affect her ability to respond to her baby's cues. If she is struggling with postpartum depression, the sleep deprivation likely will worsen her symptoms. When a mother is herself struggling in this way, it may lead to further symptoms of "dysregulation" in the baby. But conversely, if a baby is dysregulated and the mother gets help,  in the form of such things as a mother-baby group, yoga and/or therapy, and she is able to be calmer, she will be better able to help her baby manage his symptoms of dysregulation. In turn, as her baby becomes more calm, she will feel more competent and better about herself as a parent.

2) Fathers have a critical role to play. A study published last year in Pediatrics showed a significant link between paternal depressive symptoms and later child behavior problems. Again, looking at the positive side of this, when a father's emotional wellbeing is supported, he can be more emotionally available for both his partner (this study does identify stability of partner relationships as well as marital status as an important factor) and his child.

3) Symptoms of dysregulation are usually present before 6 months of age. For example babies born prematurely are very likely to be behaviorally dysregulated. One particularly vulnerable population is what is referred to as the "late preterm." When babies are born at 35-37 weeks, they are often in the regular nursery and parents have an expectation that they are "normal." However, these babies may be difficult to feed, have difficulty settling to sleep as well as increased sensitivity to sensory input. When there is this kind of mismatch between the parent's expectations and experience, significant feelings of inadequacy may emerge. In turn, these feelings, together with sleep deprivation may lead to symptoms of depression in a parent. This is another example of mutual dysregulation.

I was motivated to develop the Early Childhood Social Emotional Health program at Newton Wellesley hospital exactly because of the findings that this study calls attention to. I wanted to help families before their child was 5, 10 or 16 and being diagnosed with ADHD. Recognizing that the roots of these problems are usually present very early, it made sense to  devote resources to helping families of young children.

The risk of this study however, is that "infant dysregulation" becomes the new "ADHD," placing the problem squarely in the child, and failing to recognize that the problem occurs in relationships.   As it stand now, the study adds to the rapidly growing body of literature offering evidence that devoting resources to early childhood is important. But it is only by focusing on interventions that promote healthy relationships, and for vulnerable parent-child pairs starting these interventions at or close to birth, that this research can have a positive and meaningful impact.