What might redefining "term pregnancy" mean for parents and babies?

So far the discussion on the policy change by the American College of Obstetrics and Gynecology (ACOG) has focused on the implication for timing of delivery. While previously babies had been considered "term" at 37- 42 weeks, the new policy defines term as 39-40 weeks. Babies born at 37-38 weeks are considered "early term" and those born at 41-42 weeks "late term."

The main consequence of this policy change is an official recognition that babies at 37-38 weeks are still not optimally mature for delivery.  The main objective of the policy is to "expand efforts to prevent nonmedically indicated deliveries before 39 weeks gestation*." In other words, doctors should not electively induce delivery or perform c-sections before 39 weeks. An article in Time magazine on the subject refers to a recent study showing an increased incidence of medical complications in what are now officially "early term" deliveries.

But given my interest in the parent-baby relationship and its impact on healthy development after birth, I had a different take on the significance of this change. Many babies born at 37-38 weeks are not induced or delivered by c-section. For a range of reasons, most of the time not an identifiable one, a mother may spontaneously go in to labor at 37 weeks. And, in contrast to the babies in the above study, the vast majority of these babies do not end up in the neonatal intensive care unit. They are in the regular nursery for the typical 48 hour stay.

My hope is that the policy change will focus more attention on the vulnerabilities of these babies.  The important question is,  "What is the implication for these babies who are not at optimal states of maturity, yet are cared for along side the now "term" babies and treated by professionals as if they are no different?" I put this question to a colleague of mine who is a hospitalist in a major teaching hospital in Boston. Her full time job is to care for newborns and parents following delivery and up to discharge in the regular nursery.

Personally I think this more nuanced classification of who the "full-term" baby is will be important for the parents and other professional who are supporting and teaching the family in the early weeks of life - eg. nurses in the well nursery, lactation consultants and medical providers.  Currently, unless a baby is under 37 weeks, they are all seen as fairly similar in their capabilities with differences being attributed to temperament or "personality" rather than gestation maturity.

There's a continuum to observed physiological parameters that may not be appreciated or fully noticed when babies are lumped together as full-term between 37-42wks; these include degree of sleepiness, subtlety of feeding cues, amount of energy reserves, ability to regulate state changes, muscular tone to name a few.  All of these impact the newborns' behaviors; especially feeding which is a primary focus for parents with their newborns.

Understanding that their infant's capabilities are related very often to his/her gestational age will reassure parents about their own capabilities as they learn to observe/make sense of their new infant's behaviors/cues with a more informed/understanding eye and less self-blame when trying (or struggling) to feed or to calm or to awaken their newborn.  

As my colleague wisely points out, what it looks like in real life when a baby is not "optimally mature," is that the baby may be difficult to arouse,  cry more or in general be more challenging to care for. Much of a new parent's sense of competence comes from successfully feeding her baby. If the baby's challenges with feeding are not identified and linked to his early gestational age, a parent may experience feelings of frustration and failure. She may abandon breast feeding or slide in to depression as she struggles to meet the needs of her baby.

In previous posts, I have referred to a wonderful tool, the Newborn Behavioral Observation System, that offers the opportunity to identify a baby's unique strengths and vulnerabilities.  This video of a brief excerpt of the NBO with a 3-day-old infant shows the newborn's tremendous capacities for communication. The NBO offers the opportunity to look at these qualities in a systematic way.

My hope is that now that the ACOG has officially identified these "early term " babies as vulnerable, professionals who interact with these families will offer parents the opportunity to identify possible challenges and develop strategies to manage these challenges, which with care and attention will resolve in a short time as the baby matures.

*Gestational age refers to the number of weeks since a mother's last normal menstrual period.

Moving beyond the DSM paradigm of mental health care

A paradigm is a way of thinking about things. For the past 60 or so years, our thinking about mental health and illness has been dominated by what can be referred to as the "DSM (Diagnostic and Statistical Manual of Mental Disorders) paradigm." What this looks like in everyday practice is that when a child is referred to my behavioral pediatrics practice for say, anxiety, the questions that parents, referring doctors, and teachers ask is, "Does he have anxiety disorder?" followed by  "How to we manage his behavior?" and "Does he need medication?"

The DSM paradigm has been useful as a way of organizing our thinking. But it is important to recognize that these "disorders" of anxiety, depression, ADHD etc, are simply lists of symptoms that tend to go together. They do not correspond to any known biological processes in the way that, for example, diabetes is a result of lack of insulin.

When the DSM system was first created, we did not have the powerful health insurance and pharmaceutical industries that we have today. Because of the existence of these entities, we are currently in a position of being forced in to a very narrow view of mental health and illness.

The DSM system is a black and white paradigm with only the possibility of "normal" or "disordered."
According to the DSM paradigm, if the answer to the first question about my anxious patient is no, and there is no diagnosis, there is no insurance coverage, and so no help. But clearly such a family is struggling.

 We need a paradigm shift, defined as a fundamental change in approach and underlying assumptions. A new paradigm is needed that gives room for the complexity that we have learned from the abundance of research at the interface of developmental psychology, neuroscience and epigenetics.

The child above may have a strong family history of anxiety traits. He may have a strong genetic vulnerability for anxiety. However, if a parent who shares these traits was slapped across the face for her "difficult behavior" when she was a child, she may become so overwhelmed with stress in the face of her child's challenges that she is unable to help him to manage his anxiety. Marital conflict, perhaps exacerbated by the stress of a child who is struggling, can further add to the complexity. The environment in which this child grows and develops will determine the way in which his genetic vulnerability is expressed.

As I described in a previous post, the field of infant mental health offers such a paradigm. It is relational, developmental and founded in the basic principle that behavior has meaning. It gives us a way to organize our thinking about the problems of the family I describe above.  It offers a path to treatment, namely to support the efforts of the child's parents to recognize the complex meaning of his behavior. Once parents feel heard and understood, and have the opportunity to make sense of their child's behavior, they will be better able to help him manage his anxiety. They might involve him in physical activities or creative activities that help him to feel calm in his body. They might get help for their own relationship. They might work together with the child's teachers to strategize about how to support him in the school setting.

Thanks to my book, Keeping Your Child in Mind, I had the honor of being invited to give the Paul A. Dewald lecture this week in St Louis.  My book is about the idea that rather than jump  "what to do" about a child's behavior, it is important to simply "be" with that child,  to think about that child. As I prepared the talk I came to recognize that the same holds true for our whole system of mental health care.  Before we can plan "what to do" to apply the wealth of research I refer to above, we must first recognize that we need to "think" differently. We need move beyond the DSM paradigm and embrace a new paradigm; to facilitate a paradigm shift. An important first step is to name it as such.

Reflections on the government shutdown: why is health care so threatening?

 I may be putting myself out on a bit of a limb here, but the draw of the blog makes it hard to sit silent while our country heads towards disaster.

As I listen helplessly to a report on NPR  about our country being in the grips of an irrational game of chicken, I found myself being curious about the motivations of the tea party conservatives. Drawing a lesson from psychoanalyst Peter Fonagy, who identifies the ability to attribute motivations to behavior as a uniquely human characteristic, I wonder if taking a stance of curiosity rather than anger might be useful.

This led me to consider another psychoanalytic construct, namely that of transference.  The tea party hardliners refer to Obamacare as an invasion of privacy. This idea is grotesquely depicted in the commercial showing a creepy Uncle Sam invading a gynecologic exam. Before he enters, the patient,  a young woman, is being cared for by what appears to be a kind, motherly doctor.

The notion of transference describes how strong feelings from a past relationship, often with a parent, find there way in to a current relationship. This phenomenon can occur in relationships with spouses, children, co-workers, in addition to the setting where Freud originally identified it, namely in the patient-therapist relationship.

In the intimacy and privacy of the patient-doctor relationship, such as that between a young woman and her female gynecologist, these type of transference feelings naturally occur. That made me wonder if to those who made the commercial, Obamacare, as represented by Uncle Sam, in some way represents a third invading the primary caregiver-child relationship. If so, that might help explain the intransigent behavior of those who are unable to accept that Obamacare, or the Affordable Care Act, is the law, and are willing to hold the country hostage rather than face that fact.

But Obamacare is not a threat to that intimate private relationship. In fact, if it works, and health care costs do go down, and insurance companies lose some of their power, it may in fact strengthen the relationship.  With increased emphasis on prevention, the healing power of the patient-doctor relationship might be brought in to better focus than under the current system, when doctors are forced to see more and more patients in less and less time.

Mental illness and motherhood: lessons from Miriam Carey

We do not have medical records or diagnoses. The news is filled with speculation. What we do know is that Miriam Carey’s one-year-old daughter lost her mother, and that because the incident occurred in Washington D. C. in front of the White House, it is shining a spotlight on the subject of mental health and motherhood. And the message should be simple. Diagnoses don't matter. As part of our nation's health care system (another complex and fraught subject this week!) we must provide a safety net for mothers who are struggling emotionally in the weeks and months following the transition to motherhood.

Recently in my role as director of Newton-Wellesley Hospital’s Early Childhood Social Emotional Health program I have had the privilege of participating in a mother-baby group on a regular basis. During the 90 minute session, as these moms share feelings about such things as sleep deprivation, navigating new territory with a spouse, and going back to work, the babies cycle through sleep, alert interaction,  fussy periods, crying and feeding. These mothers, all of them doing this for the first time, intuitively guide their infants through multiple transitions while simultaneously engaging in meaningful conversation.

But it doesn’t always go well. Almost every session, there is a mother-baby pair who struggles. A baby may scream inconsolably, and his mother may leave, overwhelmed by helplessness and shame despite the reassurances from the other moms and group leaders.  A mother may break down in tears as she describes the way her own family is not supportive, and how alone she feels. The contrast between the easy attentiveness of the rest of the group, and the pain these mother-baby pairs are experiencing is striking. We expect motherhood to be a time of falling in love; a time of joy and bliss.  When it is not, the suffering can be profound.

There is nothing quite like the aloneness of mental health struggles in the setting of motherhood. I recall being startled by the story of  one mother in my behavioral pediatrics practice who had struggled with severe postpartum depression. She told me that she had experience relief when her father died when her daughter was about a year old. It was not that she didn’t love her father. But in sharing the grief with her mother and siblings, she no longer felt so terribly alone.

The Massachusetts Postpartum Depression Commission, led by Representative Ellen Story,  in collaboration with such organizations as MotherWoman and the Massachusetts Child Psychiatry Access Project, is working hard to provide a safety net for every mother-baby pair who is struggling in this way.

Through a combination of screening, support groups and a network of clinicians who are experienced in working with mothers and babies in the setting of perinatal emotional complications, the aim is to be able to identify and treat every one of these pairs.

This type of effort is also occurring on national level, through such organizations as the National Coalition of Maternal Mental Health. Perhaps the attention on the issue, due to the fact that an incident involving a car chase occurred on Capitol Hill, will give some meaning to Miriam Carey’s daughter’s loss.

Protecting a space for parenting in an age of expert advice

In my behavioral pediatrics practice, it never ceases to amaze me how, given the space and time, parents come around to making sense of their child's "difficult" behavior without my giving "advice" about "what to do." They may recognize that they share a trait with their child that has troubled them their whole life. They may become tearful, thinking of how that child represents a lost loved one.  There are countless variations. The process of telling the story, of finding the meaning in the behavior, is often itself the treatment. Once parents have these insights, "what to do" follows naturally. In contrast, if I give advice without a full understanding of the story, things may not go well.

Recently in working on a new book, I have had the pleasure of returning to a close look at the work of D. W. Winnicott, pediatrician turned psychoanalyst and a kind of British Dr. Spock. In my review of his writings on the subject of advice, I came across a wonderful piece from this past spring in The Guardian: Mothers on the naughty step: the growth of the parenting advice industry, that references Winnicott.

Winnicott abhorred the idea of giving advice. He believed that when mothers tried to do things by the book – or by the wireless: "They lose touch with their own ability to act without knowing exactly what is right and what is wrong." Yet today there are far more parenting advice books (each with their own regime to promote) than 30 years ago, and the radio and TV schedules are full of programmes such as Supernanny, which train a critical eye on what are generally called parents but most of us understand to be mothers. It sometimes seems it is mothers, rather than children, who are being dispatched to the naughty step...

Winnicott feared that focusing on pathological families rather than "the ordinary devoted mother and her baby" (the title of his most famous series) could excite anxiety in listeners without access to therapy. "I cannot tell you exactly what to do," he said, "but I can talk about what it all means." And so he did, extolling the role of the good enough mother – one who can be loved, hated and depended on – in enabling the baby to develop into a healthy, independent, adult. While many of today's parenting gurus focus on a child's deviant behaviour and the contribution of supposed misparenting, Winnicott tried to help mothers understand the significance of their child's behaviour, whether it was "cloth-sucking" or a display of jealousy, and the ways that they instinctively contained their child's anxieties.

The author refers to the British program "Supernanny," the "high priestess of behaviorist parenting."

Tracey Jensen, lecturer in media and cultural studies at Newcastle University, says Supernanny reverses Winnicott, offering up the spectacle of the "bad enough mother", usually working-class, who is shamed before she is transformed. Jensen watched the programme with a group of mothers, relieved that it was not their parenting practices being scrutinised, but those of someone else onto whom all their own worries and fears could be displaced. But they also shouted back at the programme, discomfited by the judgment and humiliation meted out to the mothers featured. Such series foster the very anxiety they claim to assuage, and substitute "training" for thinking and feeling.

This last phrase captures the essence of the issue. I shudder whenever I see the term "parent training."  But this phrase, as well as others such as "management of symptoms" or "parent education" are pervasive in our culture. These kinds of interventions may improve behavior in the short term. But if they substitute for "thinking and feeling" it is likely that symptoms will re-emerge at a later date, in a different form. 

When we talk about parents and children, we are talking about passionate love relationships. The feelings are deep, intense and sometimes painful. It makes sense that we might choose to avoid them. But this is not a long-term solution.  We would do well to instead make a space for them, starting from birth.

I borrowed this phrase "protecting a space" from my good friend Gale Pryor, who's wonderful book Nursing Mother, Working Mother was also heavily influenced by Winnicott. In such a space parents can connect with their natural intuition. It is in this space that we give room for healthy development of parent and child together.

In the age of DSM 5, what is normal?

In an interesting coincidence, a couple of weeks ago I received two emails on the same day asking me to write about books that are about the same subject. One is  Child Temperament: New Thinking About the Boundary Between Traits and Illness,  the second Back To Normal: Why Ordinary Childhood Behavior is Mistaken for ADHD, Bipolar Disorder, and Autism Spectrum Disorder.

The first was written by David Rettew, MD a child psychiatrist at the University of Vermont College of Medicine, where at the Vermont Center for Children, Youth, and Families ( VCCYF) they have an innovative family centered, strength-based approach to children's emotional and behavioral problems.

In a language that is based in science and research,  Rettew explores the overlap and interplay between the concepts of "temperament" and "psychopathology. He tackles the complex science of behavioral epigenetics- the impact of life experience on gene expression and subsequent behavior and development. He then describes how he integrates these ideas in to his care of children and families. For example, he describes how he might speak to a child patient:

I've heard a lot about you today and one of the things that I hear from you and your parents is that you are a very kind person who can really tune in to other people.  That is a wonderful quality that will serve you well in the future. At the same time, I also hear that you can get so concerned about what others think about you that you avoid things you like doing just so there is no chance you will feel embarrassed. Doctors sometimes use the term  social anxiety disorder to describe this situation, and if you are willing there are things we can do to help you feel more at ease in social situations.

He masterfully takes on very complex issues, including the way a child's behavior may provoke a parent's negative response.

A father of a temperamentally irritable boy who is prone to shout at the boy for  relatively minor infractions is certainly not relieved of responsibility for his behavior, but can be understood from a prespective that some of his suboptimal responses are evoked by the child's behavior, partially influenced by shared genes that cause both of them to escalate in negative ways.

The second book is organized around examples from the practice of the author Enrico Gnaulati, PhD, a clinical psychologist specializing in child and adolescent therapy. He examines our cultures rush to diagnose and medicate, and what he terms the "casualties of casual diagnosis." He writes:

In the past four decades we have gone from blaming parents for kids' problem behavior to blaming kids' brains....yet rarely can a child's behavior be explained exclusively in terms of child rearing or brain chemistry. In most cases, it is causes- plural, not singular- that explain why a child behaves the way he or she does. 

The underlying problem both authors address is embedded in the paradigm of mental health in which they practice.  Rettew seems to be trying to wrestle out of the paradigm in the last section where he describes an evaluation process that makes use of other tools besides DSM. However, the above example shows how the language of DSM permeates care, when albeit reluctantly, he uses the term "social anxiety disorder." This "disorder" may be in the DSM, but it is not a "real" disorder in the way, for example, diabetes is.

Earlier this year, the head of the National Institute for Mental Health tried to discredit DSM 5 by saying that they would not fund research based on the DSM system but rather aim to find the underlying "cause" in the realm of neuroscience and genetics. But as Gnaulati points out, we will never find the cause by just looking at the brain.

Gnaulati is similarly trying to find another way to think about this paradigm that offers oversimplified labels. But I am concerned that framing the issue as "normal" vs "disordered" is  misguided, and a result of the author being unable to see his way out of the DSM paradigm.

If a child and family are seeking help, then by definition the behavior is not "normal." Given the continued stigma associated with mental health problems, for a family to make the effort to call, make an appointment and actually show up, they are likely to be struggling in a significant way. Thus to call this "normal," even though the intention may be to be reassuring, is actually dismissive of the family's suffering. I wrestle with this dilemma every day in my clinical practice. Parents come to me and ask, "Is my child normal?"

I speak to this issue in a previous post: Answering the question: is something wrong with my child?
I refer to an article by Daphne Merkin on the question of whether depression is inherited:

The concept of "being attuned to your child's nature, especially when it differs from your own,"  is the essence of healthy parenting. She is describing a parent's recognition of what D. W, Winnicott termed the child's "true self." It involves recognizing a child as a person with thoughts and feelings that are his own. It is an excellent goal to work towards, though not always easy.   Issues that get in the way of recognizing the child's true self, including stresses in a parent's life and other relationships, may need to be addressed.

When viewed from this perspective, the question becomes not "is there something wrong with my child?" but rather "Who is this child, and how is he or she both alike and different from me?"

I wonder if Rettew and Gnaulati are so much a part of the prevailing paradigm that they do not recognize that what they are actually doing in their books is questioning the very paradigm in which they practice. If they were to step outside of the paradigm, they might, rather than asking the question "does a child have ADHD?" , asking the more salient question, "Is ADHD ( or autism or bipolar disorder or OCD for that matter) the way we as a culture use the term, a "real" thing, or is it an artificial construct defined by the DSM system and perpetuated by the pharmaceutical and health insurance industries?"

I believe that what both of these authors are actually doing is describing a new paradigm of mental health care that recognizes the relational nature of human development and offers opportunity for curiosity about the complex meaning of behavior. I'm calling them on it.

Investing in early childhood means investing in infants

Why is this so difficult for us to see? The United States has one of the most restrictive parental leave policies in the world, as my fellow blogger Claire McCarthy accurately described in a recent post. We fail to recognize the importance in investing in early relationships. The closest we seem to be able to get is age four. But the abundance of research at the interface of developmental psychology, neuroscience and genetics tells us that 4 years may be too late.

I wonder if the answer lies in child development researcher Ed Tronick's  still-face experiment. I remember well when I first learned of his research. I felt a kind of outrage, asking "how did he get this past the IRB( institutional review board for human subjects)?" In his well-known experiment, a mother plays with her infant in a usual way, then presents a still-face for a specified period of time, and then resumes normal interaction.

I now work closely with Dr. Tronick and well recognize the brilliance of his work. He sometimes remarks that it is his students in his Infant Parent Mental Health program at UMass Boston who seem to have the most initial outrage at seeing the experiment. I now understand that as a kind of deep empathy with the experience of both the mother and the baby. With that comes a passion for protecting this relationship, a passion that drives those of us who chose this field.

There is a great poignancy to recognizing the tremendous capacity of the newborn to communicate when we have a system that fails to support stressed early parent-child relationships. The Newborn Behavioral Observation System developed by T. Berry Brazelton and Kevin Nugent beautifully brings out these capacities.

But if a parent is stressed in the setting of such things as emotional distress, her own history of abuse, marital conflict and domestic violence, social isolation and poverty, being available to her infant in the way he needs is difficult. This is where the investment needs to be. Not 4 years, but 4 months, 4 days, 4 hours.

In Sunday's New York Times Nobel prize winning economist James Heckman has an op ed Lifelines for Poor Children where he again speaks to the need to invest in early childhood. He refers to Obama's policy proposal. However in the actual text of Obama's proposal there is relatively little for infants. The emphasis is on the four-year-old.

All we know about the science of early childhood tells us that the brain grows in relationships. The volume of the brain doubles in the first year. The brain makes millions of synaptic connections every minute. It is in infancy that the parts of the brain responsible for emotional regulation have the most rapid development.

 A startling article in the New York Times Can Emotional Intelligence Be Taught? begins with a vignette from a Kindergarten classroom where a child says, "My Mom does not like me," When he describes how his mother screams at him every day, he is taught how to handle the situation in a calm way. Somehow the tables are turned and it is the child's responsibility to manage his out-of control mother. The answer is not to teach this child emotional regulation, but to help this parent-child pair to grow together in a healthy loving way. And this help needs to start in infancy.

This week I will again attend a meeting of Representative Ellen Story's postpartum depression commission at the State House. It is always an uplifting experience as leaders in the field grapple with the question of how best to support parents and young infants. The commission recognizes that this work occurs primarily in the realm of health care, which is where young infants and their parents can most reliably be found.