(Three recent news items lead me to republish a post that predated my Boston.com days. The first is a new study showing that antipsychotics and stimulants can be used together in treatment of aggression associated with ADHD. The second is a recent New York Times article, The Selling of Attention Deficit Disorder, the third an article from today's New York Times: ADHD Experts Re-evaluate Study's Zeal for Drugs. I am hopeful that 2014 will be a year of radical rethinking about what we now call "ADHD.")
In the Tony award winning play God of Carnage two couples meet in an elegant living room for an ostensibly civilized conversation about the aggressive act of one couple’s child against the other’s. The meeting soon degenerates to reveal the underbelly of conflict in the two marriages. Husband and wife hurl insults, precious items and even themselves with escalating rage. We see, as they attempt in vain to focus on the children’s behavior, the proverbial “elephant in the room.”
It brought to mind another depiction of the nature of the elephant, presented by the pharmaceutical industry. A recent issue of The Journal of Developmental and Behavioral Pediatrics features prominently a two page ad from Shire, makers of drugs commonly used for treatment of Attention Deficit Hyperactivity Disorder (ADHD). A mother and her son sit at the desk of a doctor in a white coat. Behind them is a large elephant draped in a red blanket on which is printed the words, “resentful, defiant, angry.” The ad recommends that these symptoms, in addition to the more common symptoms of inattention and hyperactivity, should be addressed. This is the message: doctors should be treating these symptoms with medication.
From my vantage point of over 20 years of practicing pediatrics, where I sit on the floor, not in a white coat, and play with children, I believe that the play’s depiction of the nature of the elephant is much more accurate and meaningful than that of the pharmaceutical industry. In the play the elephant is the environment of rage and conflict in which the aggression occurs, while in the ad the elephant is the child’s symptom. Consider these two stories from my pediatric practice (with details changed to protect privacy.)
Everything was a battle with six year old Mark. Though I asked both parents to come to the visit, Mom came alone. She was furious.”Tell me what to do to make him listen.” We had a full hour visit, and as she began to relax, she shared a story of constant vicious fighting between herself and her husband. Mark, who had been playing calmly and quietly, took a marker and slowly and deliberately made a black smudge on the yellow wall. His mother was too distracted by her own distress to stop him. I said, “You cannot draw on the wall, but maybe you are upset about what we are talking about.” He came and sat on his mother’s lap. She reluctantly revealed her suspicion that his angry behavior was a reflection of the rage he experienced at home. She agreed to get help for her marriage, and Mark’s behavior gradually began to improve.
Jane’s parents became alarmed when her aggressive behavior began to spill over into school. Her third grade teacher told them that not only was she distracted and fidgety, but she seemed increasingly angry. At our second visit, Dad became tearful as he described his cruel and abusive father. He acknowledged being overwhelmed with rage at Jane when she didn’t listen. He yelled at her and threatened her. He longed for a positive role model to learn how to discipline her in a different way. He realized he needed help to address the traumas of his own childhood in order to be a more effective parent for Jane.
If the elephant in the room is the child’s symptoms, as the drug companies would have us believe, then medication may be the solution. Children taking medication for ADHD often tell me that it makes them feel calm. The full responsibility for the problem then falls squarely on the child’s shoulders.
For Mark and Jane, and countless children like them, the elephant in the room, however, is not the child’s symptoms. It is the environment of conflict in which the symptoms occur. If the family environment is the elephant, the treatment of the problem is not as simple as prescribing a pill. Families must acknowledge and address seemingly overwhelming problems. The parents’ relationship with each other, and each parent’s relationship with his or her own family of origin, often contributes significantly to this environment.
In the supportive setting of my office, Mark and Jane’s parents were freed to think about their child’s perspective and experience. Rather than focusing on “what to do” they understood what their children might be feeling growing up in an environment of conflict and rage. This ability for parents to think about their child’s feelings has been shown, in extensive research at the intersection of developmental psychology, genetics and neuroscience, to facilitate a child’s development of the capacity to manage strong emotions and adapt in social situations.
In another interesting link between this ad and God of Carnage, one of the fathers is an attorney representing a drug company. He speaks loudly on his cell phone, seemingly oblivious to the effect of his behavior on the other people in the room. His conversation reveals the profit motive of the drug company taking precedence over the well being of the patient.
God of Carnage was written by Yasmina Reza, a French playwright. While the play itself is hugely entertaining as a witty farce about family life, an important message was in a brief scene at the very end. The telephone rings. The mother answers. It is her daughter, all upset about the loss of her pet hamster, which the father had “set free” one night because he was annoyed by the animal’s habits. Suddenly the mood of the play, which was lively with scintillating dialogue throughout, becomes serene as the mother speaks lovingly to her distraught daughter. Perhaps most of the audience was barely aware of the sudden mood change. Yet it lifted this delightful play into universal significance. Freeing herself from the preceding chaos, she calmly gives her full attention to her daughter’s experience.
The popularity of the play gives me hope that people are hungry for a different way to think about children and families than that offered by the pharmaceutical industry, which, with the money to place an attention getting ad, has a very loud voice. It is joined by the equally loud voice of the private health insurance industry, which supports the quick fix of medication over more time intensive interventions. In contrast, Mark, with his black smudge on my yellow wall, has a very small voice. His voice says “Please think about my feelings, not just my behavior.”
His voice is particularly critical now, as our country strives to create social policy and a health care system that values prevention and primary care. Parents, if they are supported and nurtured, know what is best for their children. We as a culture must demonstrate that we respect both the difficulty and the critical importance of being an effective parent. In this way we will be able to help children, not only by treating their symptoms, but giving an opportunity for deeply rewarding changes in the important relationships in their lives.
Monday, December 30, 2013
Sunday, December 22, 2013
Why substituting "behavioral" health care for "mental" health care is wrong
A colleague of mine recently pointed out a study by the Center for Health Care Strategies (CHCS) about mental health care for children. Among their findings was this
However, in reading about this study I was distracted by, and am struggling with as I write, the repeated reference to "behavioral health care" rather than "mental health care." This change in language is now common in our culture. It is significant and worrisome for two reasons.
First, it serves to perpetuate the stigma of mental illness. Implied in this word substitution is the idea that mental illness is something that should not be talked about.
Recently I came up against this stigma when giving a talk that included a discussion of the connection between "colic" and perinatal emotional complications such as anxiety and depression. An audience member, a mother of several grown children, spoke of resentment, that was still very much alive over 20 years later, that her friends and colleagues had been concerned about her mental well being when caring for her first very challenging child.
Severe sleep deprivation, feelings of isolation and low self esteem are an almost inevitable consequence of having a very fussy baby. The stigma associated with identifying this constellations of concerns as a "mental health problem" is part of the reason for inadequate identification and treatment of postpartum depression and anxiety.
Research has shown that when untreated, these problems can in turn lead to mental health problems in the developing child. If we could, as the saying goes "call a spade a spade," without having it be associated with blame and shame, there might be more hope for helping for these mothers, and for preventing the development of mental health problems in their children.
The second, and perhaps more worrisome issue related to the substitution of "behavioral" for "mental" is the idea that treatment involves controlling behavior, rather than understanding the meaning of behavior. The ability to attribute motivations and intentions to behavior is a uniquely human quality. Extensive research, that I describe in my book Keeping Your Child in Mind has shown that children develop a healthy sense of self, the capacity for emotional regulation, flexible thinking, social engagement, and overall mental health, when the people who care for them think about and understand the meaning of their behavior. In contrast, there may be significant disturbances when there is an absence of such curiosity about a child.
This brings us full circle to the problem identified by the above study. By treating these children with psychiatric drugs with no other form of treatment, there is no room for curiosity or understanding. Children living in poverty, especially those in foster care, may have experienced significant early trauma and loss. The consequences of treating the behavior alone, in these and other circumstances can be significant. For example, a recent long-term follow up study of children diagnosed with "ADHD" treated with "behavior management" and medication showed that there was a five times higher risk of suicide, and 3% of adults at follow up were in prison.
The CHCS study calls for "expanding access to appropriate and effective behavioral health care." For it to be appropriate and effective, we need to call it mental health care. It needs first and foremost to allow for time and space for listening, for understanding the meaning of behavior.
- Almost 50 percent of children enrolled in Medicaid who are prescribed psychotropic medications receive no identifiable behavioral health treatment.
Children with significant behavioral health needs typically require an array of services to support their physical, intellectual, and emotional well-being. These children, however, are often served through fragmented systems, leading to inefficient care, costly utilization, and poor health outcomes. As a significant source of funding for children’s behavioral health care, Medicaid programs can advance fundamental improvements in care coordination and delivery for these vulnerable children.This would certainly be a goal to work towards.
However, in reading about this study I was distracted by, and am struggling with as I write, the repeated reference to "behavioral health care" rather than "mental health care." This change in language is now common in our culture. It is significant and worrisome for two reasons.
First, it serves to perpetuate the stigma of mental illness. Implied in this word substitution is the idea that mental illness is something that should not be talked about.
Recently I came up against this stigma when giving a talk that included a discussion of the connection between "colic" and perinatal emotional complications such as anxiety and depression. An audience member, a mother of several grown children, spoke of resentment, that was still very much alive over 20 years later, that her friends and colleagues had been concerned about her mental well being when caring for her first very challenging child.
Severe sleep deprivation, feelings of isolation and low self esteem are an almost inevitable consequence of having a very fussy baby. The stigma associated with identifying this constellations of concerns as a "mental health problem" is part of the reason for inadequate identification and treatment of postpartum depression and anxiety.
Research has shown that when untreated, these problems can in turn lead to mental health problems in the developing child. If we could, as the saying goes "call a spade a spade," without having it be associated with blame and shame, there might be more hope for helping for these mothers, and for preventing the development of mental health problems in their children.
The second, and perhaps more worrisome issue related to the substitution of "behavioral" for "mental" is the idea that treatment involves controlling behavior, rather than understanding the meaning of behavior. The ability to attribute motivations and intentions to behavior is a uniquely human quality. Extensive research, that I describe in my book Keeping Your Child in Mind has shown that children develop a healthy sense of self, the capacity for emotional regulation, flexible thinking, social engagement, and overall mental health, when the people who care for them think about and understand the meaning of their behavior. In contrast, there may be significant disturbances when there is an absence of such curiosity about a child.
This brings us full circle to the problem identified by the above study. By treating these children with psychiatric drugs with no other form of treatment, there is no room for curiosity or understanding. Children living in poverty, especially those in foster care, may have experienced significant early trauma and loss. The consequences of treating the behavior alone, in these and other circumstances can be significant. For example, a recent long-term follow up study of children diagnosed with "ADHD" treated with "behavior management" and medication showed that there was a five times higher risk of suicide, and 3% of adults at follow up were in prison.
The CHCS study calls for "expanding access to appropriate and effective behavioral health care." For it to be appropriate and effective, we need to call it mental health care. It needs first and foremost to allow for time and space for listening, for understanding the meaning of behavior.
Wednesday, December 11, 2013
Are iPad attachments for bouncy seats and potty seats a violation of infants' rights?
I was contemplating writing a blog post about the movement by the Boston-based advocacy group Campaign for a Commercial Free Childhood urging Fisher-Price to recall the baby bouncy seat with an attachment for insertion of an iPad. When I then received an email from a colleague with a link for another product- a potty seat with an attachment for an iPad- there was no going back. I decided not to include the link to that product so as not to inadvertently be a source of free advertising, but it is easy to find.
In our technology driven culture, a position maintaining that we need to put on the brakes is a challenging one to take. The force of "progress" is so powerful that one runs the risk of seeming out-of-touch or old fashioned. But in these two products I believe we have come face-to-face with exploitation of children ( and their parents) or what I have described in a previous post as a "prejudice" against children. I would even go so far as to say it is a violation of infants' rights.
In today's society, where parents are often living in a state of high stress, with little support, either practical or emotional, the appeal of these products is very understandable. The allure of the screen is equally, if not more powerful for the infant. So from a marketing perspective, from a moneymaking perspective, it is a recipe for success.
I became aware of the concept of infants' rights in my role as a board member of the Massachusetts chapter of the World Association of Infant Mental Health. A preliminary version the Declaration of Infants' Rights, a work in progress, reads:
Turning to the Ipad in the bouncy seat, the possible effects are more insidious and diffuse. Sitting in the bouncy seat in kitchen watching mom or dad prepare dinner is a time of great learning; a time of significant brain development. This learning occurs both through direct interactions with adults and older siblings, as well as through observation. The iPad interferes with both. As CCFC writes:
In our technology driven culture, a position maintaining that we need to put on the brakes is a challenging one to take. The force of "progress" is so powerful that one runs the risk of seeming out-of-touch or old fashioned. But in these two products I believe we have come face-to-face with exploitation of children ( and their parents) or what I have described in a previous post as a "prejudice" against children. I would even go so far as to say it is a violation of infants' rights.
In today's society, where parents are often living in a state of high stress, with little support, either practical or emotional, the appeal of these products is very understandable. The allure of the screen is equally, if not more powerful for the infant. So from a marketing perspective, from a moneymaking perspective, it is a recipe for success.
I became aware of the concept of infants' rights in my role as a board member of the Massachusetts chapter of the World Association of Infant Mental Health. A preliminary version the Declaration of Infants' Rights, a work in progress, reads:
The young child’s capacity to experience, regulate, and express emotions, form close and secure relationships, and explore the environment and learn are fundamental to mental as well as physical and developmental health throughout the life span.So how do these products violate these rights? Lets start with toilet training. Recently I had the opportunity to write the parent guide for a new children's book, Potty Palooza. I identify the relational nature of toilet training:
Toilet training occurs in relationships. This includes a child’s relationship with his body, as well as his relationship with you. Toilet training will occur under the influence of a child’s inborn desire for mastery in relation to his body. A normal developmental movement toward separation and independence, together with your child’s wish to be like you and to please you, will move the process forward.I do not know what will happen if you insert a screen between parent and child as part of this process (and sitting on the potty with a book is an entirely different experience.) It is likely that the draw of the screen will interfere with a child's ability to read his body's natural signals. The desire for treasured "screen time" will become the motivation for sitting on the potty, replacing his natural motivation to please his parents and to gain mastery over his body in a healthy way.
Turning to the Ipad in the bouncy seat, the possible effects are more insidious and diffuse. Sitting in the bouncy seat in kitchen watching mom or dad prepare dinner is a time of great learning; a time of significant brain development. This learning occurs both through direct interactions with adults and older siblings, as well as through observation. The iPad interferes with both. As CCFC writes:
The Apptivity Seat is the ultimate electronic baby sitter. Because screens can be mesmerizing and babies are strapped down and “safely" restrained, it encourages parents to leave infants all alone with an iPad. To make matters worse, Fisher-Price is marketing the Apptivity Seat—and claiming it’s educational—for newborns. Parents are encouraged to download “early learning apps” that claim to “introduce baby to letters, numbers and more.” There’s no evidence that babies benefit from screen time and some evidence that it might be harmful. That’s why the American Academy of Pediatrics discourages any screen time for children under two.Extensive evidence at the interface of neuroscience and developmental psychology shows how the brain is wired in relationships, with the most rapid brain growth occurring in the first three years. Instead of making products that come between parent and infant, our focus needs to be on supporting early caregiver-infant relationships, in the form of such things as parental leave, quality childcare and screening for and treatment of postpartum depression.
Wednesday, November 27, 2013
Rising incidence of "ADHD" calls for radical rethinking
When the American Academy of Pediatrics changed the guidelines for ADHD to expand age of diagnosis to include children from age 4-18 (from 6-12), that the number of cases would rise was, by definition, inevitable. The recent survey by the CDC, published in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry, indicating that one in 10 children in the US carry a diagnosis of ADHD, confirms just that.
I felt re-energized and hopeful in ongoing efforts to, in my colleague's words "move the mountain of ADHD," when I received a request to speak at an international child psychiatry conference as part of a panel with a working title: "The ADHD Diagnosis: a Deconstruction from Developmental, Psychoanalytic, Infant Mental Health and Neuropsychiatric Perspectives."
"Deconstruction" is a brilliant word, and captures well what I do in my clinical practice. Consider 4-year-old Max, whose parents brought him to my behavioral pediatrics practice to "see if he has ADHD." His preschool teacher had recommended the visit, suggesting that he might benefit from medication. I asked his parents, Ann and Peter, if we might, acknowledging that Max did have symptoms of inattention, hyperactivity and impulsivity, take the time (we had an hour) to ask why he had these symptoms: to make sense of his behavior. While they had been hopeful that they would leave the visit with a prescription, reflecting Max's teacher's concern that he might "fall behind" without treatment, they were overjoyed to consider another approach.
Max had been adopted at age 3 months. Prior to this he had lived with his biological parents who were actively using drugs. They reportedly had a history of ADHD as did some biological siblings. Ann and Peter had been struggling in their marriage in the face of caring for this challenging child, and had recently separated. While Max had been a good sleeper, for the past several months he had been getting up multiple times a night and the whole family was chronically sleep deprived. Max had multiple sensory sensitivities. He cried with the sound of the vacuum cleaner; getting dressed was an ordeal because he could not find a pair of socks that was comfortable. He had difficulties with "personal space."
We had, in a sense, "deconstructed" the "symptom" to examine its various parts. We identified a genetic vulnerability for problems of attention, early neglect, ongoing family stress, sleep deprivation, and sensory processing challenges.
At age 4, there are multiple avenues of intervention. I usually start with sleep, as chronic sleep deprivation is inextricably linked with emotional and attentional dysregulation. Child-parent psychotherapy, where a clinician works with parents and child together, has been shown to be effective in helping children develop capacities for emotional regulation, even in the face of early developmental trauma. A good occupational therapist, who addresses sensory processing challenges in the context of relationships, can help Max to use his body to manage his symptoms. Ann and Peter could examine the effects of their marital conflict on Max, and perhaps consider couples therapy.
The preliminary write up for the panel I refer to above speaks of what is now called "ADHD" as a valid symptom complex. But it proposes that
If I were to diagnose Max with ADHD and start him on stimulant medication, it would be in keeping with the current standard of care. Stimulants are powerful medications that have been shown in the short term to eliminate symptoms. But such an approach is simply a silencing of children. It would be a great disservice to Max and his family.
Just as expanding the age range for diagnosis inevitably led to a rise in cases, "deconstructing" the diagnosis would lead to a significant drop in cases. The difference is that this change would reflect, not silencing of children, but rather improving access to meaningful help.
I felt re-energized and hopeful in ongoing efforts to, in my colleague's words "move the mountain of ADHD," when I received a request to speak at an international child psychiatry conference as part of a panel with a working title: "The ADHD Diagnosis: a Deconstruction from Developmental, Psychoanalytic, Infant Mental Health and Neuropsychiatric Perspectives."
"Deconstruction" is a brilliant word, and captures well what I do in my clinical practice. Consider 4-year-old Max, whose parents brought him to my behavioral pediatrics practice to "see if he has ADHD." His preschool teacher had recommended the visit, suggesting that he might benefit from medication. I asked his parents, Ann and Peter, if we might, acknowledging that Max did have symptoms of inattention, hyperactivity and impulsivity, take the time (we had an hour) to ask why he had these symptoms: to make sense of his behavior. While they had been hopeful that they would leave the visit with a prescription, reflecting Max's teacher's concern that he might "fall behind" without treatment, they were overjoyed to consider another approach.
Max had been adopted at age 3 months. Prior to this he had lived with his biological parents who were actively using drugs. They reportedly had a history of ADHD as did some biological siblings. Ann and Peter had been struggling in their marriage in the face of caring for this challenging child, and had recently separated. While Max had been a good sleeper, for the past several months he had been getting up multiple times a night and the whole family was chronically sleep deprived. Max had multiple sensory sensitivities. He cried with the sound of the vacuum cleaner; getting dressed was an ordeal because he could not find a pair of socks that was comfortable. He had difficulties with "personal space."
We had, in a sense, "deconstructed" the "symptom" to examine its various parts. We identified a genetic vulnerability for problems of attention, early neglect, ongoing family stress, sleep deprivation, and sensory processing challenges.
At age 4, there are multiple avenues of intervention. I usually start with sleep, as chronic sleep deprivation is inextricably linked with emotional and attentional dysregulation. Child-parent psychotherapy, where a clinician works with parents and child together, has been shown to be effective in helping children develop capacities for emotional regulation, even in the face of early developmental trauma. A good occupational therapist, who addresses sensory processing challenges in the context of relationships, can help Max to use his body to manage his symptoms. Ann and Peter could examine the effects of their marital conflict on Max, and perhaps consider couples therapy.
The preliminary write up for the panel I refer to above speaks of what is now called "ADHD" as a valid symptom complex. But it proposes that
this terminology should not ever be used in our clinical thinking. "ADHD," used as a primary diagnosis, has no etiologic significance, is conceptually and diagnostically distracting, leads to a paucity of thinking about a patient's early developmental history and trauma, and is therapeutically misleading.I hope that there will be a large scale movement to "deconstruct" the ADHD diagnosis. In essence deconstructing the diagnosis means eliminating the diagnosis. Instead we would understand and treat the multiple parts that make up what is now called "ADHD." Such a process would result in effective early intervention and prevention.
If I were to diagnose Max with ADHD and start him on stimulant medication, it would be in keeping with the current standard of care. Stimulants are powerful medications that have been shown in the short term to eliminate symptoms. But such an approach is simply a silencing of children. It would be a great disservice to Max and his family.
Just as expanding the age range for diagnosis inevitably led to a rise in cases, "deconstructing" the diagnosis would lead to a significant drop in cases. The difference is that this change would reflect, not silencing of children, but rather improving access to meaningful help.
Sunday, November 17, 2013
Buddhism, brain science, and parenting: towards an integration
In the past week I had two profound yet seemingly polar opposite conversations about how to promote healthy development.
I shared with the IPMH group my recognition that pointing to the value of listening, of creating an environment of respect for all parents and children, is seen by many as "soft." For example, I felt very alone when one pediatrician referred to my work, in a none-too-kindly tone as, "that baby whisperer stuff."
I knew I was not alone when the second conversation occurred a few days later at a workshop at Austen Riggs entitled The Interplay of Psychoanalysis and Buddhism: Partners in Liberation. It was all about emotion and interconnectedness.
In a post a number of years ago, I wrote about receiving a letter from a reader who had been "awakened by the tradition of Zen Buddhism" and found my that my work, as described in my book Keeping Your Child in Mind ( see excerpt below), resonated with his experience.
Workshop leader Joseph Bobrow spoke with a kind, gentle manner while conveying a sense of quiet authority that was calming and containing. He described the Buddhist notion of "re-authoring our suffering" of "representing our suffering in safe circumstances without shame" so that the story can "take its place in a hierarchy." He described "riding the waves of affect" to "transmute them in to the waves of life." He spoke of "transmuting sorrow" so that it does not "hijack" us." He spoke of how the therapist's "presence of mind," is what calms, regulates and heals the patient.
When parents are flooded with stress and feeling overwhelmed by their child's behavior, I may ask them to slow down and describe in great detail a specific moment of disruption. This can be very difficult to do. Listening to Bobrow speak about meditation and Zen Buddhism, I heard many links to this process. Meditation can be about noticing how we become derailed by patterns of thought and behavior. Similarly, by slowing things down, parents become aware of how their child's behavior provokes them, and how they may unintentionally attribute meaning to their child's behavior that is markedly different from the child's true intention.
If a parent recognizes in his response to his child's behavior a surge of rage that is linked to a memory of his own father slapping him across the face, the tears may start to flow. Now we have an opportunity to, as Bobrow said "use the suffering to turn straw in to gold." For in the face of this realization, of this "riding the wave of affect" this father can "re-author the suffering" and in doing so separate his own experience from that of his child. It is just this slowing down that helps him to see his child as himself. In turn the child, himself feeling recognized and understood, becomes calm. This "meditative" process can be what underlies the moments of profound joy and connection between parent and child that follow.
My two experiences this week seem at first glance to be worlds apart. I wonder if a piece Bobrow wrote on his Huffington Post blog following the Newtown shooting might point in the direction of integration.
The first was among fellows and faculty of the UMass Boston Infant Parent Mental Health Post-Graduate Certificate program (IPMH) about a new study, The Effect of Poverty on Brain Development, published in the current issue of JAMA pediatrics. Using brain imaging techniques, researchers showed that the children raised in poverty had smaller volumes of specific areas of the brain. They describe how the "caregiver" can "mediate" against the effects of poverty. The effects on the brain were less in the setting of "caregiver support." The group was addressing the ways in which this study fit with the abundance of new research in developmental psychology, neuroscience and genetics.
In conversation with the IPMH group, made up of many brilliant and often like- minded colleagues, who I affectionately refer to as "my peeps," I expressed concern that the exclusive focus on "brain science," where parents are referred to as "mediators," the emotion is excluded. It can become a way to distance from, or even leave out, the passion inherent in these profound love relationships.
Perhaps even more worrisome, I said, is that by making the discussion primarily about poverty, there is a risk of creating a kind of "us-them" mentality. Certainly there are plenty of well-off families raising children in an environment of high stress and emotional neglect. Similar to the focus on "brain science," it becomes another way of distancing from the problem.
In conversation with the IPMH group, made up of many brilliant and often like- minded colleagues, who I affectionately refer to as "my peeps," I expressed concern that the exclusive focus on "brain science," where parents are referred to as "mediators," the emotion is excluded. It can become a way to distance from, or even leave out, the passion inherent in these profound love relationships.
Perhaps even more worrisome, I said, is that by making the discussion primarily about poverty, there is a risk of creating a kind of "us-them" mentality. Certainly there are plenty of well-off families raising children in an environment of high stress and emotional neglect. Similar to the focus on "brain science," it becomes another way of distancing from the problem.
I shared with the IPMH group my recognition that pointing to the value of listening, of creating an environment of respect for all parents and children, is seen by many as "soft." For example, I felt very alone when one pediatrician referred to my work, in a none-too-kindly tone as, "that baby whisperer stuff."
I knew I was not alone when the second conversation occurred a few days later at a workshop at Austen Riggs entitled The Interplay of Psychoanalysis and Buddhism: Partners in Liberation. It was all about emotion and interconnectedness.
In a post a number of years ago, I wrote about receiving a letter from a reader who had been "awakened by the tradition of Zen Buddhism" and found my that my work, as described in my book Keeping Your Child in Mind ( see excerpt below), resonated with his experience.
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.
When families come to see me in my pediatrics practice for “behavior problems,” both parents and children feel estranged and out of control. They are disconnected, angry, and sad. I help them recognize each other. Meaningful change happens when we share these moments of reconnection.While I do not know very much about about Buddhism, I have been greatly influenced by psychoanalysts D.W. Winnicott and Peter Fonagy. I attended the workshop because I was curious to learn more about the relationship between Buddhism and psychoanalysis. In particular I was interested in the place of mourning, for I have increasingly come to recognize that meaningful change, and with it the joy of connection, occur most often when parents move through moments of profound sadness.
Workshop leader Joseph Bobrow spoke with a kind, gentle manner while conveying a sense of quiet authority that was calming and containing. He described the Buddhist notion of "re-authoring our suffering" of "representing our suffering in safe circumstances without shame" so that the story can "take its place in a hierarchy." He described "riding the waves of affect" to "transmute them in to the waves of life." He spoke of "transmuting sorrow" so that it does not "hijack" us." He spoke of how the therapist's "presence of mind," is what calms, regulates and heals the patient.
When parents are flooded with stress and feeling overwhelmed by their child's behavior, I may ask them to slow down and describe in great detail a specific moment of disruption. This can be very difficult to do. Listening to Bobrow speak about meditation and Zen Buddhism, I heard many links to this process. Meditation can be about noticing how we become derailed by patterns of thought and behavior. Similarly, by slowing things down, parents become aware of how their child's behavior provokes them, and how they may unintentionally attribute meaning to their child's behavior that is markedly different from the child's true intention.
If a parent recognizes in his response to his child's behavior a surge of rage that is linked to a memory of his own father slapping him across the face, the tears may start to flow. Now we have an opportunity to, as Bobrow said "use the suffering to turn straw in to gold." For in the face of this realization, of this "riding the wave of affect" this father can "re-author the suffering" and in doing so separate his own experience from that of his child. It is just this slowing down that helps him to see his child as himself. In turn the child, himself feeling recognized and understood, becomes calm. This "meditative" process can be what underlies the moments of profound joy and connection between parent and child that follow.
My two experiences this week seem at first glance to be worlds apart. I wonder if a piece Bobrow wrote on his Huffington Post blog following the Newtown shooting might point in the direction of integration.
We are helpless, we want it fixed, and become prone... to either-or thinking. But there is no silver bullet. Silver bullet, compartmentalized thinking is the problem. Cumulative trauma compromises the capacity for making connections, for holistic reflection. At it's extreme, the other becomes "not me," so I can eliminate him or her with impunity, Intellectually, it's like bubble living: psychology here, culture there, economics somewhere else. Climate? Fuhgetaboutit. We must grasp our fundamental interconnectedness, and with it the intimate and often unseen interplay of psychological and cultural forces and social and political action.I wonder if a third conversation, including both my IPMH colleagues and Bobrow, would lead to some real progress.
Tuesday, November 5, 2013
Authoritarian parenting vs. parenting with authority
Authoritarian parenting, as in "my way or the highway," and its opposite, permissive parenting with lack of limit setting, may be linked with difficulty with emotional regulation in children. In contrast, an "authoritative" parenting style is associated with an enhanced capacity for emotional regulation, flexible thinking and social competence. An authoritative parenting stance encompasses respect for and curiosity about a child, together with containment of intense feelings and limits on behavior.
Parental authority is something that in ideal circumstances comes naturally with the job. It is not something that needs to be learned in books from "experts." In fact our culture of "advice" and "parent training" may unintentionally undermine that natural authority.
But what might cause a parent to lose that natural authority? Stress is far and away the most common culprit. That stress might be in part coming from the child himself, if, for example, he is a particularly "fussy" or "dysregulated" baby. It might come from the everyday challenges of managing a family and work in today's fast-paced culture, often without the support of extended family. It may come from more complex relational issues between parents, between siblings, between generations.
When I work with families of young children, my aim is to help parents reconnect with their natural authority. By offering space and time to listen to their story, including addressing the wide range of stresses in their lives, my hope is that together we will make sense of, or find meaning in, their child's behavior. Armed with this understanding, "what to do" usually follows naturally.
I have learned that it is important to be explicit about this approach. As I write on my website:
Parental authority is something that in ideal circumstances comes naturally with the job. It is not something that needs to be learned in books from "experts." In fact our culture of "advice" and "parent training" may unintentionally undermine that natural authority.
But what might cause a parent to lose that natural authority? Stress is far and away the most common culprit. That stress might be in part coming from the child himself, if, for example, he is a particularly "fussy" or "dysregulated" baby. It might come from the everyday challenges of managing a family and work in today's fast-paced culture, often without the support of extended family. It may come from more complex relational issues between parents, between siblings, between generations.
When I work with families of young children, my aim is to help parents reconnect with their natural authority. By offering space and time to listen to their story, including addressing the wide range of stresses in their lives, my hope is that together we will make sense of, or find meaning in, their child's behavior. Armed with this understanding, "what to do" usually follows naturally.
I have learned that it is important to be explicit about this approach. As I write on my website:
Some guidance about "what to do" may naturally enter in to the conversation. But I have found that premature "advice," without full understanding of the complexity of the situation, can often lead to frustration and failure. In contrast, when a parent has that "aha" moment of insight, the joy and pleasure that comes from recognition and reconnection, for both parent and child, can be exhilarating.
Parents often come to a pediatrician with expectation of advice and judgment. Our culture may support this expectation by our reliance on “behavior management” and increasingly on medication to treat “behavior problems” in children.
Tuesday, October 29, 2013
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.
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.
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