Holding a Mother in Mind

This past week in my pediatric practice I saw, with their babies, three mothers who all described highly troubled relationships with their own mother. The relationships were full of grief and loss (to protect privacy, I will not give any details). Now mothers themselves, they were struggling. Their babies were clingy and irritable. They were poor sleepers, waking many times a night to nurse. They refused to take a bottle.

John Bowlby, under the influence of Charles Darwin, described the essential role of attachment relationships in survival. He spoke of a child's need for what he called a secure base, from which to explore the world and grow into a separate person. He similarly recognized the need for a mother to have a secure base of her own in order to provide this for her child. In a 1980 lecture entitled "Caring for Children," reprinted in his book A Secure Base, he said:

I have referred to the ordinary sensitive mother who is attuned to her child's actions and signals, who responds to them more or less appropriately, and who is able to monitor the effects her behavior has on her child and to modify it accordingly...This is where a parent, especially the mother who usually bears the brunt of parenting during the early months or years, needs all the help she can get-not in looking after her baby, which is her job, but in all the household chores...In addition to practical help, a congenial female companion is likely to provide the new mother with emotional support or, in my terminology, to provide for her the kind of secure base we all need in conditions of stress and without which it is difficult to relax.

In some cultures an extended family can fill this role. A supportive grandmother can be very important. If a new mother holds in her mind a warm loving relationship with her own mother, even the grandmother is not nearby or even if she is deceased, this relationship can provide the secure base she needs when she becomes a mother.

But these three mothers did not have this secure base from which to parent their young child( and they certainly didn't have help with household chores!!)

Sometimes when I sit on the floor with these mother-baby pairs, and listen to the mothers' story while the child explores the room, I feel that I am in a way in the role of good grandmother. I give a mother time and space to relax and be heard with the hope that this will fortify her in her efforts to be a secure base for her child.

One mother came in with her toddler, collapsed on the couch and proclaimed,"He's having a terrible day." Her son was very fussy and easily exploded in frustration. But as she and I spoke, he seemed to relax. He climbed off her lap and explored the different toys in the room. At a few instances we could see that he might lose it, such as when his mother told him not to draw on the table with markers, but she was able to redirect him without precipitating a tantrum. When towards the end of our 50 minute visit I commented at how well he had done, she agreed that he was much more calm than he had been the rest of the day.

I am certainly not alone with this idea. The field of infant mental health grew out of the work of Selma Fraiberg who, in her groundbreaking 1974 paper, Ghosts in the Nursery, describes what was termed the ‘Infant Mental Health Program”. A staff of experienced psychologists and social workers went into the homes of mothers who had been abused. By forming a close connection in a supportive and understanding way while these mothers were interacting with their children in their own home, they were able to significantly improve the parenting capacities of these traumatized mothers. The most important part of this intervention turned out to be the relationship between the therapist and the mother. But it was different from therapy with the mother. The aim of the intervention was to help the mother to connect with her child in a meaningful way. Daniel Stern, Tessa Baradon and Alicia Lieberman, among many others, have continued and elaborated upon this tradition.

The difference between my practice, however, and that of infant mental health practitioners, is that parents come to a pediatrician expecting "advice" about what to do. The slew of parenting books and articles with such titles as "How to Get Your Child to Listen" or "Seven Essential Steps for Effective Discipline," support this way of thinking. The father of one of these babies became very frustrated when after two visits I had failed to "make the baby sleep at night."

Our culture's endorsement the use of psychoactive medication for very young children similarly promotes the idea of the "quick fix." The parents of one of these babies were so convinced that his irritable nighttime behavior was actually a seizure that I referred them to a neurologist. After an EEG determined that there was, in the neurologist's words, "nothing wrong," he recommended a tricyclic anti-depressant.

My sense is that our culture is moving away from a simplistic, "quick fix" view of mental health, which has been promoted by the combined influences of the pharmaceutical industry and health insurance industry. I hope that the wealth of knowledge about human development, and the critical role of early relationships in promotion of mental health, emanating from the discipline of infant mental health, will continue to penetrate throughout our healthcare system.

Mindful Psychopharmacology

I was pleased to read the overwhelmingly positive response to Daniel Carlat's New York Times Magazine piece Mind Over Meds in the letters to the editor, including my own.

Perhaps we are at the end of an era where, under the influence of the pharmaceutical industry and health insurance industry, clinicians prescribe psychoactive medication in 20 minute visits, with minimal attention to the experience of the person they are treating.

I am not "against" psychoactive medication, which can, in certain circumstances, offer significant benefit. Framing of the discussion as being pro or anti-medication leads to antagonism and polarization, which is not useful. Rather I would advocate for "mindful" use of medication.

David Mintz and Barri Belnap, psychiatrists at the Austen Riggs Center, in a 2006 article in the Journal of the American Academy of Psychoanalytic and Dynamic Psychiatry propose the term "psychodynamic psychopharamcology." Such an approach looks at the patients experience as a whole rather than focusing exclusively on symptoms and dose of medication. They reference a 1996 NIMH study showing that patients who had a good relationship with their doctor and took a placebo had a greater reduction in symptoms than patients who had a poor relationship with their doctor and received an active drug.

Mintz and Belnap quote Sir William Osler, the father of modern medicine, who said, "It is much more important to know what sort of patient has a disease than what sort of disease a patient has." In the conclusion, they write,

A straightforward "scientific" approach to prescription establishes a "rational" basis for treatment choice, but runs the risk of neglecting the unique impact of the patient's subjectivity, failing to attend to the patient's authority and missing the importance of relationships and of meaning to cure.

Both Carlat and Mintz's articles focus on use of medication in adults. For children the issue is equally important and significantly more complex. Family and developmental issues must be taken into account.

For example, a 10 year old boy I treated did very well initially on stimulant medication. As he entered adolescence, he began to display developmentally appropriate argumentative and occasionally oppositional behavior. His parents attributed his behavior to a "symptom" of his ADHD. All family conflict was channeled into discussion of his dose of medication. In turn he became increasingly angry, perhaps because his experience was not recognized and his legitimate feelings attributed to a "disease." The long term consequences on this boy's development of such behavior cannot be good. Dr. Mintz, in his work with seriously troubled young adults, has seen up close the ill effects of disregard for a child's developmental context, and in his words,"funnelling" of all family problems into a child's medication.

Kyle Pruett,a child psychiatrist at the Yale Child Study Center, has an eloquent discussion of this subject in Pediatric Psychopharmacology: Principles and Practice.Two Harvard psychiatrists, Peter Chubinsky and Nancy Rappaport, have an article in the 2006 Journal of Infant, Child and Adolescent Psychotherapy entitled, "Medication and the Fragile Alliance: The Complex Meaning of Psychotropic Medication to Children, Adolescents and Families"


I hope that clinicians who prescribe psychoactive medications for children, including both pediatricians and child psychiatrists, will incorporate "psychodynamic psychopharmacology" into their practice, and think about the complex meaning of medication for children and their families. Equally important is that our culture change our expectation, and accept the limitations, of the role of medication in promotion of children's mental health.

Resource for Parents

This will be a very brief blog post, simply meant to call attention to a valuable resource for parents. The Pacella Parent Child Center, which is located in New York City, offers the kind of support for parent-child relationships that I write about in my blog. The website also offers articles for parents on such common challenges as post partum depression, crying, sleep and separation issues.

Big Pharma's Misleading Marketing Hurts Children

An article in his week's New York Times reports that AstraZeneca will pay $520 million to settle investigations into its marketing practices for Seroquel. The article states:

AstraZeneca becomes the fourth pharmaceutical giant in the last three years to admit to federal charges of illegal marketing of antipsychotic drugs, a lucrative category of medications that have quickly risen to the top of United States sales charts.

In addition, the article reports

The company has been accused of misleading doctors and patients by playing up favorable research and not adequately disclosing studies that show Seroquel increases the risk of diabetes

The biggest problem with the aggressive marketing of these drugs is not, however, the metabolic side effects. Rather it is the fact that their use stops clinicians from thinking in a meaningful way about how to help their patients. The promise of a quick fix is too hard to turn down, particularly in the face of pressure from the health insurance industry to see many patients in a short period of time.

I recently attended a conference on child psychiatry aimed for an audience of primary care clinicians. Child psychiatrists from major medical centers in the Boston area described current treatment for children who are “irritable” or ”dysregulated." Increasingly children as young as 3 with these symptoms are being prescribed atypical antipsychotics, the class of drugs AstraZeneca has allegedly been illegally marketing.

The head of the course actually recommended that the audience of pediatricians prescribe these medications to their patients, with little more than phone consultation from a child psychiatrist, because of a shortage of specialized services.

I doubt the psychiatrists leading that conference would like to think of themselves as being influenced by marketing in their clinical practice. But I have to wonder. As the article in the Times states "As a result of aggressive marketing, Seroquel has been increasingly used for children and elderly people for indications not approved by the FDA."

At that full day presentation about childhood psychiatric disorders there was extensive discussion about psychoactive medication. But not one mention was made of relationships.

Contemporary research in developmental psychology, which does not have the monetary clout of the drug industry, offers a completely different paradigm from which to understand and help "dysregulated" children. I have addressed these ideas elsewhere on my blog. The essential point of this research is that children develop the capacity to regulate emotions in the context of relationships.

When a child does not have a well developed capacity for emotional regulation, it is likely due to a combination of a child’s genetic vulnerability to dysregulation, and a parent’s capacity to think about and understand the meaning of a child's behavior. The co-regulation of emotion in a caregiving relationship can lead to changes in the biochemistry of the brain, and changes in the way the brain handles stress and strong emotions.

AstraZeneca reported $4.9 billion in Seroquel sales in 2009. That kind of money will never be earned from interventions that support parent-child relationships. But these interventions do not cause weight gain and metabolic disorders, big problems in a population of children already at risk for obesity. And by investing in relationships, we will help the next generation of children grow up to be resourceful, flexible, socially adaptive members of society. Isn't that invaluable?

Study Implicates Genetics and Family Dynamics in ADHD

Trying to understand and then explain the complex interaction between environmental influences and gene expression is a challenging task. An important study published in the April issue of Behavioral and Brain Functions inspired me to give it a try. I start with the actual quote from the study and then attempt to explain it in my own words.

To date, studies have mostly focused on the effects of genetic and environmental influences on ADHD separately. Our work examines the interaction between a specific gene variant and a family environmental risk factor in order to determine their roles in the development of ADHD via behavioral and emotional dysregulation in children.

When ADHD is conceptualized as emanating from the development of emotional and
behavioral regulation, specific genetic and family environmental factors are likely to jointly influence ADHD outcomes in particular ways. The present report capitalized on the potential to investigate an important genetic marker for liability to emotional and behavioral dysregulation (5HTTLPR), along with a particularly salient marker of environmental risk -children’s appraisals of blame in relation to inter-parental conflict.

What this study shows is that a person might have a gene for a serotonin metabolism, known as 5HHTLPR, that puts them at risk for ADHD. But if that person lives in a home filled with conflict, they are more likely to actually have ADHD. Put in a more positive way, just because you have the gene, it doesn't mean you will have the disorder. This study raises the question of whether addressing the environmental risk may protect a person from the genetic risk.

It brought to mind a story of a little boy named Adam who I took care of, a story that haunts me to this day. His mother and father came to see me when he was four years old. He had been in preschool for two months. Already the teachers were encouraging his parents to have him evaluated for ADHD and consider medication.

His parents presented him as a very bright loving child who had a very high energy level. At home, everything was "fine." They had no problems at all with him until he entered school. There he would become overstimulated, particularly when at lunch or other less structured activities. He had a very hard time sitting still and, most problematic for the teachers, he would become impulsive and hit other children. It seemed to both his parents and the teachers that he did not intend to hurt the other children, but that he simply could not control himself.

His father recalled having similar difficulties as a child, but he had outgrown them. Other family members had similar qualities. Both parents seemed to be working well to help him manage his particular challenges. When I met Adam the week after I met with his parents, he was indeed a very bright and engaging little boy. He sat on the floor with me and played a game meant for much older children.

I shared with his parents my impression that likely on a genetic basis he had a tendency for high activity level, and the structured setting of school, which was so new to him, was especially challenging. We discussed some strategies for helping him manage his difficulties, and planned a follow up visit in a month.

A month later they called to say that things were going well and cancelled their appointment. Over the next year Mom called me several times and scheduled appointments, each time cancelling them. She would say that the school wanted him on medication, and she really didn't want to go that route. Then, a month or so into kindergarten, things were not going well. As it had been so long since I had seen them, I asked Mom and Dad to come alone to fill me in.

After about ten minutes of description of Adam's problem behavior, his parents, who were not married, let me know that they were no longer living together. I asked if there had been trouble in the relationship when I saw them the previous year. Reluctantly they acknowledged that "we have never really been together."

Soon I was listening to a barrage of ferocious attacks upon each other. Mom accused Dad of being inept and unavailable. Dad said that Mom simply wanted to drug her son into submission. I sat quietly on my seat as the conflict escalated, feeling increasingly alarmed. Finally I interrupted and asked them if this kind of conflict I was observing was typical, and if so, what that might be like for Adam.

The viciousness was immediately was diverted to me. They were both furious. "What does that have to do with anything? We're not here to talk about us. We just want your advice about how to manage Adam's behavior!"

I spent the rest of the visit trying to turn things around so that they felt I was working with them, not against them. I do not think I was successful. In addition to discussion what to do about Adam's behavior, I suggested that they all go for therapy to address the ongoing family conflict. They left angry and disappointed. I felt terrible. How could I have missed this?

Reading this study makes me wonder, if I could have told them that there was scientific evidence demonstrating that family conflict made a person at risk for ADHD more likely to develop the disorder, would they have been more honest with me? Would them have been more motivated to deal with the problems in their relationship?

I have great admiration for the scientists who are trying to unravel the complex interactions between genes and environment. I hope that parents will draw hope and inspiration from this work. Just because there is a "family history" of a disorder, a genetic risk, does not mean a child's fate is sealed.

Standard of Care for ADHD Violates this Pediatrician's Professional Integrity

After giving the subject much careful thought, I have decided to leave my ADHD practice. In a previous post I described how I inherited a large practice of patients with a diagnosis of ADHD. While I have treated many children who have benefited from stimulant medication, I find the standard of care by which medication is prescribed to be significantly problematic.

Consider this one observation. Many clinicians prescribe medication for ADHD based upon a visit with only one parent. Once, a father called me to set up an appointment to discuss medication for ADHD. I learned that he was divorced and that the child split time between both parents homes. I told the father that I preferred to meet with both parents for the initial evaluation. He said he would call me back to set up a time, but never did. Often I will have one parent say, "His father is totally against medication." Imagine being a child in such a position. Your mother wants you to be on a drug that affects your brain. Your father is against it. Your doctor, without even discussing it with your father, prescribes it anyway. Yet this kind of situation happens all the time.

I also wonder what it does to a child's sense of self to sit in a room once every three to six months and listen to a conversation about his behavior and its relation to a pill he takes every day. Often things are said like, "He's just terrible when he misses his dose." These visits are usually thirty minutes long, and do not offer an opportunity to explore a child's life experience in any meaningful way. Yet this frequency and duration of visit, and line of questioning, is the standard of care for ADHD, and what parents expect.

Behavior management may be recommended in addition to medication. Again, the focus is on making a child behave, rather than exploring the meaning of behavior. Often, there are significant life events contributing to a child's inattention.

Recently I was interviewed by Kaitlin Bell for her upcoming book. She writes thoughtfully about the effects of being medicated since childhood on the current generation of young adults, and explores the complex issues such treatment has raised for them. I hope her writing will help us to think more carefully about the way in which these medications are prescribed.

In addition, while I observe on a regular basis the short term benefits of these medications, I do have nagging doubts about their safety over the long term. It is only with in the last ten to fifteen years that we have huge numbers of children taking stimulant medication for many years, often well into adulthood.

In the February issue of ADHD report Russell Barkley addresses a recent article from Scientific American Mind by Edmund S.Higgins that questions whether long term use of stimulants might take a toll on the brain. Higgins expresses concern that long term effects might include increased risk for anxiety, depression and disrupted cognition, among others. Barkley dismisses the article as "well-crafted propaganda," saying there is no evidence for these adverse effects. In his reply, Dr. Higgings writes,"The history of medicine is replete with examples of treatment interventions that appeared safe but ultimately revealed their adverse effects with long term-controlled studies."

The point is that we don't have good evidence either way. Add to that the fact that there is not good data demonstrating long term benefits, and I feel that I can no longer in good conscience prescribe stimulants year after year to large numbers of children.

I know that someone will prescribe these medications in my absence. In the mean time I will continue to write about my concerns. I am fortunately joined by many others, including Daniel Carlat, in his upcoming book Unhinged:The Trouble with Psychiatry and Robert Whitaker, in his book Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America who are writing to call attention to the possibly very wrong direction we are headed in the way psychoactive medications are prescribed.

In my clinical practice I will work primarily with young children and their parents. My aim is facilitate healthy development at an age when children's brains are rapidly growing and thus most open to change.

My forthcoming book, to be published by Da Capo Press,
integrates the most contemporary research in child development with stories from my pediatric practice to support parent's efforts to think about their child's mind and the meaning of their behavior, which in turn facilitates the child’s healthy emotional development at the level of structure and chemistry of the brain.

Please stay tuned to my blog for more about both.

A Lesson from Artyom: Adopt with Hearts and Eyes Wide Open

The trauma for Artyom continues. After having been given up to an orphanage by his alcoholic mother who lost her parental rights, being adopted by a US family, sent back to Russia alone when his adoptive mother allegedly was unable to cope with his psychological problems, he has now become the object of a tug-of war between Russia and the US over his citizenship. His future seems to hold unimaginable uncertainty for a vulnerable seven year old boy.

As this battle plays out over the coming weeks to months, I hope we can learn from this tragic tale. As a behavioral pediatrician I often see families who have adopted children out of situations similar to Artyom’s. Among the most hopeful of these is the story of Rachel and Sam.

I vividly remember Rachel’s “aha” moment. She had brought her six year old son Sam to see me because he was aggressive and defiant. Sam was adopted from an orphanage in another country when he was four. Prior to the orphanage he had lived on the streets with his abusive mentally ill mother.

When Sam first came home, he was a terrified child with little language. He immediately began to thrive. But now at six, he was wearing the whole family down. Sam would argue about everything, and frequently these arguments turned into physical battles. Rachel was exhausted and discouraged. She wanted my advice about what to do to control his behavior.

Over 20 years of longitudinal child development research has demonstrated what can happen to children who have been hurt by the very person who was supposed to protect them. This paradoxical situation leads to confused and confusing behavior in relationships with people close to them. When children fear the same person they look to for safety at a time when their brains are rapidly growing, this experience affects the biochemistry of the brain. It creates what is referred to as a state of “hyper-arousal.” This means that a child has great difficulty regulating emotions and may have an overabundance of stress hormones released in response to what seems like a minor event. They do not know how to feel calm and safe.

The adoption agency gave Sam's new family none of this information. Thus his parents were bewildered by the fact that the discipline techniques that had been so effective with their biological children failed completely. I wanted to help Rachel to understand the magnitude of the challenge she and her husband faced, while at the same time not discouraging her.

My thinking was guided by an important research study termed “The Attachment Representations and Adoption Outcome Study.” Miriam Steele and her colleagues found that an adoptive parent’s ability to understand the meaning of a child’s behavior led to a positive relationship between parent and child.

On that magical day of the “aha” moment, Rachel was feeling resigned, deflated. We were focusing on some strategies to manage difficult mornings when she began to talk about her biological children. She suddenly recalled a term from the home schooling philosophy on which they had been raised. The term was “tomato staking” It referred to the way parents stand firm while their developing children twist and turn as they grow up. A parent is always present to guide them in the right direction, and does not ever abandon them.

The image was a vivid one: these plump juicy red tomatoes, healthy because of the strong and steady stake which did little more than stand there. But, Rachel realized, Sam did not have this experience in his early years of development.
Following this visit, Rachel’s approach to Sam changed. She sought out intensive help for Sam. She realized that the whole family needed support in coming to terms with the enormous challenges they faced. Though the work was very hard, the self blame and guilt from which she had been suffering all but disappeared.

I cannot claim to understand what went so terribly wrong for Artyom and his adoptive family. But if we can learn anything from this tragedy, it is that when adopting a child who has been traumatized, it is essential for a family to have both hearts and eyes wide open. And as a country we must offer access to the help they need.