In a few weeks I will launch a new program in the Boston area (more information to follow when the details are ironed out) where I will see children under the age of five. The working name is "Early Childhood Social-Emotional Health" program (ECSH) It is an infant mental health program, drawing on the explosion of knowledge coming out of this growing discipline. I had the privilege of learning about the most current research first-hand from leaders in the field in an excellent a yearlong program at UMass Boston: The Infant-Parent Mental Health Post-Graduate Certificate Program.
There are two major problems with the term "infant mental health." First of all, it implies that there is such a thing as infant mental illness, which is, in my opinion, not the case. Second, when say that I am a pediatrician who treats behavior problems in children under age five, most people are puzzled. I tell them that I give parents space and time to reflect, and to be curious about the meaning of behavior, with the aim of getting development back on a healthy path. Still the blank look. I have found that the best way to explain it is through stories, as I do in my book Keeping Your Child in Mind. As always, I protect privacy by changing identifying details.
"She always hits! I don't know what's wrong with her!" Jane despaired at the start of her visit with me. She came with her three-month-old son, who slept in his carrier. She was horrified that her 18-month-old daughter Callie (who did not come to this visit, so Jane and I could talk freely) was behaving this way. She and her husband never hit. She couldn't understand where this behavior came from. The worst time, she said, was when she was trying to nurse the baby. Callie would try to climb up on her, and when told to get down she would hit her mother, the baby or both. Jane felt tense and angry. Her husband worked long hours and she was alone with the two kids most of the day. "What can I do to make her stop?" she asked.
This is not an uncommon occurrence. I frequently hear parents describe "visions of Columbine" when they see aggressive behavior in their toddlers. Rather than jumping right in with what to do, I took some time to listen to Jane's story. She told me of a difficult pregnancy and how hard it had been when she was alone much of the time when Callie was an infant.
Then she began to talk about her own family. Her father was an alcoholic who was verbally and sometimes physically abusive to her mother. There was constant yelling. She told me that she "hated aggression." When she saw Callie hitting she had an immediate physical sensation of stress. Jane just wanted her to stop.
We began to wonder together about why Callie might be hitting. Jane described how close she and Callie had been before the baby was born. With her husband gone much of the time she rarely had time alone with Callie anymore. "Perhaps she misses me," Jane said. She was surprised when I suggested that while clearly hitting was not acceptable, aggression in a toddler could be seen as a healthy thing. It was not the same as adult aggression, which carried a whole host of complex meanings. We might reframe Callie's behavior as claiming what she felt was her rightful place. We talked about how toddlers are asserting their emerging sense of self . Yet they recognize that they are in fact powerless in many situations. "Wow!" Jane exclaimed. "I feel that way sometimes, but I have words to express my feelings!"
We talked very little about what to do. I was careful to frame the issue of her childhood trauma and its relation to the current situation. This history did not mean that Callie's hitting was her "fault." Rather Jane needed to move her issues out of the way so she could see the situation from Callie's perspective. I was confident that she would then know what to do.
Sure enough, when she returned two weeks later, this time with Callie, the hitting had almost completely resolved. "I give her a bottle," Jane said. She had thought that she was "supposed to" get rid of the bottle by a year. But when the baby was born, Callie had become interested in the bottle again. So the three of them now sat quietly while Jane nursed the baby. Callie would drink an ounce or two and then lose interest in the bottle. She would play at her mother's feet until Jane was finished nursing.
Callie was a delightful little girl who played quietly while Jane and I spoke. Then we got to see the essence of toddlerhood in action. Callie went to her mother's purse and said "passie." Jane explained to me that as with the bottle, Callie had a renewed interest in the pacifier. "I decided to just let her have it." Jane rummaged in her bag and pulled it out, handing it to Callie, who took it, looked it over and gave it back. She returned to her play. A few minutes later she again said, "passie. " Again her mother gave it to her, and again she gave it back. This, I said, is the ambivalence of toddlerhood. Part of her wants to be a baby, but she also wants to grow up and be a big girl. Jane, by being respectful of Callie's perspective, was enabling her to sort this through naturally, Had Jane refused to let her have the pacifier, it is likely that, as an assertion of her wish to control the situation, Callie would have insisted on having it, and a battle would have ensued. She might have started using the pacifier again.
Jane, through her natural intuition about her daughter, figured out what to do. I simply offered her the space and time to think and to be heard. I hope that this small intervention has set the whole family on a different path. The baby now can nurse in peace. Jane is less worried that there is something wrong with Callie, who is in turn free to express her emerging self. For a young family, a little reflection goes a long way.
Thursday, October 13, 2011
Friday, October 7, 2011
ADHD: The role of diet and sleep
I recently had a guest post published on the CNN news blog, The Charts, entitled Calming your child's ADHD symptoms. The subject clearly needs a fresh look, given the startling statistic from a recent CDC report that diagnosis of ADHD was up by 29% from 2000 to 2009, and evidence that medication use for ADHD increased at an average yearly rate of 3.4% from 1996 to 2008.
In a nutshell, I describe ADHD as a problem of regulation of emotion, behavior and attention. I offer three points of approach. The first is to address family relationships. This is because children learn self-regulation in context of relationships with primary caregivers, and family conflict is clearly associated with increased risk for ADHD. Second, I recommend involving kids in activities that promote self-regulation including, but not limited to, horseback riding, swimming, martial arts and drumming. And last I recommend careful use of medication when a child's symptoms interfere with learning and social relationships.
A number of people commented that I had not addressed the issues of diet or sleep, both of which have been associated with symptoms of inattention and hyperactivity. I gave some careful thought to why I had not included these issues among the top three. The reason is that, in my experience, problems around sleep and diet are usually embedded in problems in relationships (the major exception is obstructive sleep apnea, a sometimes overlooked condition that can cause of hyperactivity in children. This topic is well covered in a recent post by an ENT specialist on the blog KevinMD.)
For example, I took care of one teenage girl with symptoms of inattention who met diagnostic criteria for ADHD. I learned that up until her thirteenth birthday, her mother lay in bed with her every night until she fell asleep. Then on the day of her birthday, her mother decided that her daughter was too old for this habit, and abruptly stopped, insisting that she fall asleep on her own. Not surprisingly, her brain and body had no idea how to fall asleep independently, so she was staying up until two or three o'clock every morning, sneaking her laptop into bed with her.
Many children with a range of behavior problems crave sweets. Parents describe constant battles around food choices. It is likely that these problems have complex causes: sweets may be used to reduce stress, and food is a place where children can exert absolute control by simply closing their mouths.
Certainly it is important for growth, development, and learning that children eat a healthy diet. Ideally they should have three meals a day with sufficient fresh fruits, vegetables, and protein and a minimum of processed foods. However, if all attention in management of ADHD is focused on diet, to the exclusion of relationships, then the intervention is off the mark. In addition, evidence for more specific food restrictions, such as dairy, wheat or food dyes, is more anecdotal, and some of these diets can be quite restrictive.
Similarly, getting enough sleep is essential to healthy brain function and regulation of behavior, emotions and attention. But, with the exception of obstructive sleep apnea, most sleep problems develop in the context of relationships. In my work with the teenager I describe above, we needed to understand what about family relationships, between mother and father as well as between mother and daughter, led to this problematic situation. Only then could we could begin to solve the "sleep problem." Many children I see with a diagnosis of ADHD have been engaging in battles with their parents for years around sleep, but almost always in the setting of a range of conflicts within the family.
My answer to those who question the omission of sleep and diet from my discussion of ADHD is that yes, these issues are important. In my CNN piece I describe inattention, impulsivity and hyperactivity as symptoms, and urge parents and clinicians who treat ADHD to not simply treat symptoms, but rather to address the underlying cause. Similarly, problems with sleep and diet are often symptoms of problems in relationships. Many parents describe being overwhelmed by the volume of information coming at them about this complex entity known as ADHD. I believe both parents and professional would do well to be open to a variety of ideas while maintaining a focus on supporting relationships and repairing disruptions in relationships.
In a nutshell, I describe ADHD as a problem of regulation of emotion, behavior and attention. I offer three points of approach. The first is to address family relationships. This is because children learn self-regulation in context of relationships with primary caregivers, and family conflict is clearly associated with increased risk for ADHD. Second, I recommend involving kids in activities that promote self-regulation including, but not limited to, horseback riding, swimming, martial arts and drumming. And last I recommend careful use of medication when a child's symptoms interfere with learning and social relationships.
A number of people commented that I had not addressed the issues of diet or sleep, both of which have been associated with symptoms of inattention and hyperactivity. I gave some careful thought to why I had not included these issues among the top three. The reason is that, in my experience, problems around sleep and diet are usually embedded in problems in relationships (the major exception is obstructive sleep apnea, a sometimes overlooked condition that can cause of hyperactivity in children. This topic is well covered in a recent post by an ENT specialist on the blog KevinMD.)
For example, I took care of one teenage girl with symptoms of inattention who met diagnostic criteria for ADHD. I learned that up until her thirteenth birthday, her mother lay in bed with her every night until she fell asleep. Then on the day of her birthday, her mother decided that her daughter was too old for this habit, and abruptly stopped, insisting that she fall asleep on her own. Not surprisingly, her brain and body had no idea how to fall asleep independently, so she was staying up until two or three o'clock every morning, sneaking her laptop into bed with her.
Many children with a range of behavior problems crave sweets. Parents describe constant battles around food choices. It is likely that these problems have complex causes: sweets may be used to reduce stress, and food is a place where children can exert absolute control by simply closing their mouths.
Certainly it is important for growth, development, and learning that children eat a healthy diet. Ideally they should have three meals a day with sufficient fresh fruits, vegetables, and protein and a minimum of processed foods. However, if all attention in management of ADHD is focused on diet, to the exclusion of relationships, then the intervention is off the mark. In addition, evidence for more specific food restrictions, such as dairy, wheat or food dyes, is more anecdotal, and some of these diets can be quite restrictive.
Similarly, getting enough sleep is essential to healthy brain function and regulation of behavior, emotions and attention. But, with the exception of obstructive sleep apnea, most sleep problems develop in the context of relationships. In my work with the teenager I describe above, we needed to understand what about family relationships, between mother and father as well as between mother and daughter, led to this problematic situation. Only then could we could begin to solve the "sleep problem." Many children I see with a diagnosis of ADHD have been engaging in battles with their parents for years around sleep, but almost always in the setting of a range of conflicts within the family.
My answer to those who question the omission of sleep and diet from my discussion of ADHD is that yes, these issues are important. In my CNN piece I describe inattention, impulsivity and hyperactivity as symptoms, and urge parents and clinicians who treat ADHD to not simply treat symptoms, but rather to address the underlying cause. Similarly, problems with sleep and diet are often symptoms of problems in relationships. Many parents describe being overwhelmed by the volume of information coming at them about this complex entity known as ADHD. I believe both parents and professional would do well to be open to a variety of ideas while maintaining a focus on supporting relationships and repairing disruptions in relationships.
Monday, October 3, 2011
Prevention and Primary Care
One main objective of the Affordable Care Act, or health care reform, is to focus on prevention. This has been translated into requiring insurance companies to cover annual physicals and a variety of screening tests. Of course primary prevention is done in the setting of primary care. Unfortunately the government is, in a sense, working against itself because of the current system for determining reimbursement for medical services. Pauline Chen documents this well in her recent piece in the New York Times: How One Small Group Sets Doctors' Pay She writes:
Robin was distraught over Kevin's need to always have everything first, and his demands were escalating. They were having increasing difficulty getting out of the house in the morning. I saw them for 2 fifty-minute visits. The first involved the whole family and we talked about some common approaches to managing behavior. I was struck by Mom’s level of distress, which seemed out of proportion to this fairly typical sibling rivalry. Towards the end of the second visit, when Mom was alone with Kevin, she quietly began to cry. I looked puzzled. She told me of the horrible accident that had taken the life of her older brother when she was a child. Her family never spoke about it. That trauma came flooding back now that she had two children of her own. She recognized that she had to mourn this loss in order to be present with her children in the way she wanted to be.
This was 10 years ago. Recently I ran into Kevin. He is now a talented musician as well as an excellent student. I saw him in town with his arm around a girl. He gave me a big smile and a friendly "hello." Of course I can't say what path his life would have taken had this trauma of his mother's not been addressed. But I suspect that it had a role in freeing him to develop into the person he is today.
Prevention can only happen in a meaningful way if the value of primary care is recognized. This involves not only monetary value. Certainly with the burden of loan repayment, financial issues are paramount in determining what field doctors-in-training chose to go in to. But in addition we as a society need to recognize that listening, particularly listening that occurs in the context of a relationship that develops over time, is an important form of treatment. Prevention is not only about screening tests.
Why are there so many medical specialists in a time when we need more primary care doctors? Meet the RUC, a committee of 29 men and women who play a critical role in dividing the Medicare pie.She describes the close connection between the RUC and the Centers for Medicare and Medicaid Services, or C.M.S.
First, C.M.S. historically has approved 90 percent or more of the recommendations from the RUC. Second, while the RUC makes its recommendations based on an anonymous two-thirds majority vote, about 80 percent of those voting to begin with — accounting for 23 of the 29 seats — are physicians representing professional societies. Third, almost all of those physicians are specialists (currently only five RUC members are doctors from primary care fields).Prevention happens through the relationships that develop over time in the primary care setting. Consider this story from my pediatric practice( details, as always, have been changed to protect privacy) Six year old Kevin’s mom, Robin, was upset about his constant fighting with his younger sister. I had taken care of both children since they were infants.
Robin was distraught over Kevin's need to always have everything first, and his demands were escalating. They were having increasing difficulty getting out of the house in the morning. I saw them for 2 fifty-minute visits. The first involved the whole family and we talked about some common approaches to managing behavior. I was struck by Mom’s level of distress, which seemed out of proportion to this fairly typical sibling rivalry. Towards the end of the second visit, when Mom was alone with Kevin, she quietly began to cry. I looked puzzled. She told me of the horrible accident that had taken the life of her older brother when she was a child. Her family never spoke about it. That trauma came flooding back now that she had two children of her own. She recognized that she had to mourn this loss in order to be present with her children in the way she wanted to be.
This was 10 years ago. Recently I ran into Kevin. He is now a talented musician as well as an excellent student. I saw him in town with his arm around a girl. He gave me a big smile and a friendly "hello." Of course I can't say what path his life would have taken had this trauma of his mother's not been addressed. But I suspect that it had a role in freeing him to develop into the person he is today.
Prevention can only happen in a meaningful way if the value of primary care is recognized. This involves not only monetary value. Certainly with the burden of loan repayment, financial issues are paramount in determining what field doctors-in-training chose to go in to. But in addition we as a society need to recognize that listening, particularly listening that occurs in the context of a relationship that develops over time, is an important form of treatment. Prevention is not only about screening tests.
Wednesday, September 28, 2011
Parenting Toddlers and Teenagers: Much in Common
Psychoanalyst Peter Blos describes the "second individuation process of adolescence," referring to the way in which adolescence shares many qualities with toddlerhood in terms of developmental tasks. Sometimes when I listen to parents describe their struggles with their teenage children, I have an image of trying to contain a person, often bigger than themselves, who has advanced thinking skills. The tantrums of adolescence involve not thrashing arms and legs, but words, and often cruel and vicious words.
D. W.Winnicott, pediatrician turned psychoanalyst, offers some words of wisdom that can guide a parent through this challenging period. He writes, in his book Playing and Reality
But then over some little thing, Pam couldn’t even remember what it was when she told me the story in my office, Eva had exploded with a burst of venomous rage. “You never think about my feelings,” she’d started with, calmly enough. But when Pam tried to get her to explain what she meant, Eva’s anger only increased. Vicious insults started flying at her. Caught off guard, Pam found herself becoming defensive.
Their discussion escalated into a shouting match as they quickly paid their bill and left the restaurant. Pam, in an effort to get home without being in an accident, stopped talking to Eva, who, she felt, was becoming increasingly irrational in her verbal assault on her mother. Pam’s silence only further enraged Eva and she screamed at her mother, who held tight to the wheel, hands shaking.
They made it home and immediately went their separate ways. Pam called her husband. As he was not the recipient of the full intensity of Eva’s distress he was able to support his wife and help her to calm down. Eva closed the door to her room and called her boyfriend. Several hours later Eva emerged from her room. “I’m sorry, Mom, she said. I’ve been feeling so much stress trying to balance work and friends and Chris.” “I understand that this is a very difficult time for you,” Pam had replied. “But," she went on to say, "it is not acceptable for you to speak to me the way you did.”
Pam was feeling beaten down by these repeated interactions with her daughter. While she had been able to negotiate the prior stages of development with Eva, the intensity of feelings directed at her from her teenage daughter sometimes was too much to bear. I told Pam that she was doing just what she needed to do, namely withstand the full intensity of her daughters feelings , both the negative and positive ones, yet set limits on her behavior. Pam needed to show Eva that she loved and supported her daughter, but would not allow her destroy her mother.
A toddler needs similar kinds of limits as he tries to make sense of who he is as a person separate from his parents. While two-year-olds will not say "thank you for setting limits," when parents contain both their behavior and their intense feelings, it helps them to feel safe and secure. This safety and security is needed just as much for teenagers as they begin to separate and develop their emerging identity. Ironically just when a teenager is most actively and aggressively pushing you away, she most need you to be there.
Winnicott offers a hopeful look at the future if a parent has withstood the “long tussle” of adolescence. He writes:
D. W.Winnicott, pediatrician turned psychoanalyst, offers some words of wisdom that can guide a parent through this challenging period. He writes, in his book Playing and Reality
If you do all you can to promote personal growth in your offspring, you will need to be able to deal with startling results. If your children find themselves at all they will not be contented to find anything but the whole of themselves, and that will include the aggression and destructive elements in themselves as well as the elements that can be labeled loving. There will be this long tussle which you will need to survive.This idea resonated with Pam, mother of 16 year old Eva, who had come to see me for a consultation. She described the following scene. Pam and Eva had planned to have a nice lunch together. Eva was busy at school and had developed an increasingly serious relationship with her boyfriend, Chris. Eva and Pam had always been close and both eagerly anticipated this opportunity to spend a bit of time together. Things started off well enough. Eva excitedly told her mother about the latest social happenings at school and about a paper she was working on.
But then over some little thing, Pam couldn’t even remember what it was when she told me the story in my office, Eva had exploded with a burst of venomous rage. “You never think about my feelings,” she’d started with, calmly enough. But when Pam tried to get her to explain what she meant, Eva’s anger only increased. Vicious insults started flying at her. Caught off guard, Pam found herself becoming defensive.
Their discussion escalated into a shouting match as they quickly paid their bill and left the restaurant. Pam, in an effort to get home without being in an accident, stopped talking to Eva, who, she felt, was becoming increasingly irrational in her verbal assault on her mother. Pam’s silence only further enraged Eva and she screamed at her mother, who held tight to the wheel, hands shaking.
They made it home and immediately went their separate ways. Pam called her husband. As he was not the recipient of the full intensity of Eva’s distress he was able to support his wife and help her to calm down. Eva closed the door to her room and called her boyfriend. Several hours later Eva emerged from her room. “I’m sorry, Mom, she said. I’ve been feeling so much stress trying to balance work and friends and Chris.” “I understand that this is a very difficult time for you,” Pam had replied. “But," she went on to say, "it is not acceptable for you to speak to me the way you did.”
Pam was feeling beaten down by these repeated interactions with her daughter. While she had been able to negotiate the prior stages of development with Eva, the intensity of feelings directed at her from her teenage daughter sometimes was too much to bear. I told Pam that she was doing just what she needed to do, namely withstand the full intensity of her daughters feelings , both the negative and positive ones, yet set limits on her behavior. Pam needed to show Eva that she loved and supported her daughter, but would not allow her destroy her mother.
A toddler needs similar kinds of limits as he tries to make sense of who he is as a person separate from his parents. While two-year-olds will not say "thank you for setting limits," when parents contain both their behavior and their intense feelings, it helps them to feel safe and secure. This safety and security is needed just as much for teenagers as they begin to separate and develop their emerging identity. Ironically just when a teenager is most actively and aggressively pushing you away, she most need you to be there.
Winnicott offers a hopeful look at the future if a parent has withstood the “long tussle” of adolescence. He writes:
Your rewards come in the richness that may gradually appear in the personal potential of this or that boy or girl. And if you succeed you must be prepared to be jealous of your children who are getting better opportunities for personal development than you had yourselves. You will feel rewarded if one day your daughter asks you to do some baby-sitting for her, indicating thereby that she thinks you may be able to do this satisfactorily; or if your son wants to be like you in some way, or falls in love with a girl you would have liked yourself, if you had been younger. Rewards come indirectly. And of course you know you will not be thanked.
Friday, September 23, 2011
Music Therapy
Recently in my behavioral pediatrics practice I saw James, a 5-year-old boy (details, as always, have been changed to protect privacy) who struggled with severe social anxiety. The lunchroom and gym were particularly difficult, and he would retreat into silence. In a visit with his parents we were discussing how to approach the teachers about making him comfortable in school. We had a full 50 minute appointment so we were, in a sense, free to let ideas emerge. That's when his father observed, "You know, he loves classical music." His mother described a recent outing where there had been a lot going on and James was quite agitated. But when someone put on some classical music, James became completely calm and seemed at peace.
It was an important detail. We began to brainstorm about how they might make use of this observation in the school setting in addition to social experiences outside of the classroom.
This story led me to wonder how this piece of information might help us to understand James' brain. For some reason he couldn't process all the sensory information coming at him in a busy social scene. But with the help of classical music, it was as if the neurons, the cells of his brain, lined up and began to work properly.
This visit got me thinking about a movie I recently saw The Music Never Stopped. It is based on the story of an actual patient as described by neurologist and writer Oliver Sacks in his essay "The Last Hippie." The movie's main character is a young man who suffered severe brain injury, and was socially disconnected even from his immediate family. But he had been a passionate musician, and when when he listened to music he loved from the time before his injury he became completely clear thinking and engaged. Like my young patient, his brain was a place of confusion and disorganization until the music allowed things to, in a sense, fall into place.
Interestingly, while working on this post I received an email from the publicist at Berklee College of Music alerting me to an upcoming program (October 5th-6th) about music therapy for autism spectrum disorders. The press release for the program states:
There is currently an explosion of research at the intersection of neuroscience, genetics, and developmental psychology to help us understand young children who are struggling with a range of what are usually referred to as "behavior problems." I am a clinician, not a researcher. However, I listen carefully to my young patients. I encourage their parents, as James' parents clearly were, to be curious about what the world is like for them. If we listen and observe in this way, these children can be our greatest teachers.
It was an important detail. We began to brainstorm about how they might make use of this observation in the school setting in addition to social experiences outside of the classroom.
This story led me to wonder how this piece of information might help us to understand James' brain. For some reason he couldn't process all the sensory information coming at him in a busy social scene. But with the help of classical music, it was as if the neurons, the cells of his brain, lined up and began to work properly.
This visit got me thinking about a movie I recently saw The Music Never Stopped. It is based on the story of an actual patient as described by neurologist and writer Oliver Sacks in his essay "The Last Hippie." The movie's main character is a young man who suffered severe brain injury, and was socially disconnected even from his immediate family. But he had been a passionate musician, and when when he listened to music he loved from the time before his injury he became completely clear thinking and engaged. Like my young patient, his brain was a place of confusion and disorganization until the music allowed things to, in a sense, fall into place.
Interestingly, while working on this post I received an email from the publicist at Berklee College of Music alerting me to an upcoming program (October 5th-6th) about music therapy for autism spectrum disorders. The press release for the program states:
There is scientific evidence that music therapy influences children on the autism spectrum in several ways, like enhancing skills in communication, interpersonal relationships, self-regulation, coping strategies, stress management, and focusing attention,” says Berklee’s Music Therapy Department Chair Dr. Suzanne Hanser.Similar to my young patient with social anxiety, children diagnosed with autism spectrum disorders are often overwhelmed by sensory input. It makes perfect sense to me that music would help them to organize their experience and engage with the world around them.
There is currently an explosion of research at the intersection of neuroscience, genetics, and developmental psychology to help us understand young children who are struggling with a range of what are usually referred to as "behavior problems." I am a clinician, not a researcher. However, I listen carefully to my young patients. I encourage their parents, as James' parents clearly were, to be curious about what the world is like for them. If we listen and observe in this way, these children can be our greatest teachers.
Sunday, September 18, 2011
Postpartum Depression: Listening to Mothers
When I see children in my pediatric practice for behavior problems, I often hear stories from mothers who struggled terribly when their children were very young infants. Among the most dramatic example of this was a mother with severe postpartum depression whose father died suddenly when her baby was four months old. Much to my astonishment, she described being relieved by this event. It wasn't because she didn’t love her father. Rather, in sharing the grief with her siblings and extended family, she no longer felt so completely alone.
A Massachusetts law passed last summer calls attention to the public health problem of postpartum depression (PPD). The most common complication of pregnancy, extensive research has demonstrated its significant long term effects on a child’s development, with increased risk for behavior problems in childhood and depression in adolescence.
The new law requires Massachusetts health insurers to submit annual reports on their efforts to screen for postpartum depression. The department of Public Health will develop regulations and policies to address postpartum depression. In addition the law calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.
The Boston Globe editorial board endorsed this legislation with the following statement: "Early detection could stave off far more serious problems for mothers and their babies, whose well-being is deeply linked to the first few months of care. And universal screening would ensure that no woman falls through the cracks. The sooner new mothers can be diagnosed, the sooner they will recover."
This legislation is an important first step. A lot of work needs to be done, however, to turn the Globe's very optimistic statement into a reality. This summer I became involved with two organizations who are working towards this goal. One is a working group of the Massachusetts Chapter of the American Academy of Pediatrics. One of the biggest problems with mandatory screening, which is done primarily by obstetricians and pediatricians, is that the people doing the screening may not know what to do with a positive screen.
Interestingly, a study of women struggling with PPD ( which I prefer to call "perinatal emotional complications" thus avoiding the stigma associated with major mental illness- I must give credit to Liz Friedman-see below-for coining this phrase) shows that mothers may not want a referral or medication but simply for their clinician, a person with whom they have an established relationship, to listen to them. Primary care clinicians need to feel comfortable with what our group called "engagement," - to stay in the room with a distraught mother before jumping to a referral.
Perhaps equally importantly, the health insurance industry need to recognize that time and space, offering a mother, who may feel so terribly alone, a chance to be heard in a non-judgemental way by a respected caregiver, is an essential part of treatment.
The second organization I connected with is called MotherWoman. This organization seeks to educate clinicians and to create referral networks of people in communities who can offer a variety of interventions for these mothers. It is run by a remarkably energetic and enthusiastic woman, Liz Friedman. She describes her program as follows:
When I speak with mothers like the one above, I wish that I had seen them when their children were infants. This is not to say that their child's behavior problems is their fault. But the research clearly shows that when mothers are emotionally available to their young infants, development proceeds in a healthy direction. By working to address perinatal emotional complications, we have the opportunity not only to ease these mothers' suffering, but also to help them to be fully present with their babies. We can help transform these early months from a time of stress and pain into a time of joy and love.
A Massachusetts law passed last summer calls attention to the public health problem of postpartum depression (PPD). The most common complication of pregnancy, extensive research has demonstrated its significant long term effects on a child’s development, with increased risk for behavior problems in childhood and depression in adolescence.
The new law requires Massachusetts health insurers to submit annual reports on their efforts to screen for postpartum depression. The department of Public Health will develop regulations and policies to address postpartum depression. In addition the law calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.
The Boston Globe editorial board endorsed this legislation with the following statement: "Early detection could stave off far more serious problems for mothers and their babies, whose well-being is deeply linked to the first few months of care. And universal screening would ensure that no woman falls through the cracks. The sooner new mothers can be diagnosed, the sooner they will recover."
This legislation is an important first step. A lot of work needs to be done, however, to turn the Globe's very optimistic statement into a reality. This summer I became involved with two organizations who are working towards this goal. One is a working group of the Massachusetts Chapter of the American Academy of Pediatrics. One of the biggest problems with mandatory screening, which is done primarily by obstetricians and pediatricians, is that the people doing the screening may not know what to do with a positive screen.
Interestingly, a study of women struggling with PPD ( which I prefer to call "perinatal emotional complications" thus avoiding the stigma associated with major mental illness- I must give credit to Liz Friedman-see below-for coining this phrase) shows that mothers may not want a referral or medication but simply for their clinician, a person with whom they have an established relationship, to listen to them. Primary care clinicians need to feel comfortable with what our group called "engagement," - to stay in the room with a distraught mother before jumping to a referral.
Perhaps equally importantly, the health insurance industry need to recognize that time and space, offering a mother, who may feel so terribly alone, a chance to be heard in a non-judgemental way by a respected caregiver, is an essential part of treatment.
The second organization I connected with is called MotherWoman. This organization seeks to educate clinicians and to create referral networks of people in communities who can offer a variety of interventions for these mothers. It is run by a remarkably energetic and enthusiastic woman, Liz Friedman. She describes her program as follows:
The Community-based Perinatal Support Model (CPSM) has been developed to address the gap between screening and services for mothers. CPSM aims to prevent, identify and facilitate treatment of PMD(perinatal mood disorders) by creating a comprehensive, community-based, multi-disciplinary safety net for women.These two organizations are starting the hard work necessary to translate the new legislation into a form that is useful and meaningful for mothers struggling with perinatal emotional complications.
When I speak with mothers like the one above, I wish that I had seen them when their children were infants. This is not to say that their child's behavior problems is their fault. But the research clearly shows that when mothers are emotionally available to their young infants, development proceeds in a healthy direction. By working to address perinatal emotional complications, we have the opportunity not only to ease these mothers' suffering, but also to help them to be fully present with their babies. We can help transform these early months from a time of stress and pain into a time of joy and love.
Monday, September 12, 2011
Creativity in the Age of Psychiatric Medication
Recently I attended a reception at the Austen Riggs Center in Stockbridge, MA for the new medical director. Austen Riggs is an inpatient psychiatric hospital where intensive psychotherapy remains the core of treatment( thought certainly medication is used as well.) At the reception I met the new Erikson scholar, an art historian who is writing a biography of a woman, one of the first patients at Riggs, who shortly after her stay went on to become a world famous violinist. We spoke about the connection between mental illness and creativity. We wondered what this woman's fate might have been had she lived today when she most surely would have been medicated.
In the last chapter of my new book Keeping Your Child in Mind: Overcoming Defiance, Tantrums, and Other Everyday Behavior Problems by Seeing the World through Your Child's Eyes I discuss the problems associated with the exponential rise in prescribing of psychiatric medication for children. While I am not against medication per se, I have a number of concerns about what I consider to be an over-reliance on medication to treat complex problems. Not only are there side effects and unknown effects on the developing brain, but medication is often the focus of treatment to the exclusion of important family issues. Significant events in a child's life may go unaddressed. Usually a child does not have an opportunity to talk about what it means to him to be taking a pill to manage his behavior.
Following this conversation at Riggs it occurred to me that I should add yet another concern- potential loss of creative talent.
Several weeks ago there was an op ed in the New York Times: “Words Failed, Then Saved Me, “ that offers a beautiful example of turning a biological vulnerability into an adaptive asset. The author, Philip Schultz, now a Pulitzer Prize winning poet, struggled terribly as a child with what is today recognized as dyslexia. Schultz describes how his mother would read his favorite comics over and over again with the hope that this would help him to make sense of words. I wonder if this kind of tolerance and patience gave Schultz the space to, as he says, “invent a new way of reading” that was adapted to his particular form of dyslexia.
Schultz describes not only his academic struggles but also how he was kicked out of one school for hitting other children when they called him "stupid.' I wonder if he had been child today, he might have been described as "impulsive" and "distracted," classic symptoms of what now is called "ADHD." He might have been diagnosed and medicated. Had his symptoms been medicated away, he might not have invented his new way of reading, a method he now uses to teach others with similar difficulties to write fiction and poetry. He might not have become poet, much less win the Pulitzer Prize.
As a behavioral pediatrician, I often hear parents ask if there “something wrong" with their child. I help them to reframe the question, asking instead “what is his experience of the world, and how can we help him to make sense of and manage that unique experience?” I have seen kids who were "explosive" and "inflexible" as very young children. They were easily overwhelmed by a variety of sensory experiences. But in the setting of an understanding and supportive environment, they have gone on to be talented actors, musicians and artists.
Supporting children in this way involves investment of time and energy from parents, teachers, and clinicians. In our culture treatment of a child with "behavior problems" usually focuses on resolution of symptoms, often with medication, rather than understanding the meaning of behavior. Medication may more quickly control a child's symptoms. But at what cost?
In the last chapter of my new book Keeping Your Child in Mind: Overcoming Defiance, Tantrums, and Other Everyday Behavior Problems by Seeing the World through Your Child's Eyes I discuss the problems associated with the exponential rise in prescribing of psychiatric medication for children. While I am not against medication per se, I have a number of concerns about what I consider to be an over-reliance on medication to treat complex problems. Not only are there side effects and unknown effects on the developing brain, but medication is often the focus of treatment to the exclusion of important family issues. Significant events in a child's life may go unaddressed. Usually a child does not have an opportunity to talk about what it means to him to be taking a pill to manage his behavior.
Following this conversation at Riggs it occurred to me that I should add yet another concern- potential loss of creative talent.
Several weeks ago there was an op ed in the New York Times: “Words Failed, Then Saved Me, “ that offers a beautiful example of turning a biological vulnerability into an adaptive asset. The author, Philip Schultz, now a Pulitzer Prize winning poet, struggled terribly as a child with what is today recognized as dyslexia. Schultz describes how his mother would read his favorite comics over and over again with the hope that this would help him to make sense of words. I wonder if this kind of tolerance and patience gave Schultz the space to, as he says, “invent a new way of reading” that was adapted to his particular form of dyslexia.
Schultz describes not only his academic struggles but also how he was kicked out of one school for hitting other children when they called him "stupid.' I wonder if he had been child today, he might have been described as "impulsive" and "distracted," classic symptoms of what now is called "ADHD." He might have been diagnosed and medicated. Had his symptoms been medicated away, he might not have invented his new way of reading, a method he now uses to teach others with similar difficulties to write fiction and poetry. He might not have become poet, much less win the Pulitzer Prize.
As a behavioral pediatrician, I often hear parents ask if there “something wrong" with their child. I help them to reframe the question, asking instead “what is his experience of the world, and how can we help him to make sense of and manage that unique experience?” I have seen kids who were "explosive" and "inflexible" as very young children. They were easily overwhelmed by a variety of sensory experiences. But in the setting of an understanding and supportive environment, they have gone on to be talented actors, musicians and artists.
Supporting children in this way involves investment of time and energy from parents, teachers, and clinicians. In our culture treatment of a child with "behavior problems" usually focuses on resolution of symptoms, often with medication, rather than understanding the meaning of behavior. Medication may more quickly control a child's symptoms. But at what cost?
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