Pediatrics and Psychoanalysis: An Essential Partnership

D.W Winnicott, pediatrician turned psychoanalyst, has been among the most important influences on my work. Unlike him, however, I have been determined, in my professional life, not to "defect" from pediatrics to become a psychoanalyst. I have always felt it was important to bring the wealth of deeply meaningful ideas coming from the discipline of psychoanalysis to the practice of pediatrics.

For example, in my current position as a behavioral pediatrician at Newton-Wellesley Hospital I teach the pediatric residents and  medical students about colic by starting with Winnnicott's notion of "primary maternal preoccupation." I read to them from my book: Keeping Your Child in Mind, itself an effort to bring psychoanalytic ideas to a general audience:

Winnicott described the first weeks to months of motherhood as a period deserving of a name, a psychological state, which for both a newborn and mother is not only healthy but highly adaptive. The name Winnicott gave this state was “primary maternal preoccupation.” He referred to a mother who is preoccupied in this way with her baby as an “ordinary devoted mother.” This way of being in tune with the baby happens naturally and does not look like anything particularly dramatic. A mother knows what her baby feels through her intense identification with him. He is a part of her. Though her role is in this sense “ordinary,” it is in fact hugely important. Winnicott writes: “It will be observed that though at first we were talking about very simple things, we were also talking about matters that have vital importance, matters that concern the laying down of the foundations for mental health.”

Rather than asking "what to do" to "manage" colic, I encourage them to think about the meaning of the behavior within the context of this intense infant-parent relationship. Similarly, when parents come to see me about how to "manage" their child's "behavior problem," I help them to recognize that they are engaged in a kind of "dance of dysregulation" with their child, and that they both need to learn a new way to dance that is calm and coordinated.

This weekend, however, I get to do exactly the opposite, namely bring my knowledge as a pediatrician to a group of psychoanalysts.  Just as psychoanalysts are experts in relationships, so pediatricians (and all professionals who provide primary care to children) are experts in babies.  We are immersed in child development in a way that is unlike any other profession.

I am speaking at a conference at the Austen Riggs Center, co-sponsored by the Yale Child Study Center: Development of the Parent as a Person: Psychological, Biological and Genetic Contributions. Within minutes of looking at the proposed lineup of presentations, I knew exactly what I had to add. My talk is titled: "The Development of the Parent: the Child's Contribution."

 After more than 20 years of listening to countless parents and seeing thousands of babies, I have no doubt that babies come in to the world with their own unique set of qualities and characteristics, that from the first moment have a significant impact on the development of the parent. Almost every parent who is struggling with their child's challenging behavior has shared some variation of, "we saw this from the moment he was born."

I will use the photographs from Kevin Nugent's book: Your Baby is Speaking to You, that so beautifully captures the way babies are engaged in complex communication from the start. I have a video clip of a baby at three days of age having a conversation with me. I will introduce the Newborn Behavioral Observation system, a clinical tool designed to bring out these qualities in the baby, and promote healthy relationships from the start.

A number of years ago I attended a conference entitled "Pediatrics and Child Psychiatry: an Essential Partnership." I was hopeful, but sadly it ended up being primarily about prescribing medication, with a little bit about "parent training" thrown in. The word "relationship" was not mentioned once.

Here we have two parallel relationships: the parent-child relationship, and the pediatrics-psychoanalysis relationship. In each pair, one has the opportunity to have a profound and positive effect on the development of the other.

A necessary mourning

I heard the phrase, "I don't want to live in the past" three times last week. The first was from Dr.Ruth Westheimer, famous sex therapist and Holocaust survivor. Her interviewer pointed out the inconsistency of that statement and the fact that she was in town to see a play about the story of her life. The second was a mother who wept in my office as she spoke of her troubles dealing with her young daughter's behavior. She recognized how her own issues got in the way, but wished to "live life forward."  The third was from my father.  We are working together to find a way to tell his remarkable story of his life in Nazi Germany, his escape to America, and his subsequent rescue of his parents from Theresienstadt when he returned as a soldier with the US army. His ambivalence is powerful-one day he will be eager to tell more stories about his life, and the next day he will shut it down. 

I find myself thinking-do these stories, often associated with very difficult and painful memories- need to be told? Virtually every person who hears my father's story says it must be told. But why?

I think there are two answers. The first is about history. History is essentially about telling stories from the past. Our hope is to make sense of things and so to better understand the present and future. But it may be difficult for the individual person who experienced the trauma directly to carry this burden. Perhaps history needs to be written by those who can study it from a distance.

The second answer is more personal.   It is about the hold that unprocessed grief can have on an individual, and on subsequent generations. When speaking with a friend about how little I knew about my father's life until very recently, she said, "Can you imagine how much energy it takes to hold all of that in?"

When loss on the magnitude of the Holocaust has occurred, it is very difficult to wrap one's mind around the effect of unprocessed mourning. In my work with parents and young children, however, its effect can be immediate and vivid. Here is an example from my pediatric practice.

Emily brought her son Michael to see me when he was 3 and 1/2 months old. He had been born one month premature, but it was clear from a first glance that he was doing well. I remember noticing that his mother was so close, physically close. She hovered over his carriage, reluctant to let me pick him up. She stood inches from him while I examined him.

He was robust little boy who gave a big smile as he intently followed his mother's face. Emily felt he was doing well. So well, in fact, that she was attributing qualities to him for which he seemed to young. "It's good for him to comfort himself, right? I should let him cry, right?" She seemed very anxious.

About a year earlier, Emily had lost a baby, Christopher she called him, in her ninth month of pregnancy, when she was in a car accident. She conceived again almost immediately. And here was this miracle baby. I watched Michael sleeping in his blue jumper. He seemed so small and vulnerable. 

"He's doing great," I said. Emily continued to wear that uncertain look as I tried to reassure her. She asked about sleep. "Is it OK if he is still in our bed? Is it good for bonding?" she asked. I was puzzled by this question and paused, asking her to tell me what she meant.

"Is he bonded to me?" she asked. I started to attempt an answer when she interrupted me. "Can you bond in utero? I mean I bonded to Christopher, but he died. I didn't let myself bond to Michael when I was carrying him."

I felt a tingling in my arms and a clutching in my chest. Tears came to my eyes as I watched them run freely down her cheeks. We sat this way for a while, living in the unbearable pain of her loss.

With Emily I wondered aloud if getting pregnant so quickly had prevented her from doing the difficult work of grieving the loss of her first child. She said to me, "I feel like I can't give all of myself to Michael. I have to hold back to protect myself." 

At that visit with me, perhaps fortified by our moment of connection, of true empathy, she found the courage to face this task of grieving. She recognized it was critically important not only for herself, but for her relationship with her infant son.

 Sometimes there is urgency to telling these stories, to protect the next generation from the effects of unprocessed grief by enabling parents to be fully emotionally present with their children. In the case of war or massive social trauma, the work of mourning may need to be done generations later, when people are safe and comfortable and do not fear for their lives.

The French psychoanalysts I refer to in my previous post on this subject make the distinction between "big history," and individual family history, noting that the second can sometimes be a reverberation of the first. Gerard Fromm, in his book Lost in Transmission: Studies of Trauma Across Generations, elaborates on this notion through case histories from his work at the Austen Riggs Center.

A friend who knew I was writing about this subject recommended that I watch the first scene of the film Angels in America. It is the funeral of an elderly Jewish woman. The old rabbi looks out at his audience of adult children and grandchildren and, speaking of this woman's life, hardship and coming to America, says, "that ocean crossing lives in you." When they are spoke of or not, these stories live in subsequent generations, and demand to be told.

Gestational age and academic achievement: relationships at risk

A study published in the July issue of Pediatrics suggests that babies born at what is considered full term, but at 37-38 weeks, have lower academic achievement in third grade than those born at 39-41 weeks gestation. They found this effect to be independent of birthweight or an other social or economic risk factors. Authors examined birth records from a large inner city hospital, and then looked at achievement test scores of these children in third grade.  They write:

For example, children born at 37 weeks’ gestation were found to be 33% more likely to experience a severe reading deficit (defined here as 2 SDs below the mean) relative to children born at 41 weeks’ gestation.

I suggest that the issue be framed not as "are these babies at risk?" but rather "are these early relationships at risk?" When a baby is born at 37 or 38 weeks, parents are discharged home with the message conveyed that the baby is "normal." But  these babies may be more difficult to feed, may not transition as easily from awake to asleep, or may have more difficulty settling. In a supportive, relatively unstressed environment, these differences may be hardly noticeable. But in a stressed environment, including such things as single parenthood, postpartum depression or any number of social stressors, it may be more difficult for a parent to help a baby manage these biological vulnerabilities. As parents get overwhelmed by feelings of inadequacy, there may be a rapid downward spiral of increased fussiness and feeding problems, sleep deprivation and parental depression. It is likely that the stressed relationship, not simply the gestational age,  is linked to later academic achievement.

As I have written about in previous posts, the Newborn Behavioral Observation system offers a wonderful tool to support potentially at-risk mother-baby, and father-baby, pairs. It offers a way to help parents to recognize their baby's unique behavioral characteristics and ways of communicating. It can be performed in as few as 20 minutes in the hospital setting. Ideally such an intervention would be available to all parent-baby pairs. At the very least, when babies are born at 37-38 weeks,  these parent-baby pairs deserve a bit of extra time. Clinicians can assess if these types of problems of self-regulation are present, and if they are, support parents efforts to help their babies manage these vulnerabilities.

Certainly more research is needed, as the authors, suggest, to elucidate the mechanisms underlying the association between gestational age and academic achievement. In addition, exercising care with regard to elective deliveries before 40 weeks is important. But in my opinion, this study points to the need  invest resources to support newborn-parent relationships.  We know that the newborn period is a time of rapid brain development, and that the brain develops in relationship with the primary caregiver. That the newborn period may be linked to what happens at age eight should come as no surprise.

Sex and alcohol use by high school students on college visits

Recently I received an email alerting me to an important survey conducted by CARE about sex and alcohol use on overnight college visits for high school student applicants. I admit that despite practicing pediatrics for over 20 years, and having a high school senior in the thick of the college application process, I have not previously given this issue a moments thought. Certainly it seemed worthy of a blog post! The email read:

Roughly one in six surveyed teens (16 percent) who had been on an overnight college admissions visit reported drinking alcohol during the visit. Teens also reported engaging in sex or other intimate sexual behavior (17 percent), using drugs other than alcohol (5 percent) or driving while impaired (2 percent) during their overnight college visit. 

The study, conducted for CARE(Center for Adolescent Research and Education) and SADD(Students Against Destructive Decisions) by ORC International Inc. surveyed 1,070 U.S. teens from age 16 to 19, 270 of whom indicated they’d been on an overnight college admissions visit. It includes high school students currently making college visits and current college students reflecting on previous visits. Data was collected online between April 17 and 20, 2012.

Most concerning, in my opinion, is that for half of those kids, it was their first experience with sex or alcohol. This suggests that high schoolers visiting college may a particularly vulnerable group. They may be initiated into the world of college life before they are quite ready for it.  Below is a quote from A Higher Education, the Psychology Today blog post by Stephen Wallace, director of CARE:

New research from the Center for Adolescent Research and Education (CARE) at Susquehanna University and SADD (Students Against Destructive Decisions) reveals that  more than half (51 percent) of high school overnight visitors who reported drinking alcohol on campus (about one in six) report having done so for the first time.  Among those who reported having sexual intercourse (12 percent of those participating in an overnight visit), half (50 percent) said this had been the first time they had done so.

With regards to sexual encounters, it is quite likely, given the circumstances, that these are one time affairs. Such an experience may have negative consequences, particularly in the setting of emerging sexual identity.

The whole college application process challenges teenagers to focus, in what can and should be a healthy way, on their emerging sense of self and unique identity. For parents, offering background support and letting the child, with the help of college advisors, guide the process, is an excellent approach.

This survey, however, has opened my eyes to an issue that warrents parental involvement. Wallace offers some guidelines about addressing this issue, for both parents and teens. Every family has its own unique ways of communicating.  My hope is that in calling attention to the issue, it will help to prevent college bound teenagers from getting themselves into uncomfortable or unhealthy situations. 

Eliminate shame and blame from parenting: new study sheds light

In my behavioral pediatrics practice, it is not  uncommon for parents to go to great lengths to put up a good front. They feel terrible shame about moments of out-of-control behavior, and also fear that I will blame them for their child's troubles. They focus primarily on "what to do" about their child's difficult behavior. However with time, and the realization that I am interested in understanding, not shaming or blaming, they begin to open up about their own life and the enormous stress they experience in their parenting role. They acknowledge that this stress has often led them to yell at their kids or even remove themselves emotionally.

An important new study published in the current journal of the American Academy of Child and Adolescent Psychiatry provides evidence that a parent's early life stress, such as abuse, emotional neglect, or emotional abandonment, lives in the parent's body. The reactions mothers (the study is just about mothers, though fathers certainly face similar challenges) may have in the face of a child's aggressive or clingy behavior are biologically based. It is not simply that they are hitting because they were hit. The authors of the study draw on extensive animal research showing biological mechanisms for transmission of parenting behavior.

For example, when a child behaves aggressively in a way that is developmentally normal (though limits must be set) a parent with a history of early life trauma may have a surge of stress hormones that affect the functioning of his or her brain. Thinking is impaired. He or she may have a kind of fight-or-flight reaction, which may lead to aggression in return.  Another alternative is to shut down, or in psychological language to "dissociate." This leads to that sense of being emotionally disconnected. Neither are good for a child.

This study has major implications for understanding as well as treatment.  If a parent is frequently out-of-control, and is yelling at or hitting a child, or emotionally removing him or herself, it must be addressed. Focusing exclusively on the child's behavior will accomplish little in this situation. Repeated exposure to an angry, out-of-control or emotionally removed parent has significant impact on development.

If  parents can recognize that early life trauma has led to this kind of biological reaction, it may eliminate some of the guilt and shame. It may encourage them to acknowledge and address the problem. When children are young, there is ample opportunity to turn things in a better direction.

Second, if the problem is in the parents' body,  treatment needs to involve working with the parents body. Psychotherapy can be important as a way to develop insight into the impact early life experience. But this kind of work can take time. A more immediate intervention involves helping a parent to recognize the stress reaction and then to develop tools to combat it.

I am not talking about medication. While medication may calm a parent down, and may be necessary in  some cases, the hope is to identify the way a child's behavior provokes a parent, and develop strategies for remaining calm  in the moment. The mindfulness movement has much to offer in this regard. Deep breathing, yoga or simply a short walk can help to calm the body down. Music or art will work better for others.

When parents come to my office asking what to do about their child's "problem behavior," I don't think they expect that my answer will be "go for a walk." I am pleased that this current study will support me when in fact I do say something like that.

Giving thanks for fathers

This post is dedicated to my friend David, who passed away on June 13th after a battle with leukemia, leaving behind two young daughters. While we have not been in touch for many years,  we reconnected around his illness. We were roommates in medical school, and were very close before he moved to the West coast and life took us in different directions. Recently I spoke with a mutual friend, also a father  of two girls, who is godfather to one of David's  daughters. He described horsing around with the girls in the pool on a recent visit shortly before David died. Both David and my friend are athletes, and I could vividly picture the physical nature of David's relationship with his girls, and the important role our mutual friend will now play in their lives.

In my behavioral pediatrics practice I always encourage fathers to participate, and am most grateful when they come for visits.  Sometimes a mother has been dealing with with postpartum depression, and the father can offer a unique perspective. Other times, the father himself has been struggling emotionally, and we are able to address these issues and their relevance to parenting. In a previous post Supporting Fathers Emotional Health, I address this issue in detail. The bottom line is that fathers have an essential role to play in supporting a child's healthy emotional development.

Recently I was interviewed for an article in Parenting Magazine about things not to say when a child is having a tantrum. One was, "Just wait till your father gets home!" While threats of this nature are never  good, recognizing being "at the end of one's rope," and in such a moment drawing on the support of a perhaps more level headed partner is an excellent idea.

I never met David's wife, but my heart goes out to her. In addition to the grief of this terrible loss, she now is faced with the challenging task of managing these inevitable parenting moments without her other half to balance things out. l know from the chain of emails about his illness that there is an extensive support network of family and friends to take up that role. I hope she will make good use of them.

David is still very much alive in my mind. I have vivid memories of him as a thoughtful, smart and really funny person. While I never saw him in his father role, I am certain that he was much more to his daughters than a great playmate. Father's day will be one of many difficult days ahead for this young family. I know those close to them will help them to hold on to their many wonderful memories of David.

In celebration of his spirit, I give thanks for the fathers in my life- both the father of my children and my own father. I hope others will do the same.

Taking stimulants for SATs: sadly we taught them that

As a general and behavioral pediatrician I admit that I have participated in many conversations that went something like this. In a child's presence a parent says: "He does well in his morning classes, but then his grades are down in the afternoon-can we use something longer acting?" Or, "She did so well at first, but now she's getting 70's. I think she needs a higher dose." These conversations occurred in the setting of a brief follow-up visit for ADHD. These visits might be spread as far apart as 3 to 6 months. What else happened in those months? There was neither the time nor the expectation to address that question in a meaningful way.

Is it any surprise, given that this form, length and frequency of visits for ADHD is the standard of care in pediatrics, that now there is an explosion of abuse of prescription stimulants in the high pressure setting of the college application process? A recent New York Times article Risky Rise of the Good-Grade Pill addressing this issue states:

The number of prescriptions for A.D.H.D. medications dispensed for young people ages 10 to 19 has risen 26 percent since 2007, to almost 21 million yearly, according to IMS Health, a health care information company — a number that experts estimate corresponds to more than two million individuals. But there is no reliable research on how many high school students take stimulants as a study aid. Doctors and teenagers from more than 15 schools across the nation with high academic standards estimated that the portion of students who do so ranges from 15 percent to 40 percent.

My daughter is a senior at one of these "high-pressure private schools" referred to in the article. She confirms these statistics, putting the number at about one third. A previous post, Meds for ADHD: They Work But is that the Right Question?, was inspired by conversation in which she asked me about the ethics of taking these drugs for the SATs. In that post I speak to the need to understand ADHD as a problem regulation of attention, emotion and behavior, and to focus on relationship-based interventions to promote self-regulation. It is the hyperfocus on medication to the exclusion of both understanding of the child's experience, and also other forms of intervention, that has led to this problem in the high school setting.

Relationship-rich interventions include such things as martial arts, music, and team sports (Michael Phelps had severe ADHD), activities that foster relationships and also promote self-regulation. Family systems are often severely strained when a child is struggling, and interventions aimed at supporting the family as a whole are very important. Careful examination of the school setting and accommodations to decrease over-stimulation are similarly necessary. But if the drug makes the symptom go away, there is no motivation to devote effort and resources to make these kinds of changes.

When I asked my daughter today if she had ever taken stimulants before a test she replied that she thought it was a silly idea. Her reason? "If you do well on stimulants it's not really you, and you will end up at a college where you will be miserable. Then you will need to keep taking the drugs." Such a wise child!