Sleep and childhood behavior problems: a complex relationship

A study published in the July/August issue of the Journal of Developmental and Behavioral Pediatrics showing a connection between hours of sleep and childhood behavior problems has received a lot of media attention. Children who slept less than 9.4 hours of sleep had more impulsivity, anger, tantrums and annoying behavior. The obvious conclusion-more sleep, better behavior. If only it were that simple.

If one takes the time to look closely, one will discover that what is correctly described as an "association" in the original article is in fact two interlinked phenomena that have a common underlying cause. Sleep problems are behavior problems. To know the cause, one must know the family story.

Sleep is a developmental phenomenon. In infancy a child learns what is commonly called "sleep associations." The breast, a pacifier, a lovey or even a parent's hair may be what a child associates with falling asleep. Frequent night wakings, expected by parents in the early weeks and months, can become a problem if that sleep association requires a parents' physical presence. As the months wear on parents become severely sleep deprived, and often find that this pattern is not so easy to change. In toddlerhood as a child in a normal healthy way begins to assert his independence, he may resist bedtime in the way he says "no" to many things. Further complicating the picture is the fact that sleep represents a major separation. A child who handles the first day of preschool with grace may suddenly refuse to go to bed, or begin waking during the night.

Given the complexity of this process, there are many ways it can get derailed. If parents do not agree about teaching a child to sleep independently, a child in the bed can cause significant marital discord.  When  parents struggle with depression, and this includes both fathers and mothers, they will have aggravation of symptoms, which often includes irritability. in the setting of sleep deprivation. When a parent is quick to lash out at a child, he may become anxious. Sometimes this anxiety leads to "acting out" in the form of oppositional behavior. It seems illogical, but a two-year-old doesn't know how to say "I need you to be with me and I feel sad when you are angry." He may simply see that when he is "difficult" his parents are more engaged with him. Separation anxiety is common in these situations, and sleep is a major separation.  Bedtime refusal and frequent night wakings are common in this setting. This leads to a vicious cycle as both parent and child become increasingly irritable.

These are some examples, and there are as many different stories as there are families. By the time parents come to see me at the Early Childhood Social Emotional Health Program with behavior problems, which in my experience always include sleep problems, they may be hard pressed to describe moments of joy with their children.

I feel for the parent who reads an article with the title More Sleep Might Help Tots' Tantrums, with its recommendation to have a child get more sleep to improve behavior, and is unable to change the situation because the underlying cause is not addressed. This is where our culture of advice and quick fixes can lead parents to be overwhelmed by feelings of inadequacy and guilt.

The key to treating these complex problems is to give parents space and time to tell the full story. When parents themselves feel heard and understood, they are in a better position to be curious about the meaning of their child's behavior.

This study is important because it calls attention to the need to address sleep in the setting of behavior problems. However, when a child and family are struggling, simple recommendations have a child get more sleep are not only not helpful, but may make parents feel worse. A downward spiral of sleep deprivation and behavior problems will likely persist.

If a family and clinician has the time, then it is possible to make sense of the situation and take steps to set the whole family on a better path; to bring joy back in to relationships.  The younger the child, the easier this is to do.

How to grow a baby's brain

The Grow America Stronger Campaign was created to organize support for funding for investment in early childhood. This month the theme is early brain development. In support of these efforts I am publishing a short segment from my book Keeping Your Child in Mind that elaborates on how relationships grow the brain. It is a companion piece to my previous post that speaks to the need to support and value parents. Today's Rally 4 Babies, with featured guests Secretary of Health and Human Services Kathleen Sebelius, Secretary of Education Arne Duncan, and actress Jennifer Garner, will address the need for social policy supporting early learning.

A very brief discussion of the structures of the brain responsible for regulating emotions will, I hope, serve to demonstrate how parents can promote their child’s brain development in a healthy way… Research at the interface of neuroscience and infant development is offering great insights into how the exchange of looks between mother and baby actually grows the brain. Researchers have learned a great deal about infant development from a combination of detailed video observations of mothers and infants interacting and MRI studies of the brain in action. These imaging studies can actually see which parts of the brain are responsible for what behaviors. This research has shown that healthy wiring of a baby’s brain depends on attuned responses of caregivers. These responses can consist not only of words, but also looks, touch, sound of voice, and facial expressions.

A part of the brain called the medial prefrontal cortex (MPC) is primarily responsible for emotional regulation. When a person has a well-developed MPC, he experiences a sense of emotional balance. He can feel things strongly without being thrown into a state of chaos. The MPC controls and regulates the amygdala, a tiny, almond-shaped structure that is significantly more developed in the right brain and is responsible for processing such strong emotions as terror. Trauma researcher Bessel van der Kolk refers to this area as the “smoke alarm of the brain.” This structure, via another part of the brain called the hypothalamus, connects with the glands responsible for re- leasing stress hormones such as adrenaline and cortisol. These hormones give us the physical sensations of stress. 

The development of the amygdala begins in the third trimester of pregnancy; it is fully formed at birth. Development of the MPC begins in the second month of life and continues well into a person’s twenties. By virtue of its location, the MPC literally hugs the amygdala. It serves to regulate and control the smoke alarm and in turn the powerful “fight or flight response.”

A third important part of the brain responsible for emotional regulation is the insula. The insula, another primarily right brain structure, connects with the visceral organs of the body, including the heart and intestines, as well as the skin. When experiencing empathy for another person, one often has a number of physical sensations, such as a tightening in the chest and tingling in the skin. These physical experiences of empathy, literally feeling what another person is feeling, are mediated by the insula. Mirror neurons, a special set of neurons first discovered in the early 1990s, are also thought to be important in the experience of empathy. They activate when a person is either doing something or watching another person doing something. They seem to code for not only the action, but also the goal or intention of the action. Thus they may play an important role in interpretation of the meaning of another person’s behavior. The insula, and perhaps the mirror neurons as well, play a critical role in attunement and the sense of being understood by another person.

When these connections are not well developed, intense emotions are not well regulated. In the face of fear, for example, a person may be flooded with stress hormones. However, with a well-developed MPC, she will experience the feeling, but her hormonal response will be turned down so that she is not overwhelmed. If, on the other hand, she does not have a well- developed MPC, the amygdala will go off unrestrained, and she will be flooded with fear that she cannot manage. In the face of overwhelming distress, she cannot make use of the parts of her brain responsible for rational thinking. She may become completely overwhelmed and be unable to function. In fact, the amygdala is overactive in post-traumatic stress disorder (PTSD) and all anxiety disorders. 

When a parent gazes into her baby’s eyes, she literally promotes the growth of her baby’s brain, helping to wire it for a secure sense of self. The MPC has been referred to as the “observing brain.” It is where our sense of self lies. When a mother looks at a baby in a way that tells her, not with words but with feelings, “I understand you,” the baby begins to recognize herself, both physically and psychologically. This mutual gaze, in which the baby is literally and figuratively “seen,” actually encourages the development of the MPC and with it her sense of self. As her brain matures in this kind of secure, loving relationship, it becomes wired in a way that will serve her well for the rest of her life. She will be able to think clearly and to regulate feelings in the face of stressful experiences.

Obama Rallies for Babies to Grow America Stronger

President Obama is investing in our future by investing in early brain and child development.  The July 8th event, Rally4Babies, sponsored by Zero to Three, was organized to call attention to the importance of this investment. Obama's "Preschool for All" proposal in its entirety can be seen on the Grow America Stronger website that describes the research behind the Early Childhood Initiative. It includes a link to sign a petition in support.

I was very pleased to learn that while the main focus of the proposal is on preschool, it includes a good deal of funding for programs for infants and very young children. For example, the voluntary home visiting program allocates $15 billion over 10 years to expand home visiting services for families with very young children. The proposal speaks of "evidence-based home visiting programs [that] demonstrate improved maternal and child health in the early years, long-lasting positive impact on parental skills, and enhanced children's cognitive, language, and social-emotional development and school readiness." The Nurse-Family Partnership is one such evidence-based program.

In my book Keeping Your Child in Mind, essentially an argument for his proposal, I outline all of the contemporary research and knowledge at the interface of developmental psychology, neuroscience and genetics supporting this investment in early childhood (although I examine the issue from the perspective of health care, rather than education.) This excerpt offers an explanation for the success of home visiting programs.

John Bowlby, describing the essential role of attachment relationships in survival, 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 also recognized the need for a mother to have a secure base of her own in order to provide this security for her child:

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 if the grandmother is not nearby or is deceased, this relationship can provide the secure base she needs when she becomes a mother.

It is not uncommon in our culture for a mother to raise her children without benefit of her own secure base (and most do not have help with household chores!!). Families are fragmented by geography and/or divorce. A spouse may be relied upon both to be the breadwinner and sole emotional support, which can put significant strain on a marriage. Many new mothers I see describe highly troubled relationships with their own mothers, full of grief and loss.

A home visiting program provides such a secure base to at-risk families. In our society today, where many live in poverty and families are fragmented, many mothers are raising children without a secure base of her own.

When a parent herself has experienced abuse, providing such a secure base is especially difficult. The home visiting programs share much in common with Selma Fraiberg's original infant mental health program, described in this excerpt.

This way of thinking about and working with children and families is well described in a relatively new field known as “infant mental health.” The field grew out of the work of Selma Fraiberg, a child psychoanalyst who, in her groundbreaking 1974 article “Ghosts in the Nursery,” described 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 homes, the staff 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. It was different from therapy with the mother. The aim of the intervention was to help the mother connect with her child in a meaningful way.

This intervention, and others modeled on Fraiberg's approach, actually serves to wire healthy brains, as described in this excerpt (stay tuned for more on this subject in my next post):

Contemporary research in neuroscience reveals that a child’s brain develops in relation to other people, not simply on its own. When parents are attuned to their child’s emotional experiences, new connections are formed that control the way that child regulates her experience. These relationships actually wire the brain. This is particularly true in the first year, when the volume of the brain doubles, but relationships can continue to shape the structure of the brain well into adulthood. 

Quality preschool is for all is a good thing. But equally, if not more important, is finding a way to provide a secure base for all new parents, with the aim of supporting their efforts to provide such a secure base for their children.  Currently the United States lags significantly behind many countries in the value we place on parents and young children (A lovely alternative example is Finland, where every expectant mother receives a box of baby goods-a baby box- from the Finnish state social services agency.) Fortunately, not only does Obama recognize this fact, but he also understands that remedying the situation is essential for the future of our country.

The made-up reality of psychiatry's new DSM 5

A member of the American Psychoanalytic Association posted the following on an internal email list, and I am reproducing it with permission. It captures the kind of circular reasoning behind the current paradigm of psychiatry as represented by DSM 5. As in "we define the disease by these symptoms, therefore if you have these symptoms, you have the disease."

The following two questions were published in a recent (June 8) issue of Psychiatric News and also distributed by APA in an email message, apparently as part of a PR quiz program to popularize the DSM-5.  However, I'm posting them here to convey an idea of what many of us feel has gone wrong in American Psychiatry in the last decades.  Each of these clinical vignettes describes a patient with some kind of mental disorder.  Each vignette ends with a quiz question. Fair enough.

However, I have changed to UPPER CASE some words in the two questions to which I'd like to call your attention.  Note in both cases, the question is phrased in such a way that the task is to decide which of the listed DSM-5 entities CAUSED the patient's symptoms and clinical "picture" described in the vignette.  However, the real task is to try to guess which set of symptoms listed in the DSM-5 most closely matches the patient's symptoms.

Framing the questions as they are indicates a mind set that these DSM-5 "disorders" are "real" things which are somehow present in the patient (like a bacteria) and which then CAUSE the patient's symptoms.  In actual fact, because there are no such entities other than in the DSM-5's attempt to classify the myriad variations of human mental disorders into convenient slots, the actual meaning of psychiatric diagnoses in the current state of our knowledge is being turned on its head in the minds of contemporary (biologically based) psychiatric thinking. As you know, in the DSM-5 all "disorders" supposedly reflect an "underlying psychobiological dysfunction" which then leads to the conclusion that all one has to do is to discern the biological mechanism underlying the disorder, find the right pill, and voila!  Cured! What a great doctor!  What a great specialty!!

He then quotes the two quiz cases.

 A 65-year-old woman reports being housebound despite feeling physically healthy. She reports falling while shopping several years ago; although she sustained no injuries, the situation was so distressing to her that she becomes extremely nervous when she has to leave her house unaccompanied. She has no children and few friends. She is very distressed by the fact that she has few opportunities to venture outside her home. Which of the following disorders BEST ACCOUNTS FOR her disability?

a) specific phobia*situational subtype

b) social anxiety disorder

c) posttraumatic stress disorder

d) agoraphobia

e) adjustment disorder

 A 35-year-old man is in danger of losing his job; the job requires frequent long-range traveling, and for the past year he has avoided flying. Two years prior, he traveled on a particularly turbulent flight, and although he was not in any real danger, he was convinced that the pilot minimized the risk and that the plane almost crashed. He flew again one month later, and although he experienced a smooth flight, the anticipation of turbulence was so distressing that he experienced a panic attack during the flight. He has not flown since. Which of the following disorders IS THE MOST LIKELY CAUSE of his anxiety?

a) agoraphobia

b) acute stress disorder

c) specific phobia*situational type

d) social anxiety disorder

e) panic disorder

He references a commentary in the very same issue of Psychiatry News entitled New Evidence Said to Challenge Psychiatry's Basic Paradigms that calls attention to the lost state of the discipline.

Psychiatry is at a crossroads, according to Patrick Bracken, M.D., Ph.D., clinical director of the West Cork Mental Health Service in Ireland, at APA’s annual meeting in San Francisco in May.

“Accumulating evidence challenges the current paradigm underlying psychiatric thinking and practice,” said Bracken. The problem lies deeper than just “too many drugs....”

Psychiatry is not like cardiology, he said. The mind is not simply another organ of the body, but encompasses relationships, values, and meaning.

Clearly a new paradigm is needed.  

Too many psychiatric diagnoses for children: an epidemic of labels

Allen Frances, professor of child psychiatry at Duke University and chair of the DSM IV(Diagnostic and Statistical Manual of Mental Disorders) task force hit the nail on the head in a recent commentary "Why So Many Epidemics of Childhood Mental Disorders?" in the Journal of Developmental and Behavioral Pediatrics. Because he makes his argument so clearly and persuasively (and the full article is only available to those who subscribe to the journal) I will quote it at length.

Since the publication of DSM-IV in 1994, the rates of 3 mental disorders have skyrocketed: attention deficit disorder (ADD) tripled, autism increased by 20-fold, and childhood bipolar disorder by 40-fold. It is no accident that diagnostic inflation has focused on the mental disorders of children and teenagers. These are inherently difficult to diagnose accurately because youngsters have a short track record; are in developmental flux that makes presentations transient and unstable; are sensitive to family, peer, and school stresses; and may be using drugs. If ever diagnosis should be conservative, it should be in kids. Instead, we have experienced an unprecedented diagnostic exuberance encouraged in part by DSM-IV, but mostly stimulated by the powerful external forces of drug company marketing and the close coupling of school services to a diagnosis of mental disorder.

He gives the example of ADHD, describing how the revisions to DSM IV had anticipated a jump in diagnoses in girls with the additon of an "inattentive" subtype. But in fact there was an unexpected tripling of ADHD rates and parallel increase in use of psychiatric medication. He writes:

Three years after DSM-IV was published, drug companies introduced new and expensive on-patent drugs that provided the incentive and resources for an aggressive marketing campaign to psychiatrists, pediatricians, and family doctors. Simultaneously, successful drug company lobbying gave them unrestricted freedom to advertise directly to consumers. Parents and teachers were inundated with the message that ADD was terribly underdiagnosed and easily treated with a pill. Sales of ADD drugs ballooned to an astounding $7 billion.

He then moves on to bipolar disorder:

Childhood bipolar disorder is an even more chilling case. DSM-IV had wisely rejected a proposal that there be a separate and much looser definition of bipolar disorder in children. The argument for inclusion rested on the unreplicated findings of just 1 (albeit very influential) research group suggesting that kids present a developmentally different prodromal form of bipolar disorder characterized by ambient irritability, impulsivity, and temper outbursts, rather than the typical cyclical mood swings of adults. Rejection by DSM-IV did not stop charismatic thought leaders (who were heavily financed by drug companies) from spreading the gospel of childhood bipolar disorder. The 40-fold increase in rates was accompanied by an increase in antipsychotic spending up to $18.2 billion in 2011. These drugs frequently cause massive weight gain in children. The overuse of antipsychotics in kids was not deterred by the fact that childhood obesity is an important risk factor for diabetes and heart disease. Drug companies have received billion dollar fines for off-label marketing to kids, but these pale in comparison to the enormous revenues. Of note, the inappropriate use of antipsychotics is most pronounced among children who are economically disadvantaged.

He then accurately depicts the link between the rise in diagnoses of autism with the fact that a diagnosis is needed for a child to receive appropriate services:

The introduction of Asperger's by DSM-IV was expected to result in a 3- to 4-fold increase rates of autism. Severe classic autism had an unmistakable presentation with rates lower than 1 per 2000. Asperger's blends imperceptibly into normal eccentricity, and the rates of autism are now reported at 1 per 88 in the United States and 1 in 38 in Korea. Theories connecting the increase in prevalence to vaccination have been discredited. Instead, the rates have grown so rapidly because a diagnosis of autism is required to allow a child access to greatly enhanced school services. About half the youngsters who now receive the diagnosis do not really meet the DSM-IV criteria when these are carefully applied. And follow-up studies finding that half the kids no longer meet criteria also confirm that diagnostic inflation is rampant. Eligibility for school services should be decoupled from an unreliable clinical diagnosis and instead be based on educational need. 

The challenge, and Frances does acknowledge this fact, is to avoid over-diagnosis while at the same time not undertreating those who need help. Most of the children who receive these labels, and their families, are struggling in significant ways. They do need help,  and sometimes lots of it. The issue is inextricably linked with the need to "name" the problem, a need comes in part from both clinicians and parents, who may feel more of a sense of control if what they are struggling with has a name, and also insurance companies who require a diagnosis for reimbursement of services.

Psychiatric diagnoses in children, by definition, place the problem squarely in the child, when in fact it is almost always more complex than this. Genetic vulnerability and environment both have an important role to play. A recent article in the Archives of Diseases of Childhood; Poverty, Maltreatment and Attention Deficit Hyperactivity Disorder offers insight in to this complexity:

This paper hypothesises that the population of children receiving a clinical diagnosis of ADHD is aetiologically heterogeneous: that within this population, there is a group for whom the development of ADHD is largely genetically driven, and another who have a 'phenocopy' of ADHD as a result of very adverse early childhood experiences, with the prevalence of this phenocopy being heavily skewed towards populations living with poverty and violence. A third group will have a high genetic risk and have been exposed to violence.

The key phrase here is "aetiologically heterogeneous." Psychiatric labels, be it "ADHD" "bipolar disorder" or "autism," are artificial constructs that provide a false sense of simplicity.  When I see a child and family in consultation, the aim of the work is to take the time to listen to the story and understand where, and it may be in several places, the "problem" actually lies. In order to help these children and families in a meaningful way, we need to be able to, in the words of one of my mentors Ed Tronick, "embrace complexity."

Pediatricians and prevention of toxic stress

The Harvard Center on the Developing Child has produced a new video: Building Adult Capabilities to Improve Child Outcomes: A Theory of Change. The video wisely identifies the need to support the adults in a child's life in order to promote long-term health, both physical and emotional. It points to the abundance of scientific evidence showing the need for providing safe and secure relationships in early childhood to reach these goals. Exposure to stress in the absence of such safe, secure relationships is termed "toxic stress."

As pediatricians have regular contact with young children and their families, the need to translate this research in to the clinical setting of pediatric practice is clear. The American Academy of Pediatrics (AAP) has embraced this task. The 2013 AAP national conference titled Early Brain and Child Development: Building Brains, Building Futures, will present the science of early childhood.

In addition, concurrent with the release of the above video are a number of publications addressing the need to integrate the research in to practice. One article, Listening to the Baby's Brain to Reduce Toxic Stress: Changing the Pediatric Check Up to Reduce Toxic Stress  describes new interventions.

Purposeful Parenting materials, for example, emphasize “face time” with infants, a type of “serve and return” interaction fundamental to the wiring of the brain: When an infant smiles, the caregiver should smile back—and should do so repeatedly throughout the day. When infants learn early on that smiling, then cooing, then words, are the best way to get attention, they keep using those strategies. But if face time fails to occur frequently enough, infants may learn less healthy ways—such as crying or whining—to get the attention or support they crave. The lack of something as simple as face time can lead to more infant stress and less healthy ways to cope with stress in the future.

This recommendation appears to draw on the powerful research of Ed Tronick showing the distress caused to an infant when a caregiver presents an unresponsive "still-face." His research has shown that when a caregiver is attuned with an infant in 30% of interactions, and if the remaining misattunements are recognized and repaired, the child develops a positive affective core-  an ability to experience joy and connection.

Given these findings, the AAP recommendation is a good one. But most caregivers intuitively provide this attunement without needing anyone to tell them what to do. They naturally experience what D. W. Winnicot termed "primary maternal preoccupation," acting as what he called the "ordinary devoted mother." When they do not, simply telling them to smile at their baby will likely be ineffective. This is where the link to the video comes in. To "build adult capacities" in this situation, there needs to be an opportunity to listen to that parent, who may be struggling with postpartum depression, may be socially isolated, or may herself have been abused.

Fortunately the AAP model also looks at the larger context. The director of Developmental and Behavioral Pediatrics at Yale University is quoted:

In order to make these changes, Weitzman says, pediatricians will need broad systemic changes to support them, including better medical training, payment systems, treatment options, and help to coordinate care.

What is needed is space and time to listen. That includes listening to the pediatricians who are themselves under tremendous pressures. This need is addressed my book Keeping Your Child in Mind, whose  second chapter  is titled "Strengthening the Secure Base: Listening to Parents." The book demonstrates this idea of supporting adults with the aim of supporting children, showing what this approach looks like from infancy to adolescence, as seen from the front lines of pediatric practice. It concludes:

 If those who care for children and families on the front lines have the time to develop these relationships, if there is a strong system of mental health care to support families who are struggling and a medical education system that encourages clinicians to listen to parents’ stories, we will be well on our way. The image comes to mind of a set of Russian dolls. When the health care system allows the primary care clinician time to listen to the whole of parents’ experience and to support their inherent wisdom and intuition, parents are enabled to be fully present with their child. In other words, the system holds the clinician, who holds the parents, who hold the children. 

NYT on mental illness, talk therapy, drugs: what about children?

Last week there was an invitation to dialogue in the New York Times on this subject.  In today's Times there is a fascinating array of responses, but none addresses the issue as it relates to children, for whom there has been an exponential rise in prescribing of psychiatric medication in the last decade. Here is the letter I sent in.

We live in a culture of advice and quick fixes. Increasingly, understanding of human experience is reduced to lists of symptoms, diagnosis and medication. There is less curiosity, less careful listening to one another.

Talk therapy, which perhaps should be called “listening therapy,” offers space and time to create a meaningful narrative, including an opportunity to experience feelings of grief and loss.

This is particularly important in work with children. When symptoms are medicated away, the opportunity to tell stories that give meaning to behavior may be lost. Research has shown that a child’s knowledge of family narrative, both the ups and downs, is highly correlated with self- esteem, resilience and mental health. Giving a parents an opportunity to tell their story to a nonjudgmental listener, to integrate their own narrative,  is critical to treatment of childhood “behavior problems.”

I am not advocating for talk therapy for children. Rather, in order to help children who are struggling with a range of "behavior problems," it is essential to listen to their parents, to give them an opportunity to reflect on the meaning of behavior. The behavior is a symptom, perhaps even an adaptive response, to the underlying problem. There is extensive evidence, that I describe in my book Keeping Your Child in Mind, that when parents reflect on the meaning of behavior in this way, they have the opportunity to promote healthy development at the level of gene expression and structure and biochemistry of the brain.

In my practice, where I see children under the age of five, parents typically present with concerns like, "he never listens" or "she is defiant." But as we take the time to think about how the problem developed, meaningful shifts in understanding occur. For example, parents may recognize the way a child's behavior pushes their buttons because of their own history of abuse. Or serious marital conflict, that often has zeroed in on the child's behavior, comes to the fore.  Or the impact of an easygoing sibling may be recognized. Tantrums and meltdowns at birthday parties may be understood in the context of a child's longstanding difficulty with processing sensory input.

Creating this narrative, this story that makes sense of the problem, may only be the beginning of the treatment. Intensive work with parent and child together, to address the way the child's behavior provokes the parent, is often indicated. Marital counselling, or even working with a couple who are not together, to help them work together to support their child may be necessary. Quality occupational therapy can be invaluable to help a child to feel calm in his body. Parents may benefit from things such as yoga to help them to calm their own reactions.

Here is where the trouble really starts. Quality clinicians who offer these services are in short supply. Insurance is often a huge obstacle. But, creating perhaps an even bigger obstacle, is the cultural norm of the "quick fix" approach of medicating symptoms, even in children as young as 5.  Not only must parents overcome these obstacles of finding a provider, making the time, allocating funds, as well as doing the important but often challenging emotional work of addressing these issues. They must go against pressure from teachers, relatives, friends and  health care providers.

I will continue to offer parents space and time to be heard, to create meaningful narrative, because I am confident that telling stories, and working through the feelings of grief and loss that often accompany them, is the path to meaningful connection and healthy emotional development.  It causes me great heartache when these efforts are thwarted by a system that works in opposition to this approach.