Take new smartphone use study with a hefty dose of empathy for parents

A new study documenting the ubiquitous use of smartphones by parents at fast food restaurants with their young children is getting a lot of media attention. From Time magazine there is this headline: " Don't Text While Parenting- It Will Make You Cranky." "Put Down that Cellphone" from NBC. "Parents on Smartphone Ignore Their Kids," from ABC News.

I doubt that anyone is surprised by the findings of this study. People everywhere are on their smartphones all the time. In the arena of parenting, it is important to call attention to the impact of this behavior. There is extensive evidence that face-to-face interaction is critical for healthy emotional development. Mealtime offers an important opportunity for this type of interaction, especially in today's fast-paced culture.

However, I worry about the parent blaming tone of these headlines. Rather than saying, "This is bad, don't do it," perhaps we should be curious about why parents are using smartphones in this way.

One answer lies the increasing recognition of the addictive nature of these devices. Everyone, not just parents in fast food restaurants, is using smartphones all the time. The other may lie in the fact that parents, especially parents of young children, often feel alone, stressed and overwhelmed. Putting these two together and the allure of the screen becomes understandable.

The American Academy of Pediatrics press release states:

The study raises several questions for future research, including ...what are the long-term effects on child development from caregivers who frequently become absorbed with a device while spending time with their children.

I think we already know the answer to this question. I wonder if another important question might read: "How do we support parents in being more fully present with their young children, given the combination of high stress and an easy available, socially acceptable addictive device?"

Legal marijuana, antidepressants, and the danger of not listening

 A popular blog post Why I Tried to Kill Myself at Penn is making its way around the college-age crowd. The author calls attention a high-stress a culture that does not value listening.

During my sophomore year at Penn, I tried to kill myself by swallowing a bottle of Wellbutrin. I spent 4 days in the hospital.
Penn’s response? – Sending some administrator to see me in the hospital (HUP). The first and only thing that she said was, “Are we going to make this an annual pattern?” because I had been hospitalized the year before. I said “No” and she gave me her business card.
After suicides, everyone laments, “Why didn’t they talk?” Often, we did. People just didn’t want to listen, because in the moment it was easier for everyone if you put on a smile and pretended to be okay.

A parent recently described calling the emergency student support services when she was worried about her son's emotional state during his first semester at college. After a five minute conversation, she was told by the person who responded to her call, " We can make an appointment with the psychiatrist to see if he needs medication."

I thought about these two stories when a study, a survey of 1,829 people being prescribed antidepressants, was released showing a much higher than expected rate of serious psychological side effects:

Over half of people aged 18 to 25 in the study reported suicidal feelings and in the total sample there were large percentages of people suffering from 'sexual difficulties' (62%) and 'feeling emotionally numb' (60%). Percentages for other effects included: 'feeling not like myself' (52%), 'reduction in positive feelings' (42%), 'caring less about others' (39%) and 'withdrawal effects' (55%). However, 82% reported that the drugs had helped alleviate their depression. 

Professor Read concluded: "While the biological side-effects of antidepressants, such as weight gain and nausea, are well documented, psychological and interpersonal issues have been largely ignored or denied. They appear to be alarmingly common."

Psychiatric medication side effects are a double-edged sword. The first, that receives the most, though as indicated by this study insufficient, attention is from the medication itself. But the second, and equally if not more serious, is the way prescribing of psychiatric medication becomes a replacement for listening.

What makes us human is our ability to empathize. Drawing from both Buddhism and psychoanalysis, the "presence of mind" of another person is responsible for therapeutic healing. "Being with," "bearing witness," are other phrases that describe this phenomenon. When we jump to a pill we run the risk of skipping this step. If the medication itself also has psychological side effects, it is not surprising that, in combination with feeling alone and unrecognized, a person might attempt suicide.

Psychiatric medication may be necessary when an individual is unable to function without it. Ideally such a determination is made in the setting of both psychotherapy and other self-regulating activities such as yoga or meditation. But that is not the way these medications are used. Because they can be so effective at eliminating distress in the short term, our fast-paced, quick-fix culture makes them very appealing, almost irresistible.

I decided to include the topic of legalization of marijuana in this post as a kind of cautionary tale. In California cannabis is commonly prescribed to treat anxiety. Psychiatric diagnoses and drug prescribing are often based on symptoms alone, as is well captured in this amusing though disturbing anecdote from a Psychology Today post by psychologist Jonathan Shendler:

During my first week as a psychiatry department faculty member, a fourth-year psychiatry resident—I will call her Gabrielle—staffed a case with me. She gave me some demographic information about her patient (38, White, female) and then proceeded to list the medications she was prescribing. The rest of our conversation went something like this:“What are we treating her for?” "Anxiety." "How do we understand her anxiety?"Gabrielle cocked her head to the side with a blank, non-comprehending look, as though I had spoken a foreign language. I rephrased the question.“What do you think is making your patient anxious?”She cocked her head to the other side. I rephrased again.“What is causing her anxiety?"
Gabrielle thought for a moment and then brightened. “She has Generalized Anxiety Disorder.”“Generalized anxiety disorder is not the cause of her anxiety,” I said. “That is the term we use to describe her anxiety. I am asking you to think about what is making your patient anxious.”She cocked her head again.“What is going on psychologically?”“Psychologically?”
“Yes, psychologically.”There was a pause while Gabrielle processed the question. Finally she said, “I don’t think it’s psychological, I think it’s biological.”

As we are on the cusp of general legalization of marijuana (that I do not oppose) it becomes imperative that psychiatric medications not replace listening. It is essential that we protect time and space for being present, for curiosity, for empathy. Otherwise we are simply offering another way, and one that is not without side effects itself, to devalue the role of human relationships in healing.

ADHD, bipolar disorder and the DSM: A need for uncertainty?

A recent article in the New Republic, provocatively titled “ADHD Does Not Exist,” starts out well enough. The author, a psychiatrist with “over 50 years experience” points to the fact that ADHD describes a collection of symptoms, rather than their underlying cause. Using stimulants to control these symptoms, he argues, is analogous to prescribing pain medication for cardiac chest pain rather than addressing the underlying circulatory problem.  But my antennae went up when he applied his views to a case, and concluded that his patient, a 12-year-old-boy, was misdiagnosed with ADHD, when in fact he had bipolar disorder. My level of alarm rose when he went on to describe his treatment:

In William’s case, the family agreed to try medication first without psychotherapy, to see what kind of impact the pharmaceutical treatment could have. The first medication we tried, an anti-seizure drug commonly prescribed for bipolar disorder, reduced the boy’s mood and behavioral symptoms dramatically but resulted in side effects including upset stomach and dizziness. We started William on lithium, and within two months we found a dosage that worked well for him, reducing his symptoms to very mild levels, with no significant side effects.

There is no mention of developmental history or family relationships. There is no exploration of the context in which these symptoms occur, and certainly no evidence that William’s experience being bounced from medication to medication is being considered.  Dr. Saul in essence replaces one treatment of symptoms without determining the underlying cause with another treatment of symptoms without addressing the underlying cause.

The author points to a strong family history of bipolar disorder to support his diagnosis. Statistics from the National Institute of Mental Health indicate that when a parent or sibling has bipolar disorder, a child is up to six times more likely to develop the illness.

But when it comes to an individual child and family, not only are statistics meaningless, but they may also preclude exploration of the underlying cause of the child’s symptoms. These symptoms are usually due to a complex interplay of biology and environment. Statistics do not speak to the effect of early intervention in decreasing the risk. 

Consider Jacob, a five-year-old boy I saw recently in my behavioral pediatrics practice. He was adopted, and two biological relatives had bipolar disorder. A pediatrician, his adoptive parents and a neurologist suspected that he too had the disorder. But with space and time to hear the story, the following emerged.

Jacob had been an easy baby. Then when he was about two, he experienced a number of significant losses. A foster child with whom he was very close was removed from the home because of behavior problems. Just weeks after his adoptive mother, Alice, learned she was pregnant, her sister died suddenly of a cerebral hemorrhage. Jacob’s maternal grandmother, in the face of the loss of her own daughter, threw herself in to caring for Jacob’s baby sister. 

Jacob’s mother wept in my office as she spoke of her own loss, not only of her sister, but also of her mother who withdrew in the face of her grief. Shortly after these events, Jacob’s behavior problems began in earnest. He became alternatively clingy and aggressive. When I saw the family, no one had slept through the night for a long time.

Jacob might very well have a biological vulnerability to emotional dysregulation inherited from his parents who carried the bipolar label. But multiple losses, subsequent disruptions in attachment relationships, sleep disruption, and other factors had significant roles to play in development of his symptoms. Had he, like William, been prescribed medication for his symptoms, this story, and the meaning of his behavior, would not have been heard. For every child I see in my practice, there is a story, often equally complex, behind the symptoms. 

Rather than offer time and space for the nuances, complexities and uncertainties of human behavior and relationships, the DSM (Diagnostic and Statistical Manual of Mental Disorders) paradigm, with its diagnoses of disorders based on symptoms, often followed by prescribing of medication, creates an aura of certainty, as in “you have X and the treatment is Y.” But there is virtually no evidence of any known biological processes corresponding to either ADHD or bipolar disorder (or any other DSM diagnoses, for that matter.) This certainty implied in the giving of a diagnosis and prescribing of medication has a kind of comfort, but also a real danger. There is no room for curiosity, for wonder, for not knowing.  Jacob’s behavior was a form of communication. Giving medication to control his behavior is in effect a silencing of that communication.

A recent New York Times article, “The Dangers of Certainty,” addresses this issue in a very different context. The author describes how he was profoundly influenced by the 1973 BBC documentary series, “The Ascent of Man,” hosted by Dr. Jacob Bronowski. The article describes an episode in which Bronowski discusses Heisenberg’s uncertainty principle.  

Dr. Bronowski’s 11th essay took him to the ancient university city of Göttingen in Germany, to explain the genesis of Werner Heisenberg’s uncertainty principle in the hugely creative milieu that surrounded the physicist Max Born in the 1920s. Dr. Bronowski insisted that the principle of uncertainty was a misnomer, because it gives the impression that in science (and outside of it) we are always uncertain. But this is wrong. Knowledge is precise, but that precision is confined within a certain toleration of uncertainty….Dr. Bronowski thought that the uncertainty principle should therefore be called the principle of tolerance. Pursuing knowledge means accepting uncertainty. ..In the everyday world, we do not just accept a lack of ultimate exactitude with a melancholic shrug, but we constantly employ such inexactitude in our relations with other people. Our relations with others also require a principle of tolerance. We encounter other people across a gray area of negotiation and approximation. Such is the business of listening and the back and forth of conversation and social interaction. 

As he eloquently put it, “Human knowledge is personal and responsible, an unending adventure at the edge of uncertainty.”The relationship between humans and nature and humans and other humans can take place only within a certain play of tolerance. Insisting on certainty, by contrast, leads ineluctably to arrogance and dogma based on ignorance.

The episode takes a dark turn when the scene shifts to Auschwitz, where many members of Bonowski’s family were murdered. The article’s author, a professor of philosophy at the New School, offers this interpretation:

The pursuit of scientific knowledge is as personal an act as lifting a paintbrush or writing a poem, and they are both profoundly human. If the human condition is defined by limitedness, then this is a glorious fact because it is a moral limitedness rooted in a faith in the power of the imagination, our sense of responsibility and our acceptance of our fallibility. We always have to acknowledge that we might be mistaken. When we forget that, then we forget ourselves and the worst can happen. 

I can already hear the shouts of outrage that I dare to compare mental health care with Nazism. Having grandparents who survived a concentration camp, I know well that this is a highly fraught subject. But of course that is not what I am doing. I am simply pointing to this article as a beautiful articulation of the value of uncertainty, especially in the context of understanding human behavior.

Lessons from Atticus: is "ADHD" a problem of not listening?

Recently I reviewed my son's high school essay on To Kill A Mockingbird. I was surprised and pleased to rediscover, or perhaps discover for the first time now that I was viewing it from the perspective of over 50 years of life experience, the profound wisdom of the book.

In one of the novel's most famous quotes, Atticus tell his daughter Scout, "you never really understand a person until you consider things from his point of view, until you climb in his skin and walk around in it."

I now understand this as a description of the essence of being human, namely the capacity to be curious about the meaning of another person's behavior. Peter Fonagy, whose research has shown how the development of this capacity is intimately linked to healthy emotional development, argues, in a way analogous to Bowlby's description of attachment behavior, that this capacity has evolutionary significance, and is essential to survival. My book Keeping Your Child in Mind presents this research for a general audience, showing its application to parenting.

I wonder if our current epidemic of "ADHD" is related to having lost sight of this essential human quality.  The most common phrases I hear from parents who come to my office with concerns of problems of inattention and  impulsivity are, "he never listens," followed by "tell me what to do to make him listen."

Perhaps ADHD is a problem of not listening. But it is the adults who are not listening to each other. In our fast-paced, technology driven age, we rarely take the time to listen to each other, to put ourselves in another person's skin.

When Scout comes home from her first day of school upset with the teacher, her father tells her, "she's new too." He is helping Scout to understand her teacher's perhaps impatient behavior from a different point of view, to appreciate that the teacher herself may have been stressed and overwhelmed.

Recently parents of 4-year-old Sam, who was having problems of impulsivity in the classroom, spent a good portion of our visit expressing anger at his teacher, who they were convinced just didn't like their child. But with a full hour, and a quiet space to tell the story, they came to recognize that just as they could get overwhelmed at times by their son's behavior, so could the teacher be overwhelmed. Perhaps she felt defensive when the parents got angry, as she was trying her best in less than ideal classroom setting, with a low teacher: student ratio.

In turn, with the parents and teacher listening to each other and not behaving defensively, they could reach a new level of understanding of what set Sam off, and to develop strategies both at home and in school to help him to feel calm.

I wonder if the current epidemic of what we call "ADHD" represents a loss of this capacity to put ourselves in another person's skin. I have had the pleasure of an email exchange with the New York Times journalist Alan Schwartz, whose multiple superb article, most recently The Selling of ADHD, have served to bring the subject to the forefront of public discourse. I am hopeful that he will help us to see the big picture, rather than to place blame.

I have wondered in conversation with him if the whole phenomenon of "ADHD" is itself a symptom of larger social ills, particularly in the education and health care systems as well as the medical education system. People, including parents, teachers, pediatricians and mental health professionals, are feeling overwhelmed and not heard.

The large scale medication of a whole generation of children has potential serious and profound long-term effects. These include the silencing of children whose symptoms represent complex underlying problems, as well as abuse of stimulant medication by high school and college students.

We will never go back to the slow pace depicted in the 1960 novel, where there are large expanses of time to listen. But we need to be very careful not to give it up completely. For it does take space and time to put yourself in another person's skin. If that is the essence of what makes us human, we need to value that space and time.

Music and mental health: a tribute to Pete Seeger

This morning while driving my son and two friends to practice for their high school singing group, we listened, as part of an NPR report on his death at age 94, to Pete Seeger tell the story of his song Where Have All the Flowers Gone. His voice, his message and his music together had a profound calming effect on me, and I suspect on my passengers as well. There was quiet, and perhaps even a tear shed by others besides me.

In my behavioral pediatrics practice I make a point of asking about a child's interest in music. Whether the presenting problem is one of anxiety, frequent meltdowns, inattention, hyperactivity, or a range of other concerns, I have found that music often has a calming effect.  One little girl, whose mother was under considerable pressure to have her diagnosed with ADHD and put on medication, stopped her scattered and frenetic play to sing me a song. Another, struggling with social anxiety, who for much of the visit refused to speak, at first with his back to me and then with increasing boldness, did the same. When parents see this effect of music on their child, they are moved to incorporate music in to our efforts to support development of emotional regulation. Problems with emotional regulation are central to all of these behavioral symptoms.

I was in need of emotional regulation myself this morning after spending the weekend embroiled in a difficult discussion about the subject of "ADHD." In a conversation on a list serve made up primarily of child psychiatrists, I pointed to a recent study about ADHD that showed very poor long-term outcome. I wondered if there might be an alternative explanation to that offered by the authors of the study, namely that ADHD is a chronic illness that requires lifelong treatment. Could it be, I asked, that the poor long-term outcome is because we are not properly treating the problem in the first place? That when we diagnose based on symptoms alone, and treat with behavior management and medication, we fail to address the full complexity of symptoms of dysregulation of attention, behavior, and emotion? I wondered how we would separate this issue from the possible long-term effects of stimulant medication itself.

I got a huge amount of push back, with a number of people implying that I was "unscientific," and that I might be affiliated with the church of Scientology. Given that there is extensive scientific evidence supporting an alternative paradigm for understanding symptoms of dysregulation of attention, behavior and emotion, this suggestion particularly got under my skin.

Not only music, but dance, martial arts, yoga and other activities have an important role to play in self-regulation. This is particularly true for children who have biological vulnerability to dysregulation, including those with problems of sensory processing. All of these activities occur in the context of important relationships, relationships that themselves are essential to development of emotional regulation. My little patients perform their songs in the context of a growing relationship with me.

But if we employ a purely medical model, diagnose ADHD, anxiety or any range of problems using the DSM ( Diagnostic and Statistical Manuel of Mental Disorders), we miss the relational and historical context of these symptoms. We need to offer room to hear the individual story of a child and his family in order to make sense of his symptoms. This story is itself can be a kind of music. Dar Williams incredible song "After All"  offers a beautiful example.

When children present with a range of behavioral symptoms, if we simply "manage behavior" and treat with medication, where is there room for the music?

Arlo Guthrie, who frequently performed with Seeger, in his song Alice's Restaurant, proposed that everyone being evaluated for the draft walk in singing the chorus of his song, and in doing so create an anti-war movement.

Borrowing the idea, espoused by both Arlo and Pete, of changing the world with music, what if every new evaluation of a child with a behavior problem included singing and/or listening to one of Pete's songs? It might help calm everyone down-parent, clinician, and child alike. If, in turn, the next generation were helped to develop in a healthy way, with an ability to think creatively and engage effectively in a complex social environment, it might change the world.

Social responsibility to support new parents must follow demise of Isis Parenting

"Where I live (Paris) women are very lonely when having a baby. Is it the same in the US?"

A French journalist posed this question to me in an email interview two days ago. My verbatim response:

"Social isolation and often along with that postpartum depression are problems here in the US for new mothers.
There are mother- baby groups to try to address this issue, but not nearly enough."

Now, in our Boston communities and other places in the US, there are a lot fewer.

The economics of the sudden demise of Isis Parenting, a private retail company,is described in the Globe article today. But as my colleague at the Freedman Center at MSPP (Massachusetts School For Professional Psychology) that also runs mother-baby groups, said in reaction to the announcement by Isis, "you cant make money running mother-baby groups." 

A harsh tweet derides the company for catering to the wealthy with high end products. But in the absence of a system of social support of new parents, what choice is there? 

Isis offered what D.W. Winnicott termed a "holding environment" for new parents. Not just a physical space, but a community of relationships. This fact is reflected in a collection of tweets about Nancy Holtzman, vice president of clinical content and e-learning, at #thingsnancytaughtme.

Another way to describe what Isis offered is a "secure base:" In my book Keeping Your Child in Mind ( that was just released in France, thus the interview with the French journalist) I describe the extensive research evidence for the role of this secure base, both for parent and child, in healthy emotional development. 

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

In our culture extended families, that in past times might have offered that "holding environment" or "secure base," are often fragmented by distance and/or divorce. If one parent, usually the father, works very long hours, a new mother may feel very much alone. Isis parenting helped these parents not to feel alone. 

The United States lags behind significantly in support of new parents, as represented by a highly restrictive parental leave policy. A recent BBC article described an alternative approach in Finland: 

For 75 years, Finland's expectant mothers have been given a box by the state. It's like a starter kit of clothes, sheets and toys that can even be used as a bed. And some say it helped Finland achieve one of the world's lowest infant mortality rates.

Not only does this gift offer material help, but also an official recognition by the government that new parents have an important role to play and deserve to be valued and supported.

President Obama has recognized the need to invest resources in early childhood, and developed an Early Childhood Initiative. This is an important step in the right direction. 

But this will not help the families in the Boston area, who are now on their own with the loss of Isis. What can we do on the local level? It is my hope that government agencies, foundations and others who are in a position to support the kind of services Isis offered, that almost by definition do not make money, will step up to the plate to help fill the void. It will be an important investment in children, families and our future.

Misuse of ADHD label as symptom of a broken health care system

When the American Academy of Pediatrics came out with new guidelines a couple of years ago extending the age of diagnosis of ADHD (attention deficit hyperactivity disorder) down to age 4, it seemed as if Pfizer might have been waiting in the wings.  Soon after, a new preparation of ADHD medication in an oral suspension, for kids too young to swallow pills, became available.

I was a lone voice expressing opposition to this change in the guidelines. As a primary care pediatrician I saw up close how the diagnosis was made based on symptoms alone, missing complex underlying problems. As the standard of care is to treat what we call "ADHD" with medication and/or "behavior management" these problems, which can include a history of abuse and neglect, family substance abuse, ongoing marital and family conflict, and history of significant loss, are not addressed. As the standard of care is also to see these kids every three months for brief follow up, these issues can go unaddressed for many years, as the focus of care becomes adjustment of dose and preparation of medication.

The reason this happens is not because these primary care clinicians are unaware of these underlying problems. It is because the burden of care for children with the constellation of the symptoms of dysregulation of attention, behavior, and emotion, that we now call ADHD, falls almost exclusively on their shoulders.

The economic reality of primary care practice, due in large part to the administrative costs of managing a huge array of different health care plans, is that clinicians are under pressure to see more and more patients in less and less time. Add to that the severe shortage of quality mental health care services, and the primary care clinician is really stuck.  The appeal, both for parent and clinician, of a drug that can be very effective in controlling the symptoms of an out-of-control 4-year-old, is understandable.

Whenever I write about this subject, I get a barrage of comments from parents saying things like, "but my child really has ADHD."  Therefore, I want to state clearly that I am referring to a public health problem, not to one specific child. In fact, if the system were not broken, I would not need to be writing all these blog posts about the misuse of the ADHD label. Children who are struggling in the ways I have described would be able to get the care they need.

If a broken health care system is the problem (a problem that extends beyond my level of expertise), what can we do for these symptomatic 4-year-olds?

Here is where a model of preventive mental health care comes in. When a child is symptomatic at 4, it is very likely that the roots of the problem were present at three, two or even in infancy. Recently, after I gave  Dewald lecture at the St Louis Psychoanalytic Institute on this proposed model, I had the opportunity to have breakfast with a group of infant mental health colleagues. We spoke about what we termed "the nice lady (or man) down the hall" model.

A primary care practice would incorporate in to their team a mental health clinician trained to work with young children and parents together. The primary care clinician would have easy access to this clinician, who would work in collaboration with the primary care team. Ideally there would also be  a team of such early childhood mental health specialists, including an occupational therapist.

When children are young, and their brains are rapidly growing, a brief intervention, such as several hour-long visit over a several month period, can go a long way towards placing that child and family on a different developmental path.  It makes sense, both clinical and economic sense, to invest the greatest resources in care for this age group. By the time the child is in school, the problems have become more complex and entrenched.

There has been a lot of work lately on screening for mental health concerns in the 0-5 age population. It is imperative that we develop adequate model of treatment before screening is put in place. If such treatment is not in place first, large scale screening will likely insure that the folks at Pfizer who developed this new liquid form of ADHD medication will do very well.