Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. I aim to show how contemporary developmental science points us on a path to effective prevention, intervention, and treatment, with the aim of promoting healthy development and wellbeing of all children and families.

Sunday, January 31, 2010

Holding a Child in Mind

Sam burst into the office, a two year old wild bundle of energy. Squealing with delight--or was it distress; it was hard to tell--he ran from toy to toy not looking at me or his mother, Jane. He was unable to engage with anything. Jane had brought him to see me in my pediatric practice because, “he hits me, has explosive tantrums, and I can’t take him anywhere.” She sank into the couch. I sat on the floor, wanting to listen to Jane, but also to include Sam in the visit. At first, I focused my attention on her story, while Sam continued his frantic exploration of the room.

Jane described a scene at the playground. The other mothers had been engaged in easy conversation, but she was on edge. She knew Sam was “inflexible” and at any moment could go from happy play to a full-blown tantrum. Sure enough, as she tried to join in the group, she saw him getting upset because his toy car was stuck. She rushed over to calm him, but his crying escalated. As the other kids and moms turned to look, she quickly went from embarrassment to rage. She yelled at Sam to cut it out. This only made him scream more. Finally, she grabbed him, her bag and his toys and ran to her car, where she collapsed in tears of helplessness.

Things had not been easy for Jane. Sam’s father had abused her and was in prison. She was afraid when she felt Sam’s anger that he would turn out like his father. Of her own mother she said, “She was never there for me.” Jane was frustrated and bewildered by the fact that Sam could relate to other people, yet reserved all his difficult behavior for her.

At the beginning of the visit, Jane made several awkward attempts to interact with Sam, but without success. She was anxious and her body language felt intrusive, which seemed to cause Sam to withdraw. As she opened up and shared more of her painful feelings with me, however, an interesting transformation occurred. Sam began to engage in more focused play. Mom and I talked about what Sam was doing, observing together how he was calming down. At first he talked to me, bringing me toys and naming them and describing what he was doing. But then he spontaneously ran over and gave his mother a hug. Her whole body relaxed, she leaned forward on the couch toward him, her pleasure and relief palpable in the room. Sam began to engage her in his play, and to communicate with her. Jane told me that she had been reluctant to come for the appointment, but was glad she had.

Being a parent of such a child is a hard job. Raising a child alone, without support from extended family or a spouse, is even harder. In our culture of advice and quick fixes, in seeking help for her problems with him, Sam’s mother would find many who would offer “expert” advice about how to manage her child’s behavior. An increasing number would recommend some type of medication to control his “hyperactivity.” Helping her to be fully emotionally present with her child--supporting her in the challenges she faced as a mother--is not a common approach.

Yet current research at the interface of developmental psychology, neuroscience and behavioral genetics is showing that it is just this type of intervention that will help children like Sam to manage strong emotions and relate to other people. A child’s mind grows and develops when the people who are most important to the child are able to think about and understand a child’s experience from the child’s perspective, without being overwhelmed or shutting down. A parent’s capacity to “hold the child in mind” leads to a child’s increased cognitive resourcefulness, greater social skills, and better capacity to regulate emotions. If we, pediatricians, grandparents, spouses, neighbors--can help a mother like Sam’s to join her child, to accept his “low frustration tolerance” as part of him, not a reflection of her own failure as a parent, then she can help him regulate his frustration. He can then learn to manage his feelings on his own. Most important, if she can do this, she may actually change the way his brain handles stress and strong emotions.

Friday, January 29, 2010

The Aggressive Child and the Elephant in the Room

In the Tony award winning play God of Carnage two couples meet in an elegant living room for an ostensibly civilized conversation about the aggressive act of one couple’s child against the other’s. The meeting soon degenerates to reveal the underbelly of conflict in the two marriages. Husband and wife hurl insults, precious items and even themselves with escalating rage. We see, as they attempt in vain to focus on the children’s behavior, the proverbial “elephant in the room.”

It brought to mind another depiction of the nature of the elephant, presented by the pharmaceutical industry. A recent issue of The Journal of Developmental and Behavioral Pediatrics features prominently a two page ad from Shire, makers of drugs commonly used for treatment of Attention Deficit Hyperactivity Disorder (ADHD). A mother and her son sit at the desk of a doctor in a white coat. Behind them is a large elephant draped in a red blanket on which is printed the words, “resentful, defiant, angry.” The ad recommends that these symptoms, in addition to the more common symptoms of inattention and hyperactivity, should be addressed. This is the message: doctors should be treating these symptoms with medication.

From my vantage point of over 20 years of practicing pediatrics, where I sit on the floor, not in a white coat, and play with children, I believe that the play’s depiction of the nature of the elephant is much more accurate and meaningful than that of the pharmaceutical industry. In the play the elephant is the environment of rage and conflict in which the aggression occurs, while in the ad the elephant is the child’s symptom. Consider these two stories from my pediatric practice (with details changed to protect privacy.)

Everything was a battle with six year old Mark. Though I asked both parents to come to the visit, Mom came alone. She was furious.”Tell me what to do to make him listen.” We had a full hour visit, and as she began to relax, she shared a story of constant vicious fighting between herself and her husband. Mark, who had been playing calmly and quietly, took a marker and slowly and deliberately made a black smudge on the yellow wall. His mother was too distracted by her own distress to stop him. I said, “You cannot draw on the wall, but maybe you are upset about what we are talking about.” He came and sat on his mother’s lap. She reluctantly revealed her suspicion that his angry behavior was a reflection of the rage he experienced at home. She agreed to get help for her marriage, and Mark’s behavior gradually began to improve.

Jane’s parents became alarmed when her aggressive behavior began to spill over into school. Her third grade teacher told them that not only was she distracted and fidgety, but she seemed increasingly angry. At our second visit, Dad became tearful as he described his cruel and abusive father. He acknowledged being overwhelmed with rage at Jane when she didn’t listen. He yelled at her and threatened her. He longed for a positive role model to learn how to discipline her in a different way. He realized he needed help to address the traumas of his own childhood in order to be a more effective parent for Jane.

If the elephant in the room is the child’s symptoms, as the drug companies would have us believe, then medication may be the solution. Children taking medication for ADHD often tell me that it makes them feel calm. The full responsibility for the problem then falls squarely on the child’s shoulders.

For Mark and Jane, and countless children like them, the elephant in the room, however, is not the child’s symptoms. It is the environment of conflict in which the symptoms occur. If the family environment is the elephant, the treatment of the problem is not as simple as prescribing a pill. Families must acknowledge and address seemingly overwhelming problems. The parents’ relationship with each other, and each parent’s relationship with his or her own family of origin, often contributes significantly to this environment.

In the supportive setting of my office, Mark and Jane’s parents were freed to think about their child’s perspective and experience. Rather than focusing on “what to do” they understood what their children might be feeling growing up in an environment of conflict and rage. This ability for parents to think about their child’s feelings has been shown, in extensive research at the intersection of developmental psychology, genetics and neuroscience, to facilitate a child’s development of the capacity to manage strong emotions and adapt in social situations.

In another interesting link between this ad and God of Carnage, one of the fathers is an attorney representing a drug company. He speaks loudly on his cell phone, seemingly oblivious to the effect of his behavior on the other people in the room. His conversation reveals the profit motive of the drug company taking precedence over the well being of the patient.

God of Carnage was written by Yasmina Reza, a French playwright. While the play itself is hugely entertaining as a witty farce about family life, an important message was in a brief scene at the very end. The telephone rings. The mother answers. It is her daughter, all upset about the loss of her pet hamster, which the father had “set free” one night because he was annoyed by the animal’s habits. Suddenly the mood of the play, which was lively with scintillating dialogue throughout, becomes serene as the mother speaks lovingly to her distraught daughter. Perhaps most of the audience was barely aware of the sudden mood change. Yet it lifted this delightful play into universal significance. Freeing herself from the preceding chaos, she calmly gives her full attention to her daughter’s experience.

The popularity of the play gives me hope that people are hungry for a different way to think about children and families than that offered by the pharmaceutical industry, which, with the money to place an attention getting ad, has a very loud voice. It is joined by the equally loud voice of the private health insurance industry, which supports the quick fix of medication over more time intensive interventions. In contrast, Mark, with his black smudge on my yellow wall, has a very small voice. His voice says “Please think about my feelings, not just my behavior.”

His voice is particularly critical now, as our country strives to create social policy and a health care system that values prevention and primary care. Parents, if they are supported and nurtured, know what is best for their children. We as a culture must demonstrate that we respect both the difficulty and the critical importance of being an effective parent. In this way we will be able to help children, not only by treating their symptoms, but giving an opportunity for deeply rewarding changes in the important relationships in their lives.

Thursday, January 28, 2010

Listening to a Mother

I first met Rachel about three years ago when she brought her four year old adopted son, Sam, to see me in my pediatric practice because of problem behavior(as always, details have been changed to protect privacy). A story of severe trauma in his early years emerged. He had lived on the streets with his mentally ill mother, then been shuttled between foster homes until he was adopted at the age of three. While he was a sweet and engaging child, Rachel told of explosive rage and defiance at home. She had raised four biological children and was feeling completely undone by this one.

I did not come close to solving Sam's "behavior problems." But I did help Rachel to understand the roots of his behavior. By gradually working with her to think about the effects of this early trauma on his development, I helped to free her from the debilitating self blame from which she had been suffering. She gathered her strength and began the long and difficult task of getting the help for Sam that he needed.

Last week, Rachel called me. We had not spoken for many months. She had a adopted two more children from another country. These children had not been traumatized like Sam, and things were going smoothly. But not for Sam. The intensive therapy Sam had been receiving was no longer covered by their insurance. The only option, one Mom did not feel was a long term solution, was to increase his dose of medication. Monthly visits to the psychiatrist were still covered.

We fell into easy familiar conversation. She shared her moments of despair, when she lost her cool and felt painfully inadequate. I shared my frustration with the insurance situation. At the end of our conversation she thanked me. But for what? I, too, was helpless to get Sam the services he needed. Perhaps what I had done was simply to listen to Rachel. I recognized her experience, and in doing so recharged her in her efforts to be emotionally present with Sam at these difficult moments. I can only hope that this will help to set Sam on a healthier path of development.

Wednesday, January 27, 2010

Children, Antipsychotics and Psychoanalysis

I fear our nation has lost its soul. We are drugging poor children into submission. Antipsychotics, powerful mind altering drugs with serious side effects, are being given with increasing frequency to very young children for explosive behavior. A recent study done by researchers at Columbia and Rutgers discovered the alarming statistic that children on Medicaid were four times more likely to be prescribed antipsychotics than children with private insurance. http://www.nytimes.com/2009/12/12/health/12medicaid.html

Prescribing of antipsychotics for two to five year olds has doubled in the past several years. Most worrisome is the finding that more than half of these children had received no mental health services. They did not have a mental health assessment or any treatment from a psychotherapist or psychiatrist. http://news.yahoo.com/s/hsn/20100105/hl_hsn/moretoddlersyoungchildrengivenantipsychotics

As an antidote to the heartache these findings cause me, I attended the recent National Meeting of the American Psychoanalytic Association. There I listened to discussions offered by leading researchers at the interface of neuroscience, developmental psychology and behavioral genetics. This research offers a different paradigm from that presented by the pharmaceutical industry. Rather than describing these children as “explosive” they are understood as having difficulty with emotional regulation. Young children learn to regulate emotions in relationships. When people who care for a child can think about his experience of the world, when they can help him to contain intense emotions without becoming overwhelmed themselves, that child learns to regulate strong feelings and manage himself in a complex social environment. This research is shedding new light on the nature/nurture debate, and the question of how much a child’s innate qualities affect the problems he is experiencing. A child may be born with a genetic vulnerability for difficulty regulating emotions. Responsive parenting, however, may alter the actual expression of these genes, and even change the chemistry and structure of the brain.

I understand why we are so quick to turn to drugs. Parents feel overwhelmed. The combination of a temperamentally difficult infant and a parent who does not have support of extended family or even a spouse is particularly challenging. Parents naturally seek help from their pediatrician. Because of pressures from a complex health insurance industry, primary care clinicians must see patients in 10-15 minute slots in order to maintain a viable practice. Mental health resources are severely limited. Parents are pressured by teachers, whose classrooms are disrupted by these children. Pediatricians, parents and teachers are bombarded by intense marketing efforts of the pharmaceutical industry. Antipsychotics offer the promise of a quick easy fix.

The psychoanalytic community offers high quality research into effective interventions. On an individual level, there is the model of parent-infant psychotherapy. A therapist works with the parent and child together with the aim supporting the parent in her efforts to think about their child’s inner world. Reflective parenting programs such as the Yale-based Minding the Baby program work toward the same goal with groups of parents, many of whom are poor and have suffered abuse. Both types of interventions have demonstrated positive impact on child development.

As a pediatrician and advanced scholar with the Berkshire Psychoanalytic Institute I have had the privilege to be part of the psychoanalytic community while practicing pediatrics in a small town. I have applied the ideas derived from contemporary developmental theory in my practice with remarkably positive results. When parents can themselves be heard, it helps them to think about their child. This experience often results in immediate improvement in behavior. As parents feel greater competence, a positive cycle of interaction is set in place. The rapidly moving train of development can get back on track.

Compared to the roar of the pharmaceutical industry, the voice of the psychoanalytic community is barely a whisper. Add to this fact a seriously undervalued system of primary care and mental health care, and it is no wonder that we turn to drugs. Our current health care system does not support interventions that value relationships.
Perhaps it was necessary for us to get to such a terrible place. I am confident that no one wants to be part of a culture that drugs its poor children into submission. I hope that we can use this time of health care reform to rethink our priorities. If we are going to invest in our nation’s children, primary care, preventive health care and mental health care should be at the top of the list.

Monday, January 25, 2010

Children Abandoned by the Health Insurance Industry

After submitting an op ed about the health insurance industry published in today's Boston Globe
I learned about another story of possible mass abandonment of children by the health insurance industry. As with all of my stories, details have been changed to protect the patient's privacy.

Seven year old James was having frequent stomach aches. A full evaluation showed no medical explanation. His mother, Stephanie, was convinced it was "stress." A one hour visit Stephanie by herself revealed the cause. In a slow calm deliberate manner she told me a story of violence and terror.

Stephanie described multiple arrests of James' father for violence towards her, all witnessed by James. Yet now, two years after the latest event, the parents shared custody. James went between the home of his mother and father every other weekend. None of these traumas had ever been addressed in any way.

I told Stephanie I agreed that the stomach aches were indead a symptom of stress. But it was critical that we address not only the symptom, that is not only "what to do" about the stomach aches, but also the meaning of the symptom. I said that James had likely been traumatized by these events and that he continued to experience significant stress on a psychogical level as he traveled between these two homes. Therapy, where both James and his mother together could come to understand what had happened, was essential. Furthermore, the younger James was when he was given this opportunity, the more likely he would be able to get past it.

Mom agreed, and I gave her names of some excellent colleagues who accept their insurance. Later that afternoon, I called one of these colleagues to make sure that he had time. That was when the horror really began.

He said that he was not taking any new patients with this insurance for the following reason. He had received notification a few weeks earlier that this company was now outsourcing its mental health care to another company. All providers would have to get recredentialed, a long labor intensive process. This new company would lower the fee from $75 for a one hour session to $60. There were tighter restrictions on extending coverage beyond a set number of weeks.

This means that mental health practitioners all over Massachusetts are facing a heartbreaking decision. Doing therapy with children is much more than a 50 minute session. It involves speaking with teachers, talking to divorced parents at separate times on the phone, going to school meetings. None of this time is reimbursed. So being paid $60 per visit is impossible. One cannot earn a living with a practice of kids on this insurance. And effective treatment takes months to years, not weeks. Fighting with the insurance company over coverage for each visit is an untenable situation.

I had to call James' mother and tell her that with her insurance she would have difficulty finding a therapist, and that the people I recommended were not available at this time. She was reluctant to pursue therapy in the first place. The fact that I could not connect her with a person I trusted made her back away in full retreat.

Perhaps the worst part of this story is about all of my other patients who are in treatment with my colleague. If he makes the agonizing choice that he cannot afford to contract with this new insurance company, he will no longer be able to see those children.

Multiply this by hundreds of therapists seeing thousands of kids all over Massachusetts. This decision by the insurance company, with its unlimited power, could lead to abandonment of countless vulnerable children.

Sunday, January 24, 2010

A Pill to be Nice

This past week, a mother in my pediatric practice (details, as always, have been changed to protect my patients privacy) asked if I would increase the dose of her 13 year old daughter’s ADHD medication “so she would be nice all of the time.” She was perfectly serious, saying, “I know she’s capable of it, she can be so sweet.” When I told her that in my experience most 13 year old girls were not “always nice” to their parents, and that I might be worried about a child if she were, she became furious with me. She accused me of giving her daughter permission to be oppositional.

Later that day I opened the most recent issue of the Journal of Developmental and Behavioral Pediatrics. I found the following two page ad placed prominently on the inside cover.

“His ADHD symptoms can be disruptive, but there’s a great kid in there.
Now there’s a new way to help him out”
Below this writing is a photograph of a big green monster, with the head removed to reveal a sweet, smiling boy inside.

I am not pleased with this ad. Research in developmental psychology and neuroscience clearly shows that recognizing the meaning of a child’s behavior leads to healthy emotional development. In this case, my patient is working on becoming her own person and so, to leave the comfort and security of her mother’s embrace, she must sometimes actively run in the opposite direction. While certainly her mother does not need to condone her behavior, understanding and respecting her feelings will go a long way in helping her negotiate this difficult developmental stage.

But with the powerful pharmaceutical industry running ads indicating that any unpleasant behavior can be eliminated by a pill, it’s no wonder I have a hard time getting my message across.

Monday, January 18, 2010

Medication for ADHD: Over-reliance is the Problem

At a panel discussion at the recent meetings of the American Psychoanalytic Association Esther Fine, PhD suggested that children might benefit from psychotherapy rather than medication to “understand the unconscious meaning of psychological symptoms.” It is statements like this that, in my opinion, give psychoanalysis a bad name.

Consider Sara, an eight-year-old girl in my pediatric practice(details have been changed to protect my patient's privacy). In third grade, she was unable to learn because she could not sit still, was extremely disorganized and would impulsively rush through her work. Many family members had a diagnosis of either ADHD or substance abuse, which may have been self-medicated ADHD. She had a dramatically positive response to medication. She mastered her math facts and began to enjoy going to school.

Yet at a follow-up visit about one year into her treatment, things were not going well. Her teacher reported that Sara was increasingly distracted. She suggested to her mother that she ask me to increase her medication dose. "Is anything else going on?" I asked. Sara looked directly at me and said, "I'm sad because I miss my Dad." I looked puzzled and turned to Mom, who then reluctantly told me that Sara's father was in jail for selling drugs, and that Sara had not seen him for several months.

I not only recommended psychotherapy, but explained that I could not in good conscience continue to prescribe medication unless both Sara and her mother were engaged in therapy. But my recomendation was certainly not aimed at helping her "understand her unconcious processes." It was aimed at validating her experience and offering her an opportunity to address the feeling of grief and rage around losing her father. My wish, in an ideal world, would have been for parent-child therapy, where the therapist could not only validate Sara's experience, but help her mother to understand why she did not recognize the impact of this event on Sara's emotional life.

This story is typical of many I hear on a daily basis. If we are going to help these kids, I believe it is important not to frame the discussion as therapy vs. drugs. Likely Sara has neurobiologically based ADHD in addition to significant environmental stress. Instead we should ask, "What can we do to validate the experience of both parent and child?" Limited access to quality mental health care and aggressive marketing by the pharmaceutical industry converge with a cultural acceptance of treating complex problems with medication. We need to support parents and children, not only on an individual level, but also in the form of improving access to high quality primary care and mental health care.