Reading about this subject causes me a great deal of agitation as well. But outrage is not enough. The questions that need to be answered are one: how did we allow this to happen? And two, what path can we take as an alternative to this misguided one? Without addressing these questions the outrage simply causes hypertension.
Yesterday morning I was feeling rising agitation as I delved into this selection of blog posts, when fortunately my 10 AM patient arrived. I think her story offers some answer to these questions. As always, I will change details to protect privacy while maintaining the essence of the story.
3-year-old Anna was adopted by her parents, John and Diane, about 4 months prior to this, our second visit. At our fist visit, I met for an hour with her parents. Anna had experienced significant loss and physical trauma in her early years and had been adopted out of foster care after a number of different placements. When she first came home with John and Diane, she had little language, but now after just 4 months in many ways she was thriving. But both both parents were being undone by her almost daily severe explosive tantrums. Their marriage was severely strained as they fought over how to manage these outbursts. had called me in desperation one day to say that she needed to come in sooner, despite the fact that our appointment was only two days away.
After I listened for about 45 minutes, while they told me the story of what they knew of Anna's previous life, as well as about their lives and how they came to adopt, I asked for them to describe to me in detail what these tantrums looked like. At some seemingly minor frustration, Anna would first clench her fists in frustration. When her parents intervened, this would escalate to uncontrollable kicking, biting and spitting. Diane described feeling full of anger when her otherwise sweet child behaved in this way, and John insisted that Anna needed to "learn to listen to them." Sometimes they would give her a time out, sending her to her room, or threatening to take away some beloved toy. Or they would ignore her, letting her run around. With either approach the episode ended when she eventually simply collapsed from exhaustion.
Just before our visit I had been reading the work of psychiatrist Bruce Perry, who I referred to in my previous blog post, who has written some wonderful handouts about the effects of early trauma on brain development and behavior. I had his model in my mind when Diane said to me, "Its as if she's in survival mode."
"I think you're exactly right," I said to them. "When Anna acts like this, the thinking parts of her brain are not working. In many ways she's like a helpless infant, able to use only the more primitive parts of her brain. She needs you to help her manage and contain her feelings. At that moment, likely in some way because of her earlier trauma, she is unable to do it herself." Then I said "You need to be your most generous just at the time when you feel the most angry."
Diane and John were quiet for a moment as they thought this over. For some reason, perhaps because they had a quiet time together to tell their story. they really took this idea in. In fact Diane repeated the phrase a few times, nodding in thoughtful understanding. Our time was up, and we scheduled a follow up appointment the next week, when I would meet Anna. This was the appointment following my blog reading session.
Anna gave me a charming smile as she came into the room and began to explore the toys. We all sat on the floor and I watched her easy interaction with her Mom and Dad. Then after a while we spoke about our previous visit. Diane said, " I thought about that a lot- we need to be most generous when we feel most angry." She described observing Anna begin to escalate and saying softly,"do you need a hug?" Diane described how this would sometimes cause Anna to pause, kind of stunned out of the direction she was taking. Both John and Diane were learning how to identify, and thus avoid, some of the things that triggered her meltdowns, both by diverting her attention and giving her more love and attention at these vulnerable moments.
We all acknowledged that this kind of thoughtful attention was very hard work, and that clearly they had a long and challenging road ahead. But both parents were fortified, and had an idea of what they were working towards. We planned to meet again in a few weeks.
So what does this story have to say about the Biederman issue? First of all, parents are desperate when they are struggling with a child in this way. When a clinician sees such a family, he feels that desperation and of course wants to help. The combined forces of the health insurance industry, with poor reimbursement for mental health care and thus lack of access to quality care, aggressive marketing by the pharmaceutical industry and cultural expectation of a quick fix together with this Biederman et al fiasco, allowed the "bipolar" diagnosis and atypical antipsychotics to, in a sense, fill a void. As I state in the last chapter of my forthcoming book Keeping Your Child in Mind,
Infant mental health services, unfortunately, are not well covered by third-party payers and are not marketed as widely as prescription drugs. And as we have seen, they require hard work and do not offer the “quick fix” of medication. As such, they are less available as a form of intervention for struggling young children and families.Yet it is just the discipline of infant mental health, as exemplified by the work of Dr. Perry and others I have written about over the past year, that offers the answer to the second question: what is an alternative path to that offered by Biederman and colleagues? That same morning of the blog reading and this visit, I had been communicating with colleagues about developing a new program that integrates care among obstetricians, pediatricians and psychiatrists to address perinatal emotional complications. It has been well established that explosive behavior problems in children are often associated with postpartum depression. It is this kind of preventive work that offers a meaningful alternative approach.
Now that it has, I hope, been clearly established that this explosion of "bipolar disorder" diagnosis and antipsychotic use in young children was the wrong path, we need to move on. We need to fully invest in making the changes necessary to out health care system to enable us to go down a different path towards meaningful help for these struggling families and children.