The New York Times Thinks About Parents

I felt that I was in very good company yesterday when my letter to New York Times was published in reference to last weeks op ed piece The Parent Trapped. In that piece, Katherine Ellison, responding to indictment of a mother in the murder of her two teenagers, describes her own journey from the brink in her relationship with her son. She describes feelings of barely controlled rage and her realization that she needed to get help.

While there was much that could be said about this piece, I picked up on the way in which Ms. Ellison, with the support of family, friends and professionals, took ownership of her role in the conflict. She wrote:

I spent much of the year learning about A.D.H.D., a condition I soon realized that I shared with my then 12-year-old son. Among its classic symptoms are conflict-seeking and hot-headedness. Humbling as it was, I ultimately heeded friends and professionals who encouraged me to shed my fantasy of being the victim of a raging, impossible child, and own up to the ways I was contributing to our fights.

In my response I wrote:

In the safety of my pediatric office, countless parents have revealed that they are startled by the intense rage they feel for a child whom they also have such powerful love. Katherine Ellison bravely and honestly addresses this issue in her article.

The fact is that intense opposing feelings are a normal part of any passionate relationship. But as she points out, when parents feel out of control, if they are unable to manage their own rage, it is essential to get help.

The beauty of her article is that it identifies the relational nature of the problem. All too often, a “behavior problem” is viewed as residing exclusively in the child. When parents feel recognized and understood, as Ms. Ellison seems to have felt, they are better able to be fully present with their child, in turn helping the child to manage his or her particular vulnerabilities.

Another letter identified the critical role of emotional regulation in development and the need for parents to "push the pause button" in the heat of the moment and reflect on whats going on. Yet another addressed the wrongness of corporal punishment and the need to find effective alternative measures. A third spoke of the need for friends, communities and professionals to be available to parents when they reach out for help.

What was most encouraging to me was that the majority of the letters in Saturday's paper were devoted to this subject. As the Times represents in some significant ways the cultural trends in this country, this fact gives me hope that we are seriously considering the essential role parents play, and our need as a society to support them in this very challenging yet highly rewarding task.

A Third Front in the War on Obesity

Recently I watched the Academy Award winning film Monster’s Ball. A morbidly obese young boy whose father is about to be executed sneaks a chocolate bar while his mother is out, only to be verbally and physically assaulted by her when she returns and discovers a smudge of chocolate on his face. This is an extreme example, but it highlights the complex relationship children and parents can have with food and eating.

There is no doubt that childhood obesity is a huge public health problem with complex causes and far reaching effects. Michelle Obama’s efforts, now entering their second year, are admirable. The identified culprits that she has targeted; a sedentary lifestyle and aggressive marketing efforts of unhealthy foods by the food industry, play a significant role.

However, in addition to targeting interventions focused on the food industry and physical activity, it is critical to recognize the meaning of food and eating in parent-child relationships. An example from my behavioral pediatrics practice illustrates this point.

Sylvia brought her four-year-old son Andrew to see me because “he’s always eating”(details have been changed to protect privacy.) An engaging, plump little boy, he was enthralled by the Dunkin Donuts across the street from my office. Sylvia described constant battles around his demands for sweets.

But over the course of our 60-minute visit, other important issues emerged. Andrew’s father, Richard, had lost his job and the family had moved three times in the past year. Richard struggled with severe depression. In addition to the battles around foods, Andrew was having increasing numbers of temper outbursts, and his mother revealed to me that she was at times unable to contain her own rage. She had even on occasion beaten him with a belt. As Sylvia became more relaxed and began to open up, she shared that she had been physically abused as a child.

In helping to manage Andrew’s out of control heating habits, it was essential to recognize the connection between Andrew’s insatiable appetite and the stress he was experiencing in his relationships with both his mother and father. Supporting these relationships was the aim of my work with this family.

If the child in Monster’s Ball is one end of the continuum of disordered eating, and Andrew in the middle, in my general pediatric practice I see, at the other end of the continuum, the relatively minor everyday challenges of parenting that are inextricably linked to later eating habits.

A mother whose child has sensitivity to textures of foods may feel inadequate in the face of her child’s picky eating. This in turn may lead her, at moments of desperation, to force food into her child’s mouth, setting the stage for a lifelong distorted relationship with food. The primary care setting offers an opportunity for early intervention and repair of these types of difficulties. In addition, disordered sleep patterns are closely tied to risk of obesity. These patterns develop in the first few years of life, and a primary care clinician can play an important role in both development of healthy sleep habits and in setting patterns in a healthy direction when they go off course.

Supporting parent-child relationships is a critical element to add to this “war” on obesity. Investment in primary care and mental health care, as well as in programs that have been shown to support parent-child relationships that are at risk is essential. For example, the Yale based Minding the Baby program is a preventive home visiting program that aims to support parent-child relationships in young families stressed by limited economic resources.

Research by Jack P. Shonkoff, MD founding director of the Center on the Developing Child at Harvard University, has demonstrated that safe, stable, and nurturing relationships may protect children against poor health later in life. Children who develop a strong sense of self in the context of these secure relationships are more likely to make healthy lifestyle choices.

And a word of caution regarding the language of the “war” on childhood obesity. I wonder about the experience of an overweight child who is exposed to this news. Shame, confusion, and fear- these powerful emotions may go unprocessed. At the very least, these headlines should offer an opportunity for conversation among adults and children about diet and lifestyle choices.

Proposed Ban on Antipsychotic Use in Children Five and Under

A study published in February issue of the Archives of General Psychiatry, written by Nancy Andreasen, former editor-in-chief of the American Journal of Psychiatry, provides evidence that long term use of antipsychotic medication results in loss of brain volume. She concludes that

Viewed together with data from animal studies, our study suggests that antipsychotics have a subtle but measurable influence on brain tissue loss over time, suggesting the importance of careful risk-benefit review of dosage and duration of treatment as well as their off-label use.

I propose that based on these findings, there be a ban on use of antipsychotic medication in children age five and under, the period of time when the brain is undergoing the most rapid growth and development.I specify this age group not only because they are the most vulnerable, but also because beyond age six the brain is less plastic, and so alternative interventions that aim to change the structure of the brain may be less effective. Also, it is a reasonable goal. If more evidence about damaging effects emerges it may be necessary to extend the ban to all children.

Those who advocate for use of antipsychotics in young children with a range of behavior problems argue that stress hurts the brain and that these medications can protect the brain from this stress. When children and parents feel out of control, when there is sleep deprivation and explosive behavior, both parents and children experience a great deal of stress. It is not surprising that giving a powerful drug that acts on the brain would calm a child down.

Medication, however, is not the only way to reduce stress. Being understood by people who love you also reduces stress at the level of brain biochemistry. Reducing stress and changing the brain in this way is not easy. It requires sustained effort and a lot of support for parents. But the changes are safe, and may last a lifetime.

The growing field of parent-infant mental health offers quality research and a wealth of effective interventions to support troubled children and their parents.These interventions , unfortunately, are not well covered by third party payers and are not marketed as widely as prescription drugs. , They require hard work and do not offer the “quick fix” of medication. As such, they are less available for struggling children and families.

As long as a drug is available (and the preferred mode of treatment according to the health insurance industry), motivation to do this more difficult work will be lost. In addition, there is a severe shortage of quality mental health care services. This is due to many factors, including poor reimbursement and prohibitively complex administrative costs for private practitioners. Just as motivation may be lost on an individual level, as long as the drug is available, there is little motivation to change the health care system to more effectively provide these alternative interventions.

All of this is reason enough not to use these medications in very young children. Add to this the solid evidence that these drugs damage the brains of adults, and using them in children whose brains are rapidly growing is, in my opinion, unconscionable.

Amy Chua and the role of empathy in parenting

All this talk about Amy Chua’s parenting techniques has me thinking about Brandon Fisher, the manufacturer of drilling equipment who president Obama recognized in the State of the Union Address for his critical role in the rescue of the Chilean miners. While I cannot claim to know anything about Fisher's upbringing, I do know a great deal about what qualities in a parent-child relationship lead to the characteristics he exhibited, namely empathy, flexibility and resourcefulness.

I wonder if the anxiety being experienced on a grand scale by American parents in the wake of Chua’s book is due to the fact that that while severe parenting techniques designed to achieve academic success may not be palatable, parents feel a void when it comes to finding an acceptable alternative model, as exemplified by the Boston globe op ed, The tiger mother roars, and the slacker mother shudders.

John Bowlby, the father of attachment theory (no relation to “attachment parenting” as described by William Sears) describes the importance of a secure early relationships in raising a child who, in Bowlby’s words, is “self-reliant and bold in his explorations of the world, co-operative with others, and also-a very important point-sympathetic and helpful to others in distress.”

Contemporary research offers a close up view of a secure parent-child relationship that can instill these qualities. It involves a balance of empathy and limit setting. There are four key elements. The first is wondering about the meaning of a child’s behavior rather than responding to the behavior itself. The second is empathy. This is more than saying “I know how you feel.” It means actually feeling what your child is feeling, but reflecting it back to him in a way that says, “I know you’re upset, but we’ll manage.” The third is containing difficult emotions, often in the form of setting limits. Limit setting is about teaching the essential life skills of frustration tolerance, impulse control and emotional regulation. And forth, and perhaps most challenging, is doing all this without letting your own distress get in the way.

Lest this list cause a parent to feel overwhelmed by the enormity of the task, research of Ed Tronick, chief of the child development unit at Children’s Hospital Boston, offers hope. If parents are attuned with their child only 30% of the time, if 70% of the time you don’t connect with your child in the way I describe, as long as most disruptions are recognized and repaired, development moves forward in a healthy direction. In fact, disruptions and their subsequent repair are essential in instilling resilience, an important fourth attribute to add to Bowlby’s list. D.W.Winnicott, pediatrician turned psychoanalyst coined the phrase the “good-enough mother” to describe a mother who is not perfect, and in her very imperfection helps her child to manage life’s challenges in direct proportion to what he is capable of.

Chua’s book, in addition to creating mass unease in American parents, has raised fear regarding our ability to compete with China. Towards that end, raising a generation of Brandon Fishers, citizens with the qualities of empathy, flexibility, resourcefulness, and resilience, is essential. In order to accomplish this task, we must support parent-child relationships from the beginning. There is extensive evidence that children learn these skills in infancy, when the brain is making as many as 1.8 million neural connections per second.

Unfortunately our country does not recognize parents in this way. As I have said in previous posts repeating, our lack of support of early parent-child relationships is exemplified by our maternity leave policy that lags far behind other countries, as well as the rapid increase of prescribing of psychoactive medication to very young children. This second phenomenon is in turn inextricably linked with the very powerful health insurance industry and the lack of value placed on primary care and mental health care services.

Public policy to support early parent-child relationships is essential. For example, postpartum depression can negatively impact a mother's ability to be present with her child in a way that promotes healthy emotional development. This past summer a new law was passed in Massachusetts that calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.

Contemporary research in child development offers an answer to the questions raised by Chua, both on a small scale: a model of parenting to follow, and on a large scale: a model of social policy to support parents in this task. I thank her for providing the motivation to address issues that are critical for the future of our children and of our country.

Infant-parent mental health care-where does it fit in?

When I tell friends, office staff and even some colleagues in pediatrics that I am building a behavioral pediatrics practice that is focused on infants, they sometimes give me a puzzled look. I was recently asked to write a guest post for a blog called "FreelanceMD:the cure for the common physician." The blog advertises itself as being for doctors taking charge of their own practice of medicine,and even has a section entitled "non-traditional medical careers". As the way I practice pediatrics doesn't fit into any defined category, I thought this might be a good community to join. I invite you to take a look at my guest post today, Inside Infant-Parent Mental Health Care. It has some similar themes to what I have written about elsewhere on this blog, and offers a specific example of what a pediatrician who follows the principles of the discipline of infant mental health actually does.

Extensive research has shown the long term negative effects of maternal depression and anxiety on child development. Untoward effects on development occur even when symptoms are below the level to qualify for a diagnosis, as is common in today's culture where new mothers are often struggling with minimal help and/or emotional support. We need to intervene early, when these brains are rapidly growing, when an infant’s brain is making as many as 1.8 million neural connections per second.

This kind of work fits very well in a primary care practice, where mothers and babies are seen early and often. Many programs that implement the principles of parent-infant mental health care are in university settings, or in large cities or specifically target high-risk groups. Being seen in a primary care practice avoids the stigma that still may be associated with a referral to a mental health care practitioner. It also offers the opportunity to help families that might not fit into an identified high risk category, but are struggling nonetheless.This is a model that could be applied in practices of any size in any location.The first step would be to integrate the growing ranks of mental health professionals who practice parent-infant psychotherapy into primary care practices. Next would be a large scale effort to teach these principals and practices to primary care providers themselves.

This model has worked well for me for many years. At first I did both primary care and behavioral pediatrics, but when my children reached school age and I could not meet the needs of my family if I were to continue taking call, I switched to doing exclusively behavioral pediatrics, but within a primary care practice. As far as the insurance companies are concerned I am credentialed as general pediatrician. I have always been well reimbursed for my services even when I see patients often and for 50 minute visits.

I hope that many pediatricians will follow a similar path.

A Vote for Repeal of Health Care Reform is a Vote Against Children (and so our country's future)

My forthcoming book, that has a publication date of September 2011, offers over 150 pages of evidence, based on more than 30 years of research as well as my 25 years of experience as a pediatrician, that supporting parents' efforts to be fully emotionally present with their children, to be curious about their children's minds and the meaning of their behavior, will lead to a generation of citizens who are emotionally healthy, resourceful, and adaptive to a complex social world.

The last chapter, entitled "Beyond Medication" places this view up next to an alternative paradigm offered by the combined forces of the health insurance industry and pharmaceutical industry. I am currently in the final stages of editing this last chapter. This morning I came upon this sentence, that occurs following a section in which I describe obstacles to quality care for children and families. The sentence reads:

Often when I see a family in my office [with a mental health concern] we can clearly see what is needed but cannot get from here to there. I believe there is hope, however, in this age of health care reform.

As I write this, repeal of health care reform is being debated in the House. Fortunately repeal is unlikely to happen, given its support in the Senate and Obama's veto powers. So I probably won't have to take that sentence out of my book. Still, the fact that repeal is even being discussed makes me very uneasy.

Health care reform as it stands does not directly address these obstacles to care, but is, in my opinion, a critical beginning. Next must come a renewed value on prevention, primary care and mental health care. These changes will serve to promote our children's healthy emotional development.

A vote against health care reform is a vote for the insurance companies. The powerful health insurance industry together with the pharmaceutical industry obstruct true progress in promoting children's healthy emotional development, because both support the quick fix over more difficult, yet safer and more lasting relationship-based interventions.

In this last chapter of my book, I also describe the 40 fold increase in the diagnosis of bipolar disorder in children and the exponential increase in prescribing of atypical antipsychotics, a highly profitable class of drugs, to very young children. I put the issue in perspective by including a sentence about the influence of the pharmaceutical industry on Joseph Biederman, the child psychiatrist at Harvard who is primarily responsible for this phenomenon. Here is the sentence I added this morning.

Further complicating this story is the fact that Biederman was found to have earned at least $1.6 million in consulting fees from companies that make these drugs, while reporting only $200,000 of this income to his employer, Harvard University. He is currently under investigation for possible violation of federal and university research rules designed to police potential conflicts of interest.

The health insurance industry and the pharmaceutical industry often seem not to have our children's best interests in mind. Yet as Nobel Prize winning economist James Heckman has argued, an investment in young children is an investment in our country's future. Health care reform as it stands is an essential first step in the right direction.

An Epidemic of Uncontained Aggression

Josh Marshall, a guest of Keith Olberman's news program Countdown, made a brilliant analogy when discussing the recent assassination attempt on congresswoman Gabrielle Giffords. He compared the current climate of incitement and violent rhetoric to a flu epidemic in which, while many are affected, the weak and infirm are the most vulnerable. Similarly, the mentally ill, like Jared Loughner appears to be, are most vulnerable to act on the inflammatory and hateful words so rampant in our culture today. But what is the cause of this epidemic? What is the "virus" responsible for this "illness?" Many blame the political situation which has become increasingly polarized and divisive. Others point to the media and the talk show hosts who promote the free expression of rage and hate.

I propose that while these may be proximate causes, the true cause may have much deeper roots. Extensive research has shown that children learn to regulate emotions, including aggression, at a young age, in relationships with their caregivers. This learning takes place at the level of gene expression and biochemistry of the brain. The centers of our brain responsible for observing and monitoring our behavior actually grow fibers that control lower centers of the brain responsible for fear and the fight-flight response. This growth takes place in the context of attuned loving relationships in which children feel understood.

We as a society now seem to be failing at this task of regulating aggression. I wonder if this failure is in some way connected to our culture's failure to nurture and support early parent-child relationships, as exemplified by our maternity leave policy that lags so far behind other countries, as well as the rapid increase of prescribing of psychoactive medication to very young children. The second phenomenon is in turn inextricably linked with the very powerful health insurance industry and the lack of value placed on primary care and mental health care services.

Aggression is a normal healthy emotion, which, if all goes well, children learn to regulate and contain. It then may be transformed into assertiveness, which is considered a positive trait. When children lack close secure relationships that help them to think about and understand their feelings, these aggressive feelings don't go away. Without the ability to think about feelings, a person is more likely to impulsively act them out.

This weekend I will have the privilege, as part of the UMass Boston Infant Parent Mental Health Post Graduate Certificate Program
to hear leading researcher Peter Fonagy present the most current research demonstrating the critical role of understanding children's minds and helping them to contain intense feelings in promoting their healthy emotional development.

Public policy to support early parent-child relationships is essential. For example, postpartum depression can negatively impact a mother's ability to be present with her child in a way that teaches him to regulate intense feelings. Program leader Ed Tronick has been instrumental in calling attention to this very important issue, and this past summer a new law was passed that requires Massachusetts health insurers to submit annual reports on their efforts to screen for postpartum depression and calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.

Certainly there are other angles for intervention in the aftermath of this horrific event, in the political realm as well as in the media. It may also inspire those strive to support these early relationships to, in the words of Dr. Tronick, "Press on with our work for children and families."