Early Relationships and Brain Development as the Core of Medical Practice

Given the current explosion of knowledge about the effects of early relationships on brain development, I believe that research at the interface of developmental psychology, neuroscience and genetics will soon need to be at the center of our medical education system. Thus I was excited and heartened to read about the Bayview Child Health Center and its medical director Nadine Burke in this week's New Yorker. An article entitled The Poverty Clinic describes a practice in a poor inner city neighborhood that applies this research to their daily care of patients.

Burke was most heavily influences by what is referred to as the ACE study, a retrospective review that showed a strong connection between adverse childhood experiences(including such parental divorce, abuse and neglect, being raised by a family member with mental illness) and many long term health outcomes. These include chronic medical conditions as emphysema and heart disease illness, substance abuse and other mental illness. She is also influenced by research in neuroendocrinology and behavioral genetics, including work of Michael Meaney and Bruce McEwen.

Burke's idea, drawing on the evidence that adverse experiences affect the brain and body on a molecular level, is to treat early childhood trauma as a medical problem. She describes "multidisciplinary rounds" modeled on treatment of cancer where care is coordinated among surgeons and other specialists. The article states:

At Bayview clinic, having the patient's ACE data, and a theoretical framework for discussion the effects of trauma, has inspired Burke and her colleagues to be more vigilant about abuse and neglect. It also makes them more likely to help children get the social services they need, and better prepared to talk to parents early about the importance of secure attachment.

Treatment interventions may include one or more psychological interventions and alternative therapies including yoga and medication. Alicia Lieberman, a leader in the field of infant parent mental health, is collaborating with Burke.

I wonder if Dr. Burke's medical model is successful in part because it allows clinicians to put the emotional component of this very difficult work at a distance. Bruce Perry, a brilliant psychiatrist at the Child Trauma Academy who has written extensively about working with traumatized children, describes very similar interventions. It may be that for clinicians who have not chosen a mental health profession, such as internists and pediatricians, viewing early trauma as a biological problem may be adaptive. It may allow them to do the work without being overwhelmed by feelings that the emotional suffering of their patients may bring up. This form of defense may be particularly important for clinicians who themselves have experienced some kind of early trauma, and for whom their patient's experiences are a bit too close to home. In the mental health professions, there are opportunities to discuss these types of reactions to the work. However, training in medicine and pediatrics rarely offers such opportunities.

In a sense analogous to testing for iron deficiency because of our knowledge about its importance in brain development, primary care clinicians on the front lines with young children and families will need to know about and apply our knowledge of the importance of early relationships on brain development. Dr Burke's clinic is an important step in the right direction. As this model makes its way into medical practice, however, it will be important to find a place for recognizing the emotional piece of the work. Not only will this avoid clinician "burn out" but it will give value to the relationship between clinician and patient. It can be the clinician him or herself who is the most important part of the treatment.

Psychiatric "Disorders" in Young Children: Proceed With Caution

"Mental Health Disorder" are big words to put on a small person. Sensory processing disorder, major depressive disorder, anxiety disorder, to name a few, are being given to preschoolers, toddlers and even infants. Certainly young children and their families can suffer terribly with the symptoms that characterize these "disorders." Yet I worry that a child's "true self," to quote pediatrician turned psychiatrist D.W.Winnicott, can be lost under the weight of such a label.

Based on my years of clinical experience as a pediatrician, together with evidence offered by contemporary research in developmental psychology, genetics and neuroscience, I believe that supporting parents efforts to understand their child's experience of the world, to help him or her to make sense of whatever particular vulnerabilities he or she has, without labelling him or her with a disorder, is a better approach.

An article just published in The American Psychologist, Developmentally Sensitive Diagnostic Criteria for Mental Health Disorders in Early Childhood, a comment on my new Psychology Today blog and a family I recently saw has got me thinking further about this controversial issue.

I met with Joanne and Peter, parents of five-year- old Andrew, in my behavioral pediatrics practice (details,as always, have been changed to protect privacy) He was having increasingly inflexible and explosive behavior. They wanted to know "what to do" so he would stop getting upset about "little things." They described him as challenging since birth, a picky eater who had difficulty with loud noises. He could take hours to put on his socks because he hated the bumps.

Recently, he and his parents were at the playground and his younger sister fell and hurt herself. It wasn't anything major, but they had to leave suddenly without giving him usual warnings that made transitions less difficult for him. The result was that he was inconsolable for hours-unable to stop repeating, "Its not fair! I didn't get to go down the slide!" His parents tried to be patient and understanding, while simultaneously tending to their other child, but eventually Peter lost his cool. He yelled at Andrew and sent him to his room.

What prompted them to call me, after months of increasing frequency of similar scenes, was what happened next. Andrew kicked the wall and threw his toys. Then he began to call out,"I'm so sad!! I'm a bad person" I'm so sorry." It was his words that most frightened them. Joanne admitted to being worried that he might intentionally hurt himself. After a while, when she felt more comfortable with me, Joanne spoke of her own longstanding struggle with depression. There were other family members with similar difficulties. Both parents confessed their fear that Andrew was depressed.

Drawing on the research of Peter Fonagy and others, I sought to help Joanne and Peter in their efforts to help Andrew make sense of the world, to manage his inflexibility and sensory difficulties. It seemed to me, based on his history, that he had some biologically based genetic vulnerabilities. To them it seemed that he got upset about "little things." But it sounded from their description that at times for Andrew the world felt like an overwhelming and incomprehensible place. Joanne and Peter needed to help him learn to manage himself in the face of his particular challenges. Trying to reason with him when he was out of control did not work. I explained that at moments such as the playground incident, the higher centers of his brain were likely temporarily not working, and so Peter and Joanne hit a brick wall. They needed, in the heat of the moment, to find other means to help Andrew to regulate himself, even something as simple as going for a walk. Talking about what happened could come after he calmed down. Eventually their repeated efforts would give him the tools and language to regulate himself in these difficult moments.

Andrew's mother had a vivid memory of being taken to the psychiatrist as a child and given medication. She did not want Andrew to come to my office-to get the feeling that there was "something wrong with him." We agreed that they would try this new way of being with Andrew, and come back and see me in a few weeks to talk about what happened. Within a week or so of simply thinking differently about Andrew, he was more calm. Joanne and Peter felt more relaxed and sure of themselves. They found it easier to be with him and help him manage these moments of frustration.

Several weeks after this visit, I received the following comment on a blog post questioning the use of antipsychotics for young children. As a pediatrician I don't have the opportunity, other than stories from parents like Joanne, to hear adults describe their experience of being diagnosed and/or medicated, and I find these comments to be helpful. I quote him in full:

I was a so called HFA when I was a kid, "Aspergers Syndrome" they called it and was tortured on Risperdal.
Dropped out of school when I was 13 and finished my education on the
internet. Looking back I never fail to notice that 100% of my problem was not
that I was sick but that other people considered me so.I say leave them alone. I once bit myself and screamed cause someone was chewing paper (Couldn't stand paper, pencils, chalk, people bending their
hands and about 10 other things) and so what? Get me out of the room for a
minute and I'm fine. Any kid should have the right to take that over
permanent drug induced damage.

While I can't claim to know anything about this person, his wish to be recognized and understood, rather than labeled and medicated, comes through loud and clear. I wonder how many others have a similar experience without the opportunity to give voice to it until many years later.

Those who advocate for a new system of diagnostic criteria for mental health disorders in early childhood are not advocating for use of medication in this age group. It is a reasonable concern, however, that a consequence of psychiatric diagnosis, in the age of intense marketing efforts of the pharmaceutical industry and limited access to quality mental health services, will be an increase in prescribing of psychoactive medications to young children. In fact, an article in today's New York Times Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy offers a close up look of the realities of the practice of psychiatry today.

Even putting the issue of medication aside, the label of mental health "disorder" may obscure parents efforts to truly understand their child's experience. It is this kind of understanding that Peter and Joanne are working towards. In the setting of such recognition and understanding, children, even those with Andrew's quirks and vulnerabilities, have the opportunity to develop a strong, healthy sense of self.

Protecting infants from the ill effects of mental illness

Three-month-old Jenna sleeps peacefully in her mother’s lap. The cards seem stacked against her. Cara at 17 is struggling to finish high school. She has been diagnosed in the past with depression and anxiety, but currently is receiving no treatment. Her primary care doctor, who referred her to me, has been prescribing an anti-anxiety medication as a temporizing measure. Cara has been playing phone tag for over a month with the therapist at the community mental health center, whom she needs to see in order to get an appointment with a psychiatrist.

Cara is scheduled as my patient in my behavioral pediatric practice. I put anxiety as the diagnosis on the billing form. But in truth the aim of my work with this mother-infant pair is to protect her daughter’s developing brain from the well-documented ill effects of maternal mental illness on child development.

Cara talks in a rambling manner about a range of subjects- her older sister at 20 pregnant with her second child, but neglectful of the first, her father who abandoned the family when she was two. She is particularly focused on her difficult relationship with James’ father, Ed. She tells of his drug use, his neediness and his difficulty accepting his role as father.

An infant’s brain makes as many as 1.8 million neural connections per second. The way in which these connections are formed is highly influenced by human relationships. As Cara responds to Jenna’s face and voice, is attuned with her rhythms and needs, both physical and emotional, she is literally growing her brain.

Important research has shown that when a mother can think about her baby’s mind and attribute meaning to his behavior, she helps him to develop a secure sense of himself and of his relationship with her. This security helps him to regulate himself in the face of difficult emotions. As he grows older he will have the capacity to think clearly and flexibly and manage himself in a complex social environment.

When I work with mother-baby pairs like Cara and Jenna, I focus on one simple thing. I listen to these mothers with the aim of helping them to reflect on their baby’s experience of the world and the meaning of their behavior. It never ceases to amaze me that with this singular focus, meaningful communication happens even in what appears to be chaotic and dismal circumstances.

As I listen to Cara’s rambling story, I know I need to help her start thinking about how all of this affects her relationship with Jenna. I use a technique I learned from leading researcher and clinician Peter Fonagy to help a person who is stuck in this kind of non-reflective thinking. I hold up my two hands. “Wait, I say. “I want you to help me understand how you think these problems with Ed connect with your relationship with Jenna.”

She pauses for a moment and then begins to cry. “When Jenna is so needy of me, it makes me think she’s just like her father, and I get so mad. Then I feel terrible for getting angry at her.” It’s a remarkable insight. But she isn’t done. She looks down at Jenna. “See how relaxed she is when I am calm. But when I get upset, she starts to cry.” Then she tells me of a time when she felt about to lose control, but somehow had managed to make Jenna laugh. “We were having a conversation,” she says joyfully, “even though she doesn’t say any words!”

It is a small moment in one 50-minute visit. I am confident, however, that with a string of moments like this, where Cara is fully present with her daughter, there is hope that she may break the cycle of intergenerational transmission of mental illness and help to grow a healthy brain.

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.