Why Pediatricians Need to Know About Infant Mental Health

I recently became recertified by the American Board of Pediatrics. My certification was due to expire at the end of this year. In order to accomplish this task I had to do two things. One was to complete an assessment of my knowledge base. The other was to complete an approved "quality improvement activity." I chose one referred to as the "Attention Deficit Hyperactivity Disorder (ADHD) Performance Improvement Module" Clinicians who are currently seeing very few patients(the case for me due to the book writing) are able to use simulated patients for this online activity. By giving data for patients over three time points, this "performance improvement module" scored me in the high range of improvement of care because I gave the Vanderbilt( a standardized assessment tool for ADHD evaluation with a parent and a teacher version that assesses symptoms and academic performance) to every patient, discussed the option of medication, and if they were on medication, measured weight and blood pressure at every visit. That and pay $1,000 and I am now recertified until 2016.

This experience brought to mind a case of a seven-year-old boy who was referred to me for evaluation of ADHD. He arrived with the completed parent and teacher Vanderbilt forms on which he scored in the high range for inattentive and hyperactive ADHD. His mother had a high expectation that I would put him on medication. In our first visit, when I met with the mother alone, the following story emerged (details have, as always, been changed to protect privacy.)

For the first six years of his life this boy lived with his father, who was an actively drinking alcoholic. His mother lived in a different state and was intermittently involved in his life. When his father became ill with advanced liver disease, his mother moved closer to him and began to be more involved in his care. His father continued to drink despite his rapidly declining health, and though his mother was at first reluctant to share details, her son had witnessed his father's rather gruesome death at home about 6 months prior to our visit. He was now living with his mother and was struggling in school. He was receiving no psychotherapy or intervention of any kind. His teachers, who knew little of this story, had recommended the "ADHD evaluation" and had suggested strongly that he might benefit from stimulant medication.

The work of psychiatrist Bruce Perry, who taught one of the weekends of the Infant-Parent Mental Health Post Graduate Certificate program of which I have been writing for the past year, helped me to understand what was likely happening for this boy in school (for the sake of this blog post his work is simplified. For further information see the Child Trauma Academy website.) For most of his life this boy lived with an unreliable caregiver, who, when he was drinking likely was unrecognizable. The same person who he relied on for safety and security was frightening and unpredictable. The subsequent witnessing of his father's death adds a level of trauma that is almost unimaginable.

When children experience this kind of trauma from an early age, it affects the areas of the brain responsible for regulation of the most basic functions. A child may in a constant state of "hyper-arousal" in which he is constantly vigilant for possible danger. He does not have a normal sense of time and may exist only in the present. In the face of any kind of stimulation, he may experience either a fight-flight response or alternatively what is referred to as a dissociative response, in which his mind in a sense shuts down. In either state the brain does not function well and a person is unable to think, much less to learn.

In order to treat this kind of early trauma, one must start at these lower centers of the brain in order to help a child develop the basic capacity for self regulation. This may involve such activities as massage, walking, or martial arts. In essence, one needs to rebuild the brain from the bottom up. Only in this way can one hope to engage the higher centers of the brain and help a child make sense of his experience and begin to use his brain to learn.

Yet the standard of care in pediatrics, as reflected in my successful recertification experience, is to document symptoms of inattention and hyperactivity and then treat with stimulant medication. And the fact is that in the short term, stimulants may help a traumatized child to calm down. But the benefits are short lived, and often there is an escalation to higher and higher doses of medication over time.

A teacher of mine who is a leader in the discipline of infant mental health recently asked me why pediatricians should do this work, and not "a new front line practitioner trained in well child medicine and developmental mental health." The fact is that pediatricians, who are on the front lines and see children and parents early and often, do treat behavioral and developmental problems as a huge part of their practice. A 2001 policy statement The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care by the American Academy of Pediatrics reflects this fact.

As is clear from the above story, pediatricians are doing this work under the influence of a powerful pharmaceutical industry and pervasive culture of medication. Therefore, if we are to "do no harm" it is imperative that pediatricians are exposed to the wealth of knowledge and research generated in the discipline of infant mental health. This research offers a different model for understanding and treating behavior problems from the "advice giving", "parent training", "behavior management" and medication prescribing that is currently the standard of care in pediatrics. In my experience, as well as that of as small but growing number of pediatricians who are learning about infant mental health, these ideas have great relevance to our practice, and offer the opportunity to help young children and families in profoundly meaningful ways.

President Obama, Parenting and Personal Responsibility

When President Obama was interviewed on 60 Minutes following the capture and killing of Osama bin Laden, he compared the wait while the Navy SEALs were in the compound and he didn't know what was happening with the wait to hear if his sick young daughter had meningitis. What struck me about this was the ease with which he, in front of an audience of millions, equated in value his role as father with his role as leader of the free world.

I am currently making my way through David Remnick's brilliant book The Bridge: The Life and Rise of Barack Obama. Remnick quotes Obama, describing what Remnick refers to as Obama's "credo for his career:"

What if a politician were to see his job as that of an organizer, as part teacher and part advocate, one who does not sell voters short but who educates them about the real choices before them?...The right wing, the Christian right, has done a good job of building these organizations of accountability, much better than the left or progressive forces have. But it's always easier to organize around intolerance, narrow-mindedness, and false nostalgia. And they also have hijacked the higher moral ground with this language of family values and moral responsibility.

Now we have to take this same language-these same values that are encouraged within our families-of looking out for one another, of sharing,of sacrificing for each other-and apply them to a larger society. Let's talk about creating a society, not just individual families, based on these values. Right now we have a society that talks about the irresponsibility of teens getting pregnant, not the irresponsibility of a society that fails to educate them to aspire for more.

Obama's version of family values clearly includes both personal and social responsibility.

In the last chapter of my forthcoming book Keeping Your Child in Mind I address the changes that need to be made to our society in order to apply the explosion of knowledge about the importance of supporting early parent-child relationships to promote children's healthy development. There are many obstacles. These include lack of value we place on primary care and mental health care services, need from more emphasis on prevention, need for changes to our medical education system to attract more primary care clinicians, and a modification of the influence of the powerful health insurance and pharmaceutical industries. The last chapter states:

If parents are to embrace this challenging yet highly rewarding task, they need to feel valued themselves. Just as a parent needs to hold a child in mind, we as a society need to hold parents in mind.

At times when the obstacles seem overwhelming, President Obama has been my inspiration. He forged ahead, despite what may at times have seemed overwhelming obstacles, because he believed he had something important to do. To again quote from Remnick's book:

Before embarking on the story of the political rise of Barack Obama, it may be useful to take time out for a mental exercise. Here it is:
Name your state senator.
No, not the two legislative titans who represent your state in Washington, D.C. The question is, who represents your district in your state capital?
Fine. Now that you have Googled the name and are trying to wrap your mind around the pronunciation and other such details, imagine that this undoubtedly decent, if generally anonymous, man or woman emerges in a very few years from Trenton or Harrisburg, Tallahassee or Lansing to become, as if in a reality television show, President of the United States.

I feel that I have an ally in President Obama. While of course I don't personally know him (though our birthdays are 2 months apart- me June 8th 1961 and him August 4th 1961-yes we will both be 50 soon-, and we got married and had kids within a few years of each other, both have University of Chicago ties, and lived just blocks apart in Hyde Park when he was a community organizer and I was in medical school!!) I know that he will understand what I am trying to do. I hope he reads my book.

Continuing Medical Education (CME) Cost and Over-Reliance on Psychiatric Drugs for Children: A Possible Link

On the day I began to formulate the idea for this piece, I received an email announcing a continuing medical education (CME) course in psychiatry. Number one on the list of course objectives was: "Implement recent developments in psychopharmacology in clinical practice." I was mulling over the issue of CME after having been recently informed that offering CME credits for the intensive program in Infant-Parent Mental Health at University of Massachusetts Boston in which I am a fellow might be prohibitively expensive. In contrast, my colleagues in psychology, social work, and counseling will be able to get CEU’s (continuing education units).

There are four MDs in my group of 25(three pediatricians and one psychiatrist.) For us CME is necessary for maintaining professional licensing as well as obtaining hospital admitting privileges and being credentialed with insurance companies. Staying up-to-date with important new research and knowledge is certainly an essential part of practicing medicine. Yet given the already massive time pressures on physicians, MD's are unlikely to take a course that does not offer CME credit. We are a distinct minority.

Not having any knowledge about this subject, I did some research. Apparently the cost of offering CME is regulated by an organization called the Accreditation Council for Continuing Medical Education (ACCME.) If a person or organization wants to offer CME for a course, they must apply to the ACCME. According to their website the cost for "pre-application"(I'm not sure what that is) is $1000. The initial accreditation fee is $7,500 and the annual fee is $3,000. The reaccreditation fee is also $7,500. The International Association for Continuing Education and Training(IACET) in contrast, charges an application fee of $450 and an overall fee of $2,300 for CEU accreditation.

In the Infant-Parent Mental Health Post-Graduate Certificate Program(IPMHPCP), in ten intensive three-day weekends over the course of a year, we learn from leading researchers and clinicians from a range of disciplines about how early relationships shape the brain and influence healthy emotional development. The same program is run in Napa, California. The program’s website states:

“The IPMHPCP goals are to prepare individual professionals who:
Are highly skilled and invested in infant-parent work;
Have an integrated understanding of infant-parent relationships, regulatory, and social-emotional/mental health concepts and theories;
Have an understanding of the major theorists, researchers, and clinicians in the area of social-emotional development, infant-parent mental health, and infant-caregiver relationships;
Are invested in an interdisciplinary approach to promotion, prevention, screening, assessment, treatment, monitoring, and policy development; and,
Are able, within their scope of practice, to provide promotion, prevention, screening, assessment, treatment, and monitoring of children age 0-5, their parents and other caregivers.”

How very relevant is this work both to pediatricians who see families early and often, and to child psychiatrists who treat young children. Yet if this program is unable to provide CME it is less likely that these disciplines will have access to this important information.

Instead pediatricians and psychiatrists learn primarily about how drugs shape the brain. I recently attended a full day CME course on “Child Psychiatry in Primary Care.” While we learned a great deal about medication, including the use of atypical antipsychotics for explosive behavior in young children, there was not one mention of the word "relationship."

In contrast, a pediatrician colleague of mine took a course last week given by leading childhood trauma researcher Bessel van der Kolk, (who I refer to in my two previous posts.) He offers a different model for understanding explosive behavior that is very much tied relationships, and he is critical of over-relaince on psychiatric medication. My colleague found the course extremely helpful and relevant, but CME was not offered.

I do not know why CME credits are so much more expensive than CEUs. But I do wonder if this system, which seems to have a good deal of control over who knows what, contributes to how we understand and treat emotional problems in young children.

I have no doubt that the IPMHPCP has left me well qualified to do the work I do, namely treat a range of behavior issues in young children within the setting of a pediatric practice. I have sought out the kind of educational opportunities I believe have most relevance for this kind of work. When it comes time to renew my license, I can only hope that the Board of Registration in Medicine will recognize this fact.

Helping a Traumatized Child: A Hopeful Follow-Up

I live in a small town, so I often have the opportunity to get follow-up on the children I cared for in my previous job. Walking down the street this morning I heard a voice call out "Hi Dr.Gold!!" I turned to see the mother of a child I had seen for a number of years. Similar to the child I described in the previous post, this child had experienced significant trauma in her early years. To protect privacy I will not go into detail. This family had come to me for medication for ADHD. While the child clearly met diagnostic criteria, and ADHD medication helped her to stay in school and not fail completely, it was obvious from the start that she needed more intensive help than I could offer. Yet her parents resisted. There were many reasons for this, ranging from transportation issues to a wish not to address some very painful subjects.

My leaving that practice actually forced the issue. The only person who would prescribe medication was a psychiatrist in a nearby town. She has a practice policy that anyone on medication must be in therapy.

When I run into families I know in public, I am hesitant to talk about our work in order to protect their privacy. But this mother seemed positively joyful, so I was moved to ask, How's Jane? (not her real name) ""She's thriving!" was her response. "We have her in therapy and she's on some new medications. I don't know why I resisted for so long!!"

This morning I also received an email from a pediatrician colleague bemoaning the fact that so many pediatricians have become simply drug prescribers. She asked: "Can we wipe the slate clean and start again? - maybe by listening and telling the stories over and over again; perhaps. Slow and steady." I like this cautious optimism, and believe strongly that it is the only way. We cannot give up on these kids!!

Preserve Important Childhood Trauma Treatment Program

In a powerful recent New York Times op ed, Post-Traumatic Childhood, leading trauma researcher Bessel van der Kolk writes about the possible of loss of funding for the National Child Traumatic Stress Network, an organization developed in 2001 to evaluate and develop treatments for traumatized children nationwide. He writes:


Most traumatized children now do not even receive a proper mental health assessment. Moreover, hundreds of thousands of them are numbed by powerful drugs that help control their "bad behavior," but that don't deal with the imprint of terror and helplessness on their minds and brains. Drugs can sedate, but they do not help children deal with trauma - in fact, they may prevent recovery by interfering with learning and the formation of relationships, essential preconditions for becoming functioning adults.

This paragraph brought to mind a particularly distressing case from my previous job as a behavioral pediatrician in a busy small town practice. This eight year old boy(details have been changed to protect privacy) had recently moved to a new foster home in my town and his foster parents brought him to see me to prescribe medication for attention deficit hyperactivity disorder(ADHD), which had been diagnosed by a psychiatrist in another town about 40 minutes away.

This little boy had not only been physically and sexually abused starting at a very young age, but he had been removed from another foster home where he had allegedly sexually assaulted another young child. He was impulsive and distracted in school, symptoms which, according to his new foster mother, were helped by his medication. She wanted me to prescribe the medication because the trip to the psychiatrist was too long. At the time I saw him, he was receiving no other treatment besides monthly visits to the psychiatrist for his medication.

When I resisted, saying in as gentle a way as possible that his problems needed much more intensive intervention than I could offer as a pediatrician, his foster mother was indignant. "But his psychiatrist said I should come to you. It's only to refill the medication, and I just can't drive that far." When I called the psychiatrist, horrified to learn that she had endorsed this plan, she reluctantly agreed to continue seeing the patient, but made it clear that she felt I was just making this foster mother's life more difficult.

I don't know if I made things any better for this boy by insisting that he at least be treated by a trained mental health professional. I spoke with the psychiatrist about the need for more intensive help, but given the lack of resources and lack of motivation, both on the part of the foster mother and psychiatrist, this probably didn't happen. Yet I felt that I could not collude with the system in sedating away this child's symptoms rather than addressing the underlying trauma, the "imprint of terror and helplessness" so eloquently and dramatically described by Dr. van der Kolk.

Soon after this incident I left that job. I had begun to feel increasingly uncomfortable prescribing medication to children in this way. The standard of care for ADHD treatment, where similarly traumatized children are often treated by pediatricians who prescribe medication at visits every 3 months, did not seem right. Instead I am writing to call attention to the problem, as well as developing, within a pediatric practice, an infant mental health program that focuses on prevention.

Many others in the areas of childhood trauma research, as well as the growing discipline of infant mental health, are speaking out about the need for changes in the way we treat these most vulnerable members of our society. I hope that our combined voices will be sufficient to call attention to the problem, and reverse the proposed 70 percent reduction in funding for the National Child Traumatic Stress Network.

Supporting Successful Communication Between Parent and Child

Recently, at the UMass Boston Infant Parent Mental Health Post Graduate Certificate Program in which I have been participating for the past year, we heard a wonderful talk by Carole Gammer, a family therapist who lives in Paris, France. She has written a book entitled, The Child's Voice in Family Therapy. Among the more remarkable things about her presentation was that she spoke to us in English while showing video tapes of observed therapy sessions conducted in French and German.

In one case, a young single mother who struggled with serious depression was having constant battles with her five year old daughter. In a way typical of many families I see, she asked Dr. Gammer "what to do to make her listen." Dr. Gammer works with child and parent together in a very focal way to help develop more healthy ways of relating. I found her work similar to mine but rather than have parents tell their story, she has parent and child act it out with puppets. In the segment she showed us, she asked them to act out a typical morning. It was remarkable that despite the fact that they were being observed by psychology students, both became absorbed in the play and really showed what it was like. The mother made repeated demands of her daughter-get out of be, get dressed-which her daughter did not do. The mother finally ended up threatening to abandon her child if she did not get up and get ready for school. It left us thinking that it was no wonder the child also had severe separation anxiety.

Then Dr. Gammer did her intervention, which involved selecting one very specific interaction to work on. The one they chose was eating breakfast. After some discussion with Dr. Gammer, the mother offered a couple of choices and she and her daughter eventually agreed on cornflakes. It was the first moment of successful communication between mother and child. By chance, Dr. Gammer stopped the video at this point to answer some questions, so we got a good long look. The mother had up until this point looked very tense and angry, but in this moment of cooperation her body seemed to relax. She was smiling, and her pleasure at her success was evident. Her daughter looked directly at her, smiling at her as she agreed, "OK, cornflakes( a word that is shared by all three languages!)

This was a lovely example of supporting parents by helping them" be" with a child rather than telling them "what to do." When things are out of control as was the case for this mother-daughter pair, both parent and child are angry and sad, yet they are longing to connect. I have found that meaningful change happens in my behavioral pediatrics practice when we share these powerful moments of re-connection. One can imagine that the levels of stress hormones in this mother, likely at a constant high level as she battles with her child over every little thing, decreased in that instant. In turn, the same probably happened for her daughter.

It is only a tiny moment, but at least they both know what is possible and what to work for. This focal intervention, along with others like it in the context of the supportive, non-judgemental relationship Dr. Gammer has with this family, is likely to transform the unhealthy dance of mutual dysregulation, in which these two have been engaged, into one of mutual regulation, as they accumulate successes like the one we saw in this video. In my opinion, while it is clearly more work, this is a far better approach than giving a parent advice about "what to do."

National Children's Mental Health Awareness Day

My posts have been less frequent as I am down to the wire with the final proofreading of my forthcoming book, Keeping Your Child in Mind, which will be available on August 30th. However I did not want this day to go unacknowledged, so I will reference and quote from the bulletin Promoting Resilience in Young Children created for the occasion by the State of Massachusetts, which includes multiple resources.

The future prosperity of our nation depends on the healthy growth, development and school success of each and every one of our young children. Yet, it is estimated that one quarter of the children in our state are at risk for “toxic” or emotionally costly stress caused by domestic violence, child abuse/neglect, family substance abuse and parental depression (Boston Thrive in Five research review, 2009)1. Young children can also be strongly affected by a range of issues such as a death in the family, a car accident, or long- term separation from a parent.
Because young children’s brains are still developing, trauma and stress can have long-term effects on the developing architecture of their brains. Without supports to promote resilience as they grow, children may take with them the effects of traumatic events, and be more likely to experience problems with substance abuse, depression, and stress management.
A strong relationship with a caring adult who responds sensitively to a child is the first line of defense in protecting against stress or trauma. Due to their own stressors, sometimes a parent or caregiver may need to support to help children cope appropriately.

1 National Scientific Council on the Developing Child, 2005 ibid