Eliminate shame and blame from parenting: new study sheds light

In my behavioral pediatrics practice, it is not  uncommon for parents to go to great lengths to put up a good front. They feel terrible shame about moments of out-of-control behavior, and also fear that I will blame them for their child's troubles. They focus primarily on "what to do" about their child's difficult behavior. However with time, and the realization that I am interested in understanding, not shaming or blaming, they begin to open up about their own life and the enormous stress they experience in their parenting role. They acknowledge that this stress has often led them to yell at their kids or even remove themselves emotionally.

An important new study published in the current journal of the American Academy of Child and Adolescent Psychiatry provides evidence that a parent's early life stress, such as abuse, emotional neglect, or emotional abandonment, lives in the parent's body. The reactions mothers (the study is just about mothers, though fathers certainly face similar challenges) may have in the face of a child's aggressive or clingy behavior are biologically based. It is not simply that they are hitting because they were hit. The authors of the study draw on extensive animal research showing biological mechanisms for transmission of parenting behavior.

For example, when a child behaves aggressively in a way that is developmentally normal (though limits must be set) a parent with a history of early life trauma may have a surge of stress hormones that affect the functioning of his or her brain. Thinking is impaired. He or she may have a kind of fight-or-flight reaction, which may lead to aggression in return.  Another alternative is to shut down, or in psychological language to "dissociate." This leads to that sense of being emotionally disconnected. Neither are good for a child.

This study has major implications for understanding as well as treatment.  If a parent is frequently out-of-control, and is yelling at or hitting a child, or emotionally removing him or herself, it must be addressed. Focusing exclusively on the child's behavior will accomplish little in this situation. Repeated exposure to an angry, out-of-control or emotionally removed parent has significant impact on development.

If  parents can recognize that early life trauma has led to this kind of biological reaction, it may eliminate some of the guilt and shame. It may encourage them to acknowledge and address the problem. When children are young, there is ample opportunity to turn things in a better direction.

Second, if the problem is in the parents' body,  treatment needs to involve working with the parents body. Psychotherapy can be important as a way to develop insight into the impact early life experience. But this kind of work can take time. A more immediate intervention involves helping a parent to recognize the stress reaction and then to develop tools to combat it.

I am not talking about medication. While medication may calm a parent down, and may be necessary in  some cases, the hope is to identify the way a child's behavior provokes a parent, and develop strategies for remaining calm  in the moment. The mindfulness movement has much to offer in this regard. Deep breathing, yoga or simply a short walk can help to calm the body down. Music or art will work better for others.

When parents come to my office asking what to do about their child's "problem behavior," I don't think they expect that my answer will be "go for a walk." I am pleased that this current study will support me when in fact I do say something like that.

Giving thanks for fathers

This post is dedicated to my friend David, who passed away on June 13th after a battle with leukemia, leaving behind two young daughters. While we have not been in touch for many years,  we reconnected around his illness. We were roommates in medical school, and were very close before he moved to the West coast and life took us in different directions. Recently I spoke with a mutual friend, also a father  of two girls, who is godfather to one of David's  daughters. He described horsing around with the girls in the pool on a recent visit shortly before David died. Both David and my friend are athletes, and I could vividly picture the physical nature of David's relationship with his girls, and the important role our mutual friend will now play in their lives.

In my behavioral pediatrics practice I always encourage fathers to participate, and am most grateful when they come for visits.  Sometimes a mother has been dealing with with postpartum depression, and the father can offer a unique perspective. Other times, the father himself has been struggling emotionally, and we are able to address these issues and their relevance to parenting. In a previous post Supporting Fathers Emotional Health, I address this issue in detail. The bottom line is that fathers have an essential role to play in supporting a child's healthy emotional development.

Recently I was interviewed for an article in Parenting Magazine about things not to say when a child is having a tantrum. One was, "Just wait till your father gets home!" While threats of this nature are never  good, recognizing being "at the end of one's rope," and in such a moment drawing on the support of a perhaps more level headed partner is an excellent idea.

I never met David's wife, but my heart goes out to her. In addition to the grief of this terrible loss, she now is faced with the challenging task of managing these inevitable parenting moments without her other half to balance things out. l know from the chain of emails about his illness that there is an extensive support network of family and friends to take up that role. I hope she will make good use of them.

David is still very much alive in my mind. I have vivid memories of him as a thoughtful, smart and really funny person. While I never saw him in his father role, I am certain that he was much more to his daughters than a great playmate. Father's day will be one of many difficult days ahead for this young family. I know those close to them will help them to hold on to their many wonderful memories of David.

In celebration of his spirit, I give thanks for the fathers in my life- both the father of my children and my own father. I hope others will do the same.

Taking stimulants for SATs: sadly we taught them that

As a general and behavioral pediatrician I admit that I have participated in many conversations that went something like this. In a child's presence a parent says: "He does well in his morning classes, but then his grades are down in the afternoon-can we use something longer acting?" Or, "She did so well at first, but now she's getting 70's. I think she needs a higher dose." These conversations occurred in the setting of a brief follow-up visit for ADHD. These visits might be spread as far apart as 3 to 6 months. What else happened in those months? There was neither the time nor the expectation to address that question in a meaningful way.

Is it any surprise, given that this form, length and frequency of visits for ADHD is the standard of care in pediatrics, that now there is an explosion of abuse of prescription stimulants in the high pressure setting of the college application process? A recent New York Times article Risky Rise of the Good-Grade Pill addressing this issue states:

The number of prescriptions for A.D.H.D. medications dispensed for young people ages 10 to 19 has risen 26 percent since 2007, to almost 21 million yearly, according to IMS Health, a health care information company — a number that experts estimate corresponds to more than two million individuals. But there is no reliable research on how many high school students take stimulants as a study aid. Doctors and teenagers from more than 15 schools across the nation with high academic standards estimated that the portion of students who do so ranges from 15 percent to 40 percent.

My daughter is a senior at one of these "high-pressure private schools" referred to in the article. She confirms these statistics, putting the number at about one third. A previous post, Meds for ADHD: They Work But is that the Right Question?, was inspired by conversation in which she asked me about the ethics of taking these drugs for the SATs. In that post I speak to the need to understand ADHD as a problem regulation of attention, emotion and behavior, and to focus on relationship-based interventions to promote self-regulation. It is the hyperfocus on medication to the exclusion of both understanding of the child's experience, and also other forms of intervention, that has led to this problem in the high school setting.

Relationship-rich interventions include such things as martial arts, music, and team sports (Michael Phelps had severe ADHD), activities that foster relationships and also promote self-regulation. Family systems are often severely strained when a child is struggling, and interventions aimed at supporting the family as a whole are very important. Careful examination of the school setting and accommodations to decrease over-stimulation are similarly necessary. But if the drug makes the symptom go away, there is no motivation to devote effort and resources to make these kinds of changes.

When I asked my daughter today if she had ever taken stimulants before a test she replied that she thought it was a silly idea. Her reason? "If you do well on stimulants it's not really you, and you will end up at a college where you will be miserable. Then you will need to keep taking the drugs." Such a wise child!

Childhood trauma: stories that must be told

My 51st birthday is approaching. My father is 87 years old. Yet it was not until this spring that I learned details of the story of his childhood in Nazi Germany, his escape to America as a teenager, and his dramatic rescue of his parents from the concentration camp Theresienstadt when he returned to Germany as a soldier with the United States army.  It took his grandson, my 13-year-old son, to get him to break this silence, when my son requested that his grandfather speak to his 8th grade class following their visit to the Holocaust museum in Washington, DC.

My father's story is one of not only survival, but of triumph in the midst of unimaginable horror. He would never use the word "trauma" to describe his experience.  Bits of the story had emerged at times, in part around my daughter's bat-mitzvah 4 years earlier. But in general he ascribed to Elie Weisel's notion that it was a horror so great it could not be spoken of.

French psychoanalysts Francoise Davoine and Jean-Max Gaudilliere have a different adage on the cover of their book, History Beyond Trauma; "Whereof one cannot speak, thereof one cannot stay silent." They argue that personal stories of war and societal trauma, if not told in words, emerge as symptoms, sometimes as mental illness, sometimes in subsequent generations.

Davoine offers a wonderful example in a story of her own family. She and her husband were on a trip with their young children when she discovered a growth in her abdomen. Despite a fear of cancer, they decided to say nothing to their children and finish the month-long trip. Shortly after the discovery, her son developed severe anxiety around bedtime and refused to go to sleep. It emerged that, being highly sensitive to his parents emotions, as children can be, he was worried, but didn't know what to be afraid of. When his parents explained about the lump, his sleep problem resolved. They write:

Let us imagine, for a moment, the following catastrophic scenario: continuing to play the admirable mother, Francoise keeps the secret. The child would find himself burdened by the cut out truth of the story. Rushing into a hyperactive exploration, or barricaded in a hyperpassive withdrawal, nowadays he might have been quickly diagnosed and chemically brought back to reason.

In my behavioral pediatrics practice, I often hear stories like this from parents, both of major trauma in the form of such things as abuse or death of a sibling, or subtler trauma of having an emotionally troubled parent. At first parents focus on the child's "behavior problem." But in a non-judgmental atmosphere where sufficient time is given,  parents are usually eager talk about their own history, and become curious about the effects of their experience on themselves as parents, and on their child.

For example, a 4-year-old girl  had severe separation anxiety. It emerged that her mother had a miscarriage when she was three, and had never had the opportunity to mourn the loss. Her daughter was worried about her, and so did not want to leave her either to go to school or go to sleep.  A father of another boy with "defiant behavior." had been abused by his own father, and found himself full of explosive rage that came out, against his will, in his relationship with his young son.

In recent posts I have been focusing on qualities a child brings to the relationship with his parents. In our quest to understand a child's experience, this is an essential piece. But equally important is to understand what parents bring to the relationship, in particular in terms of their own unique history. Parent-child relationships are a complex, intricate dance. At times they can be clumsy and full of stepped on toes. But with work and careful attention, they can be transformed back into a dance of joy and grace.

I am blessed by the fact that my father is alive and in good health. I am hopeful that we now have the opportunity to write a book together telling of both his remarkable life, and also how his experience came to be known by me and my children. It will serve as a dramatic example of a story that needs to be told.

Could sensory integration disorder be the primary problem?

As in an Escher Print, there may be a completely different way to see this issue from that offered in a new policy statement from the American Academy of Pediatrics on the role of sensory integration therapies for children with developmental and behavioral disorders. The statement cautions against using the diagnosis of "sensory processing disorder," because these are most likely symptoms of some other disorder such as autism or anxiety.

But I wonder if, as we learn more about the genetics and neuroscience of mental illness, we will find that the sensory processing issue is primary, and we simply organize the range of symptoms that may result from this problem into categories, in the form of diagnoses such as autism, OCD, anxiety and depression. These may in fact all be regulatory sensory processing disorders.

Sensory processing is intimately tied to emotional regulation, and our  ability to manage ourselves in a complex social environment. The world may feel soft and inviting, or harsh and dangerous. In taking detailed histories from families of children with a range of behavioral and emotional problems, I have found that there is almost always some problem of sensory processing, often from birth.

Consider this poignant description from Daphne Merkin, in a New York Times Magazine piece about her life-long struggle with depression:

It is an affliction that often starts young and goes unheeded — younger than would seem possible, as if in exiting the womb I was enveloped in a gray and itchy wool blanket instead of a soft, pastel-colored bunting.

One little boy (identifying information as always have been changed to protect privacy) I recently saw in my behavioral pediatrics practice carried a diagnosis of selective mutism, a form of social anxiety. He was able to tell his parents, once they became curious about experience of the world, rather than just trying to get him to talk, that he saw colors as sounds. This is a variation of sensory processing known as "synesthesia" where two sensations are combined into one. Certainly it alters a child's perception of the world. These qualities may be associated with great talents, particularly musical. But for a young child who does not have the words to express or make sense of his experience, it can be overwhelming.

Consider another little girl of three who I saw  "because she didn't play with other kids in school." Detailed history revealed that she was highly attuned to all the sights and sounds at school and intensely curious about her surroundings, at this point more so than in the other kids. There was a strong family history of similar traits. She also became easily overwhelmed by loud noise, such as fireworks. At home her social interactions were normal. Yet a question of autism was being raised. Kids with similar sensory processing challenges may become very disorganized in the school setting and receive a diagnosis of ADHD. Again the sensory issue may be the underlying problem.

I wonder if we should we abandon altogether the search for a "disorder," and instead focus on understanding a child's experience of the world and helping him to make sense of and manage that experience. As I have said many times on this blog and in my book, Keeping Your Child in Mind, children do well when the people who care for them understand them, and can see the world from their point of view. If we stay focused on this task, then a label with a "disorder" becomes necessary only  for the insurance company.

In my behavioral pediatrics practice at Newton Wellesley Hospital, where I children under age 6 with a variety of emotional and behavioral concerns, almost every child has sensory processing issues.  Many sound like Merkin's baby in a grey wool blanket. They may cry all the time and not sleep. In toddlerhood and beyond these issues take different forms, including  difficulties with daily tasks such as dressing and bathing.

I am not saying that all of these children should have "brushing therapy." The AAP statement points to the lack of evidence for sensory integration therapy. But there is a wide range in quality of these therapies. The essential element is that these problems exist in a caregiving relationship. For example, having a baby who does not like to be held and cries all the time can be a devastating experience for a parent. Feelings of inadequacy or even depression may occur. It is essential to address the sensory processing problem in the context of this relationship, and not simply treat the child. Stanley Greenspan's DIR Floortime model is the prototype of this kind of work.

I am looking to add an occupational therapist to my practice who is well versed in the field of infant mental health and understands how to work in relationships in this way. We need to bring the body into the treatment as early as possible to help children regulate their emotions. Helping them to feel comfortable in their body and manage their sensory experience, and to use the body for self-regulation, are essential elements of the treatment of any behavioral or emotional concern in a young child.

The poop wars: why Miralax is just a band-aid

A recent article in the New York Times identifies the possible overuse of Miralax for treating chronic constipation in children. Many take it on a daily basis for years, despite the fact that it is only approved for use in adults. As a pediatrician I have prescribed Miralax many times, and find it to be a very useful medication. The problem comes when only the symptom, and not the underlying cause, is treated.

In my experience the cause of chronic constipation is usually not insufficient fiber in the diet, but rather a combination of a habit of stool holding with sometimes complex emotional issues around autonomy and control (the exception being an underlying neurologic or other medical condition.) I'm all for a healthy diet, but if you make this an issue about eating more fruits and vegetables, you may be simply shifting the battleground from one end to the other. It is best to avoid battles over either what goes in or what comes out, because in these battles the child, by using his body, will always win.

 I hope readers don't mind some details-as a pediatrician I have to be comfortable talking about poop.  On excellent use for Miralax is for a toddler who has a hard painful stool and then holds in his stool for fear of repeating this experience.  This may be more likely to happen in a child who is sensitive not only to bodily sensations but also other forms of sensory input, such as sound and touch.  This problem can occur whether or not a child is in diapers. It is best nipped in the bud. Miralax acts by drawing water into the stool. If you give the right amount, the stool is too soft for the child to hold it in. With time the child will forget the painful experience and then go back to normal stooling.

Stool holding and conflicts around toilet training may also occur if a child feels things are out of control in some other aspect of his life. For example, most parents intuitively recognize that toilet training a toddler around the time of the birth of a sibling is not a good idea. One child I took care of dug in his heels around potty training when his parents were going through a difficult divorce.

Parents who have dealt with this problem know that kids can be very adept at holding in stool. They may stand in a corner turning red in the face with effort.  This may be interpreted as trying to push the poop out, but most of the time what is actually happening is that they are working to hold the stool in. Just as biceps get strong when you lift weights, the anal muscles can get very strong with repeated use in this way.  If this cycle is not broken, kids can go on to have problems for many years. However, with time and careful attention, kids can learn to use their muscles the right way and to have a healthy relationship with their body and bowel habits.

There are often tremendous social pressures on parents to toilet train their children. When parents come to see me in my behavioral pediatrics practice, they often have had ongoing conflicts with their child about sitting on the potty, but have recognized that this approach is not working. They may even wish to have their child take charge of the issue, only to be thwarted by pressures in the school setting. I am all for using motivation for encouragement when a child is ready. Pediatrician Barton Schmitt coined the term "poop candy" for rewards for pooping in the potty. But if a child is not ready, either physically or emotionally, even the promise of a trip to Disney World will not get him to poop in the potty.

Toilet training occurs at a time when children are taking ownership of their bodies. Eric Erikson referred to it as the stage of autonomy vs. shame and doubt. As much as is possible, its best to simply let a child take charge. If problems arise, short term use of Miralax to avoid stool holding while the underlying issues are addressed is certainly reasonable. But it should not be used for long-term treatment. I am not speaking to the safety of the drug, because its long-term risk is not known. Rather, using any drug for years without in- depth exploration of the cause of the problem, a trend far too common in our medication-happy culture, is not a good idea.

Is big pharma's grip on children's mental health care loosening?

Is it possible that our culture's over-reliance on the quick fix of medication to treat complex problems is waning? That alternative models of care offering meaningful support for early parent-child relationships are gaining increased recognition? My inspiring weekend with the current group of fellows in the UMass Boston Infant-Parent Mental Health Post-Graduate Certificate Program gives me hope that this is in fact the case.

One person in the group, an experienced neonatologist, has in the course of her clinical work increasingly recognized that what makes some premature babies do well and others not lies in the quality of their early caregiving relationships. She sent the group an article as evidence of the above trend, writing: 

I am attaching a very short paper from this month's Journal of Perinatology that describes incorporation of relaxation techniques into perinatal counseling. It uses terms such as "being with," "connections," and "compassionate presence." Ten years ago, this paper would have been flatly rejected by a prestigious journal as being anecdotal and merely descriptive. 

Peter Fonagy, the weekend's featured speaker, a great mind who has been likened to a modern-day Freud in terms of the transformative nature of his ideas, offers an alternative model from that presented by the pharmaceutical industry. Relationships can change the brain in more specific ways than drugs.

Fonagy identifies the quality that makes us uniquely human, different from animals. It is the ability to interpret other's behavior as having meaning. Humans alone understand that behavior is driven by motivations, intentions, desires and beliefs.

But the thing is, babies are not born knowing how to make sense of their own and other's behavior. They learn it from the people who care for them. When a parent is attuned with her baby in such a way that says, "I understand you," that child learns to understand not only his own mind, but also the minds of others. This learning takes place at the level of structure and biochemistry of the brain. This ability to interpret other's behavior in turn allows that child to make sense of the wider social world.

 Attuned early relationships of what Fonagy called "epistemic trust" are critical because they are "the superhighway for transmitting cultural knowledge." They are the means by which we learn about the world: how we learn to engage with others in a healthy and productive way.

Where does the motivation come from to shift from a quick-fix model of disease to one that promotes healthy relationships? The ACE study, which I have written about in previous posts, offers a kind of negative motivation. If we do not do something to change direction, there will be lots of bad outcomes in the form of such things as mental illness, violent crime, diabetes and heart disease. Fonagy offers more positive motivation. If we intervene early to promote secure safe relationships, we give children the tools to go out into the world, think creatively and move our society forward.

Fonagy points to three trends offering hope that things are changing in the way we as a society care for children and families. One is the increasing evidence of the impact of stressed early relationships on such long-term health outcomes as heart disease and obesity. The second is the decreasing influence of big pharma on mental health care, as evidenced by the marked decrease in development of new drugs to treat mental illness.  And third is the role of the Internet in disseminating new information. I am hopeful that this blog is one small part of that trend.