In the age of DSM 5, what is normal?

In an interesting coincidence, a couple of weeks ago I received two emails on the same day asking me to write about books that are about the same subject. One is  Child Temperament: New Thinking About the Boundary Between Traits and Illness,  the second Back To Normal: Why Ordinary Childhood Behavior is Mistaken for ADHD, Bipolar Disorder, and Autism Spectrum Disorder.

The first was written by David Rettew, MD a child psychiatrist at the University of Vermont College of Medicine, where at the Vermont Center for Children, Youth, and Families ( VCCYF) they have an innovative family centered, strength-based approach to children's emotional and behavioral problems.

In a language that is based in science and research,  Rettew explores the overlap and interplay between the concepts of "temperament" and "psychopathology. He tackles the complex science of behavioral epigenetics- the impact of life experience on gene expression and subsequent behavior and development. He then describes how he integrates these ideas in to his care of children and families. For example, he describes how he might speak to a child patient:

I've heard a lot about you today and one of the things that I hear from you and your parents is that you are a very kind person who can really tune in to other people.  That is a wonderful quality that will serve you well in the future. At the same time, I also hear that you can get so concerned about what others think about you that you avoid things you like doing just so there is no chance you will feel embarrassed. Doctors sometimes use the term  social anxiety disorder to describe this situation, and if you are willing there are things we can do to help you feel more at ease in social situations.

He masterfully takes on very complex issues, including the way a child's behavior may provoke a parent's negative response.

A father of a temperamentally irritable boy who is prone to shout at the boy for  relatively minor infractions is certainly not relieved of responsibility for his behavior, but can be understood from a prespective that some of his suboptimal responses are evoked by the child's behavior, partially influenced by shared genes that cause both of them to escalate in negative ways.

The second book is organized around examples from the practice of the author Enrico Gnaulati, PhD, a clinical psychologist specializing in child and adolescent therapy. He examines our cultures rush to diagnose and medicate, and what he terms the "casualties of casual diagnosis." He writes:

In the past four decades we have gone from blaming parents for kids' problem behavior to blaming kids' brains....yet rarely can a child's behavior be explained exclusively in terms of child rearing or brain chemistry. In most cases, it is causes- plural, not singular- that explain why a child behaves the way he or she does. 

The underlying problem both authors address is embedded in the paradigm of mental health in which they practice.  Rettew seems to be trying to wrestle out of the paradigm in the last section where he describes an evaluation process that makes use of other tools besides DSM. However, the above example shows how the language of DSM permeates care, when albeit reluctantly, he uses the term "social anxiety disorder." This "disorder" may be in the DSM, but it is not a "real" disorder in the way, for example, diabetes is.

Earlier this year, the head of the National Institute for Mental Health tried to discredit DSM 5 by saying that they would not fund research based on the DSM system but rather aim to find the underlying "cause" in the realm of neuroscience and genetics. But as Gnaulati points out, we will never find the cause by just looking at the brain.

Gnaulati is similarly trying to find another way to think about this paradigm that offers oversimplified labels. But I am concerned that framing the issue as "normal" vs "disordered" is  misguided, and a result of the author being unable to see his way out of the DSM paradigm.

If a child and family are seeking help, then by definition the behavior is not "normal." Given the continued stigma associated with mental health problems, for a family to make the effort to call, make an appointment and actually show up, they are likely to be struggling in a significant way. Thus to call this "normal," even though the intention may be to be reassuring, is actually dismissive of the family's suffering. I wrestle with this dilemma every day in my clinical practice. Parents come to me and ask, "Is my child normal?"

I speak to this issue in a previous post: Answering the question: is something wrong with my child?
I refer to an article by Daphne Merkin on the question of whether depression is inherited:

The concept of "being attuned to your child's nature, especially when it differs from your own,"  is the essence of healthy parenting. She is describing a parent's recognition of what D. W, Winnicott termed the child's "true self." It involves recognizing a child as a person with thoughts and feelings that are his own. It is an excellent goal to work towards, though not always easy.   Issues that get in the way of recognizing the child's true self, including stresses in a parent's life and other relationships, may need to be addressed.

When viewed from this perspective, the question becomes not "is there something wrong with my child?" but rather "Who is this child, and how is he or she both alike and different from me?"

I wonder if Rettew and Gnaulati are so much a part of the prevailing paradigm that they do not recognize that what they are actually doing in their books is questioning the very paradigm in which they practice. If they were to step outside of the paradigm, they might, rather than asking the question "does a child have ADHD?" , asking the more salient question, "Is ADHD ( or autism or bipolar disorder or OCD for that matter) the way we as a culture use the term, a "real" thing, or is it an artificial construct defined by the DSM system and perpetuated by the pharmaceutical and health insurance industries?"

I believe that what both of these authors are actually doing is describing a new paradigm of mental health care that recognizes the relational nature of human development and offers opportunity for curiosity about the complex meaning of behavior. I'm calling them on it.

Investing in early childhood means investing in infants

Why is this so difficult for us to see? The United States has one of the most restrictive parental leave policies in the world, as my fellow blogger Claire McCarthy accurately described in a recent post. We fail to recognize the importance in investing in early relationships. The closest we seem to be able to get is age four. But the abundance of research at the interface of developmental psychology, neuroscience and genetics tells us that 4 years may be too late.

I wonder if the answer lies in child development researcher Ed Tronick's  still-face experiment. I remember well when I first learned of his research. I felt a kind of outrage, asking "how did he get this past the IRB( institutional review board for human subjects)?" In his well-known experiment, a mother plays with her infant in a usual way, then presents a still-face for a specified period of time, and then resumes normal interaction.

I now work closely with Dr. Tronick and well recognize the brilliance of his work. He sometimes remarks that it is his students in his Infant Parent Mental Health program at UMass Boston who seem to have the most initial outrage at seeing the experiment. I now understand that as a kind of deep empathy with the experience of both the mother and the baby. With that comes a passion for protecting this relationship, a passion that drives those of us who chose this field.

There is a great poignancy to recognizing the tremendous capacity of the newborn to communicate when we have a system that fails to support stressed early parent-child relationships. The Newborn Behavioral Observation System developed by T. Berry Brazelton and Kevin Nugent beautifully brings out these capacities.

But if a parent is stressed in the setting of such things as emotional distress, her own history of abuse, marital conflict and domestic violence, social isolation and poverty, being available to her infant in the way he needs is difficult. This is where the investment needs to be. Not 4 years, but 4 months, 4 days, 4 hours.

In Sunday's New York Times Nobel prize winning economist James Heckman has an op ed Lifelines for Poor Children where he again speaks to the need to invest in early childhood. He refers to Obama's policy proposal. However in the actual text of Obama's proposal there is relatively little for infants. The emphasis is on the four-year-old.

All we know about the science of early childhood tells us that the brain grows in relationships. The volume of the brain doubles in the first year. The brain makes millions of synaptic connections every minute. It is in infancy that the parts of the brain responsible for emotional regulation have the most rapid development.

 A startling article in the New York Times Can Emotional Intelligence Be Taught? begins with a vignette from a Kindergarten classroom where a child says, "My Mom does not like me," When he describes how his mother screams at him every day, he is taught how to handle the situation in a calm way. Somehow the tables are turned and it is the child's responsibility to manage his out-of control mother. The answer is not to teach this child emotional regulation, but to help this parent-child pair to grow together in a healthy loving way. And this help needs to start in infancy.

This week I will again attend a meeting of Representative Ellen Story's postpartum depression commission at the State House. It is always an uplifting experience as leaders in the field grapple with the question of how best to support parents and young infants. The commission recognizes that this work occurs primarily in the realm of health care, which is where young infants and their parents can most reliably be found.

Did Electroconvulsive Therapy or Storytelling Cure Simon Winchester?

Joe Donahue, the brilliant host of WAMC's Roundtable recently interviewed Simon Winchester about his short e-book "The Man With the Electrified Brain. In the book Winchester describes his four-year experience as a young adult with an undiagnosed serious mental illness that was at the time apparently successfully treated with electroconvulsive therapy (ECT.) 

There is much speculation of the nature of the illness. Winchester himself, on discovering DSM (Diagnostic and Statistical Manual of Mental Disorders) IV many years later while writing The Professor and the Madman, diagnosed himself with a "dissociative disorder." A professor of psychiatry at Stonybrook who is a proponent of ECT, based on correspondence with Winchester,  has diagnosed him with "simple melancholia," an illness he recognizes is not in the DSM and attributes to "abnormal hormone functions."  A Psychology Today post entitled What Did Simon Winchester Really Have?" refers to "psychotic episodes."

In his introduction to the e-book Winchester explains his reasons for writing about this subject so many years later. He describes living with feelings of shame, and, following the death last year of both his parents, a desire to "come clean." He writes; 

My mother and father, tough old greatest-generation Britons who lived well on into their nineties, belonged to a time and class that disapproved mightily of any kind of mental infirmity...Stuff and nonsense, my father would bellow on hearing of my troubles. Damn tomfoolery was his only diagnosis, Pull yourself together his only prescription.

The answer to my question may be found at the end of Donahue's masterful interview. After covering the scope of Winchester's story, Donahue moves on to material that is most definitely not in the book. "Without getting overly psychological," sharing that he, like Winchester, had recently lost his parents, Donahue wonders about a wish to " fill in the blanks," about his history, and in particular his genetic history.

What follows is, in my opinion, the most fascinating and important part of the interview. Winchester tells of his elderly mother going with him to Buckingham Palace in 2006 when he became an OBE (Officer of the Order of the British Empire) He describes her getting tipsy on two glasses of sherry and telling "unbelievable stories about her life," stories of "espionage and affairs." Winchester tells of his father's history of being badly treated as a prisoner of war, and in the final weeks of his life, after suffering a stroke, beginning to open up about his own history. He speaks of his father's growing tolerance of talking about mental illness. Then, most poignantly, Winchester says, “It was brimming, I could feel a sense that this is all going to break, and then he died."

After this comes an exchange where Winchester describes an uneasy sense that his illness may return, having been told by a number of people that the ECT, " didn't cure you."

I wonder if it is this very telling of the story, including his incomplete yet meaningful connection with his parents towards the end of their lives that will prove to be the “cure.” This telling of stories as cure is well known within the discipline of psychoanalysis. I describe it in a previous post Childhood Trauma: Stories that Must Be Told:

French psychoanalysts Francoise Davoine and Jean-Max Gaudilliere have an 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. 

Of course I do not know if Winchester's family history had any relation to his illness. Yet I cant help but wonder, if this silence, this "British reserve" had a role to play, both in the illness and also in Winchester's chosen profession as a writer, or "storyteller." Perhaps it is his storytelling that was/is the cure.

We are currently in hot pursuit of the science of mental illness. This past Sunday, in an op ed in the New York Times, The New Science of the Mind,  Nobel Prize winning neuroscientist Eric Kandel writes about our growing ability to understand the biological basis of psychiatric disorders.

Listening to Winchester's story motivates me to again point to the need to attend to the relational and historical context of being human in our quest to understand mental illness. If we focus exclusively on the "biology" without attending to the way the brain grows and changes in the context of relationships, we miss what a colleague referred to as the "poetry" of human nature. 

I have great respect for the complexity of the kidney. But the way the proximal and distal tubules transport ions is likely not related to, for example, the owner of those kidneys' relationship with his mother, or his father's survival of the Holocaust. But the function of his brain/mind most certainly is.

My hope is that what we will take away from Simon Winchester's story, thanks to Joe Donahue's  interview, is that in our pursuit of the science of mental illness we must find a way to make room for storytelling.

Gym as treatment for ADHD?

An article in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry about the role of exercise in treatment of ADHD gives me hope that there is some movement in the direction of non-pharmacological treatment of problems of regulation of emotion, behavior, and attention. ( I do not use the term "ADHD" for as readers of my blog know, I believe that ADHD as defined by DSM is an oversimplified, artificial construct.)

However, the accompanying editorial entitled "Gym for the Attention Deficit/ Hyperactivity Disorder Brain?" gives me concern that this idea represents yet another oversimplification. The editorial calls for "empiric support" from "well- designed studies." Our culture has a love of "evidence-based medicine."  I hope that before embarking on these studies, there is consideration given to what a colleague referred to as "medicine-based evidence," or research based on what we have learned from both clinical experience as well as other disciplines.

Primarily what we have learned is that its not just "exercise" or "gym," but a very specific use of the body to help the brain with the task of self-regulation. In fact, for a child who is overwhelmed by sensory input and easily dysregulated, as many of the children carrying the "ADHD" label are, traditional "gym" may be a disorganizing experience.  I described this concept in detail in a previous post, Emotional Regulation in Children: Using the Body to Help the Brain. It preceded my Boston.com blog so I have re-posted it below:

I recently heard a great story from a parent in my behavioral pediatrics practice. Their son was very active and had a hard time settling down to learn, and so, before an early morning tutoring session, a very resourceful teacher suggested he ride a scooter down the empty halls to the room where a group of kids with reading difficulties met. To make it fair, the teacher allowed all of the students in the group to ride scooters to class. The kids lay on their stomachs and used their arms to propel them down the long hall. Interestingly, not only this boy, but also all of the kids in the class began to do better!

One of the best weekends of the Infant-Parent Mental Health Post-Graduate Certificate Program that I have been attending and writing about over the past year, was with child psychiatrist Bruce Perry. He spoke of the importance of what he referred to as "rapid alternating movements' in achieving emotional regulation. Dr. Perry's ideas grew out of his frustration with the traditional model of psychiatric care, where children who have experienced significant trauma are expected to sit and talk with a therapist about their experience( and of course are also medicated.) His model of intervention is based on knowledge of brain development and is termed the "Neurosequential Model of Therapeutics.'

While it is not my intention to describe the model in detail, one of the main messages, which has relevance not only to traumatized children, is that in order to think, learn and process experience, one must first feel calm. A range of activities can achieve this calm. Dr. Perry does therapy sessions with very troubled children while going on walks. Horseback riding, martial arts, drumming and dance are other activities that can serve to achieve this kind of calm. A group of fellows from the program got to try out the theory. After a long, very stimulating (and also somewhat dysregulating) day of learning with Dr. Perry, we went ice-skating. Not only was it a lot of fun, but it worked wonders in helping us to process the experience.

Often when kids are struggling in school, teachers express concern that they are "over-scheduled." But if extracurricular activities are carefully planned and well thought out, they can be considered an essential part of treatment. It is best to have some kind of a calming activity interspersed with homework, tutoring or therapy. These can be tailored to a child's particular talents and interests. Many know the story that Michael Phelps struggled terribly with ADHD. Swimming can be a very regulating activity, but some kids with learning and behavior problems also have sensory processing difficulties and can't stand to have their head under water. Clearly swimming isn't the right choice for them.

The more children I see with a range of "behavior problems," the more I recognize the importance of using the body to help the brain. Occupational therapy for young children can accomplish this goal. But as children get older, and can learn to express their feelings, parents can help them identify what works for them. This same boy on the scooter, several years later, learned to recognize that when he was feeling overwhelmed, going down to the basement to play his drums helped him to regroup. This kind of awareness, both of mind and body, can serve kids well not only in childhood, but over the course of a lifetime as they learn to adapt to their particular vulnerabilities.

Central to this notion of using the body to help the brain is that movement take place in relationships. We know that children develop the capacity for emotional regulation in the context of relationships. Things like martial arts, horseback riding and swimming involve intimate relationships with teammates, coaches and instructors.

So I hope that before psychiatrists head down the road in search of "evidence" that "gym" is good for ADHD, there is sufficient thought and attention to what kind of physical activity, how and when it occurs, and if it occurs in the context of meaningful relationships.

Can we stem the rising tide of serious psychiatric illness in college?

Last week I "launched" my oldest off to college. As anticipated, it was an intense emotional experience full of joy, sadness, and many things in between. (I have to tip my hat to fellow Globe writer Beverly Beckham for her piece I was the sun, the kids were my planets that was very helpful. However, I might have written that my child was the sun, a burst of light in our household, and the experience of leaving her is like being temporarily knocked out of orbit as our family re-orients to life without her.)

The same week I received in the mail, in exchange for filling out a questionnaire about a study on diversion -use of ADHD medications by individuals for whom it was not prescribed- this pretty laminated poster of all the drugs currently available for treatment of ADHD.

Statistics indicate that serious mental health problems in the college community are growing at rapid rates. Some optimistically speculate that this is because of decreased stigma for getting care. But I wonder at the paradox of the parallel increase in availability of new psychiatric drugs- I counted 22 different formulations for ADHD medications on that poster- and the rise of serious mental health problems. Could it be that the drugs themselves are responsible for this increase? If the drugs were effective in childhood, shouldn't we see a significant decline in serious mental illness in college?

How would this work? Starting at a young age, rather than learning to manage stress in the context of supportive relationships, the symptoms are medicated away. The brain is actually wired in relationships, and in the absence of this kind of co-regulation of emotion, the areas of the brain responsible for emotional regulation do not develop properly. All forms of mental illness, including depression, anxiety and attention problems are essentially problems of emotional regulation. Then as the challenges of life increase in complexity, the medications often increase in strength and complexity. Children learn to be defined by their medication and are further estranged from a core sense of self. Add to that unknown side effects on the developing brain, and it is no wonder that there is a significant increase in serious mental illness by the time a child gets to college.

But what about that issue of decreased stigma? That also is likely true. At a superb talk given by a psychology professor at our child's orientation, we learned about the school's  "invisible safety net." It is made up of an elaborate interconnected system of students, faculty and mental health professionals to monitor the emotional well-being of the students. It is all about relationships and connection.

The very existence of this net reduces the stigma of emotional struggles. The fact that the school goes to the trouble to train such an elaborate system of care (sophomore advisors- or "SA's" the front line of this system, must apply in January of their freshman year, and they get several weeks of training prior to the start of the school year), conveys to both students and parents that it is normal and expected that people will struggle and need help.

I believe there is something to be learned from this "invisible safety net" model. If we as a country were to implement a model of preventive mental health care, we would have in place a net made up of primary care clinicians, early childhood educators, childcare workers, mental health care professionals, as well as others who come in contact with young children and families. There would be open and expected lines of communication. (At this college, if a parent calls with a concern about their child, within the hour there is a person making face-to-face contact with that student, even if it is just inviting them out for a slice of pizza- and that person is trained to recognize when it is necessary to call in a higher level of intervention.)

If such a net were there from infancy-including a system for identification and treatment of perinatal mental health problems- through adolescence, then maybe kids wouldn't need all those pretty little pills to take to college.

The doctor as drug

Psychoanalyst Michael Balint said: “If you ask questions, you get answers, nothing else.” In his work with primary care doctors in post World War II London, where many patients had symptoms related to complex psychological trauma, he supported efforts to use the “doctor as drug,” encouraging these physicians to be fully present to listen to their patients rather than asking questions guided by a need to make a diagnosis.

I thought about this idea of the "doctor as drug" when reading two recent articles in the New York Times on the same day. The first, A Dry Pipeline For Psychiatric Drugs, bemoaned the lack of development of new psychiatric drugs. 

This is news that I would cheer for, if only our system of health care allowed for doctors to use themselves as the drug. What is needed is value of time and space for listening. In such an environment the doctor, (or I should say clinician, as today the caregiver is often someone other than an MD) can let the story emerge rather than being guided by a need to make a diagnosis, which is now more often than not followed by prescribing of psychiatric medication. 

For example, a recent study identified an alarming rise in prescribing of atypical antipsychotics to young children. 

Data from the inspector general's five-state probe indicate that 482 children 3 and under were prescribed antipsychotics during the period in question, including 107 children 2 and under. Six were under a year old, including one listed as a month old. The records don't indicate the diagnoses involved.

The very availability of such powerful drugs, that can quickly suppress symptoms, may actually act in direct opposition to careful listening and meaningful change.

The second article , A Powerful Tool in the Doctor's Toolkit, addresses the issue of placebo effect. It refers to the work of Dr. Ted Kaptchuk, director of the center for placebo studies at Harvard:

Dr. Kaptchuk thinks of placebo effects as just one of the many things in the toolkit of medicine. It would never be a substitute for appropriate medical care, but it is something that can enhance medical care greatly. Wise doctors and nurses already do this. They’ve found, usually just by personal experience, that their “everything else” — respect, attention, comfort, empathy, touch — often does the lion’s share of medical care, no deception required. Sometimes the prescription is just the afterthought.

Under the influence of Big Pharma and the health insurance industry this issue has gotten turned on its head. The pill has become known as the treatment, and the relationship- the respectful, careful listening- has become the "everything else." Balint and Kaptchuk wisely recognize that it is actually the other way around.

Should pediatrics and child psychiatry marry for the sake of the children?

There is an interesting exchange of letters in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry between a prominent pediatrician and two psychiatrists regarding an article that recently appeared entitled "Is There a Child Psychiatrist in the House?" The pediatrician, William Carey, argues that pediatricians are well trained to manage such things as colic, sleep disturbances, toilet training and temper tantrums, perhaps more so than child psychiatrists. The authors of the original article reply that they are puzzled that Carey sees anything in the original article that threatens the role of the primary care clinician, and agree wholeheartedly with the proposed marriage.  Carey quotes a prominent British pediatrician, probably Winnicott, saying "many years ago" that "pediatrics and psychiatry have been living together long enough and its time we got married, if only for the sake of the children."

Here I would like to point out that Winnicott, a pediatrician turned psychoanalyst, practiced in a time before the explosion of psychiatric medications, and when psychoanalytic thought heavily influenced the practice of psychiatry. If that were still the case, I would agree with this marriage. However, in our current climate of mental health care, where the 15 minute "med check" is the most common type of visit, I think both fields would do well not to marry each other, but rather to marry the growing field of infant parent mental health.

I trained in both general and developmental and behavioral pediatrics, and work in a department of child psychiatry.  I know that for the most part neither discipline is exposed to the explosion of research and knowledge coming out of this new discipline, at the interface of neuroscience, genetics and developmental psychology. This knowledge has great bearing on preventive mental health care.

Here is a case in point. Prior to my own education in this new field, that came in part from my studies as a scholar with the Berkshire Psychoanalytic Institute and in part from a superb post-graduate training in infant parent mental health at U Mass Boston, I would not have known how to work effectively with mother-baby pairs in the setting of maternal 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 Jenna’s 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!”

After a year of visits like this every one to two months, despite having grown up in a quite chaotic environment, Jenna is a bright, curious well-regulated toddler. The research from infant-parent mental health clearly supports devoting this kind of time and attention early on to parent-child relationships as a model of preventive mental health care.

However, in order for a marriage between the two disciplines and infant-parent mental health to be successful, both need to divorce the current climate of health care where, under the influence of a powerful health insurance industry, there is no time for listening.