Insel of NIMH Misses the Mark: Medication as Social Control

Tom Insel, director of the National Institute of Mental Health (NIMH,) in his recent blog post Are Children Overmedicated? seems to suggest that perhaps more psychiatric medication is in order. Comparing mental illness in children to food allergies, he dismisses the "usual" explanations given for the increase prescribing of medication.  In his view these explanations are; blaming psychiatrists who are too busy to provide therapy, parents who are too busy to provide a stable home environment, drug companies for marketing their products, and schools for lack of recess.  Concluding that perhaps the explanation for increase in prescribing of psychiatric medication to children is a greater number of children with serious psychiatric illness,  he shows a lack of recognition of the complexity of the situation. 

When a recent New York Times article, that Insel makes reference to, reported on the rise in prescribing of psychiatric medication for toddlers diagnosed with ADHD, with a disproportionate number coming from families of poverty, one clinician remarked that if this is an attempt to medicate social and economic issues, then we have a huge problem. He was on to something.

In conversations with pediatricians (the main prescribers of these medications) and child psychiatrists on the front lines, I find many in a reactive stance. When people feel overwhelmed, they go in to survival mode, with their immediate aim just to get through the day.  They find themselves prescribing medication because they have no other options.

From many I have heard some variation of this statement:  "In light of my inability to address the family dynamics and social-economic circumstances, all I have available is medications to help with the child’s symptoms. I see patients who come from unstable environments, where parents are themselves stressed and overwhelmed. I recognized that a child's “difficult,” “impulsive,” “oppositional” behavior is most often a communication about family, social, and economic stressors that are making a child's family less competent at caring for him. However, I lack the resources or the tools to do anything about these overwhelming issues. I hate that feeling of impotence.  So I use the only tool I have, medication. When I can bear to think about it, I recognized that medication is just shutting off the child's efforts to tell me something – in effect silencing his voice- and that I have become a force for social control."

When that child is in a school setting, with a high student-teacher ratio, perhaps also with teachers who have little experience working with kids from stressed family backgrounds who are struggling with emotional regulation, the pressure to control the child’s behavior increases significantly. It is not simply that schools have reduced unstructured time (though this is a problem as well.) Medication again becomes an agent of social control. Rather than devote the resources to address the underlying issues, we can use the medication, so effective in the short term, to silence the children.

Insel also does not address contemporary research demonstrating the developmental and relational nature of emotional and behavioral problems in children, well known within the discipline of infant mental health. Referring to "biomarkers" he seems to have an idea that one day we may be able to test for mental illness in children with a blood test or a brain scan.   The importance of safe, secure primary caregiving relationships in healthy emotional development is supported by an abundance of research in neuroscience, genetics, and developmental psychology, One cannot treat emotional and behavioral problems in children by treating only the child.

As knowledge about early childhood mental health makes its way in to mainstream health care, there have been calls for universal screening. But if we are using medication as an agent of social control, we need to be very careful not to put the cart before the horse. 

If we do not first have a health care system, and an education system, that has time and space to listen, to support parents, to appreciate the complex interplay of biological vulnerability and environmental stress, to understand the meaning of a child's behavior, what may happen is that the huge numbers of children who screen positive will have no meaningful, relationship-based treatment available (and the medication/talk therapy dichotomy is another oversimplification- there are multiple evidence-based interventions that support parent-child relationships.)  This together with universal preschool has the potential, unless there is significant change, to result in massive numbers of young children silenced by psychiatric medication.

I wonder if Dr. Insel is himself feeling overwhelmed. Perhaps he realizes that the increase in children with emotional and behavioral challenges, as well as medicating of these children, is a symptom of an enormous social problem. That problem is our society's undervaluing of children and parents, our failure to devote resources to support healthy growth and development, described by Elizabeth Young Breuhl as childism, or prejudice against children. He has good reason to feel overwhelmed with this realization, as it makes his task as director of the NIMH exponentially larger. 

Celebrating Fathers, Relationships, Being Present

In his beautifully illustrated children's book Magic Always Happens: My Daddy Loves Me; psychologist Neo Papaneophytou follows a father and son through the seemingly mundane events of the day. He shows the "magic in moments," or the value of simply being present in supporting a child's healthy growth and development. The book's introduction states:

To write “Magic Always Happens: My Daddy Loves Me!” the author drew from his experiences raising his own son. Seeing every day as a blessing, father and child find joy in all their daily activities, especially when their two-year-old therapy dog, Mya, joins in! While this father was born and raised on the Mediterranean island of Cyprus—a world away from his son’s upbringing in the New York City metropolitan area, the experience reflected in “Magic Always Happens: My Daddy Loves Me!” shows the impermeable bond between father and son spending quality time together, wherever in the world that may be. Such loving bonds are relevant to all dedicated fathers all around our global village!

Proceeds from sales of the book are going towards development of an international center for treatment of children with autism.

Neo is part of a community of colleagues who have all been educated in the latest developmental science as fellows in the U Mass Boston Infant Parent Post Graduate Certificate Program. Last week I had the pleasure of being reunited with the group (I graduated in 2011) at the conference I described in my previous post.

From conference speaker Stephen Porges I learned a new phrase, "connectedness as biological imperative." Listening, being present, is not just some "soft" extraneous concept (one pediatrician referred to it in a less than kind tone as "that baby whisperer stuff, " making me wonder if she herself did not feel heard.) Porges' work echoes John Bowlby, whose recognition of the central role of attachment relationships in survival drew from Charles Darwin's theories of evolution. Porges demonstrates how connectedness is necessary for regulation of physiologic and behavioral states. In other words, the way we learn to manage ourselves in a complex social world is through connectedness, through relationships. This is first learned in our primary caregiving relationships in our earliest years, and continues to be developed and supported in relationships throughout our lives.

In describing his book, Papaneophytou wisely identifies the need for a village to raise a child. Increasingly we offer parents "behavior management," "parent training," or even medication to address challenges in raising children.  The best science of our time tells us we should instead focus on protecting space and time for parents, for children and for each other. We need that space and time for listening, for "being with," for supporting that connectedness that is central to our very survival.

Quotidian Trauma, Quotidian Resilience: Boston Conference on Contemporary Developmental Neuroscience

When Frank was a young boy, and he committed some typical toddler transgression such as having a meltdown when it was time to leave the playground, his father would slap him across the face, hurting and humiliating him in a very public way.

When I spoke with Frank over 20 years later, in the context of helping him with his own son Leo's frequent tantrums in my behavioral pediatrics practice, he did not describe this experience as "trauma." Rather, he described it in a very matter-of-fact tone.

But when we explored in detail his response to his son's tantrums, we discovered that, flooded by the stress of his own memories, Frank in a sense would shut down. Normally a thoughtful and empathic person, he simply told Leo to "cut it out." As we spoke he recognized how he was emotionally absent during these moments, which were increasing in frequency. It seemed as if Leo was testing Frank, perhaps looking for a more appropriate response that would help him manage this normal behavior. Once this process was brought in to awareness, Frank was able to be present with Leo- to tolerate his tantrums and understand them from his 2-year-old perspective. Soon the frequency and intensity of the tantrums returned to a level typical for Leo's developmental stage. Frank, greatly relieved, once again found himself enjoying his son.

The upcoming Boston conference; Psychological Trauma: Neuroscience, Attachment, and Therapeutic Interventions, promises to offer insight in to the developmental neuroscience behind this story.

What Frank experienced as a young child might be termed "quotidian" or "everyday" trauma. It was not watching a relative get shot, or having his house washed away in an avalanche. It was a daily mismatch with his father- he was looking for reassurance and containment and instead got a slap across the face. It was what leading researcher Ed Tronick would term "unrepaired mismatch." Frank, in a way that is extremely common- termed "intergenerational transmission of trauma" was then repeating this cycle with his own child. When this dynamic was brought in to awareness, was able to "repair the mismatch," setting his relationship with his own son on a healthier path.

Tronick, who runs the Infant Parent Mental Health Postgraduate Certificate Program at UMass Boston, and will be presenting at next week's conference, describes this process in a paper entitled Quotidian resilience: Exploring mechanisms that drive resilience from a perspective of everyday stress and coping. Resilience is a capacity that develops over time through the typical misattunments that inevitably occur between parent and child. D. W. Winnicott, pediatrician turned psychoanalyst, coined the phrase "the good-enough mother" to describe this phenomenon.

Quotidian trauma, on the other hand, occurs when these mismatches are not repaired. Tronick's research as shown that even if they are only repaired 30% of the time, development still proceeds in a healthy direction.

Steven Porges, a professor of psychiatry at University of North Carolina Chapel Hill, another speaker at the conference, has developed through his research, a fascinating theory to explain this process on a neurobiological basis. Tronick dramatically demonstrates the effects on an infant of these misatunement, or mismatches, in his Still Face experiment. In it we see how a young infant becomes highly distressed and disorganized when his mother does not respond to him in the typical way.

Many are familiar with the term "fight-flight" response to describe how when the body is faced with extreme stress, the sympathetic nervous system kicks in. What Porges brilliantly identifies is that in the setting of parenting, the drive to protect one's child may override this response. So what happens when a parent, like Frank, is flooded with stress, but cannot fight or take flight? A more primitive stress response, mediated not by the sympathetic, but by the parasympathetic nervous system, takes over. This is the "freeze response" that leads an animal to play dead in the face of overwhelming threat.

The parasympathetic nervous system innervates the muscles of the face and voice, controlling on a neurobiological basis that attunement that is so important to healthy development. Putting this together with Tronick's research, we can understand what happened to Frank. In a way that was unconscious and so out of his control, flooded with stress but with his fight-flight reaction unavailable, his parasympathetic system took over. The result is a literal still face. Leo's increasing tantrums match the increasing distress seen in the infant in Tronick's experiment.

At this week's conference, organized by Bessel van der Kolk, whose work with psychological trauma is featured in the New York Times Magazine this weekend, there will be much more to learn. This exploding field of study, while often identified with "Trauma" with a capital "T," has much to teach us about prevention. From the research that will be presented, we are able to understand not only how to treat trauma, but also how to intervene in the earliest months and years to break the cycle of transmission of trauma and set development on a healthy path.

Roz Chast on Parent-Child Relationships

Roz Chast's new book Can't we talk about something more pleasant?, a touching, funny, sad, and thought provoking graphic memoir, is primarily about her caregiving role as her elderly parents approach death. She makes her painful subject tolerable with humor. For example, at a point when Chast thinks her mother's death is imminent, she arrives at the "the Place" where her mother is under the care of a new nurse. She finds her sitting up, dressed, and eating lunch. Chast writes, "Where in the five Stages of Death, is EAT TUNA SANDWICH?!?!?"

Chast has a troubled, fraught relationship with both parents, though more so with her mother, right up to the end. Though the focus of the book is the final years, Chast gives some insights in to the origins of these difficulties.  Reading the memoir with an eye to understanding parent-child relationships, I found an interesting example of the way parent and child can dysregulate each other. Of how when things go wrong, the problem is not either exclusively in the parent or the child, but in the relationship.

Chast was born one month premature, delivered by cesarean section as a precaution because her mother's first baby, a girl, had died at 7 and 1/2 months. A family narrative suggested that the death was related to standing on a stool to change a lightbulb, something Chast's meek and fearful father refused to do. But the actual cause was placenta previa. An obstetrician had told Chast's mother that her "uterus would rupture" if she carried to term.

Chast describes herself as "probably not a fun baby." She had low tone, cried a lot, didn't like to eat or sleep. Likely some of these traits were related to her prematurity. Chast writes, "I had one cold after another, and from the time I could speak, one anxiety after another." Temperamentally she was much more like her father than her mother. While as an adult she writes of her mother, "I can sympathize with her desire to leave me in the care of someone else for a while," she follows with," who knows what I thought back then."

Chast's mother came from a history of trauma. Her father, Chast's maternal grandfather, was an engineer in Russia but came to the US, presumably following persecution of the Jews, to a life of extreme poverty that left him "bitter and angry."  It is possible that her mother's experience as a parent was colored not only by this history, but also her history of loss. Even today pregnancy loss may not be recognized as an experience with its own significant grieving process. Certainly in 1940 it is likely that one was expected to just carry on.

The aim of the book, I believe, is to call attention to the inherent challenges of caring for aging parents. But it is a rich and beautiful story, with other lessons as well. Chast, with her sparse details, offers us a picture of a parent-child relationship that got off on the wrong foot. I wonder if Chast's brilliant creativity is in part a result of having to cope with this difficult and painful family story. If so, her struggles become our gift.

Keep Mothers in Mind for Mother's Day and Mental Health Month

In recognition of May as National Mental Health Awareness Month, President Obama made a proclamation that included this statement

My Administration is also investing in programs that promote mental health among young people. 

While he went on to speak of working with teachers and students, my hope is that Obama will recognize that prevention starts with parents and babies. A social and cultural valuing of parents, as occurs in countries like Australia and Finland, is the path to a truly preventive model.

A recent issue of the journal Current Problems in Pediatric and Adolescent Health Care identifies the following:

The presence of parental psychological problems, such as depression or anxiety, can lead to prolonged periods of disorganized parent-infant social interaction, compromising long-term infant outcomes. A wealth of studies has shown that maternal depression is a strong predictor of infants' social, emotional, and cognitive problems throughout the lifespan.

Representative Ellen Story and her Postpartum Depression Commission have recognized this fact. While the initial focus of the group had been on screening for postpartum depression, it has expanded to focus on the emotional well being of parents during pregnancy and in the postpartum period. This includes supporting of strong, healthy parent-child relationships.

One of the initiatives is a new program MCPAP for Moms. The aim of the program is to provide statewide support for pediatricians, obstetricians and other clinicians who have the opportunity to identify and treat new parents who may be struggling with a range of perinatal emotional complications. MCPAP for Moms is partnering with the wonderful organization, MotherWoman, to integrate the community based perinatal support model, as well as the important and valuable program at the Massachusetts School of Professional Psychology,  the MSPP Interface Referral Service, that connects people in need of help with appropriate care.

D.W.Winnicott observed in his work as a pediatrician and psychoanalyst what he termed the "ordinary devoted mother." In the early weeks and months, when the infant is completely helpless, he relies on this devotion. When his caregivers are present in this way, development proceeds in a healthy direction. But when a parent is, in the words of Winnicott's biographer Adam Phillips, "preoccupied by something else," in the face of such things as social isolation, depression, anxiety or even PTSD, containing the helpless baby can be very difficult. Add a fussy baby to the mix, and this is where development can first get off track.

I am happy to be part of the MCPAP for Moms initiative because its leaders recognize the need to the focus is on the relationship. It is not only about treating the mother, but also bringing in the baby- identifying stressed early relationships and finding ways to support those relationships.

The baby is an active participant from the start. Crying, sleep and feeding problems often affect the emotional well being of new parents. The baby's mood can affect the parents, and the parents' mood can affect the baby. Parent and baby can interact in a way that causes worsening of each other's distress. This is the point at which help is needed- for the parent, for the baby, for the relationship.

By valuing the role of parents, and investing resources in the early weeks, months, and years when the baby's brain is most rapidly developing, we will be engaging in promotion of mental health and primary prevention of mental illness.

Accepting Gratitude

How often, when someone thanks us for something, do we respond with some variation of, "don't worry about it," or, "it's nothing?"  My yoga teacher, a beautiful and inspirational person who starts every class with thoughts to guide our practice for the day, first brought this issue to my attention. She confessed to having difficulty accepting gratitude. She was making an effort to pause, check her natural reaction, and instead respond with a simple, "you're welcome." To remind herself, she would accompany the words with a gesture of hand to heart.

The subject again came up at a medical conference and really got me thinking. In the health care setting, thanking can have particularly great significance. For the person who is doing the thanking, it isn't "nothing."  Our natural inclination to be dismissive in the face of gratitude may feel, to the person expressing it, like a form of pushing away, a kind of rejection. Of course it isn't meant that way, and is more likely to come from an honest place of being humble or perhaps even self-effacing.

The person giving the conference suggested a response of thanks in return. But this didn't feel right to me. It may be away of getting the last word, and also may communicate rejection. Some form of "I'm glad I could help,"  seems closer to the mark. But perhaps the exact words don't matter as much as the feeling behind them.

There is much evidence that expressing gratitude is good for our mental health.  It can be a form of meaningful connection, a kind of expression of love. Perhaps we need to be more mindful of the benefits, on both sides, of graciously receiving it.

Alex's Wake: trauma, creativity, and healing

Martin Goldsmith's new book, Alex's Wake: A Voyage of Betrayal and a Journey of Remembrance is at one level a history lesson as memoir. It offers a view of the horrors of the Holocaust from a deeply personal perspective. Goldsmith describes a six week journey with his wife in 2011 to follow the path of his grandfather Alex and uncle Helmut. Revisiting the locations where they lived, he describes the transformation from a life of prosperity and success, through the early years of Hitler's regime, to their ill-fated voyage aboard the SS St Louis where the promise of freedom in Cuba ended in return to France, and eventually to a final demise at Auschwitz.

The book also reads as demonstration of the healing power of story telling, and of the transformation of terrible loss in to great beauty. The book has its origin in tragedy, as the death of the author's father is followed less that a year later by the sudden death of his brother. Goldsmith writes:

Exactly eleven months later, on March 30, 2010, I received the shocking inexplicable news that my brother had died. A once brilliant student at Stanford University...Peter had in recent years been struck low by physical ailments and a profound depression that, I am sure, was exacerbated by the long-standing family guilt and shame. Now he was gone, quickly felled by a heart attack. He was 60.

The guilt and shame to which he refers is connected to his own father's untold history; the story of how his father and brother, Goldsmith's grandfather and uncle, were left behind to experience a brutal and gruesome end. In the wake of the loss of his own father and brother, Goldsmith finds himself driven to tell that story before his own 60th birthday.

Both Goldsmith's parents escaped Nazi Germany, a story he tells in his previous book, The Indistinguishable Symphony. But his grandfather and uncle were left behind, despite desperate letters of appeal.

There were reasons aplenty why every effort under the sun might have failed to win his family's freedom, but the inescapable fact remains that Alex begged his son to save his life and my father failed to do so.

Goldsmith's parents never spoke of this early history, a fact he understands as an effort to protect him and his brother from the truth. He describes the experience of growing up in that silence:

The guilt that my father carried he passed on to my brother, Peter, and me as our emotional inheritance...How little they suspected that, even without words, we could feel and absorb the unspoken pain that circulated like dust in the air of our home, and how much we were aware of the darkness, the enormous unknown yet deeply felt secret that obscured the light of truth. 

Goldsmith is motivated by his own loss to follow a different path from his father and brother. He sets off on this journey of discovery. As such loss is transformed in to creativity.

Many reviews focus on the fascinating history revealed in the book, particularly the terrible, but less well recognized, maltreatment of Jews in France during World War II. I found myself drawn to the story of the two Goldsmith brothers. One lost his way, eventually succumbing to depression and ill health. The other, I hope, found his way to health, in part through the very book I am writing about.

I well understand how those who directly experienced the horror of the Holocaust may be too close to speak about, much less mourn their loss. It may be for them, in a sense, unmournable.  It is left to the next generation, inheriting not only their loss, but also their strength, to tell their story.

Goldsmith's father denied his Jewish heritage. Goldsmith writes:

 And there was no acknowledgement that we were Jews, despite that being the singular reason for our family's violent dismemberment. When I, as a teenager, discovered our religious roots, my father dismissed it all by declaring that we were, at most, "so-called Jews," He did not choose to regard himself as a Jew despite the unavoidable fact that he'd been bar mitzvahed, that his parents were both Jews..."Adolf Hitler thought I was a Jew, so I had no choice. I choose to exercise that choice now. I am not a Jew," he said.

Yet Goldsmith finds his way to his Jewish identity, resonating on a profound level with the Kol Nidre prayer of Yom Kippur and eventually being Bar Mitzvah'd himself at the age of 55.

At one point in his journey Goldsmith discovers a memorial etched with the words of the Talmud, "Who Saves One Life Saves the Entire Universe." Knowing how this untold story may have been instrumental in Goldsmith's brother's death, one can view this book as an effort to save his own life. This brings to mind yet another Jewish concept, Tikkun Olam, which refers to humanity's shared responsibility to "heal the world." With the writing of Alex's Wake, Goldsmith has done his part.