Why is this Post Different From All Other Posts?

My son's bar mitzvah is this September (yes-two weeks after my book comes out!!) and so despite the fact that we are not a particularly observant family, we found ourselves at Shabbat services on Saturday morning of Passover. The Rabbi has members of the congregation take turns reading parts of the service. By total random chance, it was my turn to read when we got to the translation of the day's Torah portion. And this is what I read:

A God, compassionate and gracious, slow to anger, abounding in kindness and faithfulness, extending kindness to the thousandth generation, forgiving iniquity, transgression, and sins. Yet He does not remit all punishment, but visits the iniquity of parents upon children and children's children, upon the third and fourth generations.

So there it is in the Torah, what in the world of child development is referred to as "intergenerational transmission of trauma," or "intergenerational transmission of attachment." This can take many forms. Parents who have been abused are more likely, without adequate help, to abuse their own children. Most parents I see in my office who are struggling with their child’s challenging behavior tell me some variation of the statement "Í don’t want to do to Charlie what my parents did to me.” Yet they are horrified to find that they are in fact behaving in exactly the same way as their parents. They find themselves distracted and emotionally unavailable, or explosive and full of rage. In the book History Beyond Trauma two French psychoanalysts describe how psychiatric symptoms can represent trauma of war that has not been expressed, sometimes for generations.

"So why is this in the Torah?" the Rabbi asked. One member of the congregation said that it was about taking responsibility for your behavior as a parent. I thought this was a good answer. When this question of how parents behavior affects their children comes up, it is often heard as blaming parents for their children's problems. In the first chapter of my book I have a section entitled "Guilt, Blame and Responsibility" (also a previous blog post of the same title) because I think is is important to address this problem up front. When people feel blamed, they may become defensive and shut down. Here's an excerpt

Guilt and blame are negative words, and responsibility is a positive one. People generally feel good about themselves when they take responsibility for their lives. They feel empowered. But taking on the responsibility for raising a child in a meaningful and effective way is not an easy task. In the setting of
fragmented families, financial stress or a parental history of abuse or neglect, it is especially difficult. Add to this a child with a challenging temperament, and the responsibility can easily feel overwhelming.

As I've said many times before, supporting parents in this essential task of raising the next generation is critical. The flip side of recognizing our society's responsibility to support parents is for parents to recognize their responsibility for facilitating their child's healthy development. For what its worth, the Torah seems to support this point of view.

A Beautiful Parenting Moment at the Local Coffee Shop

It was a peaceful Saturday morning at Fuel, a local coffee shop in Great Barrington. People sat quietly murmuring with friends over coffee and muffins, or intently working at their laptops. I was doing the final edits for my forthcoming book Keeping Your Child in Mind, when I looked up to see a small boy of about two years tottering down the narrow aisle holding a plate with an enormous cinnamon bun almost the size of his head. His father followed close behind and they sat down at a table right next to me. The boy was proudly surveying his prize when his father innocently reached over and asked "May I share?" Instantaneously the peace was shattered."NO!!! MINE!!! NO SHARE!!!" His father made a hasty retreat but it was too late. The boy quickly descended into an all out tantrum despite his father's attempts to soothe him.

His mother, who had been at the cash register, rushed back to try to help. While she joined the efforts to quiet his screams, now transformed into sobs of “no share!”, she and the boy’s father looked to be deciding whether to abandon their outing or try to repair the situation. Fuel is a friendly place, and the other customers, including myself, smiled at them knowingly. This, together with a gradual decline in the intensity of their son's crying, seemed to lead to a decision to stay. His mother sat with him while his father went to finish the transaction at the register. He returned with breakfast for the grown-ups and after a bit more time, the boy's crying slowed to a quiet whimper. Calm once again descended, and the three of them were quietly eating their breakfast when the boy took a piece of his cinnamon roll, reached across the table to his father and said, “Share?”

Mine is a favorite word of most toddlers. This word doesn’t represent greed, but rather the toddler’s great joy in his newly emerging sense of self. Certainly limits must be set, and a toddler must learn over time that everything is not in fact, "mine." Just how to impart this sense of limits while at the same time facilitating a healthy sense of self is one of the great challenges of being a parent of a toddler. Sometimes a child might feel particularly vulnerable, such as when he is hungry or tired, and can collapse in the face of a parent who shatters the illusion of his omnipotence. I imagine this was the case with this little boy and his cinnamon bun.

His parents, clearly attuned to the emotional state of their child despite the pressure of a public scene, sensed that this was not a moment to set a limit. He had his two-year-old reason for feeling that sole possession of this prize was essential. They were all rewarded by a happy repair of the disrupted morning. And with their respect for his autonomy, he was able to take in the idea of sharing, though for the time being, he needed to share at his own initiative.

This was a tiny moment, yet full of such richness and complexity. Strung together, such moments, when parents respond to the meaning of a child's behavior rather than simply the behavior itself, serve to set a child on a path of healthy emotional development.

Early Relationships and Brain Development as the Core of Medical Practice

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

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

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

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

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

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

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

Psychiatric "Disorders" in Young Children: Proceed With Caution

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

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

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

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

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

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

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

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

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

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

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

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

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

Protecting infants from the ill effects of mental illness

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

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

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

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

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

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

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

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

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

The New York Times Thinks About Parents

I felt that I was in very good company yesterday when my letter to New York Times was published in reference to last weeks op ed piece The Parent Trapped. In that piece, Katherine Ellison, responding to indictment of a mother in the murder of her two teenagers, describes her own journey from the brink in her relationship with her son. She describes feelings of barely controlled rage and her realization that she needed to get help.

While there was much that could be said about this piece, I picked up on the way in which Ms. Ellison, with the support of family, friends and professionals, took ownership of her role in the conflict. She wrote:

I spent much of the year learning about A.D.H.D., a condition I soon realized that I shared with my then 12-year-old son. Among its classic symptoms are conflict-seeking and hot-headedness. Humbling as it was, I ultimately heeded friends and professionals who encouraged me to shed my fantasy of being the victim of a raging, impossible child, and own up to the ways I was contributing to our fights.

In my response I wrote:

In the safety of my pediatric office, countless parents have revealed that they are startled by the intense rage they feel for a child whom they also have such powerful love. Katherine Ellison bravely and honestly addresses this issue in her article.

The fact is that intense opposing feelings are a normal part of any passionate relationship. But as she points out, when parents feel out of control, if they are unable to manage their own rage, it is essential to get help.

The beauty of her article is that it identifies the relational nature of the problem. All too often, a “behavior problem” is viewed as residing exclusively in the child. When parents feel recognized and understood, as Ms. Ellison seems to have felt, they are better able to be fully present with their child, in turn helping the child to manage his or her particular vulnerabilities.

Another letter identified the critical role of emotional regulation in development and the need for parents to "push the pause button" in the heat of the moment and reflect on whats going on. Yet another addressed the wrongness of corporal punishment and the need to find effective alternative measures. A third spoke of the need for friends, communities and professionals to be available to parents when they reach out for help.

What was most encouraging to me was that the majority of the letters in Saturday's paper were devoted to this subject. As the Times represents in some significant ways the cultural trends in this country, this fact gives me hope that we are seriously considering the essential role parents play, and our need as a society to support them in this very challenging yet highly rewarding task.

A Third Front in the War on Obesity

Recently I watched the Academy Award winning film Monster’s Ball. A morbidly obese young boy whose father is about to be executed sneaks a chocolate bar while his mother is out, only to be verbally and physically assaulted by her when she returns and discovers a smudge of chocolate on his face. This is an extreme example, but it highlights the complex relationship children and parents can have with food and eating.

There is no doubt that childhood obesity is a huge public health problem with complex causes and far reaching effects. Michelle Obama’s efforts, now entering their second year, are admirable. The identified culprits that she has targeted; a sedentary lifestyle and aggressive marketing efforts of unhealthy foods by the food industry, play a significant role.

However, in addition to targeting interventions focused on the food industry and physical activity, it is critical to recognize the meaning of food and eating in parent-child relationships. An example from my behavioral pediatrics practice illustrates this point.

Sylvia brought her four-year-old son Andrew to see me because “he’s always eating”(details have been changed to protect privacy.) An engaging, plump little boy, he was enthralled by the Dunkin Donuts across the street from my office. Sylvia described constant battles around his demands for sweets.

But over the course of our 60-minute visit, other important issues emerged. Andrew’s father, Richard, had lost his job and the family had moved three times in the past year. Richard struggled with severe depression. In addition to the battles around foods, Andrew was having increasing numbers of temper outbursts, and his mother revealed to me that she was at times unable to contain her own rage. She had even on occasion beaten him with a belt. As Sylvia became more relaxed and began to open up, she shared that she had been physically abused as a child.

In helping to manage Andrew’s out of control heating habits, it was essential to recognize the connection between Andrew’s insatiable appetite and the stress he was experiencing in his relationships with both his mother and father. Supporting these relationships was the aim of my work with this family.

If the child in Monster’s Ball is one end of the continuum of disordered eating, and Andrew in the middle, in my general pediatric practice I see, at the other end of the continuum, the relatively minor everyday challenges of parenting that are inextricably linked to later eating habits.

A mother whose child has sensitivity to textures of foods may feel inadequate in the face of her child’s picky eating. This in turn may lead her, at moments of desperation, to force food into her child’s mouth, setting the stage for a lifelong distorted relationship with food. The primary care setting offers an opportunity for early intervention and repair of these types of difficulties. In addition, disordered sleep patterns are closely tied to risk of obesity. These patterns develop in the first few years of life, and a primary care clinician can play an important role in both development of healthy sleep habits and in setting patterns in a healthy direction when they go off course.

Supporting parent-child relationships is a critical element to add to this “war” on obesity. Investment in primary care and mental health care, as well as in programs that have been shown to support parent-child relationships that are at risk is essential. For example, the Yale based Minding the Baby program is a preventive home visiting program that aims to support parent-child relationships in young families stressed by limited economic resources.

Research by Jack P. Shonkoff, MD founding director of the Center on the Developing Child at Harvard University, has demonstrated that safe, stable, and nurturing relationships may protect children against poor health later in life. Children who develop a strong sense of self in the context of these secure relationships are more likely to make healthy lifestyle choices.

And a word of caution regarding the language of the “war” on childhood obesity. I wonder about the experience of an overweight child who is exposed to this news. Shame, confusion, and fear- these powerful emotions may go unprocessed. At the very least, these headlines should offer an opportunity for conversation among adults and children about diet and lifestyle choices.