Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary research in child development can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Thursday, January 8, 2015

Preschool Depression and Pathological Guilt: A Call for Listening

 Research by Dr Joan Luby at Washington University, whom one might call the mother of preschool depression, exemplifies the illness model of biological psychiatry. While Luby and her group do advocate for interventions that support parent-child relationships as a form of prevention, the danger of this model is its absence of opportunity for listening, for discovering meaning in behavior.
She and her research team have evidence of brain differences in children with behaviors that fall under the  category of Major Depressive Disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM). A recently published study showed that at age 6, children who had received a diagnosis of preschool depression had smaller volumes of a structure called the insula than children who did not have this diagnosis. Furthermore, children who exhibit what they call “pathological guilt” were more likely to have a smaller volume of the insula. Their conclusions are twofold. One is that the insula is implicated as a “biomarker” for major depression. The second is that helping children to “manage” symptoms of “pathological guilt” might offer a path to prevention.
This interpretation sounds alarm bells for me. As there is a pharmacologic treatment for depression, I hope to sound these bells before the DSM defined preschool depression goes the way of ADHD, with children being medicated in the absence of space and time to listen to the story, to understand behavior not as a symptom of a "disorder," but as a form of communication.
4-year-old Isabel’s parents, Martin and Andrea, were distraught that she often described herself as “bad, “even on occasion saying, “I hate myself.” She quickly accepted blame when something went wrong. With time and space to feel safe in my office, they told me the following story. When Martin misbehaved as a child, he was made to sit for hours on the bottom step of the basement stairs, his father berating him for being, “an embarrassment to the family.” He shared vivid memories, accompanied by deep feelings of shame and humiliation, of being grabbed by the ear and dragged away from family gatherings to this spot. Now a father himself, with no other model for discipline, he found himself repeating the same pattern with his own daughter. “What’s wrong with you?” he would shout. Her frequent meltdowns, the reason for the visit with me, precipitated not only yelling and commands to “go to your room” but also such expressions as, “why can’t you be more like your brother?”
Isabel, temperamentally more like her mother than her father, was very sensitive and easily disorganized, a quality she displayed since birth, in contrast to her “easy” baby brother. Both parents acknowledged deep conflict over discipline.  Andrea grew up in a home that, in contrast to Martin’s, had little discipline. “But,” she said, “I was  “good girl” so it wasn’t problem. Now Martin frequently blamed her for Isabel’s behavior, leading to an atmosphere of tension in the home, aggravated by the chronic sleep deprivation accompanying the arrival of a new baby.
I wonder if what Luby and colleagues are calling “ “pathological guilt” is actually shame.  Guilt can be a normal and healthy emotional experience. "I'm guilty" can also mean, “I’m responsible.” Shame, in contrast is pathological, and is associated with both depression and anxiety in childhood and adulthood. But without  opportunity to hear the story, it is impossible to know. Knowing this story, we can understand it as a kind of intergenerational transmission of shame. Perhaps if this pattern were to continue in Isabel’s family, a brain scan in a few years might show that Isabel has a smaller insula than her brother. 

Prevention does not lie in teaching Isabel to “manage her guilt.” This approach represents a devaluing of listening, a devaluing of the healing power of human connection, a direct result of the DSM illness model that places the problem squarely in the child. Supporting parent child relationships makes sense when it is not about "managing behavior," but rather listening and discovering meaning.

Once Martin had an opportunity to identify the source of his behavior in his own history, he could change his behavior with his daughter. He felt heard and understood, and so was better able to listen to his daughter, recognize what pediatrician/psychoanalyst D.W. Winnicott termed her “true self.” both parents could adopt a model of discipline suited to her unique qualities. Andrea and Martin saw how their own conflict, even when they tried to keep it from their children, affected the level of tension in the home. In the normal frenzy of activity that occurs in a household with a new baby, they had no time or space to reflect on these problems. 

The greatest risk of the model of biological psychiatry is failure to protect space and time for listening.  Listening is a kind of bridge between neuroscience and psychology. Without opportunity for listening, by diagnosing preschool age children with major depression we may leave many  standing alone on the shore, with no way over to the other side to growth, healing and resilience. 

Monday, December 29, 2014

Traumatized Kids Who Were Drugged Offer Lessons for Mental Health Care

Extensive use of psychiatric medication for children in foster care offers a striking example of childism,  or societal prejudice against children.  A powerful five part film “Drugging Our Kids  by Dai Sugano and Karen De Sa documents this issue in a thorough and dramatic way, using interviews with young adults who were in the foster care system, some from as early as 2 years of age. They were  labeled with every psychiatric diagnosis under the sun, when really what they were suffering from was trauma and loss. After experiencing physical, sexual and emotional abuse, they were on multiple psychiatric medications for many years. With the help of a range of individuals who saw through the haze of drug effects to who they really were, those interviewed for the documentary were able to get off all medications.   In a segment entitled “Treatment for a Broken Heart is Not Another Medication,” child psychiatrist David Arendondo says, “The first line treatment not another medication. It is to understand, to listen to the child, to ask, ‘what’s going on, why are you sad in this way?’”

The film offers an even-handed approach, acknowledging that psychiatric medication can help children access other form of therapy, and in certain circumstances be lifesaving. But, they point out, most often that is not the way these medications are used. Many kids in foster care are on multiple powerful medications as their primary treatment, with new ones added whenever there is an escalation in “problem behavior.” Arendondo points to the fact that we do not know the long-term effects of these medications on the developing brain. But at the very least, large quantities of medication “blunt the developmental process.”

Many clinicians interviewed for the documentary describe how psychiatric medications are used as  “chemical restraint” to control a child’s behavior. Another way to describe this phenomenon is a silencing of children. Angry, out-of-control behavior is a form of communication. It says, “ I have never learned to manage my feelings. I have never been held in a loving and safe relationship.” Medication silences that communication.

The film points to the critical role of relationships and creativity in healing. DAnthony, a child in the foster care system whose development took a different path in large part through a relationship with a volunteer,  describes the role of music in his life. “Music keeps me out of trouble. I take anger and make music.” Anna Johnson, a health policy analyst interviewed for the piece, speaks of the therapeutic value of forms of self-expression like music, dance and yoga. She describes “creativity as therapy” helping children to process trauma and connect with others who may have had similar experiences. DAnthony's words exemplify this idea; “Music is about being better, being somebody.” 
The children in these stories have experienced Trauma with a capital "T." However, many children who are similarly diagnosed with psychiatric illness and medicated with psychiatric drugs have trauma in their history.  The CDC sponsored ACES Study offers extensive evidence that a range adverse childhood experiences including not only frank abuse and neglect, but also parental mental illness,  separation and divorce, substance abuse, and domestic violence are highly associated with a range of negative outcomes in both physical and mental health. 

These cumulative experiences are a kind of trauma with a small "t," more ubiquitous than frank physical and sexual abuse.   When we diagnose and medicate, without offering time and space for listening to stories, for healing through human connection and creativity, we are doing something quite similar to what was done to these foster care children, but in a more subtle and pervasive way. 
There is urgency to the problem of medicating children in foster care.  Many of these kids are on large numbers and high doses of medication that are interfering with the course of their development. However, the mental health care system urgently needs to be fixed not only for these most vulnerable kids, but also for the huge numbers of kids experiencing trauma with a small "t." Time for listening, time for creativity, time for meaningful human connection needs to be not optional, not an extra, but rather the cornerstone of our mental health care system. 

Friday, December 12, 2014

Dads and Postpartum Depression: A Reframing

Recently I worked with Susan, a new mom who was struggling terribly with feelings of depression. Her doctor had recommended medication, but she hesitated.  Susan's depression lifted when her husband Tom started attending a new dads group.

How can we make sense of this? In today's culture, where mothers are usually the primary caregivers, fathers are often relied upon to be breadwinner and caregiver, as well as primary and often sole source of emotional support for a mother.

A colleague of mine, Ed Shapiro, pointed out a potential vast disparity between a mother's and a father's experience of life with a new infant. A mother usually feels taken care of when her husband takes care of the baby. In contrast, a father, whose spouse may also be his sole source of emotional support, may feel alone and abandoned when a mother is- in a natural and healthy way- preoccupied with the baby.

In addition, many mothers may give mixed signals, asking for help while conveying, in both words and actions, that they know better how to read the baby's signals.

Putting all of these together with the helpless infant who requires care 24-7, and both parents may be physically in the same house but feeling terribly alone and disconnected. Depression, for both mother and father, is an understandable outcome.

A new dads group has the potential to address all of these issues. Similar to a moms group, dads can share with others who are having similar struggles. With the baby present, they have the opportunity, in a safe, supportive environment, to learn to read the baby's cues and connect with the baby.

When in turn, a father feels an increased sense of competence, he may be more available, both physically and emotionally.  A mother may feel less alone and isolated and be more available for both baby and spouse. A positive cycle of connection may be set in place.

In my previous post,  I offered a re-framing of postpartum depression in mothers, pointing to social isolation and unrealistic expectations that contribute to the experience. While the response of readers was in general positive, many readers reacted with the criticism that I was implying postpartum depression wasn't "real."

Having worked with many new mothers and fathers, I have no doubt that depression is real. What I am interested in is a deeper exploration of the cause of the depression.  Certainly in mothers, though not in fathers, hormonal changes may play a role. Feelings exist in the realm of the mind/brain. Medication may help to alleviate the symptoms.

But to discover the cause of the depression, and in doing so to intervene with effective treatment, we need to look beyond the individual to the social context. The way our society does and does not offer support and services to new families is intimately intertwined with the occurrence of postpartum depression in both mothers and fathers.

Perhaps a reframing, from a disease model, that proposes "there is something wrong with you and I will fix it" to a wellness, or resilience, model is in order. Listening and meaningful connection regulate our physiology. Being heard and understood promotes growth and healing.

Offering new parents a space to be heard, held and supported is integral to the treatment of postpartum depression, in both mothers and fathers. This may mean mobilizing of family and friends, individual therapy, dyadic therapy with parent and infant together, parent-baby groups, or some combination of these. Support around sleep, crying and feeding, as well as yoga, mindfulness and meditation may also have a role to play, Ideally these interventions occur in the first three months, when not only is the infant most helpless, but also the brain is rapidly growing.

The early weeks and months with a new baby should be a time of joy, bliss and love. When it is not, as a society we owe it to both parents and babies to see that it is. As another colleague Mara Acel-Green wisely pointed out, treatment of postpartum depression ( as well as anxiety and other perinatal complications) always works. Identifying underlying causes while thinking creatively about treatment is essential.

Susan, Tom and the new dads group offer a case in point.

Wednesday, December 3, 2014

Is Postpartum Depression Really Postpartum Neglect?

Postpartum depression may be a misnomer. A more accurate term might be postpartum neglect- not by mothers, but of mothers.

The human infant is uniquely helpless in the early weeks and months of life. His arms fly up over his head at random moments in a primitive “startle reflex.” His sleep patterns have no rhyme or reason. He eats and poops round the clock. Serving an evolutionary purpose, in part to achieve an upright bipedal posture, the human brain does 70% of its growth outside of the womb.  

For a new human parent, the young infant’s absolute dependence may translate to no sleep, no showers, no ability to do anything but care for the baby. Harvey Karp has referred to this time period as the 4th trimester. His popular Happiest Baby on the Block series offer advice about what to do for a range of behavior challenges in this time period.

But as pediatrician turned psychoanalyst D.W.Winnicott identified, a mother knows what to do. He referred to this kind of care as “primary maternal preoccupation” a preoccupation that is not only healthy but also highly adaptive. The problem lies in the fact that in contemporary culture new mothers do not themselves have a "holding environment" that supports caring for the baby in the way his immature nervous system requires.
In an equally important evolutionary adaptation, the human newborn is available from the earliest hours of life for connection and complex communication.  In a calm, quiet setting, at just a few hours of age a baby will turn to a mother’s voice, follow her face, make imitating movements with his mouth.  He makes himself available for falling in love.

These two evolutionary adaptations come together in the concept as described by J Ronald Lally of the “social womb.” The human infant, with his highly developed capacity for social interaction even from the first hours of birth:
turns this seeming weakness into strength. During this dependent period the human brain is very active, developing more rapidly than at any subsequent period of life. It is picking up clues as to how it should grow, learning what it needs to survive, how to relate to others, and how to fit in and function in various settings and situations.
However, when the expectation exists that a new mother will function as she did before the baby was born, offering this “social womb” may be very difficult. Faced with this expectation, many mothers feel very much alone. 

As Winnicott wisely observes, "It should be noted that mothers who have it in themselves to provide good-enough care can be enabled to do better by being cared for themselves in a way that acknowledges the essential nature of their task."

 In my behavioral pediatrics practice, whether a child is 2, 5, 10 or 17, mothers frequently describe feelings of deep loneliness in those earliest weeks and months that stand in stark contrast to the cultural expectation of joy and love.

Social isolation, anxiety, sadness, and marital stress color the experience of caring for a newborn who cried all the time, never slept, couldn’t breast-feed. Fussy infants became challenging toddlers. Tantrums, separation anxiety and family conflict define the preschool years. When these children enter the structured school system, problems of emotional regulation may lead to psychiatric diagnosis as defined by the DSM (Diagnostic and Statistical Manual of Mental Disorders.)

Primary prevention lies in caring for mother and infant as a unit. In the first 8-12 weeks, brain growth (the infant brain makes 700 connections per second) and with that healthy development, requires care by the mother, or mother figures, in the same way that the mother’s body held the baby in pregnancy- 24 hours a day, seven days a week.

There is an evolutionary purpose to what in this country was once termed "lying in." During a period of 3-4 weeks mothers were able to rest and connect with their baby while a group of women helped with household chores and offered emotional support.

Cultures around the world recognize the need for protecting the mother–baby pair in this way. Contemporary American society, with its unrealistic expectation of rapid return to pre-pregnancy functioning, is uniquely lacking in a culture of postpartum care.

We cannot go back in time to a period when extended family was available to provide a community of support. Nor will we be able or even want to return to a time when mothers stayed in bed for 3-4 weeks after childbirth. But some steps must be taken.

For just as we know that supporting mother-baby pairs leads to healthy development, we know that when early relationships suffer, the long-term consequences, for both mother and child, are significant and worrisome.

To optimize brain growth and development by providing a “social womb”, new families need to be held in the same way that the mother’s body holds the baby during pregnancy. Mother-baby groups, as offered by the Community Based Perinatal Support Model developed by MotherWoman, as well as increased paid parental leave and home visiting programs offer other forms of support, as does recognizing that physical recovery from childbirth does not happen overnight.

Perhaps the first and most important step in promoting healthy development lies in locating postpartum “illness” in its proper place- not in the mother, but in the way our society cares for mothers.

Saturday, November 22, 2014

Lessons from Adam Lanza: Listen Early and Listen Well

The just released report, Shooting at Sandy Hook Elementary School, from Connecticut's Office of the Child Advocate offers a searing account of the holes in our mental health care system. The report is careful to point out that no causative link exists between their findings and the events at Sandy Hook. However, this in-depth investigation offers an opportunity, if we are able to hear and take action on its recommendations, to begin to fix a system that without significant attention may lead to an ever growing epidemic of serious mental illness.

I highlight 4 key points addressed in the 114-page report:

1) Early means early.

When significant problems in social-emotional development are identified, the greatest investment of resources ideally should come well before age three. In this time period, when the brain is rapidly growing and changing,  opportunity exists to set development on a healthier path. The report states:
A review of information regarding AL’s early years with his family does not reveal any profound tragedies or traumas. However, records clearly indicate the presence of developmental challenges and opportunities to maximize therapeutic and intensive early intervention. These observations underscore the importance of parental and pediatric vigilance regarding children’s developmental well-being. AL was referred for early intervention late in his toddler years, when he was almost three. By this time, he presented with several developmental challenges, including significant speech and language delays, sensory integration challenges, motor difficulties, and perseverative behaviors.
I would also like to highlight the report's important statement:" Research-based intervention to support improved sensory processing through occupational therapy is a critical service for these children."

2) The problem is located not exclusively in the child, but in parent-child relationships.

The report describes significant ongoing marital conflict, with Adam's father described as a "weekend father" who was not involved in the emotional lives of his children. There is evidence that Adam's mother might have had significant emotional illness. She was preoccupied with her own health and mortality despite the fact that her doctors reports do not show signs of physical illness.  While these findings do not represent " profound tragedies or traumas," the story is one of a biologically vulnerable child with two parents preoccupied and emotionally unavailable.

When a problem is placed squarely in a child,  the relational nature of these problems may be missed. Perhaps by addressing the issues in the marriage and the mother's mental health, room could have been made in their minds for thinking about the meaning of Adam's increasingly disturbed behavior.

3) Need for collaborative care with adequate reimbursement. The report states:
Pediatricians’ offices must have resources to conduct comprehensive and ongoing
developmental and behavioral health screening for youth, with appropriate reimbursement strategies to support this work.
 Children and their families should have access to quality care coordination, often reserved only for children with complex medical needs, but beneficial for children with developmental challenges and mental health concerns. Care coordination should facilitate more effective information-sharing between medical, community, and educational providers.
When people are stressed and vulnerable, they will share what is important only when they feel safe. Parents may experience terrible shame in the face of a child who is struggling and a marriage that is collapsing. Clinicians need to be reimbursed for time spent listening to parents. Time spent in coordination of care, a critical part of comprehensive treatment, also should be reimbursed.

4) Listening, not placing blame, will lead to meaningful change.

The report concludes by emphasizing that it "in no way blames parents, educators or mental health professionals for AL's heinous acts." I remain hopeful that blame can stay out of the conversation. Already media coverage has focused on the one adversarial aspect of the report that suggests the school "appeased" his mother, perhaps because she was white and wealthy.

All the accumulated evidence points to extreme suffering in the Lanza home over many years; suffering that went unheard and unrecognized. Blaming the school or the mother is not only unhelpful but also diverts attention from the critically important recommendations in this report.

 We are in the midst of an epidemic of violence and mental illness. The recommendations, particularly those I have outlined above, may offer a way off that path. I hope that those in a position to effect these changes will be open to listening. If this comprehensive report can be used to make substantive changes in the education, health care and mental health care systems, then some meaning may be found in the senseless, tragic loss of life at Sandy Hook.

Tuesday, November 11, 2014

ADHD: The Role of Curiosity

3-year-old Cara smiles impishly in to the camera.” You see she’s standing on the kitchen table,” her proud yet concerned grandmother, my dental hygienist, Anne, says to me. She explains that Cara was standing on the table because she never listens, and runs away when her mother tries to take her picture.

She knows that I am a pediatrician and “expert” in behavior problems, so, after showing me the picture, as she cleans my teeth she shares with me that her granddaughter might have ADHD. “She won’t sit in the circle with the other kids for the whole story time. They’ve started an evaluation.”

I nod in shared concern while she works on my teeth, and she goes on. She’s known me for many years, so the conversation flows easily. “It’s hard,” she says, “because Mindy (her daughter) just broke up with her boyfriend. “So she’s a single Mom, “ I say after a rinse. “Yes, and she works nights and lets Cara stay up til 11 so she can be with her.” At the next pause I comment, “So Cara must be tired in school. That can lead to problems of attention.” As Cara’s grandmother resumes her work on my mouth, she agrees. Then she goes on to explain that Cara is the youngest in her class of mostly 4-year-olds.  She begins to wonder if all of these things she is telling me might be related to the problems Cara is having in school. Her tone shifts.

“She’s just so engaged and curious,” Anne explains. “Maybe we need to channel that energy and help her to find ways to use it in a positive way.” Then she reflects, “Actually Mindy was like that as a child. She was so smart that she got bored in class and sometimes got in to trouble. But after some struggles during those years she found her way.” She tells me that Mindy is passionate about her work as a neonatal nurse.

During my visit I feel a shift in Anne’s thinking. Simply by talking with me, a captive audience with whom she has a longstanding relationship, she goes from describing her granddaughter in terms of “disorders” and “evaluations” to a stance of curiosity.

As we both stand to schedule our next appointment, Anne again looks at the impish face of her granddaughter, trapped on the kitchen table. She sees the picture, cute as it is, as a kind of sign that things may feel out-of-control for Cara. She even begins to wonder if her daughter is too stressed, and perhaps needs more help from her. Maybe, she says, if Mindy had a bit of time to herself, she could be more patient with Cara. She decides to offer her daughter a day of babysitting.

Recent statistics indicate that diagnosis of ADHD has increased 42% in the past 8 years. 3-year-old Cara might be on her way to joining that statistic. I am hopeful that the system of care will offer space and time to listen to the whole story. When her grandmother was able to wonder about the meaning of that photo, Cara’s communication, in the form of behavior, was understood. Being heard and recognized in this way gives Cara the opportunity to become not another statistic, but instead to develop in to her own true self.