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 developmental science 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.

Saturday, April 18, 2015

Tsarnaev Trial Puts Spotlight on Developmental Trauma and Mental Illness

A colleague of mine, an active advocate for identification and treatment of postpartum mental illness, recently posed an interesting concern. With Susan Smith- who in 1995 infamously drowned her children- in the news again because she and Boston Marathon Bomber Dzhokhar Tsarnaev have the same lawyer-my colleague wondered if there was insufficient attention to Smith's postpartum psychosis.

As I reviewed the media coverage, both of the original trial and Judy Clarke, Tsarnaev's and Smith's shared lawyer, I discovered that she was right- there was little to no mention of postpartum psychosis. However,  Clarke's tactic clearly achieved her goal of portraying her client's humanity and vulnerability.

Smith was spared the death penalty because Clarke uncovered a story of significant early childhood trauma and abuse. Smith's father committed suicide when Smith was 6, and her stepfather sexually abused her in a secret relationship that continued in to her adulthood.   A newspaper article from 1996 quotes Clarke: 
This is not a case about evil. . . . This is a case about despair and sadness...Her choices were irrational and her decisions were tragic. She made a horrible, horrible decision to be at that lake that night. She made that decision with a confused mind and a heart without hope. . . . [But] confusion is not evil, and hopelessness is not malice. 
What does it mean to conceptualize “mental illness” as separate and distinct from trauma? One could say that, with the context offered of childhood maltreatment, a "confused mind and heart without hope" is a more evocative description than "postpartum psychosis."

Her question got me thinking about compelling research by psychiatrist Martin Teicher about the neurobiological underpinnings of adult mental illness in the wake of childhood maltreatment. 

Conduction a vast literature review, Teicher and colleagues differentiated two groups with psychiatric disorders, diagnosed according to the DSM system, with depression, anxiety, substance abuse and PTSD. One group had experienced maltreatment and another had not.

Maltreatment is broadly defined as being “characterized by sustained or repeated exposure to events that usually involve a betrayal of trust.” 

It includes not only physical and sexual abuse, but also emotional abuse, including exposure to domestic violence, humiliation and shaming, as well as emotional and physical neglect. The incidence of childhood maltreatment ranges from about 14% in one-year prevalence to 42% in retrospective reviews covering the full 18 years of childhood.

The way maltreatment is defined has great significance in the way we think about the connection between childhood experiences and adult mental illness. The word “trauma” itself may convey a kind of “not me” response, but when the term is defined in this way, we see that these experiences are, in fact, ubiquitous.

Teicher and colleagues found two subtypes, with significant behavioral and neurobiological differences, despite the fact that individuals in both groups carry the same diagnosis. Those with maltreatment history have earlier age of onset, more severe symptoms, greater suicide risk and poorer response to treatment. There are distinct differences in brain structure and function, stress response, as well as epigenetic changes in gene expression.

These findings offer a window in to how childhood maltreatment gets in to the body and brain. They have great significance in terms of prevention, intervention and treatment. Focusing efforts on supporting young children and their families is a natural conclusion. There are implications for treatment of adults as well. Teicher writes:
Recent recommendations for adults with maltreatment- related posttraumatic stress are to adopt a sequential approach that begins with safety, education, stabilization, skill building, and development of the therapeutic alliance before endeavoring to revisit or rework the trauma, as this may be destabilizing.
He expresses concern over the way these two distinct groups have not been differentiated.
Overall, we suspect that unknowingly mixing maltreated and nonmaltreated subtypes in treatment trials may have left us with an incomplete understanding of risks and benefits. Stratifying study subjects by maltreatment history may provide more definitive insights and delineate a clearer course of action for each subtype.
In other words, rather than treating psychiatric diagnosis according to the current DSM system, that looks at symptoms and seeks to eliminate those symptoms, it is critical, in determining appropriate treatment, that we explore the developmental and historical context of the symptoms.

In his conclusion Teicher writes:
We propose using the term ecophenotype to delineate these psychiatric conditions. We specifically recommend, as a first step, adding the specifier “with maltreatment history” or “with early life stress” to the disorders discussed here so that these populations can be studied separately or stratified within samples. This will lead to a richer understanding of differences in clinical presentation, genetic underpinnings, biological correlates, treatment response, and outcomes.

If Susan Smith did have postpartum psychosis, then certainly the specifier “with maltreatment history” would have been indicated. Teicher’s work has relevance to this story in two ways. By supporting new families who are struggling in the face of parental mental illness, we offer the best opportunity to prevent mental illness in the next generation. In addition, as evidenced by Clarke’s success in avoiding the death penalty for her client, by telling the story of the individual, rather than simply naming an illness, we evoke the full complexity of experience that a current DSM diagnosis, without this specifier, does not.

Thursday, April 2, 2015

What Are We Saying When We Diagnose Autism in Infancy?

Recent research suggests that while intervention is needed, we ought to be carefully considering this question.  A fascinating and important study by Jonathan Green in the January 2015 Lancet beautifully described in an article titled, The Social Network: How Everyday Interactions Shape Autism, shows that autism research is coming out from the shadows of the “refrigerator mother” theory. This theory, first identified by Leo Kanner in 1949 and popularized in subsequent decades by psychoanalyst Bruno Bettelheim, claimed that autism was due to lack of maternal warmth.
While this theory has been widely discredited, it led to a kind of backlash, where autism is understood and researched as a biological disorder that resides exclusively in the child. Many contemporary autism researchers pose the question, "How early can one determine if a child does or does not have autism?" analogous to the way one does or does not have diabetes or food allergies.
However, contemporary research at the interface of developmental psychology, neuroscience and genetics, showing how the brain changes in relationships, flies in the face of this formulation.
Given what we know about the plasticity of the brain, rather than framing the question as “Does he or does he not have autism?” a more appropriate question might be, “How to we, in the face of biological vulnerabilities, hold parents through uncertainty to give a child the best opportunity to grow in to what D.W.Winnicott termed his “true self.” (A question echoed by Stanley Greenspan’s DIR Floortime model)
As Green’s research beautifully demonstrates, holding uncertainty does not translate to “do nothing.” As the article about his study states, “An added benefit is that the treatment is easy for parents to do and doesn’t require a diagnosis.”
While this research is specifically about autism, it has relevance for any parent-infant pair that is struggling to connect. The essence of the intervention is a clinician who has a relationship with a parent, who offers space and time to listen to parent and child together. The following case from my behavioral pediatrics practice offers an example of an intervention similar to what Green offers in his research study.
Mary was convinced that her 3-month-old son, Liam, was autistic. She felt she couldn’t connect with him. Her oldest child, Jack, now 7, carried diagnoses of autism that had not been made until he was 4. Her middle child, Jane, had recently been diagnosed with anxiety. Mary was overwhelmed with fear that Liam would follow a similar path.
Mary told me that Liam was quiet from birth. He hardly even cried in the delivery room. Despite the doctor’s reassurances, Mary wondered from those first moments if there was something “wrong with him.” Then as the weeks went on not only was he quiet, but he seemed to her not to be connected. She would put her face close to his and try to engage him to look at her face and follow. But she was rarely successful. As the weeks went on her efforts intensified while her anxiety escalated.
With a full hour together, we sat on the floor and observed Liam together.
I noticed it right away. My initial attempts to engage him by talking to him and looking in to his face were met by a rather remote expression.  He appeared to be looking past me, perhaps at the lights on the ceiling, but it wasn’t clear. I saw Mary’s rising alarm. Resisting a similar reaction in myself, I said, “Let’s give it time.”
Liam lay on a blanket on the floor, at first continuing his seemingly random scanning of the room. I spoke quietly to him, noticing how he was sticking out his tongue. I imitated his movements and gradually he began to engage. Mary noticed that he seemed to be responding to my mirroring of his expression. Then we observed a remarkable transformation. In the quiet calm of this space, so dramatically different from the normal chaos of his everyday life, he seemed to come out of his shell. It started with a smile, at first seemingly random, but then clearly in response to my smile.
Mary continued to speak with him in a soft voice, but rather than putting her face up close to him, she spoke in a more natural way as part of our conversation. Liam became increasingly animated. Mary and I noticed, with rising joy and relief, that not only was he fixing and following on his mother’s face, but he was cooing in a responsive conversation with her. He kicked his legs and moved his arms in an expression of increasing delight.
Mary is not a “bad mother.” Liam's challenges are not her "fault." She is parent overwhelmed by the stress of caring for three young children and her understandable anxiety about the future of her infant. The space and time to listen gave us opportunity to notice that the intensity of her attempts to engage him were having the opposite effect. 
Relief flooded Mary, but alongside what threatened to be a paralyzing sense of guilt and fear. Had she caused him harm by missing his cues? But I pointed out how easy it had been for us to engage Liam. Clearly Mary had been doing something right. Research(link is external)has shown that even when parents miss these cues in 70% of interactions, as long as these “misses” are recognized and repaired, development moves forward in a healthy way.
When I saw them together a month later, Mary spoke joyfully of the fun the family was having with Liam, who had developed in to an engaged and happy baby. Now, taking a few minutes every day to have some quiet time with Liam, she fell deeper in love with him every day. She marveled at his complexity as a person even at the tender age of three months. This “disruption” led to new levels of love and intimacy between Mary and her son.
If an intervention similar to the one described in Green's study was available to all parent-baby pairs who are struggling, we might find that biological vulnerabilities, rather than leading to a diagnosis of autism, or some other disorder, can be transformed in to adaptive assets.

Saturday, March 14, 2015

ADHD and Early Death: What is the Link?

Alarming headlines, based on a recent study, declare that diagnosis with ADHD doubles the risk of early death. Psychiatrist Stephen Faraone, commenting on the original study published in the Lancet, concludes that: “for clinicians early diagnosis and treatment should become the rule rather than the exception.” This conclusion represents a false assumption that the deaths occurred in cases that were not treated. 

The large cohort study in Denmark, that looked at records of 2 million individuals, identified over 32,000 who had been diagnosed with ADHD and then calculated the “all cause mortality rate.” There is no data available about whether or not they were treated. As ADHD is commonly treated with stimulant medication, it is unlikely that all of these cases were untreated. It is more likely that many, if not most, were treated with medication. If that were the case, the conclusion could be the exact opposite- namely that diagnosis and treatment with stimulant medication is associated with increased risk of early death. In that case, careful re-assessment of  the way we conceptualize and treat problems of attention would be in order.

If diagnosis and treatment with stimulants is associated with increased risk of early death, how would we make sense of this finding? The following story offers an example.

Max, whose life was cut short at 17, alone behind the wheel of his car with a blood alcohol level of well over .08, had been treated for many years for ADHD. I met his mother, Sally, when she was taking a long hard look at her son’s history and trying to make sense of his descent in to substance abuse with this tragic demise.

Max was the youngest of three. Where his two older sisters excelled in school, he was “flighty.” Even as young as three, the rest of the family would get frustrated with him when he got easily distracted when asked to do a simple task like put on his shoes. In a busy household, there was a lot of negative attention directed at Max.
But in this time of careful and at times agonizing reflection, Sally acknowledged that Max had been very curious and creative as well. He “noticed everything.” At age 5 he was uncharacteristically quiet and attentive at a classical music concert, surprising his parents by identifying the individual instruments. But in a family of high academic achievers, when in first grade he lagged behind in learning to read, they took him to the pediatrician, who diagnosed inattentive ADHD and put him on stimulant medication.
Her doctors had seen it as a straightforward problem, no different from food allergies or diabetes. Max “had “ ADHD so they gave him medication to treat it. The medication did have a remarkable effect on his ability to focus, from the first dose. But as the demands of school increased, the visits to the doctor consisted of changing dosages and formulations.
Sally’s heart ached as she recalled visits to the pediatrician where she spoke openly in front of Max about him as “unmotivated” or even “lazy.” Sally wondered if the exclusive focus on Max’s dose of medication and his ability to get his homework done- they had added and evening dose when he got in to middle school and the academic challenges increased- had distracted them from seeing Max’s true nature. In a soft voice that belied cries of agony, she wondered if the firm, demanding parenting style that had been so effective with their first two, was perhaps not ideal for Max.
Once she felt comfortable telling me her story, other relevant information emerged. When Max, an unplanned third child, was young, Sally had struggled with postpartum depression. During those early years she had not been able to give this active, sensitive toddler the attention he needed. In contrast, the two older girls had been a source of help and support. Her time and attention gravitated naturally to them. When Max was evaluated for ADHD by her pediatrician, this part of the story, a difficult chapter they all wished to forget, never came up. Now Sally wondered if Max’s “problem behavior” had been at least in part, an effort to connect, to get his mother’s attention. She had heard people speak of ADHD as a deficit not of the child’s ability to pay attention, but of the parents’ attention to their child.
She had been doing her best for Max. But perhaps she, the rest of the family, as well as the doctors who had treated Max, hadn’t really been listening to Max. The focus of visits to the doctor became almost exclusively on the dose of medication and his academic performance.

As his older sisters continued to thrive, Max attempted to distinguish himself through sports, an effort that was sadly derailed when in 11th grade he suffered a significant knee injury. His grades plummeted. Still the focus was on finding the correct regimen of ADHD medication.

Reluctantly Sally shared with me a longstanding family history of substance abuse. She suspected that this knee injury was “the beginning of the end.” Max began drinking, though, in keeping with the family tradition, he was able to keep this fact well hidden from his parents.

While medication may have a role to play, when individuals are diagnosed with ADHD and treated with medication in a system of care that does not offer space and time to listen to the story, to discover meaning in behavior, underlying problems are not addressed.

Perhaps the true association between diagnosis with ADHD and early death can be found in another large study, a long -term collaborative study sponsored by the Center for Disease Control, the Adverse Childhood Experiences or ACES study. This study offers extensive evidence of a high correlation between adverse childhood experiences (ACES) and a range of negative long-term health outcomes, including early death. ACES include not only abuse and neglect but also the more ubiquitous problems of parental mental illness, substance abuse and divorce.

What we call ADHD is a collection of symptoms of that represents problems of regulation of attention, behavior, and emotion. A biological vulnerability may be part of that story. But it is usually not the whole story.

The appropriate conclusion from this study, seen in light of Max’s story and the ACES study, should be that starting from an early age, space and time to tell the story is essential. The risk lies in diagnosing and medicating without understanding the whole story. In a safe, non-judgmental environment, when families have an opportunity be heard, to appreciate the often-complex meaning in a child’s behavior, as Sally was sadly doing after Max’s death, the path to healing becomes clear.

Friday, February 13, 2015

The Place of Love in Child Therapy

4-year-old Ella climbed on to the couch, into Susan’s lap, wrapping her arms tightly around her mother as Susan lovingly stroked her hair. They sat together in quiet loving embrace before beginning to pick up the toys, as the hour-long visit was coming to an end.

Weeks earlier Susan had wept in my office in anger and frustration. “She never listens,” preceded descriptions of explosive scenes where Ella kicked her mother, and Susan, in a haze of agitation, grabbed her daughter by the shoulders and shook her. At this visit, while Ella played quietly on the floor, Susan described a scene when Ella had told her mother, “I get so sad when you yell at me.” Susan now spoke, both to me and to her daughter, about how they were both having a hard time. Susan understood that just as she was feeling out-of-control in those moments, Ella was similarly stressed, and needed help from her mother in managing her intense feelings. This new understanding led to the moment of loving connection.

At the end of her graphic memoir, Are You My Mother?, Alison Bechdel describes a scene from a well-known case of psychoanalyst D.W.Winnicott., The Piggle. Winnicott sits on the floor with his little patient, Gabrielle, with whom he had worked for almost three years, starting when she was two. “I know you are really shy, “Winnicott says, ”and what you really want to tell me is that you love me.” He writes, “She was very positive in her gesture of assent."

Bechdel, in her last session with her own therapist, who during the course of their years of work together had gotten analytic training, has a similar experience. Her therapist says, “A lot of what we’ve done here has to do with love.” And then, “I know that you love me.” Bechdel sits quietly for a frame, and then says, “I … I do. I love you.”

Ours is a culture of advice. When parents come to me with their young children, they implore me to “tell me what to do.”  Recently I was interviewed on the radio by a child psychiatrist at a well-known New York teaching hospital. He told me that he had written a manual of “parent training” that offers “behavioral tools.” He claimed that when parents struggle with their child’s behavior it is because they “haven’t been taught” and they “don’t know what to do.”

I told him that I begged to disagree. Instead, I adhere to the wisdom of Winnicott, who wrote, “ No theory is acceptable that does not allow for the fact that mothers have always performed this essential function well enough.” As with Susan and Ella, problems occur when parents, for a range of reasons, sometimes including a child’s innate temperament, are stressed, and lose touch with their natural intuition.

Classical psychoanalytic theory supported work with an analyst alone with the child, even as young as two. Contemporary developmental science, with abundant evidence showing that the brain grows in relationships, offers a different perspective. While much of the conceptual framework of a discipline known as infant mental health is founded in psychoanalytic thinking, with the relationship
 being central to growth and healing, it offers a different model of treatment.

In the case of the Piggle,  her mother stayed home, a train ride away, with her new baby while Gabrielle traveled with her father to meet with Winnicott. In contrast, this relatively new and growing discipline of infant mental health supports working with parent and child together. While the brain can change in relationships throughout the lifespan, working with parent and child in the earliest years of life offers the greatest opportunity for change, as the brain is most rapidly growing.

In adult therapy, expressions of love, by the patient for the therapist, can be transformative and healing. But the aim is different when working with young children. As with Susan and Ella, the aim is not for the patient to express love for the therapist, but rather for the child and parent to be re-connected in love.

As Valentine’s Day approaches, I think of the deep transformative feelings of love that occurred during the visit with Ella and her mother.  It occurs to me that the work I do, along with my colleagues in the field of infant mental health, is neither parent training nor classic psychoanalysis. It is about facilitating, in the words of Simon and Garfunkel, a mother and child reunion.