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.

Monday, October 27, 2014

Childhood Anxiety: Treating the "What" Rather Than the "Why"

Recently, while studying for my recertification exam as required by the American Board of Pediatrics, using the PREP course offered by the American Academy of Pediatrics, I came across this question:
     A 7-year-old girl is having difficulty establishing relationships with other children despite repeated opportunities to do so. The girl prefers to stay near her mother or her teacher and will avoid other children. She sometimes cries and can be difficult to calm down after being dropped off at school, so her mother frequently remains in the classroom for a few minutes before quietly leaving. On days when morning transitions to school are significantly difficult, her mother will allow her to stay home. Her mother reports that, in preschool, things were worse in that she usually "couldn't" leave her daughter in the classroom. The girl typically speaks little when in public, but she speaks normally when home alone with her mother. She is an only child and the parents are divorced. When the girl spends the weekend at her father’s house, she often expresses worry that something bad is going to happen to her mother. Her mother frequently allows the girl to sleep with her to avoid temper tantrums or nightmares about sleeping alone. Of the following, the BEST next step in this child’s care is  
       A.   Initiate treatment with an SSRI (selective serotonin reuptake inhibitor)
B.   Reassure her mother that her daughter’s problems should resolve without intervention
C.   Refer for neuropsychological evaluation to assess for cognitive impairments
D.   Refer her to a cognitive behavior therapist to work on skills for managing her distress
E.    Refer her to a play therapist to assist the child in recognizing the cause of her distress 
The “correct” answer is D- refer her to a mental health specialist to initiate cognitive behavioral therapy (CBT). Medication is suggested as a second line of intervention if CBT is not effective. In other words change her behavior, but do not offer opportunity to discover the cause. Play therapy, the only alternative form of therapy suggested, leaves it up to the child and therapist to discover the cause.

What might be the cause of her anxiety? Is her mother depressed? Her father? Is there substance abuse in either parent? Did she observe conflict, perhaps even violence, between her parents in the years preceding their divorce? Is there a family history suggesting a genetic vulnerability for anxiety? Does she have sensory processing challenges that cause her to be overwhelmed in the stimulating classroom? Some combination of all of these?

One child I saw with such symptoms had a mother who lay in bed all day in the wake of a pregnancy loss. This child was terrified that something would happen to her mother while she was in school. 

Perhaps this child’s mother had similar struggles with anxiety as a child. But rather than being met with understanding, she received a slap across the face. She may be terrified that her daughter will suffer as she did. If she is flooded with stress in the face of her daughter’s behavior, she might, without thinking, lash out. Or more likely, as her maternal instinct to protect her child overrides a rage response, she might shut down emotionally. Either way, her child will be alone with these difficult feelings. 

I took care of one child who had been diagnosed with anxiety disorder by her previous pediatrician and came to me to get her prescription refilled. After several hour long visits, some with her alone and some with her mother, I learned that every weekend her father drank heavily, leaving her at the age of eight to care for her two younger brothers.  

Where in the treatment plan recommended by the AAP is there opportunity to uncover such a story? Parents may experience terrible shame about their own behavior. Taking a history, in one visit, that reveals "no psychosocial stressors" is inadequate. Parents share this kind of information when they feel safe. Safety comes in the setting of time and space for nonjudgmental listening.  

One much-cited study compared CBT, SSRI, the two in combination, or placebo. No treatment arm existed for listening to the parent, for discovering the meaning of the behavior.

This child’s behavior is a form of communication. Behavior management, and the close second of medication, serves to silence that communication. When we teach a child skills to manage behavior, the story may be buried, emerging years later, sometimes in the form of serious mental illness

When parents can make sense of a child's behavior,  they are in an ideal position to support that child in managing his or her unique vulnerabilities. In a way, parents are best suited to provide a kind of cognitive behavioral therapy. They can help a child to name feelings,  identify provocative situations and develop strategies to manage these experiences.

By bringing in to awareness the way a child's behavior may provoke their own difficult feelings, and in a sense moving these feelings out of the way, parents can be fully emotionally present with a child in a way that supports healthy emotional development.

When a child is young, there is opportunity to offer support for parents and children together and so alter a child’s developmental path. But when, rather than supporting parent-child relationships, we treat the problem as residing exclusively in the child,  such opportunities are missed.

Friday, October 10, 2014

The Time-Out Wars: A Case for Curiosity

Dan Siegel's new book No-Drama Discipline is calling attention to our innate need for connection. In his Time magazine piece provocatively titled Time-Outs Are Hurting Your Child he writes:
The problem is, children have a profound need for connection. Decades of research in attachment demonstrate that particularly in times of distress, we need to be near and be soothed by the people who care for us. But when children lose emotional control, parents often put them in their room or by themselves in the “naughty chair,” meaning that in this moment of emotional distress they have to suffer alone. 
Not surprisingly, his views are causing significant backlash from the pediatric community. This is from the Journal of Developmental and Behavioral Pediatrics
TIME magazine recently highlighted an editorial by Drs. Daniel J. Siegel and Tina Payne Bryson in their parenting section. In it, the authors claim that the time-honored tradition of time-out for discipline may actually be harming our children as a form of traumatizing experience. This has caused a wave of black lash from the behavioral health community, who retort that Drs. Siegel and Payne Bryson's claims are not only unsupported by research, but show a lack of understanding of proper use of time-out.
Extreme views generate publicity and lots of “hits” A more nuanced view is less popular in social media, as evidenced by this wise blog post on Psychology Today that got a meager 25 tweets:
To me, “time-ins” don’t solve it. But the concept does expose a nuance of giving time-outs that we don’t talk about enough. Namely, there’s a massive difference between giving your child a time out in anger and giving your child a time out in a loving, calm way. Too often we apply the technique, but not the spirit of technique. Time-outs are meant to deescalate a volatile situation and to help our children regain control, as much as they are to provide a consequence for unruly behavior.
The essence of Dan Siegel’s point is not to leave a child alone with out-of-control feelings. It is not the time out per se but rather the sense of abandonment that is potentially harmful. I articulate this point in a previous post entitled Never Leave a Child Alone During a Meltdown.
When a child is repeatedly abandoned both physically and emotionally in the middle of a meltdown, that experience in itself may be traumatic. In such a situation frequency and intensity of meltdowns often worsens.
A recent American Academy of Pediatrics document Bringing Out the Best in Your Child makes the important distinction between discipline, which means to teach, and punishment, which is rarely effective in changing behavior in a positive way. For young children, a matter-of-fact time out in the face of biting or hitting can help to teach them that this behavior is unacceptable. The shortcoming of this document is that it is very focused on the behavior, rather than the meaning of the behavior.

Taking time to listen to our child, and to take care of ourselves, is key. Rather than an either-or approach, a stance of wondering, of curiosity, will lead to the answer of “what to do.” We might ask the question, why is my child feeling out-of-control? Is he stressed from fatigue or hunger? Is he responding to tension in the home from marital conflict, a new sibling, or a parent’s new job with long hours? And what about my child’s behavior is provoking such anger, anxiety or some other intense response in me? Is it my fear that he will suffer as I did as a child with similar challenges? Is it my embarrassment, or even worse, shame, that I am not a good parent? Am I feeling alone and abandoned myself, by a spouse or parent, and so unable to tolerate my child’s need for me? When parents feel recognized and understood, they are better able to listen to their child. They are better able to connect with their natural intuition. They know "what to do."

Our ability to find meaning in behavior is essential to our humanity. Listening, being present in a way that supports connection, leads to healthy development. It is not so much about “what to do” as “how to be.” We are a culture of advice and quick fixes. Dr. Siegel's book is rich with important information and ideas. However, perhaps rather than spending precious free time reading another "how-to" parenting guide, taking a walk with a friend or going to a yoga class might be a better use of parents' all-too-limited time for themselves.

Thursday, October 9, 2014

Antipsychotics for ADHD: A Big Unknown

Polypharmacy, or use of multiple psychiatric drugs, for treatment of Attention Deficit Hyperactivity Disorder(ADHD) is on the rise. A recent study compared treatment with "basic therapy"-stimulants plus parent training- with "augmented therapy" those two plus risperidone, an atypical antipsychotic. The study concluded that treatment with risperidone was "superior." 

When children show dramatic improvements in behavior on risperidone, now being prescribed with increasing frequency for ADHD and a range of other disorders that represent difficulty with emotional regulation, we need to ask ourselves one question. Does this change in behavior represent increased capacity for organization and self-regulation, or does it reflect a kind of compliance?

We have over 40 years of longitudinal research in developmental psychology showing that safe, secure relationships support development of the capacity for emotional regulation, cognitive resourcefulness and social adaptation. We have evidence from the field of epigenetics that these relationships, through changes to gene expression, change the structure and function of the brain.
Top of Form
Bottom of Form
When children struggle with emotional and behavioral regulation, many evidence-based interventions can support development of these capacities. These include child-parent psychotherapy, DIR floortime, the Neurosequential Model of Therapeutics, and mentalization based treatment.  These relationship-based interventions foster our innate need for connection.

The mechanism of action of risperidone is to block dopamine receptors in the cortex. We do not know what changes in the lower regulatory centers of the brain, if any, are occurring. It is possible that these centers remain dysregulated, and that this dysregulated signal is blocked by the medication. The antipsychotic might promote compliance, with improvement in behavior, but the underlying disorganization might remain. If that is the case, then the medication is not changing the brain in the way that we know relationships can change the brain.

This is an important question to answer. It goes well beyond the known significant side effects of antipsychotics. For when medication is so effective at controlling behavior, the motivation for investing time and effort in relationship-based interventions may be lost. Prescribing medication takes much less time. With atypical antipsychotics the results are often immediate, and can be dramatic.

If risperidone is found to significantly alter the brain’s capacity for emotional regulation, then it might have a role to play. But if it does not, and we have well-established methods of intervention that do, then the possibility exists that by prescribing this medication to children, particularly in the absence of relationship-based interventions, we are actively interfering in their development. 

I am hopeful that all professionals who strive to promote healthy development in children can work to answer this question in a timely manner.

Sunday, September 28, 2014

Days of Awe and the Certainty of Neuroscience

Just like the digital codes of replicating life held within DNA, the brain's fundamental secret will be laid open one day. But even when it has, the wonder will remain, that mere wet stuff can make this bright inward cinema of thought, of sight and sound and touch bound into a vivid illusion of instantaneous present, with a self, another brightly wrought illusion, hovering like a ghost at its centre. Could it ever be explained, how matter becomes conscious?
The actual words written by Ian McEwan, in his novel Saturday about a day in the life of a neurosurgeon, are worthy of awe of the human mind. In a recent blog post I referred to a piece by psychologist Gary Marcus in which he calls attention to "the trouble with brain science." Perhaps inspired by this very piece of writing, he refers to the lack of a bridge between neuroscience and psychology comparable to the bridge between genetics and living beings that discovery of the double helix provided.

I describe how absence of this bridge is the problem inherent in the oft-used comparison between depression, or ADHD, and diabetes. NIMH director Thomas Insel has called for a study of the neuroscience of mental illness in the same way we study cancer, food allergies, and diabetes.

Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. For the pancreas, there is no corresponding mind in the realm of thoughts and feelings. The pancreas does not love, does not grieve, does not produce great literature.

This wish to compare psychological experience to physical illness ostensibly comes from a wish to destigmatize emotional suffering. But in fact it may have the opposite effect, as it devalues the  human relationships. It is an effort to apply certainty to situations ripe with uncertainty.

There is a dark side to the certainty of neuroscience. Years ago I treated a young girl, Charlotte, who had been diagnosed with ADHD by a previous doctor.  I took over her care, following the standard practice in pediatrics for visits every 3 months for review of "symptoms" of hyperactivity and inattention and adjustment of medications. When she continued to struggle, her parents paid a large sum of money to have a brain scan done by a doctor who claimed to identify the exact location of her problem. Despite the alleged certainty of these results, her "symptoms" continued. I referred the family to a therapist, but lost touch with them when I left that practice.

Recently I learned from her mother, Jennifer, when I ran in to her on the street, that she was doing much better. "I know why," she told me. She had hidden from me, and from herself, that all along Charlotte's stepfather had been physically and emotionally abusing her. Only now, with this story brought to light, could she begin to heal.

Missing from treatment of this girl was not knowledge of brain science, but time for listening.  In 30-minute visits every three months, with Charlotte and Jennifer together in the room, neither she nor her mother felt safe enough to share what was really going on.

The week between Rosh Hashannah, the days of Awe, and Yom Kippur, the day of Atonement, seems an appropriate occasion for contemplating these issues. It offers an opportunity for awe at the wonder of the human mind. It might also offer opportunity to atone for not listening to children like Charlotte. When we make diagnoses, and use brain scans to verify them, we may miss the complexity of human experience. The essence of being human is the ability to find meaning in behavior. I hope that going forward, we can protect space and time to listen, to discover that meaning. We are not likely to find it on a brain scan.

Tuesday, September 9, 2014

Postpartum Mental Illness: Ability to Soothe Baby Helps Mothers Most

Fascinating research at the Yale School of Medicine shows that in poor families who are under-resourced and overburdened (a more meaningful phrase replacing "high-risk,") "diaper need" or lack of reliable access to clean diapers, is the factor that most impacts on mothers' mental health. In a study published in Pediatrics, lead researcher Megan Smith found that 30% of mothers living in poverty report diaper need.

When mothers were worried about when they would be able to get the next diaper, self esteem was diminished in the face of their inability to soothe their baby, in turn negatively impacting their relationship with their baby, setting the stage for a downward spiral.

One take home message of this research is the importance of providing clean diapers. The National Diaper Bank Network, along with many local organizations, is making efforts to meet this significant need.

A second broader implication is the remarkable finding of how much the baby's well being impacts on the mother's mental health.

The converse of the finding that diaper need negatively impacts a mother's mental health, is that reliable access to clean diapers can improve a mother's mental health.

Generalizing this observation to a broader population of mothers with mental illness, the ability to soothe a baby, to take care of a baby's basic needs, may be integral to that mother's emotional well being. For that reason, the baby's behavior, including excessive crying, feeding issues, sleep issues should be an integral part of treatment of postpartum mental illness.

Traditionally treatment of postpartum depression focuses on the mother, often in the form of medication, but also support groups and psychotherapy. The baby's behavior is addressed separately, usually by a pediatrician. Innovative programs such as the Infant Behavior, Cry and Sleep clinic in Rhode Island explore the relational nature of these problems.

In a recent talk at the Austen Riggs Center Smith described a brochure addressing the question that many mothers ask- how can I prevent my baby from experiencing the effects of mental illness? Much of Smith's audience laughed at the brochures recommendations: "establish good relationships," reduce conflict," help with anxiety."

For families struggling to obtain life's basic necessities, these suggestions are laughable but certainly not funny. But for any family where a mother is struggling with mental illness, these goals may be unattainable without significant help.

In the new MCPAP for Moms program, a statewide initiative to improve identification and treatment for mothers who are struggling with perinatal emotional complications, efforts are being made to incorporate treatment of the mother and infant together.  Supporting a mother's efforts to effectively soothe and feed her baby by helping her to make sense of her baby's unique qualities and communications, is an integral part of preventing the negative impact of maternal mental illness on child development. A positive cycle of interaction can be set in place. This innovative research on diaper need offers evidence for the wisdom of this direction.

Thursday, August 28, 2014

On Rising Disability Benefits for Children: Distribute Diapers, Not Drugs

Children who grow up in poverty are at risk for problems of emotional, behavioral and attentional regulation. Today's Globe reports that SSI (Supplemental Security Income) for disabilities has surpassed traditional welfare as a source of support for poor families. The vast majority of these disabilities are mental health problems such as ADHD ( attention deficit hyperactivity disorder.) In her brilliant three part series that led to this current study, Patricia Wen uncovered some complex questions.  What does it mean for children and families that in order to receive financial support, there is incentive to get children diagnosed with psychiatric disorders and medicated with psychiatric drugs?

Current research at the Yale Child Study Center offers a novel look at this problem, literally from the other end. In a study published in Pediatrics in 2013, researcher Megan Smith showed that 30 percent of families living in poverty report diaper need.

Extensive research has  shown that when parents are fully emotionally present with their infants, they support development of emotional regulation, cognitive resourcefulness and social adaptation. But what if her baby is screaming in a dirty diaper, uncomfortable or in pain, and a mother can't reliably have access to a clean one? The stress of this predicament may make emotional regulation, both for parent and child, impossible. Smith concludes:
Although a majority of studies have examined family socioeconomic status as income and educational and employment status, emerging research suggests that indicators of material hardship are increasingly important to child health. This study supports this premise with the suggestion that an adequate supply of diapers may prove a tangible way of reducing parenting stress, a critical factor influencing child health and development. 
Next weekend, Smith will be presenting her research at the Austen Riggs Center, in conjunction with a community diaper drive sponsored by the Berkshire Psychoanalytic Institute

Wen's current Globe piece quotes Rebecca Vallas of the Center for American Progress; "Cash is what actually matters for these families, as a baseline, before you can even start talking about supports and services."

The point of juxtaposing these two studies is not that we should distribute diapers in place of cash. Rather it raises the question of whether it makes sense to invest in infants, rather than waiting until problems of emotional and behavioral regulation are so great that children meet diagnostic criteria for a psychiatric disorder. 

The infant brain makes as many as 700 synaptic connections per second. By investing resources in infancy, not only with diapers, but also such things as quality child care, paid maternity and paternity leave, and identification and treatment of perinatal mental health problems such as postpartum depression and anxiety, we literally have the opportunity to grow healthy brains. 

The current SSI system seems to be an investment in illness. In contrast, concrete support with clean diapers, as well as the broader support of parents and young children, is an investment in prevention and health. 

Sunday, August 24, 2014

Dancing Lessons: Metaphor for Healing Through Relationships

Dancing Lessonsnew play recently premiered at Barrington Stage Company, is ostensibly about an actual dancing lesson. An injured dancer reluctantly agrees to give a one-hour dance lesson to a young man with Asperger's syndrome who lives in her apartment building.

At first the two characters are cast in conventional roles, he awkwardly defining himself by DSM criteria and she drinking too much while spewing bitterness over her sudden unexpected disability. Over the course of the play's single act, as their relationship deepens, we appreciate the complexity of their characters. As they grow closer, sharing painful stories of loss from their past, they discover they are in many ways not that different from each other. In a wonderful fantasy sequence at the end, the two shed their respective disabilities and dance gracefully together.

The play, itself an act of creativity, can be seen as a metaphor for the value of play and creativity in healing. 

D.W. Winnicott, pediatrician turned psychoanalyst, is known for the playfulness he introduced to his work with children and families. I am not referring to "play therapy" but rather time and space to sit on the floor and see what unfolds.
Every summer the Austen Riggs Center in Stockbridge, MA hosts a creativity seminar in which mental health clinicians and a range of artists come together to explore the creative process. In the introduction to A Spirit That Impels, a collection of essays that grew out of the yearly seminar, editor M. Gerard Fromm shares a vignette told to him by a colleague who had the good fortune to observe Winnicott at work.  

Winnicott would see a family for one or two consultations; this one involved a young mother and her 3-year-old son.
He sat on the floor playing with the child, while also talking with the mother, who was sitting on the couch. She told Winnicott that her ordinarily sweet little boy had suddenly become quite ill-tempered and obstreperous. Worst of all, toilet training was completely set back, and the lad was now worrisomely constipated. The father in this working-class household spent long hours at two jobs, and the boys mother was at her wit’s end.
The trainee described to Fromm how she had no idea what was going on, but at the end of the visit Winnicott turned to the mother and said, “So how long have you been pregnant?” She revealed that she had not told anyone, but Winnicott suggested that the boy did in fact know and suggested she speak with him about it. When the mother returned a few weeks later, she reported that not only was her son “great fun again,” but his constipation had completely resolved.

In his book Playing and Reality, Winnicott writes:
This gives us some indication for therapeutic procedure- to afford opportunity for formless experience, and for creative impulses, motor and sensory, which are the stuff of playing.
This playfulness that Winnicott employed in his clinical work stands in start contrast to today’s system of mental health care replete with assessment tools and standardized forms.  Our reliance on DSM classification and medication may not leave room for this kind of creativity and healing through relationships.  

For example, in standard treatment of postpartum depression, the "problem" is seen as residing squarely in the mother, who may be offered nothing more than psychiatric medication. The role of the baby, the way fussiness, sleep and feeding difficulties affect the mother, may not be addressed. Similarly when we diagnose ADHD based on standard symptom checklists, and treat with "behavior management" or medication, there may be no room for creativity, either in making sense of or in treating the "problem." In the play space there is opportunity to understanding the meaning of behavior in the context of relationships.

Parent-child relationships are a complex intricate dance. At times this dance can be full of mismatches and stepped on toes. Sitting on the floor with parent and child together, rather than diagnosing disorders or managing problems, I prefer to think of my work as a form of dancing lessons.  Through playfulness and creativity, parent and child learn to dance gracefully, and as St. Germain’s characters discover in the final scene, to find beauty and joy in their relationship