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.

Monday, May 18, 2015

How Does Infant Mental Health Inform Psychoanalysis?

Distancing from interpretation, when the analyst explains back to the patient the meaning of her words as he understands them, was a common theme at three recent psychoanalytic presentations. At one, a leading psychoanalyst explained how rather than interpret a patient's words, he seeks "clarification." A second spoke of how he too steers away from interpretation, aiming instead to "get out of the way" and let the patient come to his own understanding, to,  echoing the words of D.W. Winnicott, become himself.  A third similarly tried to distance him from this classical analytic concept, describing instead an attention to the "field of characters" that inhabit the patients thoughts. 

As I sat in the audience of these lectures, I found myself trying to retro-fit what I had learned in the past few years of immersion in infant mental health -or what I prefer to describe as the developmental science of early childhood- to the classical psychoanalytic theory I was exposed to as a scholar with the Berkshire Psychoanalytic Institute. 

When a recent talk I gave about my infant mental health informed treatment of a 2-year-old boy prompted a psychoanalyst colleague to ask, "what about the unconscious?" it all came together in a kind of "aha" moment. 

Psychoanalysis, originally called the "talking cure" is sometimes described as an effort to make the unconscious conscious. The idea that we have feelings that are out of awareness but yet influence our current relationships and behavior is so integral to our understanding of ourselves that it is hard to imagine that we did not always think this way. Yet the "unconscious" was in fact Freud's revolutionary discovery. 

In infancy and early childhood we have the original experience of connecting feelings with thoughts and words.  The analytic relationship thus in a sense seeks to recreate that original experience.  That is not to say that the analyst is the "better parent." Rather, by offering similar kind of holding environment, the analyst helps the patient to discover, or re-discover, that capacity. We can become calm, creative, flexible and develop healthy relationships- or as Freud said "to work and to love" -when we are able to think about and give words to our feelings. 

The mother (or primary caregiver) originally fulfills this function by containing the infant's experience, not only with words but also with her body, her voice, her presence.  In toddlerhood the actual words take on more significance. As a mother labels her child’s feelings with words, the child develops the capacity to think about and give words to feelings.

However, when the mother is not able to hold the child in this way, feelings remain unconnected to thoughts or words. They remain unlabeled and confused. Or one could say, they remain unconscious.

There are many reasons why a mother has trouble with this holding, containing, meaning-making function. She may be depressed. She may have experienced loss- as in infertility and pregnancy loss- and/or in her own childhood.  A baby may be particularly dysregulated, making this containing function particularly challenging. As a mother feels inadequate to the task, she may then slide in to depression, especially in the context of the severe sleep deprivation that accompanies a dysregulated baby.

When I treat a parent-child pair, I have the opportunity to support- in real time- this capacity to give words and thoughts to feelings, make meaning of experience, or, as I describe in my first book, to hold a child in mind. The transformative effects, for both parent and child, are often dramatic. 

In order to support a mother’s efforts to think about her baby’s mind, it is not necessary to analyze her, a process that may be helpful but can take a long time. As soon as a mother feels recognized and understood, she begins to be more present with her baby.  The baby becomes better regulated, in turn improving a mother's sense of self-esteem and decreasing feelings of shame. These changes, in turn, positively affect the mother’s ability to hold her baby in mind, further facilitating the baby's capacity for emotional regulation and development of a healthy sense of self. This process is described by Ed Tronick as the mutual regulation model.

Without this kind of holding, this kind of giving voice to feelings, a young child will have only a bodily awareness of stress without being able to connect thoughts and words to the experience. When there are no words connected to feelings, the experience continues to exert influence, living both in the unconscious mind and in the body. As such it maintains a grip on an individual's behavior and relationships. 

The analytic process then, in making the unconscious conscious, in a sense recreates this early experience of being held, recognized and understood in such a way as to connect feelings with thoughts and words. Rather than being hijacked by these feelings that are out of awareness, an analytic patient develops the ability to pause, to think about a feeling rather than unconsciously act it out.  

As I listen to these senior analysts wrestle with the question of how to capture the therapeutic effects of the psychoanalytic process, I see how the discipline infant mental health, where the work is done in real time with infants and parents, adds an important dimension to this exploration.

Saturday, May 9, 2015

For Mothers and Babies: Big Weeks Ahead at Boston's State House

Recently the Massachusetts House of Representatives did a very good thing.  As described in a Globe editorial, they reinstated funding for a program that supports new mothers struggling with perinatal emotional complications.

At Southern Jamaica Plain Health Center (SJPHC), when a new mother reveals that she is overwhelmed and struggling in the care of her newborn, thanks to the special legislative commission on Postpartum Depression chaired by Representative Ellen Story, help is available on the spot. SJPHC is one of four sites chosen for this pilot program focused on perinatal emotional wellness and postpartum depression prevention. 

By placing perinatal support services within existing healthcare facilities, this program lowers barriers and increases access to care.  By bringing services to where women already are-- with a prenatal provider and/or a pediatrician—the program provides critical support to diverse and underserved populations, including many people who have no other access to healthcare.  

Clinicians meet with all new families at their first pediatric visit, often as early as 4 days postpartum. This is a period of uncertainty, and most new parents have many questions about sleep, feeding, caring for their baby, and managing the adjustment to parenthood.  

Divya Kumar, a doula and lactation consultation, describes how she can listen to new moms for extended periods. As she explains, “I can sit with a mom and say, ‘OK, I'm going to help you figure all of this out.  And if I don't have all of the answers, I'm going to connect you with someone who can help you get them.’ ”

It is not simply about screening for PPD and referring the mother for treatment. Divya and her team can hold the baby and mother together over time, seeing how the baby feeds, when the baby fusses, supporting a mother’s efforts to be present and calm in a way that soothes her baby. The program offers fertile ground for growing a healthy relationship.

Now another important program for mothers and babies, MCPAP for Moms, is on the chopping block.

In a new moms group, where mothers feel supported and listened to, extraordinary thing happen. As a consultant to groups at William James College Freedman Center, I have had the privilege of witnessing this powerful transformation again and again. On the first of eight weeks, when moms sense the safety of the group, they share experiences not only about the lack of sleep and ability to take a shower, but also fears, anxieties, self-doubt, sadness and even depression. By the last group meeting, these mothers, many of whom have developed powerful bonds with each other, interact with their babies, whose unique little personalities have emerged, with confidence and joy. 

In our culture today, where extended family may be far away, where spouses often return to work long hours almost immediately, mothers may be very much alone in the task of caring for a new baby. Mother-baby groups have a critical role to play in filling that void.

MCPAP for Moms, in collaboration with MotherWoman, an organization that offers a network of groups as well as training for group leaders, seeks to make these groups available to mothers all across the state.

This program, too, has its roots in the postpartum depression commission. While at first the focus of the commission was to implement statewide screening for postpartum depression, it quickly became clear that such a step was meaningless without first having resources in place to help mothers identified by the screening.

MCPAP for Moms works in collaboration with William James College INTERFACE Referral Service. When a new mother feels alone, scared and overwhelmed, a three-month- or even a three-week-wait is unacceptable. She needs help today. This program not only helps to locate a support group, but also will connect a mother with a mental health clinician who has experience treating mothers who are struggling with perinatal emotional complications. MCPAP for moms also offers toolkits, as well as immediate phone consultation, for a range of clinicians- including pediatricians, obstetricians, psychiatrists and family practitioners- who are in a position to identify and treat these vulnerable mothers and babies. 

Sadly, the $500,000 needed for MCPAP for Moms to be implemented throughout the state was not even included in the budget.

Budget amendments are due this week, and the floor debate will occur the week after. Let’s hope our legislators, and then Governor Baker, will do the right thing- reinstate the funding for MCPAP for Moms and approve the funding for the pilot programs.  When we as a community support new mothers, we promote healthy development of the next generation, and so the future of our country.  

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.