To CDC on children's mental health: consider office of homeland attachment security

Change is in the air for children's mental health care. The latest CDC (Center for Disease Control) special supplement to the MMWR (morbidity and mortality weekly report) is titled Mental Health Surveilance Among Children-United States 2005-2011. The report overview states:

Approximately $247 billion is spent each year on children’s mental health.  The mental health of children is critical to their overall health as children and as they grow into adults.

The report summary concludes:

More comprehensive surveillance is needed to develop a public health approach that will both help prevent mental disorders and promote mental health among children.

This report coincides with both the release of DSM (Diagnostic and Statistical Manual of Mental Disorders) 5, and a statement by the director of the NIMH (National Institute of Mental Health) that research funding would not be guided by DSM diagnoses, and that a new paradigm of mental health care is needed.

The time has come to recognize the overwhelming evidence regarding the importance of early relationships in healthy emotional development. The answer to the problem posed in the CDC report is in: invest in early childhood -from newborn to three- to prevent mental health disorders and promote mental health.

A huge part of this evidence comes from the CDC itself, with the ACES study, showing long-term negative impact on both physical and emotional health of a range of adverse childhood experiences.  An abundance of research coming from the discipline of infant mental health provides a more nuanced view of this issue. 

 When parents are supported and valued by society, they are able to be fully present with their children, in turn helping to grow healthy brains. Children who grow up in an attuned caregiving environment are flexible, resilient, and empathic.  In contrast, when children experience toxic stress, or stress in the absence of a safe, secure caregiving relationship, the parts of their brains responsible for emotional regulation do not develop normally. What results are symptoms that are then labeled "mental illness." 

I heard this phrase "office of homeland security of attachment" from Gerard Costa, director of the Center for Autism and Early Childhood Mental Health at Montclair State University. I was speaking at the 2nd annual Todd Ouida Children's Foundation Conference with the wonderful title: The Magic in Moments: Patterns of Early Relationships that Create Resilient Individuals and Peaceful Societies. While the phrase is meant to be humorous, the idea behind it is very serious.  

Our country is seriously lagging behind other countries in the care and attention we give to young children and their parents, with potentially devastating effects. A special government organization to take on this task would address this problem with the attention it deserves. This does not mean that the government has a role in parenting, which is a private, individual experience. Rather, such an organization could address such things as:

- parental leave policy

- comprehensive screening and treatment for perinatal emotional complications including 

depression and anxiety

- education of a workforce trained in working with young children and families

-  high quality child care, including supervision for child care workers 

Attending to early caregiving relationships will move us toward the goal of creating peaceful societies. Given that $247 billion is spent a year on children's mental health, focusing on early childhood is not only the right thing to do, it is also a worthwhile investment. 

  

DSM, NIMH on mental illness: both miss relational, historical context of being human

It seems that the National Institute of Mental Health (NIMH) may have dealt a death blow to the recently published Diagnostic and Statistical Manual of Mental Disorders (DSM 5) when the organization declared they would no longer fund research based on the DSM system of diagnosis. The views of NIMH director Thomas Insel were referenced in the recent New York Times article on the subject.

His goal was to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.

I am no fan of the DSM system, which reduces complex experience to lists of symptoms; focusing on the "what" rather than the "why."  However, the NIMH model has limits as well. There seems to be a wish to study mental illness in the same way we study cancer or diabetes. While I certainly have great respect for the complexity of the pancreas, or the process of malignant transformation of cells, trying to understand the brain/mind in an analogous way seems to be an unnecessary and even undesirable reduction of  human experience.

What is missing from both paradigms is recognition of the relational and historical context of being human. Fortunately there seems to be awareness that neither paradigm is complete. The Times article goes on to say:

Dr. Insel is one of a growing number of scientists who think that the field needs an entirely new paradigm for understanding mental disorders, though neither he nor anyone else knows exactly what it will look like.

The growing discipline of Infant Mental Health offers just such a paradigm. This discipline is characterized by four key components. First and foremost, it is relational, recognizing that humans (and that includes their genes and brains) develop in the context of caregiving relationships. Second, it is multidisciplinary. Experts in infant mental health offer different perspectives.  They come from many fields, including, among many others, developmental psychology, pediatrics, nursing, and occupational therapy.  Third, it encompasses research, clinical work and public policy.  The field looks at mental health within the context of culture and society. And last, it is reflective, looking at the meaning of behavior, not simply the behavior itself. The ability to attribute motivations and intentions to behavior is uniquely human, and research has shown that this capacity is closely linked with mental health.

Unfortunately when people hear the term infant mental health, they imagine babies lying on the couch.  In reality, the field offers a way of understanding all of human experience, well beyond infancy.  I recently taught a course on infant mental health to clinicians at the Austen Riggs Center, a hospital that offers intensive inpatient treatment for severely disturbed patients. None of them are infants- the youngest are in their late teens and most are well into adulthood.  My students found the insights from infant mental health very valuable for understanding and treating their patients.

The Center for Disease Control (CDC) Adverse Childhood Experience (ACES) study provides extensive evidence of the long-term effects of early exposure to a range of negative experience, including parental mental illness, divorce, abuse, and neglect, on mental health. The more severe the mental illness, the earlier in life disruptions to development probably occurred. Knowledge of infant mental health (that spans age 0-5) offers a textured understanding of this early experience.

Looking at an individual brain and/or genes, or listing the behavioral symptoms of an individual person, out of relational and historical context, how can one possibly understand the complexity of human experience? This complexity is represented by such things growing up in the home of a Holocaust survivor, a depressed parent,  in the setting of ongoing war trauma, with a physically and emotionally abusive parent, or some combination of all of these. A recent article on the blog ACES Too High,  "What motivated the Boston bombing suspects?" offers a fascinating look at the Tsarnaev brothers from an ACES perspective. The use of the word"motivation" in the title represents a curiosity about the meaning of behavior that is representative of an infant mental health perspective.

The ongoing research coming from the discipline of infant mental health offers growing knowledge about effective, primarily preventive, interventions. Not only do we need this research to continue, but we also need to grow a workforce trained in infant mental health to offer these interventions on a large scale. When the NIMH looks for a new paradigm towards which to direct funding, I hope they will look to the paradigm of infant mental health.

Using media to promote change while celebrating Brazelton's 95th

I had the privilege this week to participate in the 95th birthday celebration of pediatrician T. Berry Brazelton on the occasion of  the  annual Touchpoints National Forum.    I even got to sit at the table with Dr. Brazelton for the birthday lunch!  We watched a wonderful animated video about his life, created by Exceptional Minds, an animation studio for young adults on the autism spectrum. We listened to songs written about and for Dr. Brazelton, sang "Happy Birthday" and shared birthday cake.

I had been invited by Kevin Nugent, director of the Brazelton Institute, to present at a workshop entitled "Can we Use Media to Support Parents?"Much to my delight, Dr. Brazelton attended our workshop. One of my co-presenters was Lisa McElaney, president of Vida Health Communications. I learned from her about a brilliant evidence-based program called All Babies Cry, a collection of DVD's produced with the aim of preventing child abuse in infancy.  Dr. Brazelton was fully engaged and enthusiastic, asking probing questions.

Recently Dr. Brazelton was presented with the  Presidential Citizen's Medal by President Obama.  The essence of Dr. Brazelton's gift is his tremendous respect for children, parents and the people he works with. His Neonatal Behavior Assessment Scale brought to light a newborn baby's  extraordinary capacity for communication. In his work with parents he brings a nonjudgmental strength-based approach to his interactions.  Respectful listening among colleagues is central.

At first I wasn't sure what direction to take with my presentation. Unlike my fellow presenters, I am not a media professional. But then I realized that it gave me a wonderful opportunity to think about why I write for the media.  Just five years ago, I was simply a small town doc in Western Massachusetts.

As I reviewed the events of these five years, I saw that an overarching goal of all of my writing is perfectly aligned with the work of Dr. Brazelton. My aim is to promote a stance of listening with nonjudgmental curiosity. That includes listening to children and to parents, as well listening as among professionals who may approach work with children and families from different paradigms.

As part of my presentation, I told stories about pieces I have written that aim to crossing paradigms and  promote new ways of thinking. It all started with my first op-ed piece for the Globe in 2008, provocatively titled Mind Altering Drugs and the Problem Child, in the wake of the explosion of diagnosis of bipolar disorder in young children.  Continuing as a blogger for Boston.com, I had a similar aim with posts such as Diagnosing ADHD under Age 6: A Mistaken Idea, Could Sensory Processing Disorder be the Primary Problem?, and even The Poop Wars: Why Miralax is Just a Bandaid.

It was a thrill of a lifetime to share this celebration with Dr. Brazelton and then to be able to present my work to him. He is a great model and a true inspiration.

Grieving for Boston

It was a heartbreakingly beautiful day.  I work at Newton-Wellesley Hospital, and as I live in Western Massachusetts, I had not yet had reason to come in to Boston.

Though I grew up in New York City, I have felt a strong attachment to Boston since I first lived here over 20 years ago, on what my husband fondly refers to as "far out" (Farrar) Street, that I never felt for New York.

I sat at the Starbucks on the corner of Charles and Beacon, working on my new book before heading to the State House for a  meeting of Representative Ellen Story's Postpartum Depression Commission. I had a bit of extra time, so I set out for a walk on the Common.

"Can I cry, walking alone in the middle all this life?" "Can I not?" My brain conversed in this way with my heart as I fought back tears. They did not come. I continued my walk, drawn to Boylston Street. I stopped to photograph some tulips. I saw a runner sitting on a bench tying her shoes. "Are you OK? "I wanted to ask.

I walked down Boylston to the memorial that has appeared, taking time to look at a huge card filled with signatures and words of gratitude addressed to Massachusetts General Hospital. It was getting late, so I headed back towards the State House.

Once again at the corner of Beacon and Charles, I stopped. I looked out across the Common at the magnificent burst of color against the perfect blue sky. I thought of a trip in April, 16 years earlier, with my then 2-year-old daughter.  My husband and I sat among the flowers in this same spot in the brilliant sunshine. A complex mix of feelings were brewing- anger at the loss of innocence, love for this beautiful city, and deep sadness, both for the people whose lives were directly impacted, and for the city as a whole. Then I let the tears come- enough to allow myself to know that this was not just an ordinary day of work.

I went to my meeting, fully engaged in the task at hand. Walking down the stone steps into the light of dusk, I was joined by a young man who had been at the meeting who I did not know. As I again looked out over the Common, I wanted to say, "This is my first time here since the bombing." Instead we simply smiled at each other. "Have a nice evening," he said as he walked the other way. "You too," I replied.

Music, mourning, and family narrative

(I wrote this post before we learned of the complex family and historical background of the alleged Boston Marathon bombers. I was again going to postpone publishing it. But I wonder if these ideas of mourning and family narrative have something to add as we struggle to make sense of the events of the past week. There seems to have been a tragic and deadly coming together of what French psychoanalysts Francoise Davoine and Jean-Max Gaudelliere, in their book History Beyond Trauma, refer to as "big history" reverberating in individual family history. It is hard to say any more when at this time we really know so little. Rather than making any further explicit connection, I will simply share my post below. It offers what I think can be a message of hope.)

I have been meaning for some time to write a blog post about Dar Williams'  beautiful and profound song "After All." A chance meeting with Marshal Duke, the lead researcher referenced in a recent New York Times article, The Family Stories that Bind Us, provided the inspiration.

Duke's research along with that of Robyn Fivush, has shown a clear correlation between a child's knowledge of family narrative and such qualities as resilience and positive self esteem. In a 2008 paper they describe the "intergenerational self." They write:

It is this intergenerational self and the strength and guidance that seem to derive from it that are associated with increased resilience, better adjustment, and improved chances of good clinical outcomes.

William's song, both the lyrics and the music, provides solid evidence for this theory. In it she describes her struggles with pain and sadness, and her journey to find a way to embrace life.  The lyrics speak to the importance of family narrative. 

And if I was to sleep

I knew my family had more truth to tell

And so I traveled down a whispering well

To know myself through them

The historical nature of this narrative is clear in these lyrics.

Sometimes the truth is like a second chance

I am the daughter of a great romance

And they are the children of the war

For the full impact of the song, I hope that readers will listen to it. For in my view, it is not simply the telling of the story that is important. In order for parents to pass the family narrative on to their children in a way that is meaningful and useful, the feelings associated with the story, which often includes trauma, loss, and grief, must also have found a way to be expressed. This is easier said than done. It involves having a safe, containing, holding environment in which the stories can be understood.  A secure, trusting relationship with someone who can hear the story is important.  Art, including music and literature, can have a role to play as well. Those feelings are certainly present in Williams' music. In her introduction to this live version, she expresses surprise to have discovered a large community of people who could relate to her experience.

Go ahead push your luck

Find out how much love the world can hold

Once upon a time I had control and reined my soul in tight

Well the whole truth

Is like the story of a wave unfurled

But I held the evil of the world

So I stopped the tide

Froze it up from inside

And it felt like

A winter machine that you go through and then

You catch your breath and winter starts again

And everyone else is spring bound

But when I chose to live

There was no joy it's just a line I crossed

It wasn't worth the pain my death would cost

So I was not lost or found

And if I was to sleep

I knew my family had more truth to tell

And so I traveled down a whispering well

To know myself through them

Growing up my mom had a room full of books

And hid away in there

Her father raging down a spiral stair

Till he found someone most days his son

And sometimes I think my father, too, is a refugee

I know they tried to keep their pain from me

They could not see what it was for

But now I'm sleeping fine

Sometimes the truth is like a second chance

I am the daughter of a great romance

And they are the children of the war

Well the sun rose

With so many colors it nearly broke my heart

It worked me over like a work of art

And I was a part of all that

So go ahead push your luck

Say what it is you gotta say to me

We will push on into that mystery

And it will push right back

And there are worse things than that

'cause for every price and every penance that I could think of

It's better to have fallen in love

Than never to have fallen at all

'cause when you live in a world

Well it gets in to who you thought you'd be

And now I laugh at how the world changed me

I think life chose me

After all

Mourning and music: a song for Boston

I had been working on a post on the subject of mourning and music. But with the trauma of the Boston Marathon bombing still so fresh, it did not seem appropriate to write about any other subject. I wondered, what could I add to the discussion? Then this morning, with the idea of music as a means to connect with feelings on my mind,  I heard on the radio the song Learn Me Right by Mumford and Sons. The lyrics, specifically the chorus (not the verses), are perfectly fitting to the moment, though the "scream" with hope will be one of joy,  not terror. And the music, particularly the version performed by Birdy for the movie Brave, captures the spirit of resilience. It can represent hope for the triumph of the people of Boston and of the Marathon itself. It may not be everyone's cup of tea, but for me, and perhaps for others, the music can help connect with the feelings of the day.

We will run and scream
You will dance with me
We’ll fulfill our dreams and we’ll be free
We will be who we are
And they’ll heal our scars
Sadness will be far away

Lost child psych beds at Cambridge Health Alliance: now prevention is essential

In the wake of the Newtown tragedy, many people, myself included, wrote about the need to address both gun control and mental health care. So it was rather jarring, on the same day that Connecticut's governor signed comprehensive new gun control legislation, to read that Cambridge Health Alliance was planning to cut 11 of 27 child inpatient psychiatry beds, including all inpatient service for children age 3-7.

But on closer consideration, I wonder if this loss in fact presents an opportunity. With no inpatient care for young children, it now behooves us as a society to make sure they never need such care. As a pediatrician with 25 years experience working with troubled children, I can be sure that when a child needs hospitalization at age 4, 5 or 6, his problems started way before that. The Globe article suggests that plans are headed in this direction.

Burke [chief of psychiatry] said the hospital is focusing more on efforts that can keep children out of the hospital, including services in schools and placing psychiatrists in pediatricians’ offices.

This is an excellent idea. But what does it look like in practice? Number one, we need a workforce experienced in early child development. There is an explosion of knowledge and research, coming out of the discipline known as infant mental health, that informs us of how to work with parents and children together to help set young children on a path of healthy development.

Such training programs are erupting all over the country. One superb program is right here in Boston- the UMass Infant-Parent Mental Health Post-Graduate Certificate Program under the direction of renowned researcher Ed Tronick.

Fellows in that program learn from leaders in the field, including child psychiatrist Bruce Perry, whose neurosequential model of therapeutics informs us of how to use knowledge of neurodevelopment to guide treatment.

We need these programs because most child psychiatrists have minimal to no education in early child development, and pediatricians, who live and breathe child development and have long-term relationships with families, are under pressure to see 6 patients an hour, and so have no time to help. In the ideal world, training in infant mental health would also be incorporated in to pediatric and child psychiatry training.

We cannot let the bottom fall out for these children. By taking away these beds, a preventive model is no longer optional. A person trained in early childhood mental health should be in every primary care office, and every childcare center should have easy access to early childhood mental health care professional for on-site consultation. I wonder if this might even cost less than maintaining inpatient beds.

Of course this does not help the children today who need inpatient care. Ideally we would be able to offer both forms of help. Perry's model is relevant for treatment of older children as well. I do not know the answer to this problem. However, I can be sure that parents, who are suffering terribly waiting with their severely troubled young child for an inpatient bed to become available, would have much preferred to get meaningful help years before.