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.

Tuesday, April 22, 2014

Alex's Wake: trauma, creativity, and healing

Martin Goldsmith's new book, Alex's Wake: A Voyage of Betrayal and a Journey of Remembrance is at one level a history lesson as memoir. It offers a view of the horrors of the Holocaust from a deeply personal perspective. Goldsmith describes a six week journey with his wife in 2011 to follow the path of his grandfather Alex and uncle Helmut. Revisiting the locations where they lived, he describes the transformation from a life of prosperity and success, through the early years of Hitler's regime, to their ill-fated voyage aboard the SS St Louis where the promise of freedom in Cuba ended in return to France, and eventually to a final demise at Auschwitz.

The book also reads as demonstration of the healing power of story telling, and of the transformation of terrible loss in to great beauty. The book has its origin in tragedy, as the death of the author's father is followed less that a year later by the sudden death of his brother. Goldsmith writes:
Exactly eleven months later, on March 30, 2010, I received the shocking inexplicable news that my brother had died. A once brilliant student at Stanford University...Peter had in recent years been struck low by physical ailments and a profound depression that, I am sure, was exacerbated by the long-standing family guilt and shame. Now he was gone, quickly felled by a heart attack. He was 60.
The guilt and shame to which he refers is connected to his own father's untold history; the story of how his father and brother, Goldsmith's grandfather and uncle, were left behind to experience a brutal and gruesome end. In the wake of the loss of his own father and brother, Goldsmith finds himself driven to tell that story before his own 60th birthday.

Both Goldsmith's parents escaped Nazi Germany, a story he tells in his previous book, The Indistinguishable Symphony. But his grandfather and uncle were left behind, despite desperate letters of appeal.
There were reasons aplenty why every effort under the sun might have failed to win his family's freedom, but the inescapable fact remains that Alex begged his son to save his life and my father failed to do so.
Goldsmith's parents never spoke of this early history, a fact he understands as an effort to protect him and his brother from the truth. He describes the experience of growing up in that silence:
The guilt that my father carried he passed on to my brother, Peter, and me as our emotional inheritance...How little they suspected that, even without words, we could feel and absorb the unspoken pain that circulated like dust in the air of our home, and how much we were aware of the darkness, the enormous unknown yet deeply felt secret that obscured the light of truth. 
Goldsmith is motivated by his own loss to follow a different path from his father and brother. He sets off on this journey of discovery. As such loss is transformed in to creativity.

Many reviews focus on the fascinating history revealed in the book, particularly the terrible, but less well recognized, maltreatment of Jews in France during World War II. I found myself drawn to the story of the two Goldsmith brothers. One lost his way, eventually succumbing to depression and ill health. The other, I hope, found his way to health, in part through the very book I am writing about.

I well understand how those who directly experienced the horror of the Holocaust may be too close to speak about, much less mourn their loss. It may be for them, in a sense, unmournable.  It is left to the next generation, inheriting not only their loss, but also their strength, to tell their story.

Goldsmith's father denied his Jewish heritage. Goldsmith writes:
 And there was no acknowledgement that we were Jews, despite that being the singular reason for our family's violent dismemberment. When I, as a teenager, discovered our religious roots, my father dismissed it all by declaring that we were, at most, "so-called Jews," He did not choose to regard himself as a Jew despite the unavoidable fact that he'd been bar mitzvahed, that his parents were both Jews..."Adolf Hitler thought I was a Jew, so I had no choice. I choose to exercise that choice now. I am not a Jew," he said.
Yet Goldsmith finds his way to his Jewish identity, resonating on a profound level with the Kol Nidre prayer of Yom Kippur and eventually being Bar Mitzvah'd himself at the age of 55.

At one point in his journey Goldsmith discovers a memorial etched with the words of the Talmud, "Who Saves One Life Saves the Entire Universe." Knowing how this untold story may have been instrumental in Goldsmith's brother's death, one can view this book as an effort to save his own life. This brings to mind yet another Jewish concept, Tikkun Olam, which refers to humanity's shared responsibility to "heal the world." With the writing of Alex's Wake, Goldsmith has done his part.

Tuesday, April 15, 2014

Antipsychotics for foster care kids with ADHD?

A recent study, one that received relatively scant media attention (compared with a concurrent New York Times piece about a new psychiatric diagnosis termed "sluggish cognitive tempo" that may be the "new ADHD") showed that antipsychotics are being prescribed to nearly one third of kids (age 2-17) in foster care who are diagnosed with attention deficit hyperactivity disorder (ADHD.)

This disturbing statistic brought to mind a common complaint I hear from parents about putting on shoes to go out of the house. A child will dawdle, ignoring multiple requests. The situation will escalate to the point where the parent becomes increasingly angry and frustrated, and the child descends in to an all out tantrum.

This kind of scene likely plays out in some form in every household with a young child. It can be useful to keep in mind as we aim to understand why a child who is in foster care might exhibit behavior that calls for bringing out these pharmaceutical big guns.

While there is a range of reasons for a child to be in foster care, one can assume that there has at minimum been some experience of trauma and loss. This might include physical and/or emotional abuse.

Research in the field of developmental psychology and attachment offers a way to understand this situation. Young children inevitably have tantrums. It is a normal healthy part of development. But if a caregiver herself has a history of trauma, her child's behavior may, as they say, "push her buttons." She may become flooded with stress in the face of her child's acting out. Unable to think clearly, she may respond with behavior that is either frightened or frightening. She may either become overwhelmed with rage, or shut down emotionally. In the language of psychology this is termed "dissociation." For the child, it is as if his caregiver suddenly isn't there. In this situation, the child learns to recognize his own emotional distress as a signal for abandonment.

Now put this same child in foster care and ask him to put his shoes on to go outside. What starts out as a "typical" parent-child interaction can quickly descend in to wildly uncontrollable behavior. I've heard parents who have adopted kids out of trauma say, "its like he's not even there." When the child was in this kind of situation with an abusing caregiver, he might, in a way that is in fact adaptive, responded to her dissociation with his own form of dissociation. Now he has learned that behavior. But out of context, in foster care with a non-abusing caregiver, it may look "crazy."

When this kind of "not listening" extends to other arenas, it may be reframed as "not paying attention."  This behavior often occurs together with the impulsivity. Impulsivity literally means to act without thinking. An inability to think in the face of strong emotions, as I describe in my book Keeping Your Child in Mind, can also be understood as part of the trauma, of not having been held in mind by caregivers early in development.  With problems of both inattention and impulsitivity the child may, according checklists commonly used to make the diagnosis, earn the ADHD label.

Perhaps this is how kids in foster care end up on antipsychotic medication for ADHD.

But by taking this path, we are essentially putting a muzzle on the child. The child's behavior is a form of communication. It says, "I have never learned how to manage myself in the face of life's inevitable frustrations." Rather than silence him with a powerful drug, that is well known to have serious side effects, we need to listen to that communication.

The first step is to recognize the meaning of the behavior. Once caregivers understand the "why" of the behavior, they can better support the child's efforts to regulate himself in the face of frustration. At first this might be in a very physical way. For example he might need to be held in a firm and loving embrace. Or he might need to run around the room. Or hit a punching bag. He might need a soft and gentle voice rather than a harsh and angry one. As a child gets older, regulating activities like dance, theater and martial arts can have a significant role to play. Once a child has developed the capacity to regulate his body in the face of distress, he can begin, perhaps in the setting of psychotherapy, to give words to his experience.

But if we simply silence him with medication, all of this opportunity for growth and healthy development may be lost.

Thursday, April 10, 2014

Autism: difference or disorder?

About 2 years ago, when the change in diagnostic criteria for Autism Spectrum Disorder proposed for DSM 5 was in the news, I wrote a blog post about the problem of giving children a diagnostic label in order to "get services covered" by insurance. An irate reader, himself a well know speaker and advocate for people with Autism and Asperger's, wrote a blog post in response, in which he said, "Dr.Gold simply does not understand that Autism is not a psychiatric disorder."

In the wake of the recent CDC statistics indicating that 1 in 68 children has autism, and the designation of April as autism awareness month, I have been thinking about this dilemma a great deal. For this young man and I were really exactly on the same page. Both of us were calling for a respect for and value of uniqueness and differentness.

This perspective was again beautifully articulated in a TED talk by Andrew Solomon, author of Far From the Tree. In an in-depth discussion of a range of entities including homosexuality, deafness, as well as autism, Solomon identifies the power of unconditional love in the context of complete acceptance of individual differences.

While I fundamentally agree with the perspective of these two men, my mind stumbles on these facts. The DSM 5 is the fifth version of the Diagnostic and Statistical Manual of Mental Disorders. The CDC is the Center for Disease Control. So much as we may want to think of autism as a celebration of individual differences, the prevailing view is that it is a disorder.

Solomon suggests that by hoping a child does not have autism, a parent is saying that she wishes this child did not exist and that she had a different child. I see the exact opposite. The parents I see who are in this position unconditionally love their child for who he is. They are motivated to make sense of his experience and give him space to grow in to himself.

While there is emerging evidence of the role genetic and neurobiological mechanisms in the behaviors collectively referred to as autism, it is not a know biological entity in the way, for example, diabetes is.

One little girl I worked with ran around in circles at preschool and repeated letters in nonsensical patterns. There was a strong family history of both anxiety and "quirky" behavior. She was easily overwhelmed by a range of sensory inputs.  Her mother would herself become overwhelmed in the face of her child's struggles as she recalled her own difficult childhood. Another little boy endlessly repeated whole scenes of dialogue from Disney movies. He ate only 3 different foods for the first 7 years of his life. His parents fought frequently about his challenging behavior, which usually caused it to escalate.

For both these children the diagnosis of autism was raised. But both sets of parents resisted. When they addressed the child's unique qualities as well as the environmental stresses that contributed to the problematic behavior, dramatic changes occurred. Both are now teenagers. The first is a talented actress, singer and musician. The second is a chef. Both have active and successful social lives. One view is that they "outgrew" autism. Another is that they were they given space and time to grow into themselves.

It the first five years of life there are major changes in the brain, changes that occur in the context of relationships.  We are now recognizing that changes occur not only in brain structure, but in genes and gene expression as well. It is a work in progress.

These children and families do benefit significantly from help. This may be in the form of a special preschool placement, occupational therapy, family therapy or other interventions that can set these children on a healthy path of development. In order to get these services, a diagnosis is often necessary. This is an example of the tail wagging the dog.

The massive rise in diagnosis of autism indicates that something is amiss. I wonder if that "something" is that in our fast-paced society we rarely take the time to listen to the story, to let meaning unfold. There is a need for an "answer." There is a lack of tolerance for uncertainty.

When a child is young, when his "true self" is emerging, supporting parents efforts to "hang in there" without the need to name, to label, to diagnose, may give these young children the best opportunity to transform what in early childhood may be challenges and vulnerabilities in to adaptive assets and strengths.

Thursday, March 27, 2014

Rising numbers of kids expelled from preschool and diagnosed with autism: are they linked?

Two alarming news items compete for attention. The first,  a New York Times editorial entitled Giving Up on Four-Year-Olds describes a recent report showing expulsion from preschool as a form of discipline occurring in increasing numbers. A second speaks to the new CDC statistics indicating that 1 in 68 children have autism, a change from 1 in 88 just 5 years ago.

Perhaps both represent a lack of value of space and time for listening, in particular for listening to children and parents. Elizabeth Young-Breuhl might refer to both phenomena as prejudice against children

Each child who is expelled from preschool has a story. Similarly, every child diagnosed with autism has a story. It takes time, and a safe non-judgmental environment to bring these stories to light and so make sense of a child's behavior.

There may be witnessed domestic violence. When  a child lives in fear, he may respond to the "threat" of a child standing too close to him in line by pushing him. A reprimanding voice may lead to escalation of stress and even the development of a "fight-flight reaction." Being sent to the principal's office leads to further disorganization. 

Sensory processing challenges are often prominent. A withdrawal from social interaction makes sense from the perspective of a child who is flooded and overwhelmed by a busy classroom. Crawling under a desk may not be something "wrong" but rather an adaptive response.
Increasingly structured school environments, with little room for variation and high student:teacher ratios may exacerbate both of these problems. 

However, once we have the opportunity to hear the story, what to do to help the child becomes clear. One boy whose behavior had escalated to the point where he was throwing things at the teacher felt calm if he could start the day with a few minutes buried under the plastic balls in the ball pit. Another who would run in circles much of the day discovered music. When she was invited to sing or play an instrument she could sit calmly with the other children. Another family recognized how the level of chaos in the home was particularly problematic given their son's vulnerabilities, and took steps to change that environment.

A recent New York Times article describes a wonderful school program, Head Start Trauma Smart, an example of an innovative program that takes time to listen to the story, make sense of a child's behavior and respond appropriately. In contrast, expelling children for "acting out" may result in a cascade of worsening behavior problems.

The massive rise in autism numbers may reflect a need to name a problem with certainty, rather than taking the time to let the story unfold, to let a child grow in to himself. Perhaps if parents, teachers and clinicians had the opportunity to get a child the help he needs without pressure to name the problem, the numbers would be much lower.

Clearly there are significant differences between these two issues. But an underlying theme emerges. 

Monday, March 24, 2014

Huge increase in ADHD diagnosis in young women a worrisome trend

"I know its my ADHD acting up," a mother of three young children recently said to me as an explanation for her inability to recall a particular piece of information. My observation, in the setting of my behavioral pediatrics practice, of increasing numbers of mothers of young children being diagnosed with ADHD is in keeping with a recent report from Express Scripts. This report, based on pharmacy claims data, showed a 53% rise in writing of prescriptions for ADHD in adults from 2008-2012, with "the largest gains seen in women age 26-34, climbing 85%."

A psychiatrist colleague of mine took this data at face value, saying that "ADHD is genetic" so with the rise in diagnosis in children, it makes perfect sense that there should be a parallel rise in diagnosis in adults. 

But there are big holes in this argument. Certainly problems of regulation of attention, behavior and emotion, that are all called "ADHD," have a familial component. But we are far from identifying a specific genetic cause. These qualities, both in children and adults, represent a complex interplay between genetic vulnerability and environmental effects.  

So how else might we explain this rise in writing of prescriptions for this group, many of whom are young mothers? In today's fast-paced society, parents of young children are often overextended and overwhelmed. In my practice many fathers work very long hours, leaving mothers alone to manage everything. In the absence of extended family this can be highly stressful. Physical activities such as yoga, running or even walking have a calming organizing effect on the brain, but often these mothers are unable to carve out time for themselves during the day. Sleep deprivation has a huge role to play. There is a well-established link between sleep deprivation and symptoms of distractibility, inattention, and hyperactivity. This may be an inevitable part of parenting young children. But often there are ways to improve sleep if parents have the opportunity to make sense of the situation and take the time to fix it. But often there is not this time, so families get stuck in a reactive mode, with a vicious cycle setting in as lack of sleep makes them increasingly less able to think clearly.

I have concerns about this trend of diagnosing and treating ADHD, particularly in this population of young mothers. If we label this behavior as a disorder and prescribe a pill, we are not placing responsibility (blame) squarely on the mother? Do we not have a responsibility as a society to care for mothers to support their efforts to care for the next generation? Will the motivation to find more creative solutions, such as flexible parental leave, and valuing of self-care (the airlines recognize this need in the instruction to adjust your own oxygen mask before your children's) be lost?

These medications are not without harmful effects. About a year ago, a young woman, not a mother but in this age group, wrote poignantly in the New York Times of her struggle with Adderall addiction that took hold in an environment of ever increasing demands for productivity.

I am probably not alone in wondering about an alternative explanation to that of my psychiatrist colleague. Clearly this trend is a boon for the pharmaceutical industry. Could it be that some very clever people in marketing saw an opportunity, and set about selling "Adult ADHD" to both a general and a professional audience? If so, they have certainly been very successful.

Monday, March 10, 2014

Take new smartphone use study with a hefty dose of empathy for parents

A new study documenting the ubiquitous use of smartphones by parents at fast food restaurants with their young children is getting a lot of media attention. From Time magazine there is this headline: " Don't Text While Parenting- It Will Make You Cranky." "Put Down that Cellphone" from NBC. "Parents on Smartphone Ignore Their Kids," from ABC News.

I doubt that anyone is surprised by the findings of this study. People everywhere are on their smartphones all the time. In the arena of parenting, it is important to call attention to the impact of this behavior. There is extensive evidence that face-to-face interaction is critical for healthy emotional development. Mealtime offers an important opportunity for this type of interaction, especially in today's fast-paced culture.

However, I worry about the parent blaming tone of these headlines. Rather than saying, "This is bad, don't do it," perhaps we should be curious about why parents are using smartphones in this way.

One answer lies the increasing recognition of the addictive nature of these devices. Everyone, not just parents in fast food restaurants, is using smartphones all the time. The other may lie in the fact that parents, especially parents of young children, often feel alone, stressed and overwhelmed. Putting these two together and the allure of the screen becomes understandable.

The American Academy of Pediatrics press release states:
The study raises several questions for future research, including ...what are the long-term effects on child development from caregivers who frequently become absorbed with a device while spending time with their children.
I think we already know the answer to this question. I wonder if another important question might read: "How do we support parents in being more fully present with their young children, given the combination of high stress and an easy available, socially acceptable addictive device?"

Friday, February 28, 2014

Legal marijuana, antidepressants, and the danger of not listening

 A popular blog post Why I Tried to Kill Myself at Penn is making its way around the college-age crowd. The author calls attention a high-stress a culture that does not value listening.
During my sophomore year at Penn, I tried to kill myself by swallowing a bottle of Wellbutrin. I spent 4 days in the hospital.
Penn’s response? – Sending some administrator to see me in the hospital (HUP). The first and only thing that she said was, “Are we going to make this an annual pattern?” because I had been hospitalized the year before. I said “No” and she gave me her business card.
After suicides, everyone laments, “Why didn’t they talk?” Often, we did. People just didn’t want to listen, because in the moment it was easier for everyone if you put on a smile and pretended to be okay.
A parent recently described calling the emergency student support services when she was worried about her son's emotional state during his first semester at college. After a five minute conversation, she was told by the person who responded to her call, " We can make an appointment with the psychiatrist to see if he needs medication."

I thought about these two stories when a study, a survey of 1,829 people being prescribed antidepressants, was released showing a much higher than expected rate of serious psychological side effects:
Over half of people aged 18 to 25 in the study reported suicidal feelings and in the total sample there were large percentages of people suffering from 'sexual difficulties' (62%) and 'feeling emotionally numb' (60%). Percentages for other effects included: 'feeling not like myself' (52%), 'reduction in positive feelings' (42%), 'caring less about others' (39%) and 'withdrawal effects' (55%). However, 82% reported that the drugs had helped alleviate their depression. 
Professor Read concluded: "While the biological side-effects of antidepressants, such as weight gain and nausea, are well documented, psychological and interpersonal issues have been largely ignored or denied. They appear to be alarmingly common."
Psychiatric medication side effects are a double-edged sword. The first, that receives the most, though as indicated by this study insufficient, attention is from the medication itself. But the second, and equally if not more serious, is the way prescribing of psychiatric medication becomes a replacement for listening.

What makes us human is our ability to empathize. Drawing from both Buddhism and psychoanalysis, the "presence of mind" of another person is responsible for therapeutic healing. "Being with," "bearing witness," are other phrases that describe this phenomenon. When we jump to a pill we run the risk of skipping this step. If the medication itself also has psychological side effects, it is not surprising that, in combination with feeling alone and unrecognized, a person might attempt suicide.

Psychiatric medication may be necessary when an individual is unable to function without it. Ideally such a determination is made in the setting of both psychotherapy and other self-regulating activities such as yoga or meditation. But that is not the way these medications are used. Because they can be so effective at eliminating distress in the short term, our fast-paced, quick-fix culture makes them very appealing, almost irresistible.

I decided to include the topic of legalization of marijuana in this post as a kind of cautionary tale. In California cannabis is commonly prescribed to treat anxiety. Psychiatric diagnoses and drug prescribing are often based on symptoms alone, as is well captured in this amusing though disturbing anecdote from a Psychology Today post by psychologist Jonathan Shendler:

During my first week as a psychiatry department faculty member, a fourth-year psychiatry resident—I will call her Gabrielle—staffed a case with me. She gave me some demographic information about her patient (38, White, female) and then proceeded to list the medications she was prescribing. The rest of our conversation went something like this:“What are we treating her for?” "Anxiety." "How do we understand her anxiety?"Gabrielle cocked her head to the side with a blank, non-comprehending look, as though I had spoken a foreign language. I rephrased the question.“What do you think is making your patient anxious?”She cocked her head to the other side. I rephrased again.“What is causing her anxiety?"
Gabrielle thought for a moment and then brightened. “She has Generalized Anxiety Disorder.”“Generalized anxiety disorder is not the cause of her anxiety,” I said. “That is the term we use to describe her anxiety. I am asking you to think about what is making your patient anxious.”She cocked her head again.“What is going on psychologically?”Psychologically?”
“Yes, psychologically.”There was a pause while Gabrielle processed the question. Finally she said, “I don’t think it’s psychological, I think it’s biological.”

As we are on the cusp of general legalization of marijuana (that I do not oppose) it becomes imperative that psychiatric medications not replace listening. It is essential that we protect time and space for being present, for curiosity, for empathy. Otherwise we are simply offering another way, and one that is not without side effects itself, to devalue the role of human relationships in healing.