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, August 18, 2014

Examining the Antidepressant:Suicide Link Ten Years After FDA Warning

When I hear debate over the association between SSRI’s (selective serotonin re-uptake inhibitors, a class of antidepressant medication) and suicidal behavior in children and adolescents, I am immediately brought back to a night in the early 2000's.  As the covering pediatrician I was called to the emergency room to see a young man, a patient of a pediatrician in a neighboring town, who had attempted suicide by taking a nearly lethal overdose. 

That night, as I watched over him in the intensive care unit, I learned that he was a high achieving student and athlete who, struggling under the pressures of the college application process, had been prescribed an SSRI by his pediatrician.  His parents described a transformation in his personality over the months preceding the suicide attempt that was so dramatic that I ordered a CT scan to see if he had a brain tumor. It was normal. When, in the coming years the data emerged about increasing suicidal behavior following use of SSRI's, I recognized in retrospect that his change in behavior was a result of the medication. But at the time I knew nothing of these serious side effects.

At that time, coinciding with pharmaceutical industry's aggressive marketing campaign directed at the public as well as a professional audience, these drugs were becoming increasingly popular with pediatricians.

As the possible serious side effects of these medications came increasingly in to awareness, the FDA issued the controversial "black box warning" that the drugs carried an increased risk of suicidal behavior. Following the black box warning, pediatricians, myself included, became reluctant to prescribe these medications. We did not have the time or experience to provide the recommended increased monitoring and close follow-up.

Recently the Boston Globe published an article reviewing the data addressing the concern that the warning, by discouraging prescribing, led to increased suicidal behavior. It includes this key finding.
Studies also found no increase in other treatments for depression, such as psychotherapy; leading to what Fritz called “a net decrease in the amount of treatment."
This finding offers evidence for more insidious and perhaps more dangerous side effect of antidepressant use in children. The fact that we as a society condone use of these medications in children in the absence of relationship based treatments- - CDC report from December 2013 indicated that 50% of adolescents who are on psychiatric medication have not seen a mental health professional - itself changes the landscape of mental health care.

When medications can be used alone, the professions who offer opportunity for listening and human connection are devalued, both culturally and monetarily.

This kind of devaluing sends qualified professionals away. Pediatricians, whose longstanding relationships with children and families makes them ideally suited for preventive interventions, are discouraged from using their time to listen. Social workers, psychologists and others who offer relationship based treatment in which feelings can be recognized and understood, when paid less and less while being required to jump through increasing number of hoops, are less likely to accept insurance.  The drug itself becomes inextricably linked with the shortage of quality mental health care.

A recent study, a survey of close to 2,000 people being prescribed antidepressants, showed a much higher than expected rate of serious psychological side effects. Almost half described, “feeling emotionally numb” and “caring less about others.” These findings occur in the context of a social acceptance of medicating away feelings, and in doing so, devaluing the “being with” that is necessary for growth and healing. The absence of opportunity for meaningful human connection where feelings are recognized and understood, in combination with these psychological side effects, may be what leads to increased risk of suicidal behavior.
I wonder if before we can change what we do, we need to change how we think. Prescribing psychiatric medication to a child without simultaneously offering time and space to listen to him and his family is unacceptable. A change in perspective and attitude is needed before we can to begin to repair our broken mental health care system.
Andrew Solomon, in his sweeping tome about depression, The Noonday Demon, respects the role of medication in treatment. But, recognizing that medication alone it is not sufficient, he writes, "Rebuilding the self in and after depression requires love, insight, work, and most of all, time."

Wednesday, August 13, 2014

Epigenetics, Psychoanalysis, and Listening to Parents

Psychoanalysts for over a hundred of years have recognized the significance of early relationships in health and development. Now the exploding science of early childhood offers evidence that early parental care regulates physiology, influences development of the stress response, and even affects the expression of genes and structure and function of the brain.

The latest issue of the journal Neuropsychoanalysis provides an integration of psychoanalytic thought and contemporary developmental and evolutionary science. The article by Myron Hofer, and the accompanying commentary contain an abundance of evidence for the significance of early relationships.

Michael Meaney, a father of the new and rapidly growing field of epigenetics, offers this comment.

As Hofer noted, “maternal- infant interactions ... regulate the basic physiology of developing infants (such as sleep states, body temperature, autonomic balance, level of general motoric activity, and adrenal and growth hormone levels)”. These studies also revealed that these same maternal regulators were a source of information that shaped long-term phenotypic adaptation [gene expression and individual charcteristics.]

But all the science in the world may fall on deaf ears if our culture does not support parents in being present with their infants in the way the research suggests is critically important. 

If we pass laws condoning 8-week maternity leave, how can we take in and apply this abundance of research pointing to the significance of the early weeks, months and years? If, rather than addressing the problem of parents feeling overwhelmed and alone, and offering meanignful support, we are quick to diagnose them (and their children) with ADHD and prescribe medication, opportunities to make use of this wealth of scientific evidence are lost.  

Beatrice Beebe, a leading researcher in infant development whose detailed videotapes of mothers and infants offer elegant evidence for the richness and complexity of early parent-child relationships, praises Hofer's integration of theory and research. But Beebe, in conversation with a colleague of mine who is a general pediatrician, suggested that video be used in every 4-month well child visit. This comment represents a kind of disconnect between science and reality. The science certainly supports this kind of investment in time and attention to parent-child relationships in infancy.  But in today's fast-paced world of primary care, where clinicians are under pressure to see more and more patients in less and less time, such a suggestion is almost laughable.

In his concluding remarks, Meaney points in the right direction:
Developmental psychobiology established the conceptual framework within which to better understand the biology of early experience. The challenge is to now translate the emerging scientific advances into psychiatry and clinical psychology.
It seems like a kind of chicken-egg phenomenon. If as a culture we can place value on parents caring for themselves in order to be present with their children; if we value time for listening to parents and children together in the setting of primary care as well as mental health care, we may be better able to hear what the science is (and has been) telling us. 

Sunday, August 3, 2014

Rethinking the Meaning and Use of the Word "Autism"

In the course of working on my new book about listening to parents and children, I have had the pleasure of immersing myself in the writing of D.W.Winnicott, pediatrician turned psychoanalyst.  Winnicott's professional life included both caring for countless young children and families as a pediatrician, and psychoanalytic practice, where his adult patients "regressed to dependence," giving him an opportunity to interact with their infantile qualities, but with adult capacities for communication. This combination of experiences gave him a unique vantage point from which to make his many brilliant observations about children and the nature of the parent-child relationship.

A recent New York Times Magazine article on autism prompted me to share his words of wisdom on the subject, which, though written in 1966, still have relevance today.  The following is from a collection of papers, Thinking About Children:
From my point of view the invention of the term autism was a mixed blessing...I would like to say that once this term has been invented and applied, the stage was set for something which is slightly false, i.e. the discovery of a disease…Pediatricians and physically minded doctors as a whole like to think in terms of diseases which gives a tidy look to the textbooks…The unfortunate thing is that in matters psychological things are not like that. 
Winnicott implores the reader to instead understand the child in relational and developmental context. He writes:
The subject quickly becomes one not of autism and not of the early roots of a disorder that might develop in to autism, but rather one of the whole story of human emotional development and the relationship of the maturational process in the individual child to the environmental provision which may or may not in any one particular case facilitate the maturational process.
In my behavioral pediatrics practice, parents of a young child may wish for a diagnosis to relieve them of the feeling that they are "bad parents;" that their child's challenging behavior is their "fault." Yet when I give parents space and time to make sense of their child's behavior, and in doing so help him learn to manage his unique vulnerabilities- essentially doing what Winnicott suggests-I find that most parents prefer not to have their child diagnosed with a disorder.

A recent book on the subject, Autism Spectrum Disorder: Perspectives From Psychoanalysis and Neuroscience, while still referring to a "disorder," captures the tenor of Winnicott's approach. My blurb on the book's cover reads:
This book, with its central focus on the parent-child relationship, offers a unique and very important contribution. Parents struggle terribly in their efforts to make sense of the behavior of a child with a wide range of neuro-developmental challenges that currently fall under the heading of Autism Spectrum Disorders. Drawing on extensive evidence from the fields of genetics and neuroscience as well as in-depth clinical material, the authors show how a clinician can set these children on healthy developmental paths by supporting parents’ efforts to find meaning in their children’s behavior.
Many adults with autism now advocate for the idea that autism is not a disorder. But they come from a very different perspective, arguing that their unique way of interacting with the world is simply different, not abnormal. Certainly for an adult this is a valid perspective. However, when I work with parents and young children where the diagnosis is being entertained, the whole family is struggling terribly. It feels to me a great disservice to a young child to think of calling this situation "normal." 

An approach like that of Winnicott, Sherkow and Harrison may be fraught in the context of the history of "refrigerator mothers." While this theory has been widely discounted, any attempt to consider the child's relational and developmental context may be interpreted as "blaming the parent." That is why I love Winnnicott's approach. Rather than asking, "Is it or is it not autism?" we might be wise to discard the term completely.  Instead, if we offer space and time to learn, "the whole story of human emotional development," the very act of listening to the story becomes the cornerstone of treatment. 

Friday, July 25, 2014

How Yoga Informs Parenting: Value in Not Knowing

In yoga, a pose referred to by my teacher as "how wonderful" involves a lifting of the head and chest, and opening of the arms out to the side, with a bend in the elbows.

In her introductory words of wisdom to a class in which that pose was to be the theme of the day, she asked us, "Do you ever make up stories?" She shared that she may in response to a distracted expression from a friend think, "She's mad at me," or from her 3-year-old child who refuses to put on his shoes, "He's trying to drive me crazy!" She identified how this ability to try to make sense of other's behavior has evolutionary significance. It helps us navigate a complex social world- otherwise, she said, we would have no idea what was going on. But sometimes this kind of assuming of meaning, this making up stories, can get us in to trouble.

What if instead, we employ the open stance of  "I don't know?"-words she demonstrated fit perfectly with the pose of "how wonderful."

In my behavioral pediatric practice, I find parents often driven by a  need to know. "Is there something wrong with him?" they ask. There are tremendous pressures -from teachers, from family, from insurance companies, to name the problem. There is a kind of certainty in this approach, a kind of professional declaring of "I know whats wrong with you."

What if, rather than being guided by diagnostic instruments, that ask questions with the aim of getting an answer, we approach the situation with a stance of curiosity, of inquiry, of "not knowing."

I find if, in a way not dissimilar to the hour-long yoga class, I offer space and time to let the story unfold, we uncover complex meaning in "problem" behavior. There may be a number of relatives with similar traits, suggesting a genetic component. There may have been significant stresses in a family that, even with parents' best efforts to shield a child from the effects, have been noticed and absorbed. A child may have a range of sensory sensitivities that he can manage, but under the stress of separation, often at bedtime or in the process of getting out the door, these sensitivities are magnified. "Problem" behavior may be both cause of and result of family conflict between parents, among siblings, between generations.

There is courage in a stance of not knowing. In yoga, we trust our teacher to guide us in the backbends that evolve out of the "how wonderful/I don't know" pose. The work is hard.  She challenges us while taking care to protect us from harm.

Perhaps professionals who care for children with "behavior problems" -pediatricians, psychiatrists, teachers- could learn a lesson from my yoga teacher (support from the health care system that decided what is and is not "covered" would be essential to this kind of approach.) Rather than being guided by a need to make a "diagnosis," we would support parents in a safe, holding environment through a time of not knowing, on a journey to find the true meaning of behavior.

This kind of journey might not only serve to decrease the number of children receiving psychiatric diagnoses, but also help us to discover creative solutions. We would have the opportunity to uncover both weaknesses and strengths, and to support development of resilience.  In the words of pediatrician turned psychoanalyst D.W. Winnicott, we would be promoting development of a child's "true self."

How wonderful.

Tuesday, July 15, 2014

Why Depression is Not Like Diabetes

At the recent gubernatorial candidates forum on mental health, Martha Coakley repeated the oft-heard phrase that depression is like diabetes. Her motivation was good, the idea being to reduce the stigma of mental illness, and to offer "parity" or equal insurance coverage, for mental and physical illness. However, I am concerned that this phrase, and its companion, "ADHD is like diabetes," will, in fact, have the exact opposite effect.

A recent New York Times op ed, The Trouble with Brain Science, helped me to put my finger on what is troubling about these statements. Psychologist Gary Marcus identifies the need for a bridge between neuroscience and psychology that does not currently exist.

Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. The above analogies disregard the intimate intertwining of brain and mind. For the pancreas, there is no corresponding "mind" that exists in the realm of feelings and relationships.

While there is some emerging evidence of the brain structures involved in the collection of symptoms named by the DSM (Diagnostic and Statistical Manual of Mental Disorders,) there are no known biological processes corresponding to depression, ADHD or any other diagnosis in the DSM. There is, however, a wealth of new evidence showing how brain structure and function changes in relationships.

These collections of symptoms, intimately intertwined with feelings and relationships, are problems of behavioral and emotional regulation. The capacity for emotional regulation develops in relationships.  If DSM diagnoses can only be legitimized by comparing them to diabetes-and food allergies, as was recently done by the director of the NIMH (National Institute for Mental Health)- this comparison may increase, rather than decrease the stigma by de-valuing relationships and our basic human need for meaningful connection.

The primary treatment for diabetes is a drug. This analogy works if we accept that the primary treatment for mental illness is drugs. The pharmaceutical industry must be pleased with this approach.

But, in fact, the primary treatment for problems of emotional well-being is time. What is needed is time and space for listening, where individuals can have the opportunity to have their feelings recognized and understood. In this time and space, people can make sense of, and find meaning in, their experience.

A model that compares depression to diabetes is an illness model. It promotes a kind of "there is something wrong with you and I will fix it" approach.   It is not simply a question of "therapy vs. medication" as many "evidence based" research studies suggest. It is a question of a completely different model, a resilience model. Such a model, that values time and space for listening and being heard, seeks to help people re-connect with their most competent selves.

But we will only get there if we stop comparing depression to diabetes.

Thursday, July 3, 2014

Supporting Parent-Baby Pairs in the Wake of Infertility

A new study in Denmark demonstrated a 33% increased risk of a range of psychiatric disorders in children whose mothers were treated for infertility. The authors do not offer a cause, but postulate that the increased risk is related not to the treatments, but to the infertility itself.

These findings echo research showing increased risk of psychiatric problems in children whose mothers have struggled with perinatal emotional complications such as anxiety and depression.

How can we make sense of this?

Mental health, including the capacity for emotional regulation, empathy, resourceful thinking and resilience, develops in relationships. So the answer to this question lies in the way infertility impacts on parent-child relationships.

I recently came upon a beautiful expression in a work of literature that captures pediatrician D.W. Winnicott's concept of primary maternal preoccupation, that he identifies as central to a child's healthy emotional development.

The book is James Agee's A Death in the Family. In this early scene, the father is awakened during the night because his father is ill. As he dresses to leave the house, his wife, on her way downstairs to make him breakfast, whispers to him to bring his shoes in to the kitchen.

"He watched her disappear, wondering what in hell she meant by that, and was suddenly taken with a snort of silent amusement. She looked so deadly serious, about the shoes. God, the ten thousand little things every day that a woman kept thinking of, on account of children. Hardly even thinking, he thought to himself as he pulled on his other sock. Practically automatic. Like breathing."

The experience of infertility may get in the way of this breathing. Without appropriate support, a mother may feel that she is suffocating.

A mother, and also a father who, while not experiencing the physical assaults of infertility treatments, certainly shares in the emotional trauma, may come to the experience of parenthood with a range of significant vulnerabilities.

Anxiety over the well being of a new baby, no matter how much reassurance well meaning clinicians offer, may be unrelenting. In the face of repeated loss, as occurs in the process of infertility treatment, not only with every period, but sometimes with early pregnancy loss, may lead a parent to, in an adaptive effort to protect themselves from further loss, disengage emotionally. A parent may not fully surrender to the falling in love that accompanies the birth of a baby. And parents may be simply emotionally exhausted.

The baby also may have a role to play. There is evidence that stress in pregnancy, as is almost inevitable in a pregnancy that follows infertility treatments, is associated with what is termed "behavioral dysregulation" in the baby. That is, the baby may be more difficult to feed, may cry more or have irregular sleep patterns.

The good news is that, having identified infertility as a risk factor in development of mental illness, there is ample opportunity to set these vulnerable parent-baby pairs on a healthy path. One option is suggested in a recent article in the Atlantic, How Supportive Parenting Protects the Brain, where the possible role of the pediatrician is addressed.

What if every parent-baby pair, in the aftermath of infertility treatment, got some extra time and attention? An extra hour-long visit-with clinicians reimbursed for their time- to meet with parent and baby together, to listen to them both? Even better, as pediatricians have variable interest/expertise in this kind of work, have an infant mental health specialist, physically located in the pediatrician's office. The Newborn Behavioral Observation system is a wonderful tool for listening to parent and baby together in a way that sets development on a healthy path.

The idea is to normalize, rather than stigmatize.

This study might cause alarm for parents who are already stressed by the process of infertility treatment. I was alarmed myself by the statement by one of the study's authors that "this knowledge should be balanced against the physical and psychological benefits of pregnancy." To even entertain the idea of not getting pregnant because of this potential risk to the child is absurd, and feels almost punishing.

But if instead we use this study as further evidence of the value of protecting space and time to listen to parents and babies, then alarm could be transformed in to hope.

Thursday, June 26, 2014

To MA Gubernatorial Candidates on Mental Health: What About Children?

At last night's MSPP ( Massachusetts School for Professional Psychology) sponsored Gubernatorial Forum on Mental Health there was much talk among all of the candidates about how devoting resources to mental health care is a wise investment. But there was virtually not one mention of prevention in the form of children's mental health care. This was striking, as Nobel prize winning economist James Heckman has offered extensive evidence of how devoting resources to prevention in early childhood leads to decreased long-term costs of physical and mental health care.

Investing in early childhood also leads to decreased spending on prisons, a topic all of the candidates addressed in terms of decreasing the number of people in prison for non-violent crimes and first time drug offenses. They all correctly identified the high rate of mental illness in prison and the need to offer treatment, particularly substance abuse treatment.

The whole night I was thinking, "what about the children?" This might have been due to the format, and the fact that moderator Tom Ashbrook did not ask a single question about children.
I was struck by the contrast between this discussion and last week's American Academy of Pediatrics sponsored symposium on Child Health, Resilience and Toxic Stress.

All the best science of our time, in the form of research at the interface of neuroscience, genetics and developmental psychology, tells us that to invest in prevention means to invest in parents and children.

I was disappointed by Martha Coakley in a sense towing the NIMH party line, whose great shortcomings I describe in a previous post, by saying that mental illness is like any physical illness, such as diabetes. I am one hundred percent in favor of parity for mental health care, and decreasing the stigma of mental illness. But the only way to achieve this parity is to recognize that mental illness is not like diabetes.

Resilience and emotional wellbeing develop in the context of relationships. To both prevent and treat mental illness the focus of intervention needs to be on relationships. What makes us human is our historical and relational context. We need to value space and time to listen to each other.

The most important point of the evening, that was made in some form by all three democratic candidates, is that reimbursement for mental health care needs to increase significantly. When we place value, both cultural and monetary, on taking the time to listen, whether to parents of young children, teens struggling with substance abuse, or adults with a range of diagnostic labels, then we will be making meaningful steps not only towards mental health care parity, but also towards promotion of health and resilience.