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.

Friday, August 27, 2010

Parenting Blog Posts with similar theme to Child in Mind

Being on vacation has led to a sparsity of blog posts, and now its full speed ahead with the book. I decided once again to borrow from fellow bloggers and post a few links. The first is to a parenting blog by child psychoanalyst Kerry Kelly Novick. This particular post, Wise parents a welcome sight on road trip offers an excellent demonstration of a parent holding a child's mind in mind.

Another is Reading the Baby's Mind by developmental psychologist Charles Fernyhough. Along with Elizabeth Meins, he is doing research that demonstrates the importance of parents thinking about their baby's mind in facilitating healthy emotional development.

A third, Small Steps by psychoanalyst Paul C. Hollinger offers an example of supporting a parent's efforts to reflect on the meaning of her child's behavior.

Tuesday, August 17, 2010

The Mess of ADHD Evaluation and Treatment

Two events today cause me to crash head-on into the terrible state of affairs that define ADHD diagnosis and treatment in our country. First, in my AAP SmartBrief, the daily listing I receive via email of important news stories related to pediatrics, I read this item Youngest in Class Get ADHD Label in USA today. The article states
Kids who are the youngest in their grades are 60% more likely to be diagnosed with ADHD than the oldest children, according to a study out today from Michigan State University, given exclusively to USA TODAY. A second study, by researchers at North Carolina State University and elsewhere, came to similar conclusions. Both are scheduled for publication in the Journal of Health Economics.
In my previous job,when the majority of my work consisted of seeing children who had been referred for "evaluation of ADHD" I commonly encountered children who were having their first structured school experienced. Many were among the youngest in their class. They were described as "impulsive." They found difficult to sit at circle time, and unfathomable to sit at a desk to do a written assignment. Yet parents would frequently tell me that the teacher had confided that while she wasn't supposed to make diagnoses, she was sure this child must have ADHD. The findings reported in this article confirm my suspicion that for many of these "ADHD evaluations" referred to me, it was the environment that didn't fit the child, rather than that the child had a "problem."

A few hours after reading this article, I received a phone call from the office manager from the pediatric practice I recently left. As I have written about in my blog, I changed practices to focus on working with young children and their parents in the setting of a community health center. This was in part because I was struggling with the expectation, in keeping with the standard of care in pediatric treatment of ADHD, that I fill many,many prescriptions without any opportunity to understand the complex life experience of these children.

I was sure to refer every child I had been seeing to an appropriate provider. Many of them would be followed, in keeping with the standard of care in pediatrics, by the other primary care clinicians in the practice. Some, who I felt needed more intensive help, I referred to an excellent child psychiatrist in my community. Just before I left, I learned that she had a new policy that she would only see patients for medication evaluation if they were engaged in psychotherapy. I thought this policy was very wise.

One patient, the office manager called to tell me, was very unhappy with this plan. (details,as always, have been changed to protect privacy) "He's never been in therapy before," his irate mother apparently told the office manager. I had a vivid flashback. Mother and father at opposite ends of the room, tense and angry. A small, thin 9 year old boy slumped into the corner of the exam table nervously chewing his nails. As his parents argued about his "laziness" he seemed to want to disappear into the wall. At our last visit together, however, his parents agreed that things were perhaps more complex than simply inattentive ADHD. They accepted my referral to the psychiatrist.

But apparently they had a change of heart. Just getting the prescription filled by their pediatrician was their preference. "He doesn't need any therapy." his mother said. Perhaps he doesn't. But I can be sure of what he does need. He needs someone to listen to him.

I am sad for these many children whose voices are not heard. It made me agitated to think about the state of affairs in children's mental health care that has led to a situation where countless children are mislabeled, their complex life experience tucked into vastly oversimplified categories.

Now I'm going to take a deep breath and go back to working on my book. In this task I immerse myself in describing a model of child development that acknowledges the importance of understanding children's feelings from the moment they are born. By letting children's voices be heard and recognizing the meaning of their behavior, we can facilitate their healthy emotional development. I can already feel my blood pressure going down!

Thursday, August 12, 2010

Comment on MA Enforcement of 8 Week Maternity Leave

It is not until about eight weeks of age that an infant has a fully developed capacity for mutual gaze. Then a baby looks directly into his mother’s eyes, while she, in turn, reflects back this loving gaze, cooing softly in response to her baby’s earliest communication. When a mother looks at a baby in a way that communicates with him, not with words but with feelings, “I understand you,” he begins to recognize himself, both physically and psychologically. He begins to be able to regulate his feelings. This mutual gaze, literally and figuratively being “seen,” actually facilitates the development of the baby’s brain.

The Massachusetts Supreme Judicial Court now has proposed to interrupt this newly emerging dance of co-regulation by ruling this week that woman workers are entitled to only eight weeks of maternity leave. This ruling applies only to women whose maternity falls under state law, and differs from the wiser federal Family and Medical Leave Act of 1993 which provides up to 12 weeks of unpaid leave and job protection.

Research at the interface of neuroscience and infant development is offering great insight into how mutual gaze actually grows the brain. Our knowledge about early brain development is derived from a combination of detailed video observations of mother-infant interaction and studies of the brain known as functional MRI. These imaging studies can actually see which parts of the brain are responsible for what behaviors. This research has shown that healthy wiring of the brain is contingent on attuned responses of caregivers. This attunement is not only in gaze but in touch, sound of voice and facial expressiveness.

When baby is born, the amygdala, the lower center of the brain that responds to fear and stress, is fully formed. The amygdala connects directly to the hypothalamus, which in turn connects directly with the parts of the body, like the adrenals, responsible for the release of hormones that lead us to experience the physical sensations of stress.

At about 2 months of age, another part of the brain known as the medial prefrontal cortex(MPC) begins to develop. It serves to regulate and control the smoke alarm. When a mother engages in this dance of co-regulation with her baby, she is wiring his brain, helping the fibers of the MPC to grow. The MPC continues to develop well into a person’s twenties. An infant’s brain, however, doubles in weight in the first year of life. A lot of wiring goes on in the third month.

When these connections are not well developed, intense emotions are not regulated. In the face of difficult feelings a person may be flooded with stress hormones. He may become overwhelmed by feelings of rage, anxiety or sadness.

Interesting research by Dr. Hilary Blumberg at Yale offers food for thought. Using MRI, she has found that adolescents with bipolar disorder have structural abnormalities in the amygdala and underdeveloped prefrontal cortex. She points to hopeful research using medication to rewire the brain to treat the emotional dysregulation characteristic of the disorder.

This is not to say that stressed early relationships inevitably lead to psychopathology. But doesn’t it make sense to do all that we can to insure that brains are wired well in the first place?

Important changes happen not only in an infant’s brain but also in a mother’s brain in her baby’s third month of life. When a mother sees her loving gaze reflected back at her from her baby, she develops a sense of competence. This trust in herself is critical in helping her face the many challenges ahead in her role as parent.

Certainly a mother who works full time is well able to facilitate her child’s healthy development if she is receiving appropriate support. But even under the best of circumstances, returning to work means that a mother will be stressed. Offering her the option for a full three months of what D.W. Winnicott, pediatrician turned psychoanalyst, referred to as “primary maternal preoccupation” seems an important and wise investment in the next generation.

Thursday, August 5, 2010

How to Grow a Child's Brain

Last week I took an amazing course at the Cape Cod Institute. The course, taught by Francine Lapides, was entitled "Keeping the Brain in Mind." Over the week, extensive evidence was offered to show how a parent's attunement with her child's emotional experience, or her ability to, as I have referred to elsewhere in this blog as "holding her child's mind in mind," leads to a capacity for emotional regulation and healthy emotional development at the level of structure and biochemistry of the brain.

At the end of the course, I rewrote a clinical vignette from an earlier blog post, Holding a Child in Mind, incorporating the language from the course. A very brief discussion of the structures of the brain responsible for regulating emotions will be necessary to make sense of the new piece, which follows below.

The medial prefrontal cortex(MPC), which is made up of the orbitofrontal cortex and anterior cingulate gyrus, is primarily responsible for emotional regulation. When a person has a well developed MPC he experiences a sense of emotional balance. He can feel things strongly without being thrown into a state of chaos.

The amygdala, the structure referred to by trauma researcher Bessel van der Kolk as the “smoke alarm of the brain,”, connects directly to the hypothalamus, which in turn connects directly with the parts of the body, like the adrenals, responsible for the release of these stress hormones, the hormones that lead us to experience the physical sensations of stress. Lapides describes how the medial prefrontal cortex, by virtue of its location, wrapped around the amygdala, literally hugs the amygdala. It serves to regulate and control the smoke alarm.

When these connections are not well developed, intense emotions are not regulated. In the face of difficult feelings a person may be flooded with stress hormones. He may become completely overwhelmed and unable to function. Thus in the face of fear, for example, with a well developed MPC, a person will experience the feeling, but his hormonal response will be turned down by the MPC so that he is not overwhelmed or paralyzed.

If, on the other hand, he does not have a well developed MPC, the amygdala will go off and he will be flooded with fear that he cannot manage. When the amygdala acts unopposed in this way, it impairs a person’s ability to make use of the higher cortical centers of the brain, meaning that he cannot think clearly in the face of overwhelming distress. In fact, the amygdala is overactive in PTSD and all anxiety disorders.

When a parent gazes into her baby’s eyes, she literally promotes the growth of her baby’s brain, helping it to be wired for a secure sense of self. The MPC has been referred to as the “observing brain.” It is where our sense of self lies. When a mother looks at a baby in a way that communicates with him, not with words but with feelings, “I understand you,” he begins to recognize himself, both physically and psychologically. This mutual gaze, literally and figuratively being “seen,” actually facilitates the development of the baby’s brain. As the MPC matures in this kind of secure loving relationship, the brain is wired in a way that will serve him well for the rest of his life. He will be able to think clearly and to regulate feelings in the face of stressful experiences.

The story of Sam and Jane illustrates the way in which supporting a parent’s efforts to hold her child in mind may actually promote the healthy development and growth of her child's brain.

Sam burst into the office, a two year old wild little bundle of energy. Squealing with delight, or was it distress-it was hard to tell- he ran from toy to toy not looking at me or his mother, and seemingly unable to engage with anything. His mother had brought him to see me in my pediatric practice because “he hits me, has explosive tantrums and I can’t take him anywhere.”

Jane sank into the couch in a way that suggested she was feeling discouraged and dejected in her role as mother. She needed to be heard. I sat on the floor, wanting to listen to Jane, but also to include Sam in the visit. At first, I focused my attention on her story, while Sam continued his frantic exploration of the room. Things had not been easy for her. Sam’s father had abused her and was no longer involved in thier lives. Jane was afraid when she felt Sam’s anger that he would turn out like his father. Of her own mother she said, “She was never there for me”. Jane was frustrated and bewildered by the fact that Sam could relate to other people, but seemed to reserve all his difficult behavior for her.

At the beginning of the visit, Jane made several awkward attempts to interact with Sam, but without success. She was anxious and her body language felt intrusive, which seemed to cause Sam to withdraw. However, as she opened up and shared more of these difficult, painful feelings with me, an interesting transformation occurred. Jane’s whole body relaxed and she leaned forward on the couch toward Sam. Sam, in turn, began to engage in more focused play. Jane and I talked about what Sam was doing, observing together how he was calming down. At first he talked to me, bringing me toys and naming them and describing what he was doing. But then he spontaneously ran over and gave his mother a hug. Her pleasure and relief were palpable in the room.

Sam began to engage her in his play, and to communicate with her. It seemed as if the very act of being held in mind by his mother served to calm him down. He could feel her thinking about him. She looked directly into his face, speaking with him in a soft intimate way. They were engaged in a private dance. As I observed this scene, I literally felt as if I was watching Jane growing Sam’s brain. By holding him in a loving way that reflected her recognition of him, I thought that I could see the projections forming from the MPC and reaching down to hug his amygdala.