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.

Sunday, February 20, 2011

The New York Times Thinks About Parents

I felt that I was in very good company yesterday when my letter to New York Times was published in reference to last weeks op ed piece The Parent Trapped. In that piece, Katherine Ellison, responding to indictment of a mother in the murder of her two teenagers, describes her own journey from the brink in her relationship with her son. She describes feelings of barely controlled rage and her realization that she needed to get help.

While there was much that could be said about this piece, I picked up on the way in which Ms. Ellison, with the support of family, friends and professionals, took ownership of her role in the conflict. She wrote:
I spent much of the year learning about A.D.H.D., a condition I soon realized that I shared with my then 12-year-old son. Among its classic symptoms are conflict-seeking and hot-headedness. Humbling as it was, I ultimately heeded friends and professionals who encouraged me to shed my fantasy of being the victim of a raging, impossible child, and own up to the ways I was contributing to our fights.
In my response I wrote:
In the safety of my pediatric office, countless parents have revealed that they are startled by the intense rage they feel for a child whom they also have such powerful love. Katherine Ellison bravely and honestly addresses this issue in her article.

The fact is that intense opposing feelings are a normal part of any passionate relationship. But as she points out, when parents feel out of control, if they are unable to manage their own rage, it is essential to get help.

The beauty of her article is that it identifies the relational nature of the problem. All too often, a “behavior problem” is viewed as residing exclusively in the child. When parents feel recognized and understood, as Ms. Ellison seems to have felt, they are better able to be fully present with their child, in turn helping the child to manage his or her particular vulnerabilities.
Another letter identified the critical role of emotional regulation in development and the need for parents to "push the pause button" in the heat of the moment and reflect on whats going on. Yet another addressed the wrongness of corporal punishment and the need to find effective alternative measures. A third spoke of the need for friends, communities and professionals to be available to parents when they reach out for help.

What was most encouraging to me was that the majority of the letters in Saturday's paper were devoted to this subject. As the Times represents in some significant ways the cultural trends in this country, this fact gives me hope that we are seriously considering the essential role parents play, and our need as a society to support them in this very challenging yet highly rewarding task.

Wednesday, February 16, 2011

A Third Front in the War on Obesity

Recently I watched the Academy Award winning film Monster’s Ball. A morbidly obese young boy whose father is about to be executed sneaks a chocolate bar while his mother is out, only to be verbally and physically assaulted by her when she returns and discovers a smudge of chocolate on his face. This is an extreme example, but it highlights the complex relationship children and parents can have with food and eating.

There is no doubt that childhood obesity is a huge public health problem with complex causes and far reaching effects. Michelle Obama’s efforts, now entering their second year, are admirable. The identified culprits that she has targeted; a sedentary lifestyle and aggressive marketing efforts of unhealthy foods by the food industry, play a significant role.

However, in addition to targeting interventions focused on the food industry and physical activity, it is critical to recognize the meaning of food and eating in parent-child relationships. An example from my behavioral pediatrics practice illustrates this point.

Sylvia brought her four-year-old son Andrew to see me because “he’s always eating”(details have been changed to protect privacy.) An engaging, plump little boy, he was enthralled by the Dunkin Donuts across the street from my office. Sylvia described constant battles around his demands for sweets.

But over the course of our 60-minute visit, other important issues emerged. Andrew’s father, Richard, had lost his job and the family had moved three times in the past year. Richard struggled with severe depression. In addition to the battles around foods, Andrew was having increasing numbers of temper outbursts, and his mother revealed to me that she was at times unable to contain her own rage. She had even on occasion beaten him with a belt. As Sylvia became more relaxed and began to open up, she shared that she had been physically abused as a child.

In helping to manage Andrew’s out of control heating habits, it was essential to recognize the connection between Andrew’s insatiable appetite and the stress he was experiencing in his relationships with both his mother and father. Supporting these relationships was the aim of my work with this family.

If the child in Monster’s Ball is one end of the continuum of disordered eating, and Andrew in the middle, in my general pediatric practice I see, at the other end of the continuum, the relatively minor everyday challenges of parenting that are inextricably linked to later eating habits.

A mother whose child has sensitivity to textures of foods may feel inadequate in the face of her child’s picky eating. This in turn may lead her, at moments of desperation, to force food into her child’s mouth, setting the stage for a lifelong distorted relationship with food. The primary care setting offers an opportunity for early intervention and repair of these types of difficulties. In addition, disordered sleep patterns are closely tied to risk of obesity. These patterns develop in the first few years of life, and a primary care clinician can play an important role in both development of healthy sleep habits and in setting patterns in a healthy direction when they go off course.

Supporting parent-child relationships is a critical element to add to this “war” on obesity. Investment in primary care and mental health care, as well as in programs that have been shown to support parent-child relationships that are at risk is essential. For example, the Yale based Minding the Baby program is a preventive home visiting program that aims to support parent-child relationships in young families stressed by limited economic resources.

Research by Jack P. Shonkoff, MD founding director of the Center on the Developing Child at Harvard University, has demonstrated that safe, stable, and nurturing relationships may protect children against poor health later in life. Children who develop a strong sense of self in the context of these secure relationships are more likely to make healthy lifestyle choices.

And a word of caution regarding the language of the “war” on childhood obesity. I wonder about the experience of an overweight child who is exposed to this news. Shame, confusion, and fear- these powerful emotions may go unprocessed. At the very least, these headlines should offer an opportunity for conversation among adults and children about diet and lifestyle choices.

Wednesday, February 9, 2011

Proposed Ban on Antipsychotic Use in Children Five and Under

A study published in February issue of the Archives of General Psychiatry, written by Nancy Andreasen, former editor-in-chief of the American Journal of Psychiatry, provides evidence that long term use of antipsychotic medication results in loss of brain volume. She concludes that
Viewed together with data from animal studies, our study suggests that antipsychotics have a subtle but measurable influence on brain tissue loss over time, suggesting the importance of careful risk-benefit review of dosage and duration of treatment as well as their off-label use.
I propose that based on these findings, there be a ban on use of antipsychotic medication in children age five and under, the period of time when the brain is undergoing the most rapid growth and development.I specify this age group not only because they are the most vulnerable, but also because beyond age six the brain is less plastic, and so alternative interventions that aim to change the structure of the brain may be less effective. Also, it is a reasonable goal. If more evidence about damaging effects emerges it may be necessary to extend the ban to all children.

Those who advocate for use of antipsychotics in young children with a range of behavior problems argue that stress hurts the brain and that these medications can protect the brain from this stress. When children and parents feel out of control, when there is sleep deprivation and explosive behavior, both parents and children experience a great deal of stress. It is not surprising that giving a powerful drug that acts on the brain would calm a child down.

Medication, however, is not the only way to reduce stress. Being understood by people who love you also reduces stress at the level of brain biochemistry. Reducing stress and changing the brain in this way is not easy. It requires sustained effort and a lot of support for parents. But the changes are safe, and may last a lifetime.

The growing field of parent-infant mental health offers quality research and a wealth of effective interventions to support troubled children and their parents.These interventions , unfortunately, are not well covered by third party payers and are not marketed as widely as prescription drugs. , They require hard work and do not offer the “quick fix” of medication. As such, they are less available for struggling children and families.

As long as a drug is available (and the preferred mode of treatment according to the health insurance industry), motivation to do this more difficult work will be lost. In addition, there is a severe shortage of quality mental health care services. This is due to many factors, including poor reimbursement and prohibitively complex administrative costs for private practitioners. Just as motivation may be lost on an individual level, as long as the drug is available, there is little motivation to change the health care system to more effectively provide these alternative interventions.

All of this is reason enough not to use these medications in very young children. Add to this the solid evidence that these drugs damage the brains of adults, and using them in children whose brains are rapidly growing is, in my opinion, unconscionable.

Thursday, February 3, 2011

Amy Chua and the role of empathy in parenting

All this talk about Amy Chua’s parenting techniques has me thinking about Brandon Fisher, the manufacturer of drilling equipment who president Obama recognized in the State of the Union Address for his critical role in the rescue of the Chilean miners. While I cannot claim to know anything about Fisher's upbringing, I do know a great deal about what qualities in a parent-child relationship lead to the characteristics he exhibited, namely empathy, flexibility and resourcefulness.

I wonder if the anxiety being experienced on a grand scale by American parents in the wake of Chua’s book is due to the fact that that while severe parenting techniques designed to achieve academic success may not be palatable, parents feel a void when it comes to finding an acceptable alternative model, as exemplified by the Boston globe op ed, The tiger mother roars, and the slacker mother shudders.

John Bowlby, the father of attachment theory (no relation to “attachment parenting” as described by William Sears) describes the importance of a secure early relationships in raising a child who, in Bowlby’s words, is “self-reliant and bold in his explorations of the world, co-operative with others, and also-a very important point-sympathetic and helpful to others in distress.”

Contemporary research offers a close up view of a secure parent-child relationship that can instill these qualities. It involves a balance of empathy and limit setting. There are four key elements. The first is wondering about the meaning of a child’s behavior rather than responding to the behavior itself. The second is empathy. This is more than saying “I know how you feel.” It means actually feeling what your child is feeling, but reflecting it back to him in a way that says, “I know you’re upset, but we’ll manage.” The third is containing difficult emotions, often in the form of setting limits. Limit setting is about teaching the essential life skills of frustration tolerance, impulse control and emotional regulation. And forth, and perhaps most challenging, is doing all this without letting your own distress get in the way.

Lest this list cause a parent to feel overwhelmed by the enormity of the task, research of Ed Tronick, chief of the child development unit at Children’s Hospital Boston, offers hope. If parents are attuned with their child only 30% of the time, if 70% of the time you don’t connect with your child in the way I describe, as long as most disruptions are recognized and repaired, development moves forward in a healthy direction. In fact, disruptions and their subsequent repair are essential in instilling resilience, an important fourth attribute to add to Bowlby’s list. D.W.Winnicott, pediatrician turned psychoanalyst coined the phrase the “good-enough mother” to describe a mother who is not perfect, and in her very imperfection helps her child to manage life’s challenges in direct proportion to what he is capable of.

Chua’s book, in addition to creating mass unease in American parents, has raised fear regarding our ability to compete with China. Towards that end, raising a generation of Brandon Fishers, citizens with the qualities of empathy, flexibility, resourcefulness, and resilience, is essential. In order to accomplish this task, we must support parent-child relationships from the beginning. There is extensive evidence that children learn these skills in infancy, when the brain is making as many as 1.8 million neural connections per second.

Unfortunately our country does not recognize parents in this way. As I have said in previous posts repeating, our lack of support of early parent-child relationships is exemplified by our maternity leave policy that lags far behind other countries, as well as the rapid increase of prescribing of psychoactive medication to very young children. This second phenomenon is in turn inextricably linked with the very powerful health insurance industry and the lack of value placed on primary care and mental health care services.

Public policy to support early parent-child relationships is essential. For example, postpartum depression can negatively impact a mother's ability to be present with her child in a way that promotes healthy emotional development. This past summer a new law was passed in Massachusetts that calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.

Contemporary research in child development offers an answer to the questions raised by Chua, both on a small scale: a model of parenting to follow, and on a large scale: a model of social policy to support parents in this task. I thank her for providing the motivation to address issues that are critical for the future of our children and of our country.