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, June 26, 2011

Teaching Your Teenager To Drive: How Contemporary Developmental Theory Can Help

Can I practice what I preach? I was asking myself just that question when last week, my 16-year-old daughter decided that a trip to the mall was the time for her to learn how to drive on the Turnpike. She's had her permit for about two months, and so far I've found the experience of driving with her to be much less stressful than I anticipated(she did take Drivers Ed through school, which was a big help in taking the learning out of the realm of the mother-daughter relationship!)

My forthcoming book "Keeping Your Child in Mind," is organized around one idea, an idea that comes out of contemporary developmental research at the interface of psychology and neuroscience. In a nutshell, by understanding your child's behavior, empathizing with her experience, managing difficult feelings by containing them and setting appropriate limits, all while managing your own distress, you will help facilitate her healthy emotional development. The question I asked myself that morning was, can I do this while hurling past trucks at 70 miles per hour on a busy turnpike?

Most of my book is based on stories from my pediatrics practice, but some of the stories in the book are drawn from my experience as a mother. Now that the book is done, this was a chance to see what it would be like to use the ideas in the book in a moment potentially fraught with multiple levels of difficulty.

Number one, understanding her behavior. She is capable of doing this and feels confident in her abilities. Intellectually I understand that, even though I still see her as my baby, for child of her age it is developmentally appropriate to drive on a major highway. Number two, empathize with her feelings. I think of one of my favorite phrases that I learned from a social worker many years ago; "Face your fears and watch them disappear." My daugher is probably terrified, but she knows that she needs to just do it. Third, set appropriate limits. In this context, I need to calmly yet firmly tell her that she cannot drive at 65 in the left lane. As soon as she can safely do so, she must shift back into the right lane. No discussion, no negotiating this point. And last, I must master my own distress, so that I can be fully present with my daughter and help her to manage this challenging experience. I must tuck away that fleeting thought when I said good-bye to my son in the morning that he might never see me again. I must set aside the fears that I can't even bring myself to write in this post. She successfully navigates not only passing these huge trucks and shifting back into the right lane, but exiting from the turnpike and entering the Interstate for a short distance. " You need to slow down," I say as calmly as I can a manage when, towards the end of the hour-long trip, she attempts to negotiate the exit at 40 miles per hour.

At last, she pulls into a spot in the mall parking lot. "Thank you for helping me." she says. "And for staying calm." I tell l her that
I'm glad we did it together. I would much rather she learn the nuances of turnpike driving from me than have to figure it out on her own when she gets her license.

During the trip I actually held the image of the cover of my book in my mind while taking deep breaths and working to stay calm. Certainly there have been many moments when I have lost my cool with my children. But for this critical developmental milestone, the idea of holding my child in mind really came through. I go into the mall and buy myself a new pair of shoes. I deserve it. This is hard work!

Tuesday, June 21, 2011

Storytelling As Treatment for Common Childhood "Behavior Problems": A Clinical Example

I am most grateful to my patients, who are often my best teachers. I am moved to write about them, to spread the knowledge they have given me to a larger audience. Of course confidentiality is my top priority, so I aim to protect my patients' privacy while staying true to their story. This past week in the KevinMD newsletter, there was a piece about the new discipline of narrative medicine, which looks to literature and the power of stories to enhance the practice of medicine. The following encounter, from my behavioral pediatrics practice, is a perfect example of the power of storytelling.

Eighteen-month-old Joe was drinking up to 5 six ounce bottles a day. "He won't eat anything else, but when I say no to the bottle, he screams. It's just easier to give in." Joe's mother, Sandra, had been advised at multiple visits to the pediatrician that she needed to stop. He was at risk for nutritional problems including iron deficiency anemia, and his teeth were being damaged when he fell asleep with the bottle in his mouth. Yet despite having this information, Sandra was unable to set limits with Joe. Her pediatrician referred her to me.

I met with Joe and his mother for one 50 minute visit. We sat on the floor and talked while Joe played. He was a delightful boy who was very curious and quickly got absorbed with the selection of toys. He looked healthy and robust. His mother started the visit telling me that she knew she just needed to get rid of the bottles, but that she couldn't bring herself to do it. Rather than focus on what to do, I asked her to tell me about her pregnancy and Joe's infancy. Sandra was from Ecuador, and she had met her American husband when she came to the US as a student. They had gotten pregnant much sooner than they planned. Sandra's mother was unable to get a visa and had never met Joe. I asked Sandra what it was like to have a new baby without her mother nearby. "It's terrible," she said. Her husband worked long hours and she had only recently begun to make friends. She spoke with her mother on skype, but, she said, "for Joe she's not a real person." This made her very sad because her mother so much wanted to be involved as a grandmother. In contrast, her mother-in-law, who lived nearby, did not show much interest in helping her with the baby.

Sandra spoke of great difficulty nursing in the first days, when Joe did not latch on well. "He never would have survived in the wild," Sandra told me. She conveyed sense that both she and Joe had failed in some way. I pointed out that "in the wild" she would never have been alone without extended family.

Sandra began to talk about how things were so different in Ecuador. Parents were in charge of what their kids ate, and there was none of this "offering choices" that so many had advised her to do. In addition, a fat baby was a sign of a healthy baby. Sandra felt that to fail to feed you child was to be a failure as a mother.

Then Sandra remembered that she herself had been a very skinny child. In fact, she recalled her mother telling her stories about when Sandra was an infant and the other mothers would say to her mother, "What's wrong with you that you starve your baby?" Yet Sandra recalled that she was a very busy active child, very much like Joe, who often didn't want to be bothered with eating.

"It sounds like you are having s similar experience with Joe to what your mother experienced with you," I said. Sandra was quiet as she seemed to be thinking this over. "You're right," she said. "Maybe this is more about me than about Joe."

We spoke some more about Joe's behavior around eating and the differences between American and Ecuadorian ideas about raising children. I said that she would have to decide what she wanted to do, but that I thought that if she continued to battle with Joe around eating, this would likely continue to be a problem. My only "advice" was that she consider giving Joe more independence to feed himself. We made a follow up appointment in a few days, when her husband would be able to come.

"I got rid of the bottles," Sandra told me as soon as we were settled on the floor. Joe once again was contentedly playing. "How did he do?" I asked, surprised by this rapid development. "Well he cried at night, but he seems OK during the day." Then she told me that he had eaten some new foods, and was interested in what another child was eating at a play date. "I knew everything we talked about last time. I just didn't want to do it." "What made the difference?" I asked. She claimed that she had realized she needed to protect his teeth.

We talked some more about bedtime and some other parenting issues that they had been struggling with. I asked if she wanted to schedule another appointment. "Well, we solved the problem," she said. She told me that she would call if things did not continue to go well.

In this age of "evidence-based medicine" I wonder how I would design a study to show if telling her story to a supportive non-judgmental person was the reason Sandra was finally able to follow through with what she knew she needed to do. Would one group get standard "advice" while the other had the opportunity to sit on the floor and tell their story? I'm not a researcher, but from what I know about research, designing such study to have statistical significance would be very difficult. All I can say is, "I was there." I am pretty sure that having her story heard was what enabled her to act. I'll leave it to the researchers to prove it.

Wednesday, June 15, 2011

On "Composing a Life": Women Physicians Who Work Part Time

I admit I was almost stunned into silence by this past Sunday's Op Ed in the New York Times entitled Don't Quit this Day Job. A woman anesthesiologist argued that the current shortage of primary care physicians is due to women who take residency slots and then chose to work part time. She concludes her piece by saying that:
Patients need doctors to take care of them. Medicine shouldn’t be a part-time interest to be set aside if it becomes inconvenient; it deserves to be a life’s work.
I was heartened to read the array of wise letters to the editor written in response. They all identify important issues and I highly recommend reading all of them. One that I particularly admired was from a woman ER physician who wrote;
Dr. Sibert claims that “medicine shouldn’t be a part-time interest to be set aside if it becomes inconvenient.” I would argue that the same holds true for my child.
I was encouraged to formulate my own response.

About ten years ago I read a book Composing a Life by Mary Catherine Bateson, daughter of Margaret Mead. Bateson follows the lives of 7 women, including Joan Erikson, wife of Erik Erikson, who had significant careers that were shaped around their roles as spouse and mother. In the introduction she writes:
This is a book about life as improvisatory art, about the ways we combine familiar and unfamiliar components in response to new situations, following an underlying grammar and an evolving aesthetic.
As my professional life has taken many twists and turns to accommodate the needs of spouse and children, I have found it comforting and inspiring to think of this not as a burden, but rather as creation of a work of art.

As many readers of my blog know, I have just written a book, Keeping Your Child in Mind. My hope is that this book will offer validation and support to a large number of families, more than I could ever reach in my practice. Yet had I not taken these twists and turns to accommodate the needs of my family, this book would never have been written.

I have worked part time since my children were born, and took my first break from primary care to start a parenting center when my second child was born. Then when my children reached school age, my husband and I recognized that to meet the demands of swim practice, play rehearsals, dance performances and all the other things that go along with of having school age children, one of us would have to be more available. My husband is an eye doctor who runs his own practice, so it made sense that I would be the one to change.

Much as I loved doing primary care, the inflexibility and time demands of taking call were not compatible with the way we wanted to raise our children. Reluctantly I gave it up, focusing on building a behavioral pediatrics practice that did not require taking call. It was that experience that led to my writing a column for the Boston Globe entitled Mind-Altering Drugs and the Problem Child. The overwhelmingly positive response, from parents and professionals around the world, in turn led to the writing of the book.

Being a mother is both an awesome privilege and an awesome responsibility. It is in a sense the greatest act of creativity. It makes sense that women who create in this way can also create their own professional lives. By embracing this creativity, both as mothers and as professionals, we can aim to find new and important ways to contribute to society, while at the same time being present in the lives of our children in ways that support the healthy development of the next generation.

Wednesday, June 8, 2011

Rise in Autism or Simply Autism Diagnosis?

A mother brings her two year old son, Evan, for an evaluation through the Massachusetts Early Intervention Program(EI). She and her husband are at their wits end, fighting constantly over this very challenging child. An older sister is neglected in the face of the intense demands of of her brother. He screams in the face of any transition, cannot tolerate loud noises, eats only a very narrow range of foods. He has frequent meltdowns and is difficult to comfort physically, resisting efforts of his parents to hold him. When he goes to playgroup, he runs around in circles rather than interact with the other children.

A study published in the June issue of Pediatrics, Early Autism Spectrum Disorder Diagnoses in Massachusetts, shows that more young children in Massachusetts are receiving treatment for autism spectrum disorders, with the proportion of those 3 and younger being treated rising by 66% from 2001 to 2005. A summary of the study states "Researchers did not determine whether the increase was because of improved awareness, better diagnosis or an increase in the prevalence of the disorder, but said a combination of factors was likely."

There is yet another reason for the increase in diagnosis, perhaps even the major reason . If the above child is diagnosed with an autism spectrum disorder, he will receive a whole range of services through EI including developmental specialists coming into the home on a regular basis to help the family make sense of and manage Evan's difficulties. On the other hand, if he does not get the diagnosis, this family, which is most certainly struggling, may get ZERO. Nothing. No help at all.

Evan may have some significant biologically based vulnerabilities, with a low frustration tolerance, inflexibility and number of sensory processing difficulties. But if he and his family can get the support they need, he may learn to manage these vulnerabilities. He may even be able to transform them in to an asset, becoming a musician or a professional chef.

Perhaps the rise in diagnosis is not because of a rise in autism, but because of limited access to mental health and community based support services for children like Evan and their families. The health insurance industry and managed care have contributed to this problem through prohibitively complex administrative costs for private practitioners. Many of the best mental health practitioners are therefore not on insurance plans and quality services may be inaccessible to families who most need them. Early Intervention is a superb program that is available to anyone in need. But the catch is that a child usually needs to have a diagnosis to be eligible.

Autism is a highly charged subject. Parents of children who are severely impaired understandably bristle to questions about the legitimacy of the diagnosis. I suspect that what is now called autism represents a very wide range of difficulties that we will come to learn are actually a number of different and distinct problems. While early identification and intervention is essential. I believe there is a need for caution regarding diagnosis.

Parents who receive a label of a major psychiatric diagnosis for their child inevitably go through a period of mourning. The child they had is gone and has been replaced by a child with a “disorder.” As D. W.Winnicott, pediatrician turned psychoanalyst, so wisely observed, a child develops a healthy sense of self when the people who care for him recognize the meaning of his behavior, rather than substituting their own adult meaning. Parents often begin to regard behaviors as “symptoms” of the “disorder.” For a very young child whose development is unfolding, his “true self”(again in Winnicott's words) might be lost in the face of such a frightening label.

It is my hope that we can move from an emphasis on diagnosis and labeling to an emphasis on prevention. We need to ask not “what is the disorder?” but rather, “what is the experience of this particular child and family?” and “what can we do to set things in a better direction?” This current situation, where a diagnosis is needed in order to get help, is a dangerous example of the tail wagging the dog.

Saturday, June 4, 2011

Why Pediatricians Need to Know About Infant Mental Health

I recently became recertified by the American Board of Pediatrics. My certification was due to expire at the end of this year. In order to accomplish this task I had to do two things. One was to complete an assessment of my knowledge base. The other was to complete an approved "quality improvement activity." I chose one referred to as the "Attention Deficit Hyperactivity Disorder (ADHD) Performance Improvement Module" Clinicians who are currently seeing very few patients(the case for me due to the book writing) are able to use simulated patients for this online activity. By giving data for patients over three time points, this "performance improvement module" scored me in the high range of improvement of care because I gave the Vanderbilt( a standardized assessment tool for ADHD evaluation with a parent and a teacher version that assesses symptoms and academic performance) to every patient, discussed the option of medication, and if they were on medication, measured weight and blood pressure at every visit. That and pay $1,000 and I am now recertified until 2016.

This experience brought to mind a case of a seven-year-old boy who was referred to me for evaluation of ADHD. He arrived with the completed parent and teacher Vanderbilt forms on which he scored in the high range for inattentive and hyperactive ADHD. His mother had a high expectation that I would put him on medication. In our first visit, when I met with the mother alone, the following story emerged (details have, as always, been changed to protect privacy.)

For the first six years of his life this boy lived with his father, who was an actively drinking alcoholic. His mother lived in a different state and was intermittently involved in his life. When his father became ill with advanced liver disease, his mother moved closer to him and began to be more involved in his care. His father continued to drink despite his rapidly declining health, and though his mother was at first reluctant to share details, her son had witnessed his father's rather gruesome death at home about 6 months prior to our visit. He was now living with his mother and was struggling in school. He was receiving no psychotherapy or intervention of any kind. His teachers, who knew little of this story, had recommended the "ADHD evaluation" and had suggested strongly that he might benefit from stimulant medication.

The work of psychiatrist Bruce Perry, who taught one of the weekends of the Infant-Parent Mental Health Post Graduate Certificate program of which I have been writing for the past year, helped me to understand what was likely happening for this boy in school (for the sake of this blog post his work is simplified. For further information see the Child Trauma Academy website.) For most of his life this boy lived with an unreliable caregiver, who, when he was drinking likely was unrecognizable. The same person who he relied on for safety and security was frightening and unpredictable. The subsequent witnessing of his father's death adds a level of trauma that is almost unimaginable.

When children experience this kind of trauma from an early age, it affects the areas of the brain responsible for regulation of the most basic functions. A child may in a constant state of "hyper-arousal" in which he is constantly vigilant for possible danger. He does not have a normal sense of time and may exist only in the present. In the face of any kind of stimulation, he may experience either a fight-flight response or alternatively what is referred to as a dissociative response, in which his mind in a sense shuts down. In either state the brain does not function well and a person is unable to think, much less to learn.

In order to treat this kind of early trauma, one must start at these lower centers of the brain in order to help a child develop the basic capacity for self regulation. This may involve such activities as massage, walking, or martial arts. In essence, one needs to rebuild the brain from the bottom up. Only in this way can one hope to engage the higher centers of the brain and help a child make sense of his experience and begin to use his brain to learn.

Yet the standard of care in pediatrics, as reflected in my successful recertification experience, is to document symptoms of inattention and hyperactivity and then treat with stimulant medication. And the fact is that in the short term, stimulants may help a traumatized child to calm down. But the benefits are short lived, and often there is an escalation to higher and higher doses of medication over time.

A teacher of mine who is a leader in the discipline of infant mental health recently asked me why pediatricians should do this work, and not "a new front line practitioner trained in well child medicine and developmental mental health." The fact is that pediatricians, who are on the front lines and see children and parents early and often, do treat behavioral and developmental problems as a huge part of their practice. A 2001 policy statement The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care by the American Academy of Pediatrics reflects this fact.

As is clear from the above story, pediatricians are doing this work under the influence of a powerful pharmaceutical industry and pervasive culture of medication. Therefore, if we are to "do no harm" it is imperative that pediatricians are exposed to the wealth of knowledge and research generated in the discipline of infant mental health. This research offers a different model for understanding and treating behavior problems from the "advice giving", "parent training", "behavior management" and medication prescribing that is currently the standard of care in pediatrics. In my experience, as well as that of as small but growing number of pediatricians who are learning about infant mental health, these ideas have great relevance to our practice, and offer the opportunity to help young children and families in profoundly meaningful ways.