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.

Wednesday, August 31, 2011

Promoting Healthy Emotional Development in Children: Social Media Helps the Cause

In 2006-2008, years I hope will turn out to have been the peak of the bipolar diagnosis in young children, it was not uncommon for parents to bring a child as young as 18 months to my behavioral pediatrics practice asking if he had the disorder. During the same time period, I had the good fortune to be a scholar with the Berkshire Psychoanalytic Institute. There I was exposed to a wealth of research and knowledge at the interface of developmental psychology, genetics and neuroscience, coming out of the growing discipline referred to as infant mental health (in this discipline "infant" refers to age zero to five.)*

The research I was learning about, particularly the work of Peter Fonagy, offered me the tools to help families in dramatic and meaningful ways. He and his colleagues have shown how children develop a healthy sense of self, and with that a capacity for empathy, emotional regulation and resourceful thinking, when the people who care for them respond to the meaning of their behavior, that is, motivations and intentions, rather than the behavior itself. This kind of reflection, referred to as holding a child's mind in mind, actually promotes healthy development of the regulatory centers of the brain.

Being a responsive caregiver in this way, particularly in the face of a biologically vulnerable child, is very hard work.
In my office, guided by this model, I aim to listen to the whole of caregiver’s experience in order to fortify their efforts to be fully present with their child. In doing so, I aim not only to change behavior but also to support relationships and to get the rapidly moving train of development back on track.

I longed to communicate to my pediatric colleagues, who are on the front lines with young children and families, not only this new knowledge, but also the way I was able to use these ideas everyday in my pediatric practice with such powerful results. The model of psychiatric diagnosis, often followed by psychiatric medication, needed to be counterbalanced by this alternative paradigm. But I felt that I was living in two completely separate worlds. How could I bring them together? This is where social media comes in.

At first my plan was to develop a curriculum for pediatricians in training. But as a small town doc with no academic appointment, it was hard to break in to this world. Then in June of 2008 the story broke about leading psychiatrists receiving, but failing to disclose, large amounts of money from the drug companies who manufacture the medications used to treat childhood bipolar disorder(they were subsequently found to have violated conflict of interest rules.) I was moved to write an op ed for the Boston Globe entitled Mind Altering Drugs and the Problem Child. The overwhelmingly positive response led to the decision to write a book (That book Keeping Your Child in Mind was released August 30th.) My thinking was that writing for a general audience, important in its own right, might also give me a way in to the world of academic medicine. In addition to embarking on the book project, I started writing this blog.

This past March, a follower of my blog emailed me a link to an article in the New Yorker. The article The Poverty Clinic, described the practice of Nadine Burke, a pediatrician who was incorporating principles of Infant Mental Health in her inner city clinic. I was thrilled to find another like minded pediatrician, particularly one who was so successful, and I subsequently wrote a blog post, Early Relationships and Brain Development as the Core of Medical Practice, about Dr. Burke and her work.

Shortly after this post went up, a pediatrician in Seattle, doing a search for information about Dr. Burke, found my blog. She emailed me to say that she had been up all night reading it. She too had discovered the wealth of knowledge in the world of Infant Mental Health and she too was overjoyed to find a like minded pediatrician. She told me how these ideas, as I describe above, had completely transformed her practice. Rather than "giving advice" and telling parents "what to do" from the stance of an "expert" she found herself listening to parents in a new way. By shifting her task from "fixing problems" to "supporting relationships," she had seen dramatic changes in her her ability to help young children and families. She invited me to speak this coming April at a conference she was organizing for general pediatricians on Infant Mental Health.

About a month later I received an email from a new fellow in Developmental and Behavioral Pediatrics at Boston Medical Center. She was from Seattle, and had worked with the same pediatrician who had discovered my blog via Dr. Burke. That pediatrician had suggested to this new fellow that she seek me out. She, in turn, approached the director of her program, with the suggestion that they read my book and invite me to come and speak about it. So here is my foot in the door of academic medicine in the Boston community, thanks to social media, via San Francisco and Seattle. (I will soon have an opportunity for both practice and teaching in the Boston area-stay tuned to my blog for news about this in the coming months!)

So here I am writing about what I am doing, namely using social media to bring new knowledge to a larger community. As a country doc, I fully embrace this model of shared information as a powerful tool to make the world a better place for children and families.

* Note to my regular readers: this is an introductory post for the new direct feed of my blog posts on the Boston.com website


Tuesday, August 23, 2011

Pharmaceutical And Health Insurance Industries May Harm Children's Mental Health

This will be a brief post (I'm on vacation with my family) just to call attention to two important and related items published yesterday. First, in the New York Times, an Op Ed entitled "The Kids Are Not Alright about how "corporate interests threaten children's welfare." As one example, the author states:
Another area of concern: we medicate increasing numbers of children with potentially harmful psychotropic drugs, a trend fueled in part by questionable and under-regulated pharmaceutical industry practices. In the early 2000s, for example, drug companies withheld data suggesting that such drugs were more dangerous and less effective for children and teenagers than parents had been led to believe. The law now requires “black box” warnings on those drugs’ labels, but regulators have done little more to protect children from sometimes unneeded and dangerous drug treatments.
Another related piece published on Kevin MD refers to the Wall Street Journal article describing the fact that over 25% of children in the United States are on some form of chronic medication. The author, Maggie Kozel, is a pediatrician who has written a book entitled The Color of Atmosphere: One Physician's Journey In and Out of Medicine about the effects of managed care on the practice of primary care medicine, that I will be sure to read when I get home. In her recent piece she writes:
Our system of private, fee-for-service insurance is basically a business model that focuses on the top of the health care pyramid (the doctor) and pays for quick fixes (prescriptions) with immediately observable (short term) results. That works great for bacterial pneumonia; not so much for a kid bouncing off the walls, or gaining too much weight, or who is sad. Nowhere is this more glaring than in the realm of mental health.

Health insurance companies have determined, by virtue of their reimbursement strategies, that the work of treating serious mental illness would shift to primary care providers. A recent study by the AAP predicts that treatment of mental illness and mood disorders will soon makeup 30-40% of a pediatrician’s office practice. To put this trend in perspective, an earlier study that appeared in the journal Pediatrics revealed that 8% of pediatricians felt they had adequate training in prescribing antidepressants, 16% felt comfortable prescribing them, but 72% actually did. If they don’t, who will? This is just one example of the growing disconnect between rational medical practice and the way we deliver healthcare. Furthermore, where do both pediatricians and psychiatrists get most of their information about these psychotropic medications that are now flying off prescription pads? The pharmaceutical companies that produce them, through the hundreds of millions of dollars they spend each year on marketing and the clinical studies they fund. The insurers and pharmaceutical companies aren’t necessarily the bad guys here. They are doing what they are tasked to do: run a business.
I am pleased to be joined by these intelligent voices in calling attention to the very serious problem of over-reliance on psychiatric medication to address complex problems in children's lives.

Thursday, August 18, 2011

Having Empathy for Parents: An Essential First Step

I continue here with the theme of my previous post. I was inspired to write by a conversation over dinner last night with a friend who is a prominent psychoanalyst. He was describing a case that had been discussed at a conference. Yet another well respected psychoanalyst presented an analysis of a five year old boy. Already my bristles were up, but I tried to listen with an open mind. As a kind of an aside to the main story about the child and his analyst, my friend relayed that the parents "were awful in some way." The analyst had described to the group how the little boy had become fixated on the whereabouts of his wife, to the point where he could not stay in the room and had to go and look for her. The idea, my friend explained, was that a five year old child needs to hold in his mind a relationship not only with each parent, but with the parents in relation to each other, in order to feel emotionally at ease. Fair enough, I said (though this classical model needs some careful rethinking in the face of many different family constellations seen today.)

But however important this analyst's observation may be, this case felt to me more like a use of the child as a lab specimen in the study of child development than an effective form of treatment. As I have said in multiple blog posts, and describe in detail in my new book Keeping Your in Child in Mind(in stock at Amazon now!) what is most important for a child's healthy development is that he feel understood by the people he loves. At the age of five, being understood by a therapist, should, in my opinion be part of the larger goal of supporting the parents in their understanding of their child. For this to happen, as Dr. Ornstein so wisely describes (see previous post), the parents must be an integral part of the treatment of a young child.

When a therapist judgmentally dismisses parents as, "awful in some way," it precludes any meaningful participation. Having worked with countless young children and families, I do understand where this reaction comes from. Recently I saw a four year old girl with her parents. Her fathers rage at this young child was barely contained. He spoke of her in highly negative terms while she sat playing on the floor. It was painful to listen to. But when I met with the parents alone, he broke down and cried, telling of his own abusive father and how he struggled daily with his own internal rage. He hated himself for directing it at his young daughter, who he loved more than anyone in the world. When he recognized that I was not judging him but rather was empathically listening to his struggles, he could accept a recommendation for his own therapy without becoming defensive. While the parents had come to me for advice about how to manage their daughter's behavior, now they could think about her perspective. They could ponder her experience as the recipient of her fathers displaced rage.

On my Psychology today blog, I received an interesting comment in response to my post Dyadic Therapy: Working with the Parent-Child Relationship This writer questioned my position of empathy. He had been abandoned by his mother at birth, his father died when he was nine and he was raised by a member of the Hitler youth who fled war torn Germany. She had threatened him with being sent to an orphanage for any bad behavior and admonished him not to cry at his father's funeral. He concluded his comment with "Dyadic therapy with the long-dead Nazi warlord is not likely gonna work?"

My first response was that, in the absence of frank abuse or severe mental illness, I believe one can always work with parents to support efforts to think about their child's mind and subjective experience. In another post I refer to the beautiful work of psychoanalyst Carole Gammer, who works with parents and children together in the face of with significant parental mental health problems. Not a treatment for the parents, it is instead a focal intervention whose aim is to, in a sense, support the parents' efforts to hold their child in mind. She has amazing results under highly adverse circumstances.

However, I had to rethink my response to his comment. On second thought, I wrote, "Unfortunately one could argue that, at that time in history, large segments of German society were exhibiting behavior consistent with abuse, severe mental illness, or both." The empathy I am advocating for assumes a certain level of sanity in society. Respect for parents, offering help for those who, like the father in my story, are struggling, and valuing this critical yet highly challenging task of raising the next generation, is part of that sanity.

Saturday, August 13, 2011

Parenting and Empathy: An Essential Partnership

Last week I had the privilege of reconnecting with Anna Ornstein, a brilliant child psychiatrist and one of my original mentors. In preparation for our meeting, I re-read a paper she had given me back in 2004* (written with her husband Paul Ornstein, MD about 20 years before that), when I was just beginning to develop the ideas now described in my new book, Keeping Your Child in Mind. While I do not reference the paper in my book, it is filled with such wisdom that I felt compelled to quote large segments of it in this blog post. Interestingly, much of what she says is similar to what in the current world of developmental psychology is referred to as "reflective functioning, " or what I refer to in my book as "holding a child's mind in mind." While in that language, empathy is included as one component of the more complex task of reflective functioning, in Dr. Ornstein's language "empathy" encompasses the many components of reflective functioning. She writes:
The parent who is capable of parental attunement is one who developed an adult form of empathy-a capacity in which an adult man or woman can immerse him or herself into the inner life of a child without this threatening his or her own sense of separateness and without the parent injecting his or her needs into the interaction with the child. This is a more complex and difficult task than is generally acknowledged.
She goes on to be more specific:
In other words, empathy involves the recognition of the child's motives for the behavior. Since in the case of a young child only the behavior is available for observation, it is more likely that this will be interpreted in terms of meaning that it has for the caretaker rather than the meaning the behavior has for the child. This is particularly true once the child's motive has been partially or completely ignored and the behavior has been responded to only in terms of its meaning to the caretaker. By the time the child becomes demanding, hits or bites because his intent has been originally misinterpreted or ignored, an interaction has been set in motion that precludes the possibility of recognizing and responding to the child's original motives.
But the beauty of Dr. Ornstein's paper is that not only does she capture this idea so clearly, but then goes on to articulate why this happens and how to work empathically with parents to help them to change these unhealthy patterns of interaction. She writes, " we consider parenting as on of the most important challenges in the consolidation and esteem of the adult's self." She gives an example of a toddler:
Toddlers experience themselves as the center of the universe; they are now filled with a sense of initiative and healthy vigor. They want those around them to see, recognize, and acknowledge their intoxicating sense of what they discover to be their own powers and abilities. To an environment[parent] that is fearful of losing its control over the toddler's developmentally exaggerated sense of power, this behavior will be threatening. Under these circumstances, the environment[parent] attempts to reinforce its control, battles ensue, and a child's self assertion disintegrates into the aimless and frequently destructive forms of aggression...In terms of overt symptoms, we witness an increase in the intensity of separation anxiety; the toddler becomes clingy and whiny and develops nightmares and other forms of sleep disturbances.
Dr. Ornstein then goes on to brilliantly address the implication for child therapy.

As a brief aside, Dr. Ornstein told me, over our glass of wine, that she was fired from her job for writing a paper that espoused similar ideas in the mid 1970's. In the heyday of psychoanalysis, children were treated without involvement of the parent, and Dr. Ornstein's assertion that one could not treat the child without including the parent was considered heresy. She writes:
Listening to case conferences in which families and their troubled children are being discussed, it appears extremely difficult for the professional not to create or reinforce guilt in the parents for their child's emotional difficulties...we would suggest that therapists of children of all ages, but certainly those of young children, focus their attention on the specific features in the parents' personalities that have made the parenting of this particular child at this particular time in the child's and parent's lives, difficult for them.
She goes on to say:
Parental dysfunctions are symptoms that require exploration as do other psychological symptoms...When the therapist does not appreciate the narcissistic mortification that parents experience [narcissism in relation to a child is a healthy thing in-as-much as one views the child as a part of oneself] that parents experience for having a troubled child and when parents feel further reduced in their self-esteem because they are not included in the therapeutic effort, it is then that they are likely to remove the child from treatment or look for an explanation other than a psychological one for the child's difficulties.
I believe Dr. Ornstein's elegant words speak for themselves. The contemporary world of developmental psychology, as I have said, espouses the same ideas but with two differences. One is that Dr. Ornstein's paper is filled with psychoanalytic language that can be hard to relate to. Second, and perhaps most important, is that the significance of "reflective functioning" or "holding a child in mind," in facilitating healthy emotional development, has been demonstrated by years of high quality longitudinal research. Dr. Ornstein's ideas, however eloquent, are, in contrast, based on clinical experience alone. Going back to read her paper after all these years made me recognize the importance of not only including clinical experience in development of new ideas, but also addressing the poetry and passion of parent-child relationships, which can be diluted out in pursuit of "evidence" in the research setting.

*The paper is a chapter in a book entitled Parental Influences in Health and Disease, eds James Anthony and George Pollack

Saturday, August 6, 2011

Supporting A Parent's Natural Intuition

Yesterday I had my first radio interview about my new book Keeping Your Child in Mind, which will be released this coming Tuesday. I welcome the opportunity to talk about my book, not only because it helps spread the work about ideas important to the future of our children, but because these discussions offer the opportunity for new thinking. In the interview yesterday, I was asked the question: "Do parents need to read books to be able to understand their child?" A particularly interesting question to ask a person who has just written a book for parents! I began my response by saying that I was not in general a fan of parenting books. They run the risk of trying to apply a one size fits all approach when in fact each family situation is unique. But perhaps more importantly they can undermine a parent's natural authority.

Rising to the challenge of thinking while I'm talking, I then said that the problem is that things get in the way of a parent's natural intuition, and that my book in a sense supports parents in recognizing and addressing these obstacles. I had actually never thought of it this way before. "What can get in the way," I went on to say, "includes such things as depression and marital conflict." And just stress in general," my wise interviewer added. "Yes," I agreed. "when parents are free from external stress, they have a natural intuition and understanding about their child." As I say in my book, in reference to the work of D.W. Winnicott, pediatrician turned psychoanalyst: "A mother knows what her baby feels through her intense identification with him. He is part of her."

My interviewer was particularly drawn to the title of the second chapter: "Strengthening the Secure Base: Listening to Parents." I had an image as we were talking of clearing the brush, made up of the multitude of stresses of life, to be able to gain a clear view of your child. Obviously there is more to this task than reading a book, but my hope is that parents will recognize themselves in the stories in my book, feel understood themselves and in turn be better able to access their own natural understanding of their child. Then they won't need to read any parenting books!

Tuesday, August 2, 2011

Infant-Parent Mental Health: Getting the Word Out

I was so enthralled by the movie Page One that I saw it twice in one weekend. It is a behind-the-scenes look at the New York Times. It addresses the question of how people receive information: the relative roles of traditional journalism and new media, and how things are so rapidly changing. While it may seem a bit off topic for my blog, I thought to write a post about it when yesterday I received the latest issue of Zero to Three (not published on line), the journal of the organization Zero to Three National Center for Infants, Toddlers, and Families. It is jam packed with a wealth of important information. There are articles about, among others, healing from postpartum depression, a program designed to strengthen relationships between parents and children, and a case of selective mutism, all from the perspective of the discipline of infant mental health.

Over this past year as a fellow in the U Mass Boston Infant-Parent Mental Health Post-Graduate Certificate Program, the other fellows and I had many conversations about what a treat it was to spend intensive time with like-minded colleagues, but how frustrating it could be when we returned to the "real world" and people didn't know what we were talking about. One woman, who was about to graduate from law school and plans to be a child advocate, told of speaking with judges about how early relationships shape the brain and being looked at like she had three heads. There was no support for her lawyer colleagues to encourage them to address the more complex and often painful issues involved in dealing with suspected abuse and placing children in foster care.

Tying these ideas together, I recently was referred, in my behavioral pediatrics practice, a seven-year-old girl with selective mutism. She had gone through two years at school without talking. Now her parents came to me with the question, "Should we do something or give it another year?" With a full hour to talk with her parents, I heard a story of a girl who had struggled with severe separation anxiety since infancy. The family was dealing with multiple stresses, and there were generations of similar difficulties (selective mutism is now understood as being a manifestation of social anxiety, which often occurs in multiple generations). None of this had ever been discussed until our visit. The school had had a number of meeting with the parents in which they said to give it more time, but now were telling the parents that if she did not start talking, she would have to be placed in a special education class. This is despite the fact that the girl was clearly of normal intelligence and spoke well and frequently at home.

Somehow the wealth of knowledge coming out of the growing discipline of infant mental health must find its way to the larger community. At the back of this issue of Zero to Three, there are reprints in English and Spanish of handouts "designed as tools to spark discussion on important child development topics and to support parents in developing the skills of self-awareness, careful observation, and flexible response." It has a section with the heading "Behavior Has Meaning" stating:
All behavior has a purpose. Babies and toddlers are not able to put their thoughts and feelings into words very well, so they communicate by using actions. A baby may cling and cry because she is fearful of new places. A toddler may bite to keep another child from interrupting her play. Understanding what your child's behavior is telling you helps you find supportive ways to respond to her and teach her better ways to express herself.
I wanted to bring these parents of the girl with selective mutism to place where they would ask not "what can we do to make her talk?" but "why is she behaving this way? and "what does it feel like for her to struggle in this way?" These kinds of questions would naturally lead them to "what to do" to help her and support her with these struggles. Our visit was a start. I introduced a new way to think about the problem. I can only hope that it sunk in. Having the Zero to Three handout might have helped, but certainly seeing her at four, three or even two would have been preferable.

So here I am, writing about what I am doing, namely using social media to bring new knowledge to a larger community. In the very near future (perhaps this week) I will have a direct feed of my blog on the newly designed Boston.com website (the Globe is following the lead of the New York Times in offering a separate free and subscription site) As Page One clearly shows, both traditional journalism and new media have an important role to play!