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, September 28, 2011

Parenting Toddlers and Teenagers: Much in Common

Psychoanalyst Peter Blos describes the "second individuation process of adolescence," referring to the way in which adolescence shares many qualities with toddlerhood in terms of developmental tasks. Sometimes when I listen to parents describe their struggles with their teenage children, I have an image of trying to contain a person, often bigger than themselves, who has advanced thinking skills. The tantrums of adolescence involve not thrashing arms and legs, but words, and often cruel and vicious words.

D. W.Winnicott, pediatrician turned psychoanalyst, offers some words of wisdom that can guide a parent through this challenging period. He writes, in his book Playing and Reality
If you do all you can to promote personal growth in your offspring, you will need to be able to deal with startling results. If your children find themselves at all they will not be contented to find anything but the whole of themselves, and that will include the aggression and destructive elements in themselves as well as the elements that can be labeled loving. There will be this long tussle which you will need to survive.
This idea resonated with Pam, mother of 16 year old Eva, who had come to see me for a consultation. She described the following scene. Pam and Eva had planned to have a nice lunch together. Eva was busy at school and had developed an increasingly serious relationship with her boyfriend, Chris. Eva and Pam had always been close and both eagerly anticipated this opportunity to spend a bit of time together. Things started off well enough. Eva excitedly told her mother about the latest social happenings at school and about a paper she was working on.

But then over some little thing, Pam couldn’t even remember what it was when she told me the story in my office, Eva had exploded with a burst of venomous rage. “You never think about my feelings,” she’d started with, calmly enough. But when Pam tried to get her to explain what she meant, Eva’s anger only increased. Vicious insults started flying at her. Caught off guard, Pam found herself becoming defensive.

Their discussion escalated into a shouting match as they quickly paid their bill and left the restaurant. Pam, in an effort to get home without being in an accident, stopped talking to Eva, who, she felt, was becoming increasingly irrational in her verbal assault on her mother. Pam’s silence only further enraged Eva and she screamed at her mother, who held tight to the wheel, hands shaking.

They made it home and immediately went their separate ways. Pam called her husband. As he was not the recipient of the full intensity of Eva’s distress he was able to support his wife and help her to calm down. Eva closed the door to her room and called her boyfriend. Several hours later Eva emerged from her room. “I’m sorry, Mom, she said. I’ve been feeling so much stress trying to balance work and friends and Chris.” “I understand that this is a very difficult time for you,” Pam had replied. “But," she went on to say, "it is not acceptable for you to speak to me the way you did.”

Pam was feeling beaten down by these repeated interactions with her daughter. While she had been able to negotiate the prior stages of development with Eva, the intensity of feelings directed at her from her teenage daughter sometimes was too much to bear. I told Pam that she was doing just what she needed to do, namely withstand the full intensity of her daughters feelings , both the negative and positive ones, yet set limits on her behavior. Pam needed to show Eva that she loved and supported her daughter, but would not allow her destroy her mother.

A toddler needs similar kinds of limits as he tries to make sense of who he is as a person separate from his parents. While two-year-olds will not say "thank you for setting limits," when parents contain both their behavior and their intense feelings, it helps them to feel safe and secure. This safety and security is needed just as much for teenagers as they begin to separate and develop their emerging identity. Ironically just when a teenager is most actively and aggressively pushing you away, she most need you to be there.

Winnicott offers a hopeful look at the future if a parent has withstood the “long tussle” of adolescence. He writes:
Your rewards come in the richness that may gradually appear in the personal potential of this or that boy or girl. And if you succeed you must be prepared to be jealous of your children who are getting better opportunities for personal development than you had yourselves. You will feel rewarded if one day your daughter asks you to do some baby-sitting for her, indicating thereby that she thinks you may be able to do this satisfactorily; or if your son wants to be like you in some way, or falls in love with a girl you would have liked yourself, if you had been younger. Rewards come indirectly. And of course you know you will not be thanked.

Friday, September 23, 2011

Music Therapy

Recently in my behavioral pediatrics practice I saw James, a 5-year-old boy (details, as always, have been changed to protect privacy) who struggled with severe social anxiety. The lunchroom and gym were particularly difficult, and he would retreat into silence. In a visit with his parents we were discussing how to approach the teachers about making him comfortable in school. We had a full 50 minute appointment so we were, in a sense, free to let ideas emerge. That's when his father observed, "You know, he loves classical music." His mother described a recent outing where there had been a lot going on and James was quite agitated. But when someone put on some classical music, James became completely calm and seemed at peace.

It was an important detail. We began to brainstorm about how they might make use of this observation in the school setting in addition to social experiences outside of the classroom.

This story led me to wonder how this piece of information might help us to understand James' brain. For some reason he couldn't process all the sensory information coming at him in a busy social scene. But with the help of classical music, it was as if the neurons, the cells of his brain, lined up and began to work properly.

This visit got me thinking about a movie I recently saw The Music Never Stopped. It is based on the story of an actual patient as described by neurologist and writer Oliver Sacks in his essay "The Last Hippie." The movie's main character is a young man who suffered severe brain injury, and was socially disconnected even from his immediate family. But he had been a passionate musician, and when when he listened to music he loved from the time before his injury he became completely clear thinking and engaged. Like my young patient, his brain was a place of confusion and disorganization until the music allowed things to, in a sense, fall into place.

Interestingly, while working on this post I received an email from the publicist at Berklee College of Music alerting me to an upcoming program (October 5th-6th) about music therapy for autism spectrum disorders. The press release for the program states:
There is scientific evidence that music therapy influences children on the autism spectrum in several ways, like enhancing skills in communication, interpersonal relationships, self-regulation, coping strategies, stress management, and focusing attention,” says Berklee’s Music Therapy Department Chair Dr. Suzanne Hanser.
Similar to my young patient with social anxiety, children diagnosed with autism spectrum disorders are often overwhelmed by sensory input. It makes perfect sense to me that music would help them to organize their experience and engage with the world around them.

There is currently an explosion of research at the intersection of neuroscience, genetics, and developmental psychology to help us understand young children who are struggling with a range of what are usually referred to as "behavior problems." I am a clinician, not a researcher. However, I listen carefully to my young patients. I encourage their parents, as James' parents clearly were, to be curious about what the world is like for them. If we listen and observe in this way, these children can be our greatest teachers.

Sunday, September 18, 2011

Postpartum Depression: Listening to Mothers

When I see children in my pediatric practice for behavior problems, I often hear stories from mothers who struggled terribly when their children were very young infants. Among the most dramatic example of this was a mother with severe postpartum depression whose father died suddenly when her baby was four months old. Much to my astonishment, she described being relieved by this event. It wasn't because she didn’t love her father. Rather, in sharing the grief with her siblings and extended family, she no longer felt so completely alone.

A Massachusetts law passed last summer calls attention to the public health problem of postpartum depression (PPD). The most common complication of pregnancy, extensive research has demonstrated its significant long term effects on a child’s development, with increased risk for behavior problems in childhood and depression in adolescence.

The new law requires Massachusetts health insurers to submit annual reports on their efforts to screen for postpartum depression. The department of Public Health will develop regulations and policies to address postpartum depression. In addition the law calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.

The Boston Globe editorial board endorsed this legislation with the following statement: "Early detection could stave off far more serious problems for mothers and their babies, whose well-being is deeply linked to the first few months of care. And universal screening would ensure that no woman falls through the cracks. The sooner new mothers can be diagnosed, the sooner they will recover."

This legislation is an important first step. A lot of work needs to be done, however, to turn the Globe's very optimistic statement into a reality. This summer I became involved with two organizations who are working towards this goal. One is a working group of the Massachusetts Chapter of the American Academy of Pediatrics. One of the biggest problems with mandatory screening, which is done primarily by obstetricians and pediatricians, is that the people doing the screening may not know what to do with a positive screen.

Interestingly, a study of women struggling with PPD ( which I prefer to call "perinatal emotional complications" thus avoiding the stigma associated with major mental illness- I must give credit to Liz Friedman-see below-for coining this phrase) shows that mothers may not want a referral or medication but simply for their clinician, a person with whom they have an established relationship, to listen to them. Primary care clinicians need to feel comfortable with what our group called "engagement," - to stay in the room with a distraught mother before jumping to a referral.

Perhaps equally importantly, the health insurance industry need to recognize that time and space, offering a mother, who may feel so terribly alone, a chance to be heard in a non-judgemental way by a respected caregiver, is an essential part of treatment.

The second organization I connected with is called MotherWoman. This organization seeks to educate clinicians and to create referral networks of people in communities who can offer a variety of interventions for these mothers. It is run by a remarkably energetic and enthusiastic woman, Liz Friedman. She describes her program as follows:
The Community-based Perinatal Support Model (CPSM) has been developed to address the gap between screening and services for mothers. CPSM aims to prevent, identify and facilitate treatment of PMD(perinatal mood disorders) by creating a comprehensive, community-based, multi-disciplinary safety net for women.
These two organizations are starting the hard work necessary to translate the new legislation into a form that is useful and meaningful for mothers struggling with perinatal emotional complications.

When I speak with mothers like the one above, I wish that I had seen them when their children were infants. This is not to say that their child's behavior problems is their fault. But the research clearly shows that when mothers are emotionally available to their young infants, development proceeds in a healthy direction. By working to address perinatal emotional complications, we have the opportunity not only to ease these mothers' suffering, but also to help them to be fully present with their babies. We can help transform these early months from a time of stress and pain into a time of joy and love.

Monday, September 12, 2011

Creativity in the Age of Psychiatric Medication

Recently I attended a reception at the Austen Riggs Center in Stockbridge, MA for the new medical director. Austen Riggs is an inpatient psychiatric hospital where intensive psychotherapy remains the core of treatment( thought certainly medication is used as well.) At the reception I met the new Erikson scholar, an art historian who is writing a biography of a woman, one of the first patients at Riggs, who shortly after her stay went on to become a world famous violinist. We spoke about the connection between mental illness and creativity. We wondered what this woman's fate might have been had she lived today when she most surely would have been medicated.

In the last chapter of my new book Keeping Your Child in Mind: Overcoming Defiance, Tantrums, and Other Everyday Behavior Problems by Seeing the World through Your Child's Eyes I discuss the problems associated with the exponential rise in prescribing of psychiatric medication for children. While I am not against medication per se, I have a number of concerns about what I consider to be an over-reliance on medication to treat complex problems. Not only are there side effects and unknown effects on the developing brain, but medication is often the focus of treatment to the exclusion of important family issues. Significant events in a child's life may go unaddressed. Usually a child does not have an opportunity to talk about what it means to him to be taking a pill to manage his behavior.

Following this conversation at Riggs it occurred to me that I should add yet another concern- potential loss of creative talent.

Several weeks ago there was an op ed in the New York Times: “Words Failed, Then Saved Me, “ that offers a beautiful example of turning a biological vulnerability into an adaptive asset. The author, Philip Schultz, now a Pulitzer Prize winning poet, struggled terribly as a child with what is today recognized as dyslexia. Schultz describes how his mother would read his favorite comics over and over again with the hope that this would help him to make sense of words. I wonder if this kind of tolerance and patience gave Schultz the space to, as he says, “invent a new way of reading” that was adapted to his particular form of dyslexia.

Schultz describes not only his academic struggles but also how he was kicked out of one school for hitting other children when they called him "stupid.' I wonder if he had been child today, he might have been described as "impulsive" and "distracted," classic symptoms of what now is called "ADHD." He might have been diagnosed and medicated. Had his symptoms been medicated away, he might not have invented his new way of reading, a method he now uses to teach others with similar difficulties to write fiction and poetry. He might not have become poet, much less win the Pulitzer Prize.

As a behavioral pediatrician, I often hear parents ask if there “something wrong" with their child. I help them to reframe the question, asking instead “what is his experience of the world, and how can we help him to make sense of and manage that unique experience?” I have seen kids who were "explosive" and "inflexible" as very young children. They were easily overwhelmed by a variety of sensory experiences. But in the setting of an understanding and supportive environment, they have gone on to be talented actors, musicians and artists.

Supporting children in this way involves investment of time and energy from parents, teachers, and clinicians. In our culture treatment of a child with "behavior problems" usually focuses on resolution of symptoms, often with medication, rather than understanding the meaning of behavior. Medication may more quickly control a child's symptoms. But at what cost?

Wednesday, September 7, 2011

Keeping Children in Mind on 9/11/11

When I first learned of the planes hitting the twin towers, my initial thought was that I wanted my children, then three and six, home with me. This is despite the fact that I live in a rural community 125 miles north of New York City that was in no way physically affected by the trauma. As the 10th anniversary of 9/11 approaches, I have been thinking of reaction, of how in the face of overwhelming fear our first instinct is to be near our children.

Children, in fact, have a similar reaction. This behavior was initially termed "attachment behavior" by John Bowlby, a British psychoanalyst who developed his theories in England during World War II, when he saw the devastating effects on children who were routinely separated from their parents and moved to the countryside, ostensibly to "keep them safe." Heavily influenced by Charles Darwin, he recognized this behavior, this drive to seek out primary caregivers in the face of fear, as essential to the survival of our species. Over 50 years of subsequent research based on his original theories has shown that in order for a child to feel secure in this attachment, a parent needs to be reliably available, both physically and emotionally. It is this sense of safety and security that gives children the freedom to explore, grow and develop.

In other words, in order for them to be OK, they need first and foremost for us to be OK. Certainly it is important include children in conversations about 9/11, to listen carefully to what they are thinking and feeling, and to clarify any misperceptions they may have. But this listening cannot happen effectively if parents do not first take care of themselves.

I once saw a mother in my behavioral pediatrics practice who's family had experienced a different mass trauma (to protect privacy I will omit details) She wanted me to meet with her two school age girls to "make sure they're OK," a perfect example of that instinct to protect the children first. I suggested instead that I meet with the parents. The mother came by herself- the father was still back at the site of the trauma. She had relocated to my town to stay with family. We spent an hour talking mostly about what the experience had been like for her.

She was suffering from anxiety not only about the effects of the initial trauma on her children but also the massive uncertainly of their future and such basic questions as where they would live. But we also talked about other things. One was her relationship with her own parents. Her father, who had died recently, was an incredibly stoic man who had himself survived unimaginable trauma. We talked about how she thought of him often and tried to emulate him. But she recognized that she was shouldering in a lot in trying so hard to be brave. At the end of the hour, she smiled, let out a big sigh, and said, " I really needed to talk about this. I feel so much better!" She recognized that her children were doing well, as evidenced by the fact that they were doing their schoolwork and participating in all of their usual activities. More than anything they needed for her to be fully present with them. And to do that, she herself needed to be heard .

Immediately following the terrorist attacks of September 11, 2001, leading trauma researcher Susan Coates provided critical mental health services to children and their parents at the Family Assistance Center set up by Disaster Psychiatry Outreach in New York City. In an interview Dr. Coates said, "Parents are often surprised by how much their children have taken in. And sometimes we find that we need to shift our attention to parents who are so overwhelmed already that they cannot take in what their children are communicating and find that their own posttraumatic stress is triggered by what their children are communicating."

As pediatrician, I often have parents ask me "what to do" in a range of situations. I understand this wish to have some kind of instruction manual, especially in the face of this upcoming anniversary. But in fact parents are the experts regarding their child, and if I tell them what to do I am undermining their natural authority. What I do instead, as I did with this mother, is offer them a place to be heard, with the hope that this will free them to be with their child both physically and emotionally- to be, in Bowlby's words "a secure base." From this place, "what to do" will follow naturally.