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, February 24, 2012

Colic and Migraines: A Complex Relationship

In a new study, neurologists at the University of California, San Francisco who surveyed new mothers at their pediatricians office found that mothers who suffer migraine headaches are more than twice as likely to have babies with colic than mothers without a history of migraines. Proposing a genetic link, they hypothesize that colic may represent an early form of migraine.

Before we can launch any meaningful conversation about colic, it is essential to recognize that when we talk about mothers and infants, we are talking about an intense passionate love relationship (see my previous post). When all goes well, the caregiver, who is usually the mother, is highly attuned to the needs of her infant, who in these early months is completely helpless. In a natural and healthy way that accompanies this state of falling in love, a mother is, to quote D. W.Winnicott,, "preoccupied" with her baby. They are engaged in a beautiful dance, in which the mother, by supporting and containing the baby, helps him to learn to regulate himself in the face of all the new experiences he has out in the busy, bright, loud world.

It is not as simple as "the mother has migraines, so maybe the baby has migraines." The exquisite dance of mutual regulation, that goes on naturally when both mother an baby are well, is severely disrupted. It is replaced by a dance of mutual dysregulation.

The baby may be more sensitive to sensory input, as the authors postulate. This difficulty with sensory processing is thought to be a significant component of colic, even if the mother does not have migraines. But the other person in the dance, far from being "preoccupied" with her baby, may be" lying prostrate on the couch for 10 hours," as one migraine sufferer wrote on her blog in response to this study. Certainly her ability to respond to her baby will be in some way impaired by her own distress. The crying, in turn, may worsen the migraine. This is not meant to be a judgment, but simply a fact.

The growing discipline of infant mental health looks at colic not only as a problem in the baby, who may have a variety of biological vulnerabilities, (sensitivity to sensory input being one of them) but as a problem in a relationship. For a new mother, who had anticipated this period as a time of bliss but is instead faced with baby who is either crying or sleeping, with few moments available for gazing adoringly into each others eyes , colic can be a devastating experience.

Recently I had the privilege of teaching about infant mental health to a group of psychologists and psychiatrists who work with very troubled adults, many of whom had significant disruptions in relationships starting in infancy. My students wanted to know what questions to ask when taking early developmental history. I found that they know what to ask, as in "did he have colic?" but they don't know what to listen for in the answers. I told them that my aim was to give texture to colic -to give them sense of what colic felt like, how it was experienced by both the baby and caregiver.

Interestingly this word "texture" came up again last week. I have been taking a wonderful online course on regulatory and sensory processing disorders taught by Rosemary White, who worked closely with the late Stanley Greenspan. White used the word "tailor" to describe how mothers are attuned to their babies, preferring this word to the word "calibrate" that she has used in previous courses. She said that the word "tailor" gives more "texture" to the experience.

There is yet another layer to the "texture" of colic. Mothers, even in the absence of migraines, may struggle with intense feelings of inadequacy in the face of a baby who cries all the time. Add to that chronic sleep deprivation along with an illness like migraines, and there may be a slide into depression.

Recognizing and exploring this "texture" of colic has significant implications for treatment. Rather than exclusively focusing on the baby, it is important to listen to the mother. A mother will need to know that another caregiver who she trusts, be it a spouse, close friend or relative, can watch the baby when she has a migraine. If she can count on such a person, it may lessen the guilt she will likely be experiencing. She may need to attend a group with other mothers facing similar challenges so that she does not feel so isolated. She may need to work on-on-one with an infant mental health specialist who can help the "couple' to manage the stresses on their relationship.

Even in the absence of colic, a mother needs to feel heard, valued and not alone in order to be free to provide that "primary maternal preoccupation." But when she is not well, and her infant is crying all the time, that kind of supportive environment is even more essential. When a mother has such a "holding environment," to again quote Winnicott, she is better able to provide that holding environment for her baby. Together they can make their way thorough these early months when the baby is totally dependent and helpless. It is important in those difficult months, to keep in mind that by "hanging in there," the time will come when a baby can reach for a toy, bring his thumb to his mouth, and begin to learn to comfort himself. This is a skill he will, with the help of his caregivers, continue to develop and refine as he grows increasingly more independent.

Sunday, February 19, 2012

Was Grandpa's Accident Actually a Suicide?

The central thesis of an important new book, A Lethal Inheritance: A Mother Uncovers the Science behind Three Generations of Mental Illness, is that the answer to this and other similarly painful questions about family history are critical to the mental health of future generations.The author, Victoria Costello, is a science journalist and mother of two sons diagnosed with serious mental illness, one schizophrenia and the other major depression, in their late adolescence.

As her own survival mechanism kicks in the face of such devastating circumstances, Costello explores the skeletons in her own closet, while using her considerable skill as a investigative reporter to weave her personal story with the last several decades of mental health research at the interface of psychiatry and genetics. Costello learns that her sons are the fourth generation of serious mental illness that has been previously been shrouded in secret. Capturing this well-recognized phenomenon of of intergenerational transmission of trauma and mental illness, she writes:
I've come to think that whoever is denied their rightful place in a family's collective memories will possess the hearts and minds of those left behind, unless and until he is acknowledged.
I found the book to be hopeful and refreshing, essential reading for parents, professionals and policy makers. In my behavioral pediatrics practice it is not uncommon for me to see a young child for "ADHD" evaluation who is described by parents in highly negative terms. As the "identified patient" he may have already been placed on medication by other clinicians. However, when parents are given the time and space to be heard by a person who is interested but not judgmental, they often reveal a history of family mental illness and significant trauma that has been kept secret for years, sometimes for generations. This information is essential for the family members suffering from mental illness who may now seek treatment. Equally importantly, when the child is released from carrying the burden of these secrets, her "true self," in the words of pediatrician turned psychoanalyst D.W. Winnicott, is free to emerge. This is the kind of honest family exploration Costello is advocating for. She writes:
I argue in this book that this stance of silence and secrecy is no longer a viable option, least of all for parents of young children in a family with a pattern of mental illness and addiction. Secrets can cause harm and even kill.
Costello takes on the highly charged question of "blame," She is in an excellent position to address this issue, as she took responsibility for her own lifelong struggle with depression and alcohol abuse in her journey to help her sons. She says:
If it's beginning to sound like I'm getting dangerously close to the historical tendency to blame parents for the psychological ills of a child, my answer is that to a certain degree, I am. In so far as I believe we've gone too far in the direction of "blaming" biochemistry and not taking responsibility for our own roles in shaping the health of our children's brains, I think we have to back up and reconsider. I'm advocating transparency and taking of greater responsibility by everyone-parents, extended family members, mental health practitioners, and our larger communities, including corporate healthcare and government-administered services-for the mental health of our children and future leaders.
She goes on to say that this translates into giving parents more support. Heading off the objection that "we cant afford it,"she offers stark numbers to depict the economic implications to failing to do so.
If we reduce the proportion of young people who become mentally ill by even one quarter, that would mean about 3.8 million saved each year from what can turn into a lifelong and expensive struggle. How expensive? The National Academies estimates that the total economic cost of mental disorders just among Americans under twenty-five was $247 billion in 2007.
Costello has a judicious approach to the contentious issue of psychiatric medication , showing how medication in the face of severe psychiatric illness may at times be essential not only for daily functioning but also for accessing other forms of help, such as insight oriented psychotherapy.

Costello does not address the issue of psychiatric medication in young children, but her view is implied in advocating for prevention. Starting as early as infancy, effective treatment for postpartum depression can give parents the opportunity to promote a child's health brain development, even in the face of a strong genetic vulnerability. She writes:
I've learned that although we're each born with with inherited liabilities and assets, throughout our lives, our minds become largely what we make of them. Put simply, nurture can trump nature. In some cases, it can turn even an inherited liability into a possibility-yes-an asset.
Costello vividly captures her own childhood experience which was "typically middle class."
But the visceral experience of growing up in my family consisted of thousands of moments of bone-chilling fear with no adult to help me cope.
In the concluding chapter, Costello outlines the top ten things a parent can do to safeguard a child's mental health. Costello is arguing that we as a society must work to support parent-child relationships. Every child should have the opportunity to grow up with an adult who can provide safety and security in the face of fear and stress. She advocates for a "fundamental shift in our orientation from doing things for our children to being there for them and us." Costello's recovery and the current successes of her two sons offer heartwarming evidence for the wisdom of this approach.

Monday, February 13, 2012

Childbirth: A Love Story (sometimes derailed)

She gazes into his eyes and speaks to him in soft murmuring tones. He follows her every move with rapt attention. For both, the other is a person full of light and color, while the rest of the world has faded to a kind of uniform pale background. She is obsessed by thoughts of him and worries that something terrible may befall him. He is constantly attuned to her whereabouts.

In this week of Valentine's Day, you might think I am describing romantic love. But I am, in fact, describing a mother and her newborn son. Physicians, nurses and other professionals who work with pregnant women and newborns have the frequent privilege of bearing witness to people falling in love. When all goes well, the period of time when a newborn, who is wired for successful communication from the start, meets his or her caregivers, is a time of joy and bliss.

It is particularly devastating, therefore, when this first communication, this early developing relationship, is less than successful. When this happens, it is often because of postpartum depression and/or anxiety, a very fussy baby, or both. In fact, these problems often go together, as stress in pregnancy, as well as psychiatric medication use in pregnancy, may be associated with irritability, poor sleep, and feeding problems in the newborn.

Traditionally, help for postpartum depression and anxiety has been aimed at treating the caregiver (usually the mother) with psychotherapy, psychiatric medication and support groups. Problems seen as residing in the baby are treated separately, usually by the pediatrician.

But if one thinks of these problems as disruptions in a love relationship, it makes sense to work with parent and child together (to continue the analogy- it's kind of like couples therapy.) Recent research suggests that working with mother and baby together, with the specific aim of supporting successful communication, may be effective in preventing long-term negative effects on child development. Among the more well studied of these interventions is the Newborn Behavioral Observations (NBO) system.The NBO is a set of 18 structured observations that to offer an opportunity for parents to learn about their newborn’s unique characteristics.

This tool was developed by J. Kevin Nugent and colleagues as a practical, clinical application of T. Berry Brazelton’s Neonatal Behavioral Assessment Scale (NBAS) Brazelton was among the first, in the early 1970's, to recognize the range of capabilities of the newborn, and their contribution to the parent-child relationship.

I am in the process of introducing this tool at Newton-Wellesley Hospital as part of the new Early Childhood Social Emotional Health Program. It is ideally done in the hospital when often both caregivers are present, and there is less time pressure and external stress than in an office visit. It can also be done in the home setting by home visitors. In addition, it can be done in the office setting up to about 3 months of age.

When I am consulted to do the NBO with a mother-baby pair, it never fails to be an exhilarating experience. I have been thinking about the reason for my intense reaction. When I am with a mother, particularly one who has been worried about her connection with her baby, as she experiences the way her baby responds to her voice, or learns about his ability to calm himself, or any other of a number of capacities revealed by the NBO, I am in the presence of a profound and deepening love relationship. No wonder it is a kind of a high that eclipses all other events of the day!

Wednesday, February 8, 2012

Toxic Stress and Survival of Our Species

Yesterday I listened to an important webinar from the Harvard School of Public health: Toxic Stress and Early Childhood Adversity: Rethinking Health and Education Policy. The forum centered on growing evidence that when young children experience a constant state of internal stress, it leads not only to mental health problems but long-term poor health outcomes in the form of asthma, obesity, diabetes and other chronic illnesses. Jack Shonkoff, a pediatrician and Director of the Center on the Developing Child at Harvard University, summed up the problem well when he said, in response to a question about growing and new external stresses like cyberbullying and the recent economic crisis, that "Toxic stress happens in the body." He went on to say that prevention of toxic stress is dependent on a child growing up in the company of a relationship with an adult/adults who offer a sense of safety in the face of external stress."

These words could have come straight from John Bowlby, considered to be the father of attachment theory. I summarize his work in my book Keeping Your Child in Mind as follows:
In England during World War II, as in most Western societies at that time, a mother was thought of mainly as a provider of the physical necessities of food and shelter. The mother–child relationship itself was accorded little value; children were routinely removed from their families to keep them safe, and hospitalized children were separated from their parents for long periods of time. D. W. Winnicott, a pediatrician turned psychoanalyst, was among the first to introduce a different way of thinking. He saw that children developed a strong, healthy sense of self when the people close to them accepted their feelings and helped to manage their emotional experiences. To describe this ideal situation, Winnicott coined the phrase “the holding environment.” The way in which a mother makes sense of her infant’s expression gives rise to what Winnicott referred to as the child’s “true self.”

John Bowlby, a British psychoanalyst and contemporary of Winnicott’s, observed the devastating effects of separating mother and child. He described the way a child keeps close to his mother in times of stress and fear as “attachment” behavior. Greatly influenced by Darwin, Bowlby postulated that this attachment relationship was essential to the survival of the species.
Shonkoff is saying the same thing, only now we have the scientific evidence, not available to Bowlby, of exactly how the species will become extinct if children do not have these secure, safe relationships. It will be through violence associated with mental illness, and death from chronic illness.

This is not a matter of shifting funding sources. This is a matter of survival of our species. As Shonkoff wisely said, "we find money to build prisons and cure cancer." Why then is it so hard to recognize the need to support young children? I believe it is linked to another phenomenon that I address in a previous post, namely prejudice against children. This phenomenon is described in the book by the late Elizabeth Young Breuhl, Childism: Confronting Prejudice Against Children. One particularly striking statement came from the moderator of the forum that could be seen as a reflection of this societal prejudice. Wondering about how pediatricians will be paid in keeping with the importance of their role in promoting early caregiver- child relationships, she said "the orthopedists aren't going to say "I'll get a paid less."" So now our survival is up to the orthopedists? Actually that is now in a sense true, as currently reimbursement is decided by the Specialty Society Relative Value Scale Update Committee, commonly called the RUC, which as was described in a recent New York times article, How One Group Sets Doctor's Pay. This committee has very few primary care clinicians. When it comes to policy changes, this might be a good place to start.

The policy statement upon which this forum was based comes from the American Academy of Pediatrics and calls upon pediatricians to take up this role as protectors of children from toxic stress. Over 40 years of attachment research that followed Bowlby's original observations offers solid evidence that secure attachment relationships develop when caregivers are able to listen carefully to their children, to reflect on the meaning of behavior, to, as I also describe in my book "hold their child's mind in mind." In order to support parent's efforts to be present with their child in this way, there must be a place for them to be heard, for their struggles to be recognized and understood. The primary care clinician's office can be such a place. As Dr. Block, president of the American Academy of Pediatrics, stated during the forum, a pediatrician should be able to spend 25-30 minutes instead of 10 listening to a parent. This is an excellent, very concrete plan (though 50 minutes would be better.) Next would come changes to our medical education system to value the role of taking time to listen as a form of healing. These would be small but important steps in the direction of insuring survival of our species.

Sunday, February 5, 2012

Meds for ADHD: They Work, But Is That the Right Question?

Recently my teenage daughter presented me with a moral dilemma. Up to one third of the kids in her high school are prescribed some kind of psychiatric drug, most of them stimulants like Ritalin. Many of the others students buy drugs from those who are getting them by prescription. If a person who has not been prescribed the drug takes it for the SAT's, is that cheating?

My reflexive response was "yes," but on further thought I wondered: If it has become so much the norm to be on stimulants, are the kids who are not taking them at a disadvantage? As my daughter wisely observed, anyone has trouble paying attention when sitting for a 5 hour test.

The point of this story is that there are serious long-term consequences to prescribing stimulant medication to large numbers of children. In addition to the above dilemma, by controlling symptoms with medication, the motivation to provide more comprehensive treatment is lost.

To the statement that they "work" I answer that yes, the drugs, at least in the short term, reduce symptoms of inattention and hyperactivity. They make a child conform to society's expectations. If medication helps a child to learn, then in our current educational and social system prescribing may be necessary. But is it right?

Bruce Perry, a psychiatrist who has developed a comprehensive treatment approach based on brain development captures this dilemma well when he writes:
Human beings are biological creatures. Of the 250,000 years or so that our species has been on the planet, we spent 245,000 years living in small transgenerational hunter-gatherer bands. The human brain has evolved specific capabilities that are hominid and pre-hominid adaptations to the millions of years of living in the natural world in groups of 40-50 individuals in these transgenerational groups.

The relationally-enriched, developmentally heterogeneous environment of our past is what our brain "prefers." Our brain is not well-designed for the artificial light, pervasive visual over­ stimulation from television, the distracting sounds, images, anonymous social interactions and host
of other phenomenon related to life in the modern Western world. The impact of the changes in the way we live, work and raise our children has not been completely examined. While well­ intended, many of our current lifestyle choices are likely contributing to the emotional, social, cognitive and physical health problems in our children. The most alarming is the relational poverty that many of our children are experiencing. This is most disturbing because humans are fundamentally relational creatures.
Relationship-rich interventions include such things as martial arts, music, and team sports (Michael Phelps had severe ADHD), activities that foster relationships and also promote self-regulation. Family systems are often severely strained when a child is struggling, and interventions aimed at supporting the family as a whole are very important. Careful examination of the school setting and accommodations to decrease over-stimulation are similarly necessary. But if the drug makes the symptom go away, there is no motivation to devote effort and resources to make these kinds of changes.

Obama's health care reform takes a small step in the right direction. ACO's (accountable care organizations), if they work the way they are intended to work, will encourage primary care clinicians to take the time to carefully listen to patients stories. In building relationships with parents, these clinician have the opportunity to support healthy development of the next generation in a preventive model.

Last week there was a little noticed news item about reports of the possible association between suicidal ideation and Focalin, a stimulant medication used for ADHD.
The FDA said it received eight reports of suicidal thoughts for children or adolescents who took the drug over the past six years, and four of the cases appeared to be linked to the medicine. The link for the remaining cases was less clear.
Kaitlin Bell Barnett, a journalist who writes very intelligently about psychiatric medication, asks on her facebook page "Based on 8 cases of suicidal thoughts ever reported?" I'm not sure what she meant by this question. But it seems to me that even 4 cases is enough to make us seriously rethink this path we are on to medicate away symptoms rather than address "relational poverty" in a meaningful way.