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, March 25, 2012

Possible Lessons From a Teenage Suicide

About three years ago an eighteen-year-old girl committed suicide several days after being admitted to a Boston area psychiatric hospital. A year later her family filed suit against her psychiatrist, who had seen her for one and one half sessions. The case went to trial this winter, and he was exonerated. Recently I was speaking with his wife about the case. "Nothing good came of it," she said. The girl is still dead, huge amounts of money were spent, and three years were taken from the life of my friend and her young family.

The case became public record once the suit was filed. My friend, a minister, spoke about the experience in her sermon at the time of the trial, hoping perhaps to find some life lesson in the experience. As I listened to her describe the event, her emotional pain still so fresh in her telling, I, too, was moved to try to capture it in writing.

I start by borrowing from her sermon. She poignantly describes her husband two days after the girl killed herself. He was at a party, "surrounded by friends and holding our newborn son and nonetheless looking stricken." The real tragedy of the story is, of course, the death itself. But unfortunately it became a story about other things, namely guilt, blame and responsibility.

In her sermon my friend vividly portrays her efforts to find empathy for the girl's mother.
I spent most of this past week in court with Jim, and I’ve searched my heart for the gesture Jesus hands down to us, a gesture of compassion: “My heart goes out to you.” It was there early on, but following her testimony, by which it’s become clear (at least to me) that Jim was not the problem, I can only muster such compassion when I’m removed from the situation, physically out of that courtroom: “My heart goes out to you.” But when I’m there, sitting close enough to touch her, where she sits in front of me, shoulder-to-shoulder with her gentle-faced second husband (her first having himself died from self-hanging), I haven’t got it. I haven’t got it to offer.
My friend told me of her sense that this mother was unable to think about her daughter. The mother seemed to have an image of what her daughter was or should be that did not consider her child's perspective. As an example, my friend told of the mother's insistence that her daughter's private journal be admitted as evidence in the trial.

Even though I don't know any of these people, I felt this overwhelming wish to have had time with this mother before her daughter died. Would empathy then have helped her to hold her child's mind in mind ? What in her life had caused her such pain that she was unable to do this?

For I am certain that mothers never want to hurt their children. No matter how horribly a mother speaks about or behaves towards her child, given the time and space to be heard, I believe it is possible to uncover the hurt in her own life that is making this task of holding her child in mind so difficult. But the staff at the hospital didn't have time to even try. As my friend said, "They didn't know they were working on a deadline."

But now it was too late. The girl was dead. And because the mother was on the attack, specifically attacking my friend's husband, empathy was not an option. If blame must be laid for this sad situation, I would place it on the lawyer who took the case. How could someone who saw her for less that two hours possibly be responsible for a eighteen year life?

My friend described the cross-examination of her husband. The girl had missed her last session. She had also missed the previous session, and he had gone to find her. The second time he chose not to go after her, because, as he explained to the court, she had said she didn't trust him. She probably wouldn't feel comfortable being actively chased down by a man she didn't trust.

The plaintiff's attorney asked him what he had done during that time. He answered that he had reviewed her chart and thought about her. The lawyer asked, with a sneer that my friend vividly conveyed, "You thought about her?' Her husband calmly looked him in the eye and said simply, "Yes."

Sunday, March 18, 2012

Taylor Swift Captures Secure Attachment Relationship

If my book, Keeping Your Child In Mind, were to have a theme song/video, it would be Taylor Swift's The Best Day. I have included the lyrics below, but suggest watching and listening (with tissues!) It offers a "right brain" emotional experience of what D.W. Winnicott termed the "holding environment." As I write in my book:
Winnicott describes this way of being with a baby as the “holding environment.” The mother’s ability to tolerate and contain her baby’s distress helps him to make sense of and learn to manage his experiences. Even though holding a baby may seem to be simply a physical act, it is her emotional presence that is important to the baby.
The video speaks for itself, but here are a few points that stood out for me.

As a young child Taylor's mother physically contains her after a long day playing outside: "I hug your legs and fall asleep/
on the way home" She feels safe and secure with her mother who is "not scared of anything at all."

The video captures the way in which she was included in the arrival of her baby brother. Her love for him is clear in the later lyrics, "Inside and out, he's better than me."

At thirteen she experiences inevitable social trauma, with her friends being "so mean.". Her mother does not try to fix it. Rather, Taylor receives her mother's undivided and playful attention as they go for a ride in the car. One feels confident that though, as she says, "Don't know how long it's gonna take to feel okay," Taylor, refueled and fortified by mother's love, will work it out herself.

While the song is primarily about her mother, Swift brings in her father "whose strength is making me stronger."

Overall, the video perfectly captures the great value of simply being present with our children. In our culture of "advice" about "what to do" about any range of problems, this is a breath of fresh air. The challenge is clear our own minds and lives enough to offer our children this kind of holding. If we can, we are setting the foundation for their healthy emotional development and future success, in every sense of the word.

The Best Day

I'm five years old
It's getting cold
I've got my big coat on

I hear your laugh
And look up smiling at you
I run and run

Past the pumpkin patch
And the tractor rides
Look now -- the sky is gold
I hug your legs and fall asleep
On the way home

I don't know why all the trees change in the fall
I know you're not scared of anything at all
Don't know if Snow White's house is near or far away
But I know I had the best day
With you today

I'm thirteen now
And don't know how my friends
Could be so mean

I come home crying and you hold me tight and grab the keys

And we drive and drive
Until we've found a town
Far enough away

And we talk and window-shop
Until I've forgotten all their names

I don't know who I'm gonna talk to
Now at school
I know I'm laughing on the car ride home with you
Don't know how long it's gonna take to feel okay
But I know I had the best day
With you today

I have an excellent father
His strength is making me stronger
God smiles on my little brother
Inside and out
He's better than I am

I grew up in a pretty house
And I had space to run
And I had the best days with you

There is a video
I found from back when I was three
You set up a paint set in the kitchen
And you're talking to me

It's the age of princesses and pirate ships
And the seven dwarfs
Daddy's smart
And you're the prettiest lady in the whole wide world

Now I know why all the trees change in the fall
I know you were on my side
Even when I was wrong
And I love you for giving me your eyes
Staying back and watching me shine

And I didn't know if you knew
So I'm taking this chance to say
That I had the best day
With you today

Tuesday, March 13, 2012

Behind the Scenes Look at ADHD Treatment

Recently I went to a talk given by a local "ADHD (attention deficit hyperactivity disorder) expert" to a group of primary care pediatricians. The aim of the talk was to guide these practitioners in doing "ADHD evals" given the time constraints of primary care practice.

"Its all about the rating scales," he said. "You need to train your staff to give out the right scales. The key to working kids up is getting the scales done ahead of time. Nothing happens in the office."

This doctor proudly displayed his version of the main rating scale, the Vanderbilt, which he has divided into two time slots, because "kids have different symptoms at different times of day." Evaluation and treatment of ADHD consists primarily of scoring rating scales, making a decision to use medication, and once the decision is made, having follow-up visits every three months to adjust medication dose according to symptoms and side effects.

One pediatrician, someone for whom I have great respect as a clinician, was alarmed about a 5-year-old who was placed on a very high dose of medication by another doctor. When I asked her what was going on in the child's life that might cause him to have so much trouble, she didn't know. She had changed the medication, which did in fact improve the child's symptoms. Her approach is the standard of care in pediatrics.

In other areas of medicine, we treat the underlying cause, not just the symptom. In treating bacterial pneumonia, for example, we use an antibiotic, not a cough suppressant. The Vanderbilt lists symptoms of problems with regulation of behavior, emotions, and attention, which together may be labeled as ADHD. The question should be not “How do we control the symptoms?” but rather “What is making self-regulation difficult for this particular child?” followed by “What can we do to help promote self-regulation?”

Recently I saw several children who had been diagnosed with ADHD but medication "didn't work". One mother told me about her own struggles with untreated depression. Another child spent weekends with an actively drinking alcoholic father. A third child quietly spoke with her mother of being frightened when she pulled her hair and hit her.

Nowhere on these rating scales does it ask about family history or life stressors. According to the current standard of care it is possible to diagnose and treat ADHD without ever learning about any of this history. Detailed family history (see previous post), as is well described in the book A Lethal Inheritence, is essential to diagnostic evaluation. In addition, detailed early developmental history may reveal significant sensory processing problems that have been unrecognized.

When I have written about ADHD in the past, I usually get a number of angry responses from parents who say everything is fine in their family and I shouldn't blame them for the problem. In my experience, about 10 % of kids seen for "ADHD eval" have what I refer to as "straightforward ADHD." They have symptoms and an extensive family history of inattention and/or hyperactivity with no other issues. If you are in that 10%, this blog post is not about you.

Giving a list of therapists does not solve the problem, because the child is usually the "identified patient." Family therapy can be an important component of treatment when a child struggling with self-regulation, as is well described in the recent book, Suffer the Children: The Case against Labeling and Medicating and an Effective Alternative. Furthermore, once a child is placed on medication, his behavior is "better" for the short term and the motivation to do the more challenging, time intensive work to uncover the cause is lost.

The term "ADHD eval" implies only two options- a child does or does not have ADHD. It leaves no room for curiousity about the meaning of behavior. Then there is the term "co-morbidity." This simply offers the opportunity for more labels without exploring the cause of symptoms.

There is a reason why, as one of the pediatricians at this presentation bemoaned, a parent may say, "by the way" just when when a doctor has his hand on the doorknob to leave. It takes time to develop sense of safety and trust to be able to say what's really important.

Fortunately I work in a practice that is open to a different approach. Here are some initial changes I propose:
1) Schedule the visit as "evaluation of problem of attention, behavior and emotion," or more simply "behavior problem,"rather than "ADHD eval"

2) Have a minimum of two 50 minute visits for an evaluation

3) See parents alone without the child for the first visit. Aim to include both parents whenever possible

4) Goal of initial evaluation is to get detailed family and social history, and to offer parents an opportunity to be heard. Very often the parent and/or couple need support and possibly referral

5) Medication may be considered for an older child if he is unable to learn or function in a social environment without it. Equal attention must be given to other interventions, including addressing diet, sleep, and physical activity
Such an approach involves a change in expectation on the part of parents, teachers and clinicians. Parents are often under tremendous pressure from teachers to get a prescription for medication.

Stanley Greenspan's book Overcoming ADHD: Helping Your Child Become Calm, Engaged, and Focused--Without a Pill offers an excellent holistic approach that is founded in quality scientific research. One key component of his treatment is to support "reflective thinking." This involves helping a child to recognize both his strengths and challenges, and to develop strategies to manage his own unique vulnerabilities.

"We don"t have time" is not an acceptable answer. Changes must be made in our healthcare system to insure better reimursement for time spent listening in this way, and to improve access to quality mental health care services.

This is child's life we are talking about. If the root cause of the problem is not addressed, there may be years of medication adjustment until something bad happens- car accident, school failure, violent crime, prison. If I sound alarmist, it is because I am alarmed. The current standard of care of ADHD treatment, particularly now that diagnosis is extended down to age 4, effectively silences huge numbers of children. We need to give these children a voice.

Wednesday, March 7, 2012

Pregnancy Loss and Postpartum Depression

Lately, following conversations with colleagues and patients, I have been doing a lot of thinking about pregnancy loss. In particular I've been wondering about its effect on subsequent term pregnancies, and relationships between parents and these children. In researching this subject, I came upon a study from 2011 in the British Journal of Psychiatry showing that depression and anxiety following a miscarriage may last for almost three years, even after the birth of a healthy baby. Researcher Emma Robertson Blackmore, PhD, an assistant professor of psychiatry at the University of Rochester Medical Center said of the study:
Health providers and women themselves think that once they have a healthy baby after a loss, all would be fine and that any anxiety, fears, or depression would go away, but that is simply not the case. I honestly thought that once a woman had a baby or had gone past the stage of her previous loss, the anxiety and depression would go away, but these feelings persist.
As a culture we often do not recognize the deep significance and impact of pregnancy loss. I still vividly recall my own family's well meaning reassurances of "don't worry you'll get pregnant again," that seemed so remote from the pain I felt following an early miscarriage.

In my work as a behavioral pediatrician, I frequently hear stories (identifying details, as always, have been changed to protect privacy) from mothers who have not had the opportunity to mourn the loss of a pregnancy. One mother told me about of having lost a baby at term and then suffering with severe postpartum depression (PPD) when her healthy child was born a year later. A five-year-old girl I saw struggled with severe separation anxiety. At first the focus of our work was on what to do to get her to sleep in her own room. But as we got to know each other, her mother, for the first time, spoke openly about her grief over a miscarriage when her daughter, an only child, was three. The little girl, it turned out, was worried about her mother. At the root of her separation anxiety was a wish to to protect her mother from feeling sad.

Mental health professionals who work with adults describe the phenomenon of the "replacement baby." These are adults who were born following the death of a previous child. When parents have not spoken of this child, or have not been able to fully grieve this loss, it may have significant long-term effects on the mental health of subsequent children. These effects may, in fact, persist for generations. One mother I worked with was such a "replacement baby." Her older brother had died at birth several years before she was born. When I saw this family, her son was 8 years old and the whole family was struggling. Separation anxiety was again the presenting problem. The marriage was strained because this mother had such an intensely close relationship with her son that her husband felt excluded. I learned that this son was named after her dead brother.

Interestingly, when I googled "pregnancy loss and postpartum depression" most of what I found asked if women could have postpartum depression following pregnancy loss. I think that both in terms of how we understand and how we treatment of these problems, it is important to think of them as two distinct and different phenomena.

Certainly a woman may slide from grief into depression following the loss of a baby. This may occur if the loss triggers memories of other losses, if she does not have an adequate support system, or there are other significant stressors in her life. But postpartum depression, as I describe in my previous post, is specifically a problem in a relationship. Untreated PPD often has significant long-term sequelae for the baby. Treatment of pregnancy loss focuses on the mother, while treatment of PPD needs to include the baby from the beginning.

What can we learn from these stories? As Massachusetts is currently working to address the issue of postpartum depession via the PPD commission, one very concrete we can do is to identify mothers who have had previous pregnancy loss, and especially those with multiple pregnancy losses and/or a stillbirth, as being at high risk for developing PPD. We can make sure that these mothers do not "fall through the cracks." One mother poignantly told me that because of a change in health insurance plans when her child was an infant, she was forced to give up the relationships with her health care providers that were very important to her, just at a time when she was most vulnerable.

Even before that, friends, family members, religious organizations and health care providers can be attuned to the nature of the trauma of pregnancy loss. Women themselves need to feel the right, and be given the space, to grieve a pregnancy loss. While the effects of such a loss can linger in any circumstances, it is unacknowledged and unprocessed grief that has to potential to have the tightest grip on people for years to come.

Thursday, March 1, 2012

Postpartum Depression: Bringing in the Baby

I recently had the privilege of being appointed to the Massachusetts Commission on Postpartum Depression (PPD). The Commission, co-chaired by Rep. Ellen Story (Amherst) and Senator Thomas M. McGee (Lynn), is charged with making recommendations to the Department of Public Health and the MA State Legislature on advancing best practices regarding PPD screening, treatment and public and professional education. I am on the public education subcommittee.

Lately I have been writing a lot about love, and this new role brings me again to this subject. When we support caregivers (I use this word rather than mother, as while the primary caregiver is usually the mother, it may be the father or another relative) who are struggling with postpartum depression, we are dealing with disruptions in passionate love relationships. Depression is, in fact, only one potential cause of such disruption. Perhaps our conversation should focus on relationships from the beginning. Education material about PPD does address the impact of PPD on child development, but the language is often focused on the caregiver, rather than the caregiver-child relationship.

Across the ocean in Scotland my friend and colleague Suzanne Zeedyk has had a good deal of success in calling attention to the need to support early parent-child relationships. The departments of education, health care, finance and even law enforcement are on board in recognizing this need. On her website under "what I do" she writes:
Science is helping us to better understand how relationships shape the development of human brains and human communities. I make this knowledge understandable for parents, professionals and policymakers
Suzanne has created a beautiful DVD, The Connected Baby. There is a live streaming of the film today March 1st on the blog Mothering.com. One segment entitled "The Dance of the Nappy" films a mother changing her baby's diaper, interspersing commentary. In this simple and elegant way she shows the exquisite attunment between mother and baby that goes on in countless minute to minute interactions throughout the day. It is in this relationship that a baby's brain grows and develops. It is how he develops a sense of himself.

Her film does not address disruptions in relationships. But it is only a small step from there to understand that if a mother is depressed or anxious, or in some other way preoccupied, this dance will be significantly altered. Equally important to consider is the way in which qualities in the baby may disrupt the dance. In my previous post I wrote about regulatory and sensory processing difficulties. A baby may be sensitive to touch or sound, or struggle going from awake to asleep, or any of a range of qualities that may make negotiating the big, loud, complex world more challenging. If, in addition, his caregiver is struggling with depression, the dance may be further disrupted. Or the problems in the baby may cause depression in the mother, as when the baby cries all the time and the mother never sleeps.

When these disruption are not addressed early, significant problems may develop. As I write in my book Keeping Your Child in Mind:
When I see older children for behavior problems, I often hear stories from mothers who struggled terribly when their children were very young infants. Sometimes the memories are vague, but these mothers often recall vividly the sense of being completely alone. The most dramatic example of this was a mother with severe postpartum depression whose father suddenly died when her baby was three 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, mother, and extended family, she no longer felt so terribly alone. In order for mothers to be available for the kind of preoccupation their newborns need, they must not be left alone. If I were to give one piece of advice to mothers, families, and our culture as a whole, it would be to recognize that although what a mother does with her newborn may look ordinary, it is in fact extraordinary and deserves to be valued as such.
The MA commission is doing important work to call attention to this issue of PPD that is so critical not only for the health and well being of new mothers and fathers, but for the next generation as well. This commission offers an important opportunity to broaden the conversation. An investment in resources that support early caregiver-child relationships is an investment in the future of our country.