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, April 22, 2012

Engaging Our Right Brains to Support Parents and Children

"People have to feel something in order to change the way they think and behave." This is a quote from my book Keeping Your Child in Mind. The right brain is the seat of emotional regulation. Most, if not all, emotional and behavioral problems are intrinsically tied to the ability to regulate emotions. Changes in the brain can occur only if the right brain centers that regulate emotion are actually firing.

I was thinking about this idea when I attended an amazing conference at the Picower Institute for Learning and Memory at MIT, New Insights on Early Life Stress and Mental Health. Leaders from a range of disciplines presented the explosion of scientific evidence showing that early caregiving relationships have a significant long term impact on both mental and physical health.

MIT is a particularly left brain place, and there was a lot of hard core science at this talk. One speaker, Robert Anda, did inject a bit of right brain experience. Anda is one of the main authors of the ACES study, a powerful longitudinal research project that shows the cumulative effect of adverse childhood experiences, including parental mental illness, divorce, neglect and abuse, on many outcomes related to physical and emotional health. He used art to make our right brains fire. In a painting he showed, a little boy of about seven sat at the dinner table as his parents engaged in an argument, his father holding a knife and his mother's face distorted by rage. The terror on the boy's face was palpable.

The conference was very much framed around the concept of adversity. Anda kept apologizing for making us depressed. Consider the conference description:
Within the last two decades, scientists have begun to examine the biological repercussions of early childhood stress, and have uncovered clues as to how these early life experiences cause lasting changes in DNA and the brain that predispose individuals to disabling behavioral and psychiatric disorders in adolescence and adulthood.
The whole day I found myself thinking that what was missing was a right brain experience of what it feels like when things go well. We know it is bad for kids when they do not have a secure safe relationship. But what does it feel like when parents and children do connect in a way that makes a child feel safe and secure? Earlier in the day I had had the opportunity to share just such a right brain experience.

I had given Pediatric Grand Rounds at Newton-Wellesley Hospital, where I was introducing the scientific basis of my new Social Emotional Health program, where I see families of children under age six. When families come to see me, parents and children feel sad, angry, and out-of-control. By carefully listening to parents' own experience I help them to reflect on the meaning of their child's behavior, rather than responding to the behavior itself. This approach is founded in decades of longitudinal research at the intersection of developmental psychology, neuroscience and genetics that I describe in my book.

I told my audience the story of a visit with a mother who experienced her 3-year-old son's behavior as an assault. I had reframed the child's behavior in these out-of-control moments as helpless rather than defiant. She said, "I know what you mean." She described one moment when, rather than getting angry, she had held her son firmly on her lap and said gently "What's wrong?" She told me how her son "melted in my arms" and replied softly, "I don't know."

This mother felt this change not only in her brain, but in her body. It is not uncommon for parents to have themselves experienced trauma in early relationships. They react to their child's provocative behavior on a physical level that is related to their own history, not to the child. By carefully listening to parents, in a visit that is not fifteen minutes but an hour, I help them to make these connections. Once their own issues are in a sense moved out of the way, they are free to reflect on their child's experience in a way that is not encumbered by their own trauma history. When a child feels understood in this way, his behavior improves. A positive cycle of interaction is set in place.

When I told this story during Grand Rounds, I felt a tingling in my arms as I spoke of this mother's transformation in my office. The visit with that family had been a powerful experience for me. The fact that I felt something in the telling makes me hopeful that I was able to convey this to my audience. Maybe they understood how this kind of careful listening may actually change brains.

My book is full of stories like this one. If we are going to change this path that was described at MIT, of early childhood stress leading to terrible outcomes, these conferences need to include stories of what goes right; when clinician-parent-child connect in a meaningful way. Once we know what this feels like, we will be closer to understanding what we need to do to set children and families on a better path.

Saturday, April 14, 2012

Psychiatric Medication For Children? Important New Book Gives Pause

Two things most stood out for me in Kaitlin Bell Barnett's new book Dosed: The Medication Generation Grows Up. The first is the stories of women struggling to get off of SSRI's (selective serotonin re-uptake inhibitors), started in early adolescence, when they decide to get pregnant. The second is Bell Barnett's review of the literature regarding sexual dysfunction as a side effect of SSRIs in adolescence.

The book as a whole has much to say that is very important. As I write in my blurb for the cover:
Dosed is a fascinating, well-researched, and very important book. After reading it, I hope that no parent, pediatrician or psychiatrist will give psychiatric medication to a child or adolescent without very careful consideration of the potential long-term consequences. Bell Barnett shows that these medications are often not a ‘quick fix,’ but rather have deep, lasting impact, not only on physical and emotional health, but also on a person’s core sense of self.
Bell Barnett is a journalist who was herself started on SSRIs as a teenager. Her book intertwines in depth interviews with people who were started on psychiatric medication in childhood and are now young adults, with a journalistic study of the history of psychiatric medication use in children. I could probably write several posts covering all the important issues she addresses, but have chosen to focus on these two.

I first learned of the emerging evidence that SSRIs may cause long term sexual dysfunction last fall when I attended a talk by Robert Whitaker, author of the controversial book about psychiatric illness and medication Anatomy of an Epidemic. I was so alarmed about this data that I wanted to immediately write a blog post about it. But shortly after that talk I received the galleys of Bell Barnett's book. I discovered that she has a through review of the rather scant literature on the subject along with some very poignant stories, so I decided to wait until her book came out. I recommend that anyone who is concerned about this issue (as anyone who takes or prescribes these drugs should be) read her book. The subject is covered in the chapter entitled "Side Effects." Here are a few sample quotes.
A comprehensive review of the literature conducted in 2004 found just one clinical trial that reported erectile dysfunction in a teenager; most clinical guidelines and reviews of SSRIs didn't mention sexual side effects at all.

This is pretty shocking since, as the authors of the study cited above noted, anywhere from 30-40 percent of adults experience some kind of SSRI induced problems with libido, arousal, or orgasm.
And this important point:
Despite the lack of formal studies involving young people, anecdotal evidence suggests that drugs causing decreased libido and sexual dysfunction do sometimes pose a real problem, psychologically and socially, both for teenagers who are in the process of developing a sexual identity and for young adults testing out long-term intimate relationships.
And this from Elizabeth, who started taking SSRIs in 9th grade:
I am not sure I can [over]state the extent to which it impacted things. I didn't grow up with a normal sex drive, and that was obviously due to a combination of factors, but being on and off antidepressants whose impact I really couldn't understand back when I didn't have any real understanding of my sex drive or sex in relationships to begin with means I basically went through adolescence without experiencing anything in that realm in a "normal' way.
There's more, but the bottom line is that this issue is not well studied and yet of major significance in adolescent development.

Bell-Barnett poignantly captures the challenges faced by her interviewees who were started on SSRIs in childhood and now want to have children. Aware of the potential effects on the developing fetus, they try to get off the medication, but rebound with debilitating symptoms of depression. SSRIs are one of the most common medications prescribed in pregnancy. Yet we really do not know what the effects are on the developing fetus. A policy statement put out by the American Academy of Pediatrics earlier this year points to evidence that SSRI use in the third trimester is linked to a constellation of neonatal signs and symptoms. We do know that maternal depression itself can have a negative impact on the developing fetus. So if a woman is already on SSRIs and develops symptoms of depression without them, it may be best to stay on them during pregnancy.

The take home point of Bell Barnett's book, however, is that this issue needs to be considered by parents and clinicians when girls are prescribed these medications in childhood and adolescence well before having children is on their minds. These medications have a great allure as they may very quickly resolve symptoms. But one thing that Bell Barnett makes clear, and that is also supported by the literature, is that getting off these medications is very difficult.

Certainly these children and teenager should get help if they are struggling with depression. But other forms of intervention, including psychodynamic psychotherapy combined with self-regulating activities such as yoga, offer an alternative to medication. There is a severe shortage of quality mental health services due in part to the influence of the health insurance industry. It is a complex issue that must be addressed at the level of health care policy.

Large-scale use of these medications has major life-long impact on identity and sense of self of the current generation, referred to as "Generation Rx." Considering the complex issue of SSRIs in pregnancy, there is also potential for significant impact on the next generation. The time to pay attention to this problem is now. Reading Bell Barnett's book is a good place to start.

Saturday, April 7, 2012

Relationships: The Fourth Vital Sign

Respiratory rate, heart rate, blood pressure- these are the three vital signs that those on the front lines of health care are well trained to measure as initial assessment of a patient. Given the explosion of knowledge emerging at the intersection of neuroscience, genetics and developmental psychology about the essential role of early caregiver-child relationships on lifelong health, it is time to add a fourth vital sign- relationships. I first learned of this idea from a colleague, David Willis who is Chair of the American Academy of Pediatrics (AAP) Early Brain and Child Development Initiative. He in turn learned it from Colleen Kraft. Adding this fourth vital sign puts assessment and support of early relationships front and center.

The recent AAP policy statement Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health captures the critical role of relationships in healthy development.
In contrast to positive or tolerable stress, toxic stress is defined as the excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships..toxic stress early in life plays a critical role by disrupting brain circuitry and other important regulatory systems in ways that continue to influence physiology, behavior, and health decades later.
A remarkable study coming out of the Yale Child Study Center and described in the New York Times last week shows the wisdom of this focus on relationships. It was a randomized control study of the Child and Family Traumatic Stress Intervention(CFTSI). Children who received the intervention were 65 percent less likely than those in the comparison group to have developed full-blown post-traumatic stress disorder and 73 percent less likely to experience partial post-traumatic stress disorder. These are the kind of numbers that make one stand up and take notice.

What makes this intervention different is that it specifically works with caregiver and child together to support the caregiver's efforts to understand the meaning of the child's behavior.
Unlike traditional counseling, which is often unstructured and prolonged and may not involve both child and caregiver, this program follows a proven pattern: first a session with the caregiver, then one with the child, then two sessions with them together.
Steve Marans, lead author on the study, explains the results.
When children are alone with and don’t have words to describe their traumatic reactions, symptoms and symptomatic behaviors are their only means of expression. And caregivers are often unable to understand the connection between the traumatic event and their children’s symptoms and behaviors. To heal, children need recognition and understanding from their caregivers.
These remarkable results make perfect sense to me. Children want to be understood by their parents, not their therapist. This is the model I have been using for years in my pediatric practice to address any behavioral symptom, not only those associated with trauma, and I too have had remarkable results. It is wonderful to see this approach validated by a high quality randomized control study. As I write in my book Keeping Your Child in Mind
Being understood by a person we love is one of our most powerful yearnings, for adults and children alike. The need for understanding is part of what makes us human. When our feelings are validated, we know that we’re not alone. For a young child, this understanding helps develop his mind and sense of himself. When the people who care for him can reflect back his experience, he learns to recognize and manage his emotions, think more clearly, and adapt to his complex social world
This concept of supporting parent's efforts to reflect on the meaning of a child's behavior comes out of decades of research showing how this kind of understanding promotes health development at the level of gene expression and biochemistry of the brain.

When baby is born, if heart rate, respiratory rate and blood pressure are OK, our next priority is to support the primary relationships by carefully listening to both caregiver and baby. One way to accomplish this is to use a wonderful tool the Newborn Behavioral Observation system, developed by J.Kevin Nugent, colleague of T. Berry Brazelton. If problems are identified, such as a biologically vulnerable child whose cues are hard to read, or postpartum depression, or lack of social support for mother, we can address them. We will then be setting this new life out on a course of healthy development from the start.

Sunday, April 1, 2012

Animal Therapy for Children (and Parents)

Recently there was a beautiful article, Wonder Dog , in the New York Times magazine about an emotionally troubled boy who was helped significantly by a devoted dog. I thought about this story this past week when my beloved dog, a lab-border collie mix who we adopted 9 years ago at the age of two , died rather suddenly. It turns out he had a tumor on his spleen and bled internally-at least it was quick and painless.

The thing is- he really helped me out with my emotional regulation, especially in my role as mother to my daughter, who as a young teenager had an incredible capacity to push my buttons. In the interests of full disclosure, I also had a lot of help from a wonderful therapist in understanding the roots of this issue. But Jasper was there with us on the front lines.

Whenever we would get into any kind of conflict and I would start to raise my voice, Jasper would immediately get up from his dog bed and come and lie right next to me. At once I would feel calm. My breathing slowed and I am quite sure my blood pressure went down. Rather than continue to butt heads with her, I would be able to think more clearly about what was happening and to reflect on the meaning of her behavior. Often I could identify some event in her life that was causing her stress and anxiety that she was now taking out on me. I was able to remain calm in the face of assault. Jasper helped me to much more rapidly defuse these encounters.

Now that he is gone, I think of his beautiful soulful eyes and his oh-so soft head, and I hope that I have internalized his presence enough that I can just think of him to gain that calm feeling. My daughter is older now and she herself has learned to regulate her own emotions. Part of this is simply development and maturation. But to some degree I believe she has learned this from me, and I in turn learned it in part from Jasper.

In my book, Keeping Your Child in Mind, I talk about how parents themselves need to find ways to manage their own emotions in order to be present with their children in a way that promotes healthy development. This involves having someone to hold them in mind, be it a spouse, friend, family member or therapist. I should add animals to that list.

The therapeutic value of animals for children is well known. I often recommend horseback riding as an activity for children with problems of emotional regulation. Child psychiatrist Bruce Perry, in his description of the Neurosequential Model of Therapeutics that he developed for working with traumatized children, writes:
Dogs have the capacity to provide the unconditional accepting and repetitive nurturing experiences required to help some of these children.
The wonderful documentary film Buck, clearly demonstrates how Buck's close relationship with horses has helped him to recover from the severe physical and emotional abuse he experienced as a child. He now uses this experience to help others. In training workshops he runs all over the country he shows the importance of managing your own emotions in order to be present with your horse in a way that helps him to manage his. It's an amazingly similar concept to my book!

If your child wants a dog, and you worry that you will "get stuck" taking care of it, remember that the dog can be a wonderful asset for the whole family. I know it will take our family a long time to heal from this terrible loss. I would often say to Jasper, "You are truly a good person ( as dog)." I hope that in writing this I can to some degree immortalize his gifts to us.