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.

Tuesday, February 26, 2013

What is psychoanalysis?


Five days a week on the couch may be a rarity, but in our quick-fix culture, where we are more inclined to "manage" behavior than to understand it, psychoanalytic thought is more important than ever. There is an ongoing discussion in the psychoanalytic community about professional standards. One person raised the question "What is psychoanalysis?" The answers in the ensuing conversation for the most part refer to on-the-couch long-term therapy, a valuable but marginalized form of treatment.

 As a non-psychoanalyst treating children and families in the "real world," I hope that the psychoanalytic community will keep an eye out (or both eyes out) for the goal of insuring that psychoanalytic ideas continue to be part of mainstream thinking. One colleague of mine refers to this approach as "psychoanalysis off the couch."

Towards that end, I was moved to compile a list of what I think are the most important psychoanalytic ideas (along with the person to whom the ideas are originally attributed.)

1) Symptoms have meaning

This meaning is often out of awareness, or "unconscious." This idea is particularly important in a culture where symptoms are managed with medication without effort to discover meaning. For example, the current issue of Child and Adolescent Psychopharmacology News has an article entitled "The Use of Pharmacological Agents to Treat Aggression: Is it Time to be Thinking about a Mechanism?" The author acknowledges the lack of evidence for efficacy of drug treatment, and suggests further exploration of the biochemical mechanism of action of the drugs.

Every young patient I see with aggressive behavior has a complex history. This may include biological vulnerabilities represented by sensitivity to sensory input, environmental stressors such as marital conflict or witnessed domestic violence, or even a history of abuse. The idea that we can address these problems simply by finding the drug that affects the pathway in the brain for aggressive behavior is, at this stage in our knowledge of neuroscience, pure fantasy. We can only address the symptom of aggressive behavior by understanding the underlying cause.

2) The holding environment

The original holding environment is that provided by the primary caregiver, where the whole of a child's experience, including both loving and aggressive feelings, is tolerated and contained. In providing this holding environment, the caregiver helps the child to make sense of and manage his or her unique experience of the world.

In clinical work,  the holding environment is the setting;  a quiet space and time with a trusted person who accepts and contains difficult feelings. In my office at Newton-Wellesley Hospital's Early Childhood Social Emotional Health Program I have a special room for mothers and babies that has pastel rugs and soft chairs. It is quiet, private, and filled with light from a large window. One of my young clients called it a "feel better room." I think of it as a holding environment, where both mother and baby can feel safe, contained and understood.

3) All psychotherapy is about mourning

This does not necessarily mean a death, but may refer to a range of issues including troubled past relationship or even war trauma. I vividly recall  the first case that led me to understand my work in this way, and since then I have come to recognize that tissues are my most important piece of office equipment.

When I first began studying psychoanalytic thought as a  scholar with the Berkshire Psychoanalytic Institute, I was working with a five -year-old boy in my general pediatric practice whose intense sibling rivalry with his younger sister was a source of great stress for his mother.  His relentless need to be first was increasingly disruptive to the day, often making it difficult get out of the house. His mother knew me well, as I had taken care of both kids since infancy. At a full hour visit devoted to discussion of this issue, she suddenly became tearful.  She told me that her older brother had been killed when she was a young child. Her family had never mourned this loss and had simply tried to run away from it. The task of mourning her brother had in a sense been deposited in her son, and was now represented by his symptom. Once her feelings were put in their rightful place, the intense sibling rivalry subsided and returned to a normal level, which she was well able to manage on her own.

4) Disruption and repair
     Ed Tronick

Embedded in this construct is another important contribution of Winnicott's- the good-enough mother. I summarize both ideas in my book Keeping Your Child in Mind:
Research by psychologist Ed Tronick and his colleagues provides evidence that supports Winnicott’s idea that the good- enough mother, the mother who fails at times to be attuned to her child, facilitates her child’s healthy development. Tronick refers to moments of disruption, similar to Winnicott’s “failures of attunement.” Tronick and his colleagues videotaped minute-by-minute interactions between infants and their mothers. His research has demonstrated that these moments of disruption can actually enhance development of emotional regulation. Mismatches, when they are recognized and repaired, increase a child’s sense of mastery and confidence in his ability to cope with difficult feelings. The accumulated experience gained from dealing with and repairing multiple mismatches, or disruptions, become part of the infant’s way of relating to other people.
Puting all four ideas together, it is important to recognize that behavior has meaning, and that to discover that meaning, which is often linked to loss and/or trauma, there needs to be a holding environment.  Things will inevitably go wrong in relationships, but if people can reflect on what went wrong and repair the disruption, they will have the opportunity to grow through the process, and will likely end up in a better place.


Tuesday, February 12, 2013

Preschool ADHD, preterm babies, and T. Berry Brazelton

There are two important studies published in the latest issue of the Journal of the American Academy of Child and Adolescent Psychiatry. First, the PATS (preschool attention deficit/hyperactivity disorder treatment study) showed that at 6 year follow-up the treatment, consisting of medication and/or behavior management, was not working. Ninety percent of children continued to experience symptoms 6 years after diagnosis and ongoing treatment. This is because the current standard of care does not look at the cause of the symptoms, as I have written about repeatedly on this blog and in my book Keeping Your Child in Mind. Here is an example of  a story from a previous post.
Tears ran down Elena’s cheeks as she described being so overwhelmed and full of rage that she forcefully held her fully clothed 4-year-old son, James, under the shower when he wouldn’t go to bed. Later in the same 50-minute visit she revealed that she had suffered years of physical and emotional abuse as a child. As is typical of visits to my behavioral pediatrics practice, she had brought James because he was “defiant.” “Something must be wrong with him,” was followed by, “Tell me what to do to make him listen.” James’ preschool teachers, who were having trouble managing his behavior, had suggested that he might have attention deficit hyperactivity disorder (ADHD.) They recommended to Elena that medication be considered. They knew nothing of this history. My wish in listening to this story is not to judge, but rather to understand the experience of both mother and child.
As I elaborate in more detail in that post, this prescribing of medication to young children represents a prejudice against children. A colleague described it as a massive exercise in societal repression.   Hidden abuse is an extreme example. It may be simply that the classroom environment is not suited to the child's particular vulnerabilites. There are countless different stories in between. It is not surprising that without an opportunity to hear these stories, medication and behavior management would fail to alleviate symptoms.

Second,  less well-noticed but perhaps more important, is a study showing the link between late preterm birth, maternal depression and preschool psychiatric disorders. It showed that late preterm babies (34-36 weeks) were at increased risk for anxiety disorders at preschool age if their mothers had postpartum depression.

How fitting that T. Berry Brazelton is receiving the Presidential Citizen's Medal in coincidence with these studies. It is Brazelton who taught us to look at each baby's unique qualities and capacities for complex communication. In settings such as the ones described in that study, where both mother and baby are vulnerable, his  Neonatal Behavioral Assessment Scale, as modified to the NBO, has great relevance. Brazelton, in all his wealth of contributions, shows tremendous respect for both parents and children.

These two studies show that we need to invest resources in supporting mother-baby pairs from birth, and in listening to families with young children so that their stories can be heard.

Maybe Brazelton will tell this story to President Obama!!!

Tuesday, February 5, 2013

ADHD treatment gone wrong: when prescriptions replace listening

Now that the letters to the editor in response to the New York Times article Drowned in a Stream of Prescriptions have been published, I am going to take advantage of this blog to publish mine.

There is one glaring error in the generally well-researched and deeply disturbing article Drowned in a Stream of Prescriptions. In a record review of Richard’s treatment the reporters found none of  “the more conventional talk-based therapies that experts generally consider an important component of A.D.H.D. treatment.” If only this were true. Just last week, AAP Smartbriefs, a review of newsworthy events in pediatrics, offered this headline Non-Drug ADHD Treatments Don't Pan Out in Study. The “psychological treatments” the study refers to are cognitive and behavioral training and neurofeedback. Talk-based therapy isn't even mentioned.
What is noticeably absent in Richard’s treatment is not talking, but listening. In the age of the 10-minute med check, there is no room for listening. If Richard was truly a well functioning person until mid-college, was his primary diagnosis schizophrenia? Was there some kind of trauma? In a world where ADHD is so quickly diagnosed, there was no time given to fully hear his story. That time that might have saved his life.