Recently I reviewed my son's high school essay on To Kill A Mockingbird. I was surprised and pleased to rediscover, or perhaps discover for the first time now that I was viewing it from the perspective of over 50 years of life experience, the profound wisdom of the book.
In one of the novel's most famous quotes, Atticus tell his daughter Scout, "you never really understand a person until you consider things from his point of view, until you climb in his skin and walk around in it."
I now understand this as a description of the essence of being human, namely the capacity to be curious about the meaning of another person's behavior. Peter Fonagy, whose research has shown how the development of this capacity is intimately linked to healthy emotional development, argues, in a way analogous to Bowlby's description of attachment behavior, that this capacity has evolutionary significance, and is essential to survival. My book Keeping Your Child in Mind presents this research for a general audience, showing its application to parenting.
I wonder if our current epidemic of "ADHD" is related to having lost sight of this essential human quality. The most common phrases I hear from parents who come to my office with concerns of problems of inattention and impulsivity are, "he never listens," followed by "tell me what to do to make him listen."
Perhaps ADHD is a problem of not listening. But it is the adults who are not listening to each other. In our fast-paced, technology driven age, we rarely take the time to listen to each other, to put ourselves in another person's skin.
When Scout comes home from her first day of school upset with the teacher, her father tells her, "she's new too." He is helping Scout to understand her teacher's perhaps impatient behavior from a different point of view, to appreciate that the teacher herself may have been stressed and overwhelmed.
Recently parents of 4-year-old Sam, who was having problems of impulsivity in the classroom, spent a good portion of our visit expressing anger at his teacher, who they were convinced just didn't like their child. But with a full hour, and a quiet space to tell the story, they came to recognize that just as they could get overwhelmed at times by their son's behavior, so could the teacher be overwhelmed. Perhaps she felt defensive when the parents got angry, as she was trying her best in less than ideal classroom setting, with a low teacher: student ratio.
In turn, with the parents and teacher listening to each other and not behaving defensively, they could reach a new level of understanding of what set Sam off, and to develop strategies both at home and in school to help him to feel calm.
I wonder if the current epidemic of what we call "ADHD" represents a loss of this capacity to put ourselves in another person's skin. I have had the pleasure of an email exchange with the New York Times journalist Alan Schwartz, whose multiple superb article, most recently The Selling of ADHD, have served to bring the subject to the forefront of public discourse. I am hopeful that he will help us to see the big picture, rather than to place blame.
I have wondered in conversation with him if the whole phenomenon of "ADHD" is itself a symptom of larger social ills, particularly in the education and health care systems as well as the medical education system. People, including parents, teachers, pediatricians and mental health professionals, are feeling overwhelmed and not heard.
The large scale medication of a whole generation of children has potential serious and profound long-term effects. These include the silencing of children whose symptoms represent complex underlying problems, as well as abuse of stimulant medication by high school and college students.
We will never go back to the slow pace depicted in the 1960 novel, where there are large expanses of time to listen. But we need to be very careful not to give it up completely. For it does take space and time to put yourself in another person's skin. If that is the essence of what makes us human, we need to value that space and time.
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28 Ocak 2016 Perşembe
Why substituting "behavioral" health care for "mental" health care is wrong
A colleague of mine recently pointed out a study by the Center for Health Care Strategies (CHCS) about mental health care for children. Among their findings was this
However, in reading about this study I was distracted by, and am struggling with as I write, the repeated reference to "behavioral health care" rather than "mental health care." This change in language is now common in our culture. It is significant and worrisome for two reasons.
First, it serves to perpetuate the stigma of mental illness. Implied in this word substitution is the idea that mental illness is something that should not be talked about.
Recently I came up against this stigma when giving a talk that included a discussion of the connection between "colic" and perinatal emotional complications such as anxiety and depression. An audience member, a mother of several grown children, spoke of resentment, that was still very much alive over 20 years later, that her friends and colleagues had been concerned about her mental well being when caring for her first very challenging child.
Severe sleep deprivation, feelings of isolation and low self esteem are an almost inevitable consequence of having a very fussy baby. The stigma associated with identifying this constellations of concerns as a "mental health problem" is part of the reason for inadequate identification and treatment of postpartum depression and anxiety.
Research has shown that when untreated, these problems can in turn lead to mental health problems in the developing child. If we could, as the saying goes "call a spade a spade," without having it be associated with blame and shame, there might be more hope for helping for these mothers, and for preventing the development of mental health problems in their children.
The second, and perhaps more worrisome issue related to the substitution of "behavioral" for "mental" is the idea that treatment involves controlling behavior, rather than understanding the meaning of behavior. The ability to attribute motivations and intentions to behavior is a uniquely human quality. Extensive research, that I describe in my book Keeping Your Child in Mind has shown that children develop a healthy sense of self, the capacity for emotional regulation, flexible thinking, social engagement, and overall mental health, when the people who care for them think about and understand the meaning of their behavior. In contrast, there may be significant disturbances when there is an absence of such curiosity about a child.
This brings us full circle to the problem identified by the above study. By treating these children with psychiatric drugs with no other form of treatment, there is no room for curiosity or understanding. Children living in poverty, especially those in foster care, may have experienced significant early trauma and loss. The consequences of treating the behavior alone, in these and other circumstances can be significant. For example, a recent long-term follow up study of children diagnosed with "ADHD" treated with "behavior management" and medication showed that there was a five times higher risk of suicide, and 3% of adults at follow up were in prison.
The CHCS study calls for "expanding access to appropriate and effective behavioral health care." For it to be appropriate and effective, we need to call it mental health care. It needs first and foremost to allow for time and space for listening, for understanding the meaning of behavior.
- Almost 50 percent of children enrolled in Medicaid who are prescribed psychotropic medications receive no identifiable behavioral health treatment.
Children with significant behavioral health needs typically require an array of services to support their physical, intellectual, and emotional well-being. These children, however, are often served through fragmented systems, leading to inefficient care, costly utilization, and poor health outcomes. As a significant source of funding for children’s behavioral health care, Medicaid programs can advance fundamental improvements in care coordination and delivery for these vulnerable children.This would certainly be a goal to work towards.
However, in reading about this study I was distracted by, and am struggling with as I write, the repeated reference to "behavioral health care" rather than "mental health care." This change in language is now common in our culture. It is significant and worrisome for two reasons.
First, it serves to perpetuate the stigma of mental illness. Implied in this word substitution is the idea that mental illness is something that should not be talked about.
Recently I came up against this stigma when giving a talk that included a discussion of the connection between "colic" and perinatal emotional complications such as anxiety and depression. An audience member, a mother of several grown children, spoke of resentment, that was still very much alive over 20 years later, that her friends and colleagues had been concerned about her mental well being when caring for her first very challenging child.
Severe sleep deprivation, feelings of isolation and low self esteem are an almost inevitable consequence of having a very fussy baby. The stigma associated with identifying this constellations of concerns as a "mental health problem" is part of the reason for inadequate identification and treatment of postpartum depression and anxiety.
Research has shown that when untreated, these problems can in turn lead to mental health problems in the developing child. If we could, as the saying goes "call a spade a spade," without having it be associated with blame and shame, there might be more hope for helping for these mothers, and for preventing the development of mental health problems in their children.
The second, and perhaps more worrisome issue related to the substitution of "behavioral" for "mental" is the idea that treatment involves controlling behavior, rather than understanding the meaning of behavior. The ability to attribute motivations and intentions to behavior is a uniquely human quality. Extensive research, that I describe in my book Keeping Your Child in Mind has shown that children develop a healthy sense of self, the capacity for emotional regulation, flexible thinking, social engagement, and overall mental health, when the people who care for them think about and understand the meaning of their behavior. In contrast, there may be significant disturbances when there is an absence of such curiosity about a child.
This brings us full circle to the problem identified by the above study. By treating these children with psychiatric drugs with no other form of treatment, there is no room for curiosity or understanding. Children living in poverty, especially those in foster care, may have experienced significant early trauma and loss. The consequences of treating the behavior alone, in these and other circumstances can be significant. For example, a recent long-term follow up study of children diagnosed with "ADHD" treated with "behavior management" and medication showed that there was a five times higher risk of suicide, and 3% of adults at follow up were in prison.
The CHCS study calls for "expanding access to appropriate and effective behavioral health care." For it to be appropriate and effective, we need to call it mental health care. It needs first and foremost to allow for time and space for listening, for understanding the meaning of behavior.
Reflections on the government shutdown: why is health care so threatening?
I may be putting myself out on a bit of a limb here, but the draw of the blog makes it hard to sit silent while our country heads towards disaster.
As I listen helplessly to a report on NPR about our country being in the grips of an irrational game of chicken, I found myself being curious about the motivations of the tea party conservatives. Drawing a lesson from psychoanalyst Peter Fonagy, who identifies the ability to attribute motivations to behavior as a uniquely human characteristic, I wonder if taking a stance of curiosity rather than anger might be useful.
This led me to consider another psychoanalytic construct, namely that of transference. The tea party hardliners refer to Obamacare as an invasion of privacy. This idea is grotesquely depicted in the commercial showing a creepy Uncle Sam invading a gynecologic exam. Before he enters, the patient, a young woman, is being cared for by what appears to be a kind, motherly doctor.
The notion of transference describes how strong feelings from a past relationship, often with a parent, find there way in to a current relationship. This phenomenon can occur in relationships with spouses, children, co-workers, in addition to the setting where Freud originally identified it, namely in the patient-therapist relationship.
In the intimacy and privacy of the patient-doctor relationship, such as that between a young woman and her female gynecologist, these type of transference feelings naturally occur. That made me wonder if to those who made the commercial, Obamacare, as represented by Uncle Sam, in some way represents a third invading the primary caregiver-child relationship. If so, that might help explain the intransigent behavior of those who are unable to accept that Obamacare, or the Affordable Care Act, is the law, and are willing to hold the country hostage rather than face that fact.
But Obamacare is not a threat to that intimate private relationship. In fact, if it works, and health care costs do go down, and insurance companies lose some of their power, it may in fact strengthen the relationship. With increased emphasis on prevention, the healing power of the patient-doctor relationship might be brought in to better focus than under the current system, when doctors are forced to see more and more patients in less and less time.
As I listen helplessly to a report on NPR about our country being in the grips of an irrational game of chicken, I found myself being curious about the motivations of the tea party conservatives. Drawing a lesson from psychoanalyst Peter Fonagy, who identifies the ability to attribute motivations to behavior as a uniquely human characteristic, I wonder if taking a stance of curiosity rather than anger might be useful.
This led me to consider another psychoanalytic construct, namely that of transference. The tea party hardliners refer to Obamacare as an invasion of privacy. This idea is grotesquely depicted in the commercial showing a creepy Uncle Sam invading a gynecologic exam. Before he enters, the patient, a young woman, is being cared for by what appears to be a kind, motherly doctor.
The notion of transference describes how strong feelings from a past relationship, often with a parent, find there way in to a current relationship. This phenomenon can occur in relationships with spouses, children, co-workers, in addition to the setting where Freud originally identified it, namely in the patient-therapist relationship.
In the intimacy and privacy of the patient-doctor relationship, such as that between a young woman and her female gynecologist, these type of transference feelings naturally occur. That made me wonder if to those who made the commercial, Obamacare, as represented by Uncle Sam, in some way represents a third invading the primary caregiver-child relationship. If so, that might help explain the intransigent behavior of those who are unable to accept that Obamacare, or the Affordable Care Act, is the law, and are willing to hold the country hostage rather than face that fact.
But Obamacare is not a threat to that intimate private relationship. In fact, if it works, and health care costs do go down, and insurance companies lose some of their power, it may in fact strengthen the relationship. With increased emphasis on prevention, the healing power of the patient-doctor relationship might be brought in to better focus than under the current system, when doctors are forced to see more and more patients in less and less time.
Why Depression is Not Like Diabetes
At the recent gubernatorial candidates forum on mental health, Martha Coakley repeated the oft-heard phrase that depression is like diabetes. Her motivation was good, the idea being to reduce the stigma of mental illness, and to offer "parity" or equal insurance coverage, for mental and physical illness. However, I am concerned that this phrase, and its companion, "ADHD is like diabetes," will, in fact, have the exact opposite effect.
A recent New York Times op ed, The Trouble with Brain Science, helped me to put my finger on what is troubling about these statements. Psychologist Gary Marcus identifies the need for a bridge between neuroscience and psychology that does not currently exist.
Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. The above analogies disregard the intimate intertwining of brain and mind. For the pancreas, there is no corresponding "mind" that exists in the realm of feelings and relationships.
While there is some emerging evidence of the brain structures involved in the collection of symptoms named by the DSM (Diagnostic and Statistical Manual of Mental Disorders,) there are no known biological processes corresponding to depression, ADHD or any other diagnosis in the DSM. There is, however, a wealth of new evidence showing how brain structure and function changes in relationships.
These collections of symptoms, intimately intertwined with feelings and relationships, are problems of behavioral and emotional regulation. The capacity for emotional regulation develops in relationships. If DSM diagnoses can only be legitimized by comparing them to diabetes-and food allergies, as was recently done by the director of the NIMH (National Institute for Mental Health)- this comparison may increase, rather than decrease the stigma by de-valuing relationships and our basic human need for meaningful connection.
The primary treatment for diabetes is a drug. This analogy works if we accept that the primary treatment for mental illness is drugs. The pharmaceutical industry must be pleased with this approach.
But, in fact, the primary treatment for problems of emotional well-being is time. What is needed is time and space for listening, where individuals can have the opportunity to have their feelings recognized and understood. In this time and space, people can make sense of, and find meaning in, their experience.
A model that compares depression to diabetes is an illness model. It promotes a kind of "there is something wrong with you and I will fix it" approach. It is not simply a question of "therapy vs. medication" as many "evidence based" research studies suggest. It is a question of a completely different model, a resilience model. Such a model, that values time and space for listening and being heard, seeks to help people re-connect with their most competent selves.
But we will only get there if we stop comparing depression to diabetes.
A recent New York Times op ed, The Trouble with Brain Science, helped me to put my finger on what is troubling about these statements. Psychologist Gary Marcus identifies the need for a bridge between neuroscience and psychology that does not currently exist.
Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. The above analogies disregard the intimate intertwining of brain and mind. For the pancreas, there is no corresponding "mind" that exists in the realm of feelings and relationships.
While there is some emerging evidence of the brain structures involved in the collection of symptoms named by the DSM (Diagnostic and Statistical Manual of Mental Disorders,) there are no known biological processes corresponding to depression, ADHD or any other diagnosis in the DSM. There is, however, a wealth of new evidence showing how brain structure and function changes in relationships.
These collections of symptoms, intimately intertwined with feelings and relationships, are problems of behavioral and emotional regulation. The capacity for emotional regulation develops in relationships. If DSM diagnoses can only be legitimized by comparing them to diabetes-and food allergies, as was recently done by the director of the NIMH (National Institute for Mental Health)- this comparison may increase, rather than decrease the stigma by de-valuing relationships and our basic human need for meaningful connection.
The primary treatment for diabetes is a drug. This analogy works if we accept that the primary treatment for mental illness is drugs. The pharmaceutical industry must be pleased with this approach.
But, in fact, the primary treatment for problems of emotional well-being is time. What is needed is time and space for listening, where individuals can have the opportunity to have their feelings recognized and understood. In this time and space, people can make sense of, and find meaning in, their experience.
A model that compares depression to diabetes is an illness model. It promotes a kind of "there is something wrong with you and I will fix it" approach. It is not simply a question of "therapy vs. medication" as many "evidence based" research studies suggest. It is a question of a completely different model, a resilience model. Such a model, that values time and space for listening and being heard, seeks to help people re-connect with their most competent selves.
But we will only get there if we stop comparing depression to diabetes.
In the age of DSM 5, what is normal?
In an interesting coincidence, a couple of weeks ago I received two emails on the same day asking me to write about books that are about the same subject. One is Child Temperament: New Thinking About the Boundary Between Traits and Illness, the second Back To Normal: Why Ordinary Childhood Behavior is Mistaken for ADHD, Bipolar Disorder, and Autism Spectrum Disorder.
The first was written by David Rettew, MD a child psychiatrist at the University of Vermont College of Medicine, where at the Vermont Center for Children, Youth, and Families ( VCCYF) they have an innovative family centered, strength-based approach to children's emotional and behavioral problems.
In a language that is based in science and research, Rettew explores the overlap and interplay between the concepts of "temperament" and "psychopathology. He tackles the complex science of behavioral epigenetics- the impact of life experience on gene expression and subsequent behavior and development. He then describes how he integrates these ideas in to his care of children and families. For example, he describes how he might speak to a child patient:
Earlier this year, the head of the National Institute for Mental Health tried to discredit DSM 5 by saying that they would not fund research based on the DSM system but rather aim to find the underlying "cause" in the realm of neuroscience and genetics. But as Gnaulati points out, we will never find the cause by just looking at the brain.
Gnaulati is similarly trying to find another way to think about this paradigm that offers oversimplified labels. But I am concerned that framing the issue as "normal" vs "disordered" is misguided, and a result of the author being unable to see his way out of the DSM paradigm.
If a child and family are seeking help, then by definition the behavior is not "normal." Given the continued stigma associated with mental health problems, for a family to make the effort to call, make an appointment and actually show up, they are likely to be struggling in a significant way. Thus to call this "normal," even though the intention may be to be reassuring, is actually dismissive of the family's suffering. I wrestle with this dilemma every day in my clinical practice. Parents come to me and ask, "Is my child normal?"
I speak to this issue in a previous post: Answering the question: is something wrong with my child?
I refer to an article by Daphne Merkin on the question of whether depression is inherited:
I believe that what both of these authors are actually doing is describing a new paradigm of mental health care that recognizes the relational nature of human development and offers opportunity for curiosity about the complex meaning of behavior. I'm calling them on it.
The first was written by David Rettew, MD a child psychiatrist at the University of Vermont College of Medicine, where at the Vermont Center for Children, Youth, and Families ( VCCYF) they have an innovative family centered, strength-based approach to children's emotional and behavioral problems.
In a language that is based in science and research, Rettew explores the overlap and interplay between the concepts of "temperament" and "psychopathology. He tackles the complex science of behavioral epigenetics- the impact of life experience on gene expression and subsequent behavior and development. He then describes how he integrates these ideas in to his care of children and families. For example, he describes how he might speak to a child patient:
I've heard a lot about you today and one of the things that I hear from you and your parents is that you are a very kind person who can really tune in to other people. That is a wonderful quality that will serve you well in the future. At the same time, I also hear that you can get so concerned about what others think about you that you avoid things you like doing just so there is no chance you will feel embarrassed. Doctors sometimes use the term social anxiety disorder to describe this situation, and if you are willing there are things we can do to help you feel more at ease in social situations.He masterfully takes on very complex issues, including the way a child's behavior may provoke a parent's negative response.
A father of a temperamentally irritable boy who is prone to shout at the boy for relatively minor infractions is certainly not relieved of responsibility for his behavior, but can be understood from a prespective that some of his suboptimal responses are evoked by the child's behavior, partially influenced by shared genes that cause both of them to escalate in negative ways.The second book is organized around examples from the practice of the author Enrico Gnaulati, PhD, a clinical psychologist specializing in child and adolescent therapy. He examines our cultures rush to diagnose and medicate, and what he terms the "casualties of casual diagnosis." He writes:
In the past four decades we have gone from blaming parents for kids' problem behavior to blaming kids' brains....yet rarely can a child's behavior be explained exclusively in terms of child rearing or brain chemistry. In most cases, it is causes- plural, not singular- that explain why a child behaves the way he or she does.The underlying problem both authors address is embedded in the paradigm of mental health in which they practice. Rettew seems to be trying to wrestle out of the paradigm in the last section where he describes an evaluation process that makes use of other tools besides DSM. However, the above example shows how the language of DSM permeates care, when albeit reluctantly, he uses the term "social anxiety disorder." This "disorder" may be in the DSM, but it is not a "real" disorder in the way, for example, diabetes is.
Earlier this year, the head of the National Institute for Mental Health tried to discredit DSM 5 by saying that they would not fund research based on the DSM system but rather aim to find the underlying "cause" in the realm of neuroscience and genetics. But as Gnaulati points out, we will never find the cause by just looking at the brain.
Gnaulati is similarly trying to find another way to think about this paradigm that offers oversimplified labels. But I am concerned that framing the issue as "normal" vs "disordered" is misguided, and a result of the author being unable to see his way out of the DSM paradigm.
If a child and family are seeking help, then by definition the behavior is not "normal." Given the continued stigma associated with mental health problems, for a family to make the effort to call, make an appointment and actually show up, they are likely to be struggling in a significant way. Thus to call this "normal," even though the intention may be to be reassuring, is actually dismissive of the family's suffering. I wrestle with this dilemma every day in my clinical practice. Parents come to me and ask, "Is my child normal?"
I speak to this issue in a previous post: Answering the question: is something wrong with my child?
I refer to an article by Daphne Merkin on the question of whether depression is inherited:
The concept of "being attuned to your child's nature, especially when it differs from your own," is the essence of healthy parenting. She is describing a parent's recognition of what D. W, Winnicott termed the child's "true self." It involves recognizing a child as a person with thoughts and feelings that are his own. It is an excellent goal to work towards, though not always easy. Issues that get in the way of recognizing the child's true self, including stresses in a parent's life and other relationships, may need to be addressed.
When viewed from this perspective, the question becomes not "is there something wrong with my child?" but rather "Who is this child, and how is he or she both alike and different from me?"I wonder if Rettew and Gnaulati are so much a part of the prevailing paradigm that they do not recognize that what they are actually doing in their books is questioning the very paradigm in which they practice. If they were to step outside of the paradigm, they might, rather than asking the question "does a child have ADHD?" , asking the more salient question, "Is ADHD ( or autism or bipolar disorder or OCD for that matter) the way we as a culture use the term, a "real" thing, or is it an artificial construct defined by the DSM system and perpetuated by the pharmaceutical and health insurance industries?"
I believe that what both of these authors are actually doing is describing a new paradigm of mental health care that recognizes the relational nature of human development and offers opportunity for curiosity about the complex meaning of behavior. I'm calling them on it.
Lost child psych beds at Cambridge Health Alliance: now prevention is essential
In the wake of the Newtown tragedy, many people, myself included, wrote about the need to address both gun control and mental health care. So it was rather jarring, on the same day that Connecticut's governor signed comprehensive new gun control legislation, to read that Cambridge Health Alliance was planning to cut 11 of 27 child inpatient psychiatry beds, including all inpatient service for children age 3-7.
But on closer consideration, I wonder if this loss in fact presents an opportunity. With no inpatient care for young children, it now behooves us as a society to make sure they never need such care. As a pediatrician with 25 years experience working with troubled children, I can be sure that when a child needs hospitalization at age 4, 5 or 6, his problems started way before that. The Globe article suggests that plans are headed in this direction.
Such training programs are erupting all over the country. One superb program is right here in Boston- the UMass Infant-Parent Mental Health Post-Graduate Certificate Program under the direction of renowned researcher Ed Tronick.
Fellows in that program learn from leaders in the field, including child psychiatrist Bruce Perry, whose neurosequential model of therapeutics informs us of how to use knowledge of neurodevelopment to guide treatment.
We need these programs because most child psychiatrists have minimal to no education in early child development, and pediatricians, who live and breathe child development and have long-term relationships with families, are under pressure to see 6 patients an hour, and so have no time to help. In the ideal world, training in infant mental health would also be incorporated in to pediatric and child psychiatry training.
We cannot let the bottom fall out for these children. By taking away these beds, a preventive model is no longer optional. A person trained in early childhood mental health should be in every primary care office, and every childcare center should have easy access to early childhood mental health care professional for on-site consultation. I wonder if this might even cost less than maintaining inpatient beds.
Of course this does not help the children today who need inpatient care. Ideally we would be able to offer both forms of help. Perry's model is relevant for treatment of older children as well. I do not know the answer to this problem. However, I can be sure that parents, who are suffering terribly waiting with their severely troubled young child for an inpatient bed to become available, would have much preferred to get meaningful help years before.
But on closer consideration, I wonder if this loss in fact presents an opportunity. With no inpatient care for young children, it now behooves us as a society to make sure they never need such care. As a pediatrician with 25 years experience working with troubled children, I can be sure that when a child needs hospitalization at age 4, 5 or 6, his problems started way before that. The Globe article suggests that plans are headed in this direction.
Burke [chief of psychiatry] said the hospital is focusing more on efforts that can keep children out of the hospital, including services in schools and placing psychiatrists in pediatricians’ offices.This is an excellent idea. But what does it look like in practice? Number one, we need a workforce experienced in early child development. There is an explosion of knowledge and research, coming out of the discipline known as infant mental health, that informs us of how to work with parents and children together to help set young children on a path of healthy development.
Such training programs are erupting all over the country. One superb program is right here in Boston- the UMass Infant-Parent Mental Health Post-Graduate Certificate Program under the direction of renowned researcher Ed Tronick.
Fellows in that program learn from leaders in the field, including child psychiatrist Bruce Perry, whose neurosequential model of therapeutics informs us of how to use knowledge of neurodevelopment to guide treatment.
We need these programs because most child psychiatrists have minimal to no education in early child development, and pediatricians, who live and breathe child development and have long-term relationships with families, are under pressure to see 6 patients an hour, and so have no time to help. In the ideal world, training in infant mental health would also be incorporated in to pediatric and child psychiatry training.
We cannot let the bottom fall out for these children. By taking away these beds, a preventive model is no longer optional. A person trained in early childhood mental health should be in every primary care office, and every childcare center should have easy access to early childhood mental health care professional for on-site consultation. I wonder if this might even cost less than maintaining inpatient beds.
Of course this does not help the children today who need inpatient care. Ideally we would be able to offer both forms of help. Perry's model is relevant for treatment of older children as well. I do not know the answer to this problem. However, I can be sure that parents, who are suffering terribly waiting with their severely troubled young child for an inpatient bed to become available, would have much preferred to get meaningful help years before.
What is childrens mental health care?
Patricia Wen's front page story Children's Access to Mental Health Care is Growing, in which she describes the "co-location" of mental health care services in pediatric practices, brought me back to the summer of 2011 when I attended a meeting of a working group of the Massachusetts Chapter of the American Academy of
Pediatrics (MCAAP.) The task of this working group, a subgroup of the MCAAP task force on mental health care in pediatrics, was to address the need for collaboration between pediatricians and mental health professionals in caring for children. At the meeting individuals described different models.
One pediatrician, a man who has been in practice for over 30 years in a large group with 15 pediatricians and 10 nurse practitioners, was invited to present his model, held up as an example of an innovative and workable model. This is what he said.
First, clinicians went in groups of 4 to attend conferences run by a prominent MGH child psychiatrist. Then another child psychiatrist started bi-weekly phone consultation with the group as a whole.
First, clinicians went in groups of 4 to attend conferences run by a prominent MGH child psychiatrist. Then another child psychiatrist started bi-weekly phone consultation with the group as a whole.
Now, this pediatrician said with pride, the clinicians in his practice are comfortable " treating 80% of ADHD, anxiety and depression." They were hiring a social worker, whose job it would be not to do therapy, but rather to "make sure patients are taking their medications and refilling prescriptions."
In other words, mental health care, at least for this doctor and his large group, is equivalent to prescribing psychiatric medication.
This practice is paid by Blue Cross Blue Shield under the model of AQC(alternative quality care) global budget. If the practice overspends they pay the insurance company and if they underspend they split the profit. In addition, if they practice "quality care" as defined by the insurance company, they receive more money. One measure of quality is follow up every four month for ADHD and compliance with psychiatric medication.
Another pediatrician offered an alternative model of collaborative care. She described a close personal relationship with a psychologist, who was also at the meeting. She described how, through confidential voicemail and email, they spoke frequently about their most challenging patients, working closely to provide care, and in doing so keeping a number of patients out of the hospital.
In a sense the people who presented these two models were speaking completely different languages, one in which mental health care equals medication and another in which mental health care equals providing a "holding environment" through relationships. Unfortunately the second model is at risk of being overpowered, under the influence of the pharmaceutical and health insurance industries, by the first model.
Our best hope for fighting this trend, I believe, lies in maintaining a focus on prevention- on promotion of healthy social-emotional development in early childhood through relationship-based interventions.
In the Early Childhood Social Emotional Health Program at Newton-Wellesley Hospital I collaborate closely with pediatricians who refer infants, toddlers and preschoolers. I work with children with a range of issues including, but not limited to colic, sleep problems, separation anxiety and explosive behavior. I work with parents and child together. Another program, Project Climb at Colorado Children's Hospital, described in the article Providing Perinatal Mental Health Care in Pediatric Primary Care integrates infant mental health services in to primary care.
In the Early Childhood Social Emotional Health Program at Newton-Wellesley Hospital I collaborate closely with pediatricians who refer infants, toddlers and preschoolers. I work with children with a range of issues including, but not limited to colic, sleep problems, separation anxiety and explosive behavior. I work with parents and child together. Another program, Project Climb at Colorado Children's Hospital, described in the article Providing Perinatal Mental Health Care in Pediatric Primary Care integrates infant mental health services in to primary care.
This is a role that primary care clinicians can and should embrace. In a previous post I wrote about a proposed model of including a professional who is experienced with working with parents and infants together in every primary care practice. This person could work with parent-infant pairs when parents are struggling with postpartum depression or anxiety, and/or an infant is fussy/colicky, or in other ways "dysregulated."
Research at the interface of developmental psychology, neuroscience and genetics offers extensive evidence that supporting early parent-child relationships is an essential part of promoting healthy emotional development.
This important aspect of children's mental health care was not mentioned in Wen's article. Instead, the focus was on treatment of "ADHD" and other DSM diagnoses in collaboration with MCPAP- the Massachusetts Child Psychiatry Access Project- whose role Wen describes:
The Massachusetts Child Psychiatry Access Project provides a hotline for pediatricians to call for consultations with psychiatrists, especially for help with the complexities of prescribing psychotropic drugs.
The co-location model described in Wen's article is an excellent one. Pediatricians have relationships with children and families that are invaluable. They are important collaborators with mental health professionals. Parents and young children can be found frequently in a primary care office. However, any conversation about "co-location" of children's mental health care is lopsided and incomplete without a discussion of preventive care focused on infancy and early childhood.
Evidence mounts that our current approach to "ADHD" is way off base
An NIH funded study published last week in the Lancet revealed that five major mental health disorders- ADHD, autism, bipolar disorder, depression and schizophrenia- share genetic roots. The authors state that their findings blur diagnostic categories. They write:
Another study on ADHD published this week points to the problems inherent using this oversimplified diagnostic category. The study, published in Pediatrics, showed that not only do symptoms of ADHD persist into adulthood in 30% of cases, but there is also a significant amount of "co-morbidity," including these alarming statistics:
What we are calling "ADHD" is a constellation of symptoms that represent problems with regulation of attention, behavior, and emotion. The term itself gives the illusion that we know the specific biological mechanism in the way that we know how lack of insulin causes diabetes. This is however, far from true.
As the first study I refer to indicates, we are just beginning to learn about the underlying biology of mental illness, and those findings suggest that "ADHD" may be an artificial construct.
My clinical experience tells me that these genes they have described may be functionally related to sensory processing. Problems with sensory processing seem to be common to many diagnostic categories for mental illness that we currently use. However, children develop the capacity for self-regulation in the context of relationships. Identifying the problematic gene is only part of the answer. Understanding and addressing the environmental risk is the other.
If we consider the interplay of genetics and environment, then a third study published last week, this one also in Pediatrics, will point us in the direction of meaningful preventive intervention. This study identified the problem of postpartum anxiety, concluding that:
These results provide evidence relevant to the goal of moving beyond descriptive syndromes in psychiatry, and towards a nosology informed by disease cause.Epigenetics, or the environmental influence on gene expression, must immediately be brought in to any discussion of these important findings. "Cause" is related to a complex interplay between genetic risk and environmental effects.
Another study on ADHD published this week points to the problems inherent using this oversimplified diagnostic category. The study, published in Pediatrics, showed that not only do symptoms of ADHD persist into adulthood in 30% of cases, but there is also a significant amount of "co-morbidity," including these alarming statistics:
The study also found the risk for suicide was nearly five times higher among those diagnosed with ADHD than in the comparison group, and nearly 3% of study participants were in jail when recruited for the adult portion of the study.A review of the study published in USA today includes this telling line:
Symptoms[of ADHD] can be controlled by a combination of behavioral therapy and medication.Maybe the reason that so many people have such poor outcomes is that we are neglecting to understand the underlying cause of the problem and instead simply labeling and "managing" symptoms. These dismal long-term results, along with the similarly dismal results reported in the preschool ADHD study showing that 90 percent of children had signficant symptoms at 6 year follow up, state loud and clear that the way we approach what we are now calling "ADHD" is not working. We need to do something dramatically different from the current standard of care.
What we are calling "ADHD" is a constellation of symptoms that represent problems with regulation of attention, behavior, and emotion. The term itself gives the illusion that we know the specific biological mechanism in the way that we know how lack of insulin causes diabetes. This is however, far from true.
As the first study I refer to indicates, we are just beginning to learn about the underlying biology of mental illness, and those findings suggest that "ADHD" may be an artificial construct.
My clinical experience tells me that these genes they have described may be functionally related to sensory processing. Problems with sensory processing seem to be common to many diagnostic categories for mental illness that we currently use. However, children develop the capacity for self-regulation in the context of relationships. Identifying the problematic gene is only part of the answer. Understanding and addressing the environmental risk is the other.
If we consider the interplay of genetics and environment, then a third study published last week, this one also in Pediatrics, will point us in the direction of meaningful preventive intervention. This study identified the problem of postpartum anxiety, concluding that:
Postpartum state anxiety is a common, acute phenomenon during the maternity hospitalization that is associated with increased maternal health care utilization after discharge and reduced breastfeeding duration.Given what we already know about the risk of psychiatric disorders in children of parents struggling with depression, these findings only increase the urgency of focusing our resources on supporting parent-infant pairs. We need to help set development in a healthy direction from the start. Genetic vulnerabilities are present at birth, and if we devote maximum resources to supporting the environment, then we may significantly decrease the risk of those vulnerabilities manifesting as psychiatric illness.
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
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.
27 Ocak 2016 Çarşamba
Is ADHD a real disorder? Part 2
A number of people commented that my previous post seemed unfinished in that I did not offer an alternative approach. This is a valid point, and in part due to the fact that my household has been under siege by the flu. I decided to republish a post from two years ago (before I wrote for the Globe.) It offers an example of my approach, which I describe in detail, along with the research to support it, in my book Keeping Your Child in Mind: Overcoming Defiance, Tantrums, and other Everyday Behavior Problems by Seeing the World Through Your Child's Eyes.
Holding A Child in Mind
Sam burst into the office, a two-year-old wild bundle of energy. Squealing with delight--or was it distress; it was hard to tell--he ran from toy to toy not looking at me or his mother, Jane. He was unable to engage with anything. Jane had brought him to see me in my pediatric practice because, “he hits me, has explosive tantrums, and I can’t take him anywhere.” She sank into the couch. I sat on the floor, wanting to listen to Jane, but also to include Sam in the visit. At first, I focused my attention on her story, while Sam continued his frantic exploration of the room.
Jane described a scene at the playground. The other mothers had been engaged in easy conversation, but she was on edge. She knew Sam was “inflexible” and at any moment could go from happy play to a full-blown tantrum. Sure enough, as she tried to join in the group, she saw him getting upset because his toy car was stuck. She rushed over to calm him, but his crying escalated. As the other kids and moms turned to look, she quickly went from embarrassment to rage. She yelled at Sam to cut it out. This only made him scream more. Finally, she grabbed him, her bag and his toys and ran to her car, where she collapsed in tears of helplessness.
Things had not been easy for Jane. Sam’s father had abused her and was in prison. She was afraid when she felt Sam’s anger that he would turn out like his father. Of her own mother she said, “She was never there for me.” Jane was frustrated and bewildered by the fact that Sam could relate to other people, yet reserved all his difficult behavior for her.
At the beginning of the visit, Jane made several awkward attempts to interact with Sam, but without success. She was anxious and her body language felt intrusive, which seemed to cause Sam to withdraw. As she opened up and shared more of her painful feelings with me, however, an interesting transformation occurred. Sam began to engage in more focused play. Mom and I talked about what Sam was doing, observing together how he was calming down. At first he talked to me, bringing me toys and naming them and describing what he was doing. But then he spontaneously ran over and gave his mother a hug. Her whole body relaxed, she leaned forward on the couch toward him, her pleasure and relief palpable in the room. Sam began to engage her in his play, and to communicate with her. Jane told me that she had been reluctant to come for the appointment, but was glad she had.
Being a parent of such a child is a hard job. Raising a child alone, without support from extended family or a spouse, is even harder. In our culture of advice and quick fixes, in seeking help for her problems with him, Sam’s mother would find many who would offer “expert” advice about how to manage her child’s behavior. An increasing number would recommend some type of medication to control his “hyperactivity.” Helping her to be fully emotionally present with her child--supporting her in the challenges she faced as a mother--is not a common approach.
Yet current research at the interface of developmental psychology, neuroscience and behavioral genetics is showing that it is just this type of intervention that will help children like Sam to manage strong emotions and relate to other people. A child’s mind grows and develops when the people who are most important to the child are able to think about and understand a child’s experience from the child’s perspective, without being overwhelmed or shutting down. A parent’s capacity to “hold the child in mind” leads to a child’s increased cognitive resourcefulness, greater social skills, and better capacity to regulate emotions. If we -pediatricians, teachers, therapists, grandparents, neighbors--can help a mother like Sam’s to join her child, to accept his “low frustration tolerance” as part of him, not a reflection of her own failure as a parent, then she can help him regulate his frustration. He can then learn to manage his feelings on his own. Most important, if she can do this, she may actually change the way his brain handles stress and strong emotions.
Holding A Child in Mind
Sam burst into the office, a two-year-old wild bundle of energy. Squealing with delight--or was it distress; it was hard to tell--he ran from toy to toy not looking at me or his mother, Jane. He was unable to engage with anything. Jane had brought him to see me in my pediatric practice because, “he hits me, has explosive tantrums, and I can’t take him anywhere.” She sank into the couch. I sat on the floor, wanting to listen to Jane, but also to include Sam in the visit. At first, I focused my attention on her story, while Sam continued his frantic exploration of the room.
Jane described a scene at the playground. The other mothers had been engaged in easy conversation, but she was on edge. She knew Sam was “inflexible” and at any moment could go from happy play to a full-blown tantrum. Sure enough, as she tried to join in the group, she saw him getting upset because his toy car was stuck. She rushed over to calm him, but his crying escalated. As the other kids and moms turned to look, she quickly went from embarrassment to rage. She yelled at Sam to cut it out. This only made him scream more. Finally, she grabbed him, her bag and his toys and ran to her car, where she collapsed in tears of helplessness.
Things had not been easy for Jane. Sam’s father had abused her and was in prison. She was afraid when she felt Sam’s anger that he would turn out like his father. Of her own mother she said, “She was never there for me.” Jane was frustrated and bewildered by the fact that Sam could relate to other people, yet reserved all his difficult behavior for her.
At the beginning of the visit, Jane made several awkward attempts to interact with Sam, but without success. She was anxious and her body language felt intrusive, which seemed to cause Sam to withdraw. As she opened up and shared more of her painful feelings with me, however, an interesting transformation occurred. Sam began to engage in more focused play. Mom and I talked about what Sam was doing, observing together how he was calming down. At first he talked to me, bringing me toys and naming them and describing what he was doing. But then he spontaneously ran over and gave his mother a hug. Her whole body relaxed, she leaned forward on the couch toward him, her pleasure and relief palpable in the room. Sam began to engage her in his play, and to communicate with her. Jane told me that she had been reluctant to come for the appointment, but was glad she had.
Being a parent of such a child is a hard job. Raising a child alone, without support from extended family or a spouse, is even harder. In our culture of advice and quick fixes, in seeking help for her problems with him, Sam’s mother would find many who would offer “expert” advice about how to manage her child’s behavior. An increasing number would recommend some type of medication to control his “hyperactivity.” Helping her to be fully emotionally present with her child--supporting her in the challenges she faced as a mother--is not a common approach.
Yet current research at the interface of developmental psychology, neuroscience and behavioral genetics is showing that it is just this type of intervention that will help children like Sam to manage strong emotions and relate to other people. A child’s mind grows and develops when the people who are most important to the child are able to think about and understand a child’s experience from the child’s perspective, without being overwhelmed or shutting down. A parent’s capacity to “hold the child in mind” leads to a child’s increased cognitive resourcefulness, greater social skills, and better capacity to regulate emotions. If we -pediatricians, teachers, therapists, grandparents, neighbors--can help a mother like Sam’s to join her child, to accept his “low frustration tolerance” as part of him, not a reflection of her own failure as a parent, then she can help him regulate his frustration. He can then learn to manage his feelings on his own. Most important, if she can do this, she may actually change the way his brain handles stress and strong emotions.
Is ADHD a real disorder?
I have deliberately given this post a provocative title to offer a counter weight to the outpouring of news covering the California study demonstrating a close to 25% increase in ADHD diagnosis from 2001 to 2010. I will say at the outset that I am not against medication, and recognize that a small percentage of children who have the diagnosis of ADHD may have a well-defined neurologically based difficulty with focusing and attention. If such a child is already school-age and falling behind academically, treatment with stimulants may protect that child from the damaging effects of low self esteem.
However, for the vast majority of children who have this label, things are much more complex. ADHD is diagnosed by DSM criteria that define the disorder by symptoms alone. In clinical setting in which these diagnoses are made, usually with one 50-minute visit for diagnostic evaluation and subsequent medication checks in 15-30 minutes at 3 month intervals, the child's story is usually not heard.
This story may be of an active, curious boy too restricted by the highly structured setting of today's kindergarten classrooms (a November 2012 study showed that the youngest in the class was 50% more likely to be treated with stimulants for ADHD), or of a child with sensory hypersensitivity who is unable to manage the barrage of sensory stimuli in a lunchroom or hallway.
The story may be one of a child who witnesses domestic violence or a parent who actively abuses alcohol, or both. A child may herself have been abused. In my behavioral pediatrics practice I have listened to countless stories of children, some as young as 2, who has been suspected to have ADHD. I find almost without exception a mulilayered story, sometimes involving multiple generations, that represents a complex interplay of biology and environment. The dignosis of ADHD as defined by DSM in these cases represents an artificial construct.
This past week I attended the National Meeting of the American Psychoanalytic Association in New York. Multiple excellent presentations offered a refreshing change from the oversimplified approach that is now the standard of care in both pediatrics and child psychiatry. Dr. David Mintz, a psychiatrist who has written extensively about what is termed psychodynamic psychopharmacology, in his presentation, entitled "Recovery from Childhood Psychiatric Treatment," addressed the complex developmental meaning of medication. The presentation was filled with rich insights from his research and clinical experience, including, for example, his observation that a pill is often used to localize family pathology in a concrete way in one child.
Another highly instructive presentation came from Jack Novick, co-author with Kerry Kelly Novick of the book Emotional Muscle:Strong Parents, Strong Children, on the out-of control child. I was particularly struck by the opening paragraphs to this presentation, which offered an alternative model, similar to what they describe in their book. The paper is not yet published, but the authors gave me permission to use it. I have included the quote in its entirety, as it is an apt response to the current ADHD study.
However, for the vast majority of children who have this label, things are much more complex. ADHD is diagnosed by DSM criteria that define the disorder by symptoms alone. In clinical setting in which these diagnoses are made, usually with one 50-minute visit for diagnostic evaluation and subsequent medication checks in 15-30 minutes at 3 month intervals, the child's story is usually not heard.
This story may be of an active, curious boy too restricted by the highly structured setting of today's kindergarten classrooms (a November 2012 study showed that the youngest in the class was 50% more likely to be treated with stimulants for ADHD), or of a child with sensory hypersensitivity who is unable to manage the barrage of sensory stimuli in a lunchroom or hallway.
The story may be one of a child who witnesses domestic violence or a parent who actively abuses alcohol, or both. A child may herself have been abused. In my behavioral pediatrics practice I have listened to countless stories of children, some as young as 2, who has been suspected to have ADHD. I find almost without exception a mulilayered story, sometimes involving multiple generations, that represents a complex interplay of biology and environment. The dignosis of ADHD as defined by DSM in these cases represents an artificial construct.
This past week I attended the National Meeting of the American Psychoanalytic Association in New York. Multiple excellent presentations offered a refreshing change from the oversimplified approach that is now the standard of care in both pediatrics and child psychiatry. Dr. David Mintz, a psychiatrist who has written extensively about what is termed psychodynamic psychopharmacology, in his presentation, entitled "Recovery from Childhood Psychiatric Treatment," addressed the complex developmental meaning of medication. The presentation was filled with rich insights from his research and clinical experience, including, for example, his observation that a pill is often used to localize family pathology in a concrete way in one child.
Another highly instructive presentation came from Jack Novick, co-author with Kerry Kelly Novick of the book Emotional Muscle:Strong Parents, Strong Children, on the out-of control child. I was particularly struck by the opening paragraphs to this presentation, which offered an alternative model, similar to what they describe in their book. The paper is not yet published, but the authors gave me permission to use it. I have included the quote in its entirety, as it is an apt response to the current ADHD study.
Children Out Of Control: Working With Unregulated Affect
Jack Novick and Kerry Kelly Novick
Vulnerable Child Workshop
APsaA, New York, January 2013
There seems to be an exponential increase in the number of children who are described by parents, teachers and therapists as out of control. How are we to understand this kind of behavior, and how as therapists are we able to intervene and help restore these children to the path of progressive development? Currently the tendency is to diagnose these children as having neurological difficulties characterized as ADHD, OCD, executive function disorder (EFD), pervasive developmental disorder (PDD), or, increasingly, bipolar disorders.
These children now seldom come for psychotherapy, but instead are treated by their desperate parents and teachers with reactive, repressive models of external behavioral controls, almost a reversion to 19th-century modes of authoritarian domination. More perniciously, there is an explosive increase in the prescription of stimulant, anti-anxiety and antidepressant medications, as well as widespread off-label use of antipsychotic drugs. The assumption seems to be that there is a one-to-one relationship between atypical behavior and some specific brain disorder. This of course is the age-old dream of finding a single cause in the body or the mind.
Recent neuroscience investigations, utilizing advances in the development of computer algorithms for classifying MRI images, have made possible large scale studies of normal and atypical brain development. These are able to capture any changes associated with these diagnoses. In an overview of such studies the authors conclude, "There is no identified 'lesion' common to all, or even most, children with the most frequently studied (psychiatric) disorders"
Ignoring such findings, pediatricians, psychiatrists and other clinicians continue to prescribe at ever-growing rates. ADHD and bi-polar diagnoses and their accompanying prescriptions have increased drastically in the past twenty years. 2.5 million American children are medicated for ADHD (10% of all 10-year-old boys); between 1994 and 2003 the number of children diagnosed with bi-polar disorder increased 40-fold. The proportion of underprivileged and minority children sedated for life is a blot on our health system, a social/political disgrace, and a permanent drain on our economy. Despite all the millions spent by pharmaceutical companies in marketing these drugs, the number of children struggling with such troubles continues to rise. If this rate of treatment failure occurred with a strictly medical treatment, the drugs would be withdrawn.
Where is the media coverage of the DSM V vote?
Last Sunday I awoke to a news story in our local paper, The Berkshire Eagle, about the vote by the American Psychiatric Association the previous day approving massive revisions for DSMV, the newest version of the Diagnostic and Statistical Manual of Mental Disorders. The article stated:
But I was wrong. Mainstream media had virtually nothing on the story. There was not one word about the DSM vote in the New York Times. The Boston Globe similarly did not cover the story. There was a brief mention on NPR's Morning Edition on Monday. Boston.com had my piece as well as an article about Asperger's being dropped from the new version.
There was news on the blogs. Most striking was from Allen Frances, MD, professor of psychiatry at Duke University, who was chair of the DSM IV task force. On his Huffington Post blog he wrote:
Some may suggest that the weekend DSMV vote and lack of media coverage is related to the power of the APA and big pharma to squash controversy. For the sake of children, families and adults who struggle with mental illness, I hope that there is a more benign explanation.
Board members were tight lipped about the update, but its impact will be huge, affecting millions of children and adults worldwide (italics mine.)Figuring that this would be big news, I asked my husband if we could delay our morning hike while I wrote a blog post about it. I was sure there would be an active public discussion on the subject.
But I was wrong. Mainstream media had virtually nothing on the story. There was not one word about the DSM vote in the New York Times. The Boston Globe similarly did not cover the story. There was a brief mention on NPR's Morning Edition on Monday. Boston.com had my piece as well as an article about Asperger's being dropped from the new version.
There was news on the blogs. Most striking was from Allen Frances, MD, professor of psychiatry at Duke University, who was chair of the DSM IV task force. On his Huffington Post blog he wrote:
This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry. The Board of Trustees of the American Psychiatric Association has given its final approval to a deeply flawed DSM-5 containing many changes that seem clearly unsafe and scientifically unsound. My best advice to clinicians, to the press, and to the general public -- be skeptical and don't follow DSM-5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication.While he defends his colleagues against accusations that they have been influenced by big pharma, he writes that:
The APA's deep dependence on the publishing profits generated by the DSM-5 business enterprise creates a far less pure motivation. There is an inherent and influential conflict of interest between the DSM-5 public trust and DSM-5 as a best seller... The current draft has been approved and is now being rushed prematurely to press with incomplete field testing for one reason only -- so that DSM-5 publishing profits can fill the big hole in APA's projected budget and return dividends on the exorbitant cost of 25 million dollars that has been charged to DSM-5 preparation.When MGH psychiatrist Joseph Biederman was found guilty of violating conflict of interest rules in accepting large amounts of money from the pharmaceutical industry, the news was announced on July 2nd 2011, a Saturday of a holiday weekend. A number of bloggers suggested that this timing was deliberate: an effort to bury the story.
Some may suggest that the weekend DSMV vote and lack of media coverage is related to the power of the APA and big pharma to squash controversy. For the sake of children, families and adults who struggle with mental illness, I hope that there is a more benign explanation.
Addressing the question: Is something wrong with my child?
In the setting of my behavioral pediatrics practice, this can be a loaded question. One would assume that parents are hoping very much for the answer to be "no." But they wouldn't be in my office if there weren't something wrong. Therefore if I say "no," parents may be left feeling there is something wrong with them. At moments like this, I turn to the growing discipline known as "infant mental health." (Here infant refers to children under age five.) Charles Zeanah, MD, in the Handbook of Infant Mental Health writes:
"Infant mental health" can be a confusing term, as it may imply that there is such a thing as "infant mental illness." As those who read my blog know, I am very much opposed to diagnosing mental illness in young children. Rather, infant mental health is about understanding and supporting the young child's ability to experience, regulate and express emotions, form close relationships, and explore the environment and learn.
Many forces, including the education system and health insurance industry, push parents in the direction of answering the above question in the form of a diagnosis. On a purely emotional level, during the time it takes to address the problems in the relationship (and it does take time, but for a young child, not that much time) it can be hard to hold on to the complexity. The need to answer this question with a definitive "yes" or "no" may be put aside, only to resurface at a later time.
Daphne Merkin, in last week's New York Times piece Is Depression Inherited? tackles this challenging issue. Merkin, who has had a lifelong struggle with depression, looks at the question from her perspective as mother to a now 22-year-old daughter. She writes:
When viewed from this perspective, the question becomes not "is there something wrong with my child?" but rather "Who is this child, and how is he or she both alike and different from me?"
As I write in my book Keeping Your Child in Mind, where I explore this issue in much more depth:
The relational focus of infant mental health has been the sine qua non of this field from the beginning. It is not the infant who is the target of intervention but rather the infant-parent relationship. . . . Instead of the problem or disturbance being understood as within the child or within the parent, the problem may be understood as between the child and caregiver.The child brings his or her own qualities to the relationship, qualities referred to as "biological vulnerabilities." These may include difficulties with sensory processing and inflexibility. The parent brings his or her own issues, which include not only biological vulnerabilities, that in adult life may manifest as actual mental illness, but a whole history of relationships and experience.
"Infant mental health" can be a confusing term, as it may imply that there is such a thing as "infant mental illness." As those who read my blog know, I am very much opposed to diagnosing mental illness in young children. Rather, infant mental health is about understanding and supporting the young child's ability to experience, regulate and express emotions, form close relationships, and explore the environment and learn.
Many forces, including the education system and health insurance industry, push parents in the direction of answering the above question in the form of a diagnosis. On a purely emotional level, during the time it takes to address the problems in the relationship (and it does take time, but for a young child, not that much time) it can be hard to hold on to the complexity. The need to answer this question with a definitive "yes" or "no" may be put aside, only to resurface at a later time.
Daphne Merkin, in last week's New York Times piece Is Depression Inherited? tackles this challenging issue. Merkin, who has had a lifelong struggle with depression, looks at the question from her perspective as mother to a now 22-year-old daughter. She writes:
Probably the most basic error we make is in trying to frame the puzzle of how human character evolves in stark oppositional terms — nature or nurture — rather than seeing it as an inextricable mix of things.Her most important point comes in a parenthetical statement. In considering how to use the current information available to guide parenting, she writes:
Until more compelling genetic information becomes available, it seems that the best we can do is to keep our children’s predispositions in mind while focusing on the pieces of the developmental puzzle over which we can exert control. (This includes being attuned to your child’s nature, especially when it differs from your own.)This last concept of "being attuned to your child's nature, especially when it differs from your own," is the essence of healthy parenting. She is describing a parent's recognition of what D. W, Winnicott termed the child's "true self." It involves recognizing a child as a person with thoughts and feelings that are his own. It is an excellent goal to work towards, though not always easy. Issues that get in the way of recognizing the child's true self, including stresses in a parent's life and other relationships, may need to be addressed.
When viewed from this perspective, the question becomes not "is there something wrong with my child?" but rather "Who is this child, and how is he or she both alike and different from me?"
As I write in my book Keeping Your Child in Mind, where I explore this issue in much more depth:
It is my hope that we can move from an emphasis on diagnosis and labeling to an emphasis on prevention. We need to ask not “what is the disorder?” but rather, “what is the experience of this particular child and family?” and “what can we do to move things in a better direction?”
26 Ocak 2016 Salı
The poop wars: why Miralax is just a band-aid
A recent article in the New York Times identifies the possible overuse of Miralax for treating chronic constipation in children. Many take it on a daily basis for years, despite the fact that it is only approved for use in adults. As a pediatrician I have prescribed Miralax many times, and find it to be a very useful medication. The problem comes when only the symptom, and not the underlying cause, is treated.
In my experience the cause of chronic constipation is usually not insufficient fiber in the diet, but rather a combination of a habit of stool holding with sometimes complex emotional issues around autonomy and control (the exception being an underlying neurologic or other medical condition.) I'm all for a healthy diet, but if you make this an issue about eating more fruits and vegetables, you may be simply shifting the battleground from one end to the other. It is best to avoid battles over either what goes in or what comes out, because in these battles the child, by using his body, will always win.
I hope readers don't mind some details-as a pediatrician I have to be comfortable talking about poop. On excellent use for Miralax is for a toddler who has a hard painful stool and then holds in his stool for fear of repeating this experience. This may be more likely to happen in a child who is sensitive not only to bodily sensations but also other forms of sensory input, such as sound and touch. This problem can occur whether or not a child is in diapers. It is best nipped in the bud. Miralax acts by drawing water into the stool. If you give the right amount, the stool is too soft for the child to hold it in. With time the child will forget the painful experience and then go back to normal stooling.
Stool holding and conflicts around toilet training may also occur if a child feels things are out of control in some other aspect of his life. For example, most parents intuitively recognize that toilet training a toddler around the time of the birth of a sibling is not a good idea. One child I took care of dug in his heels around potty training when his parents were going through a difficult divorce.
Parents who have dealt with this problem know that kids can be very adept at holding in stool. They may stand in a corner turning red in the face with effort. This may be interpreted as trying to push the poop out, but most of the time what is actually happening is that they are working to hold the stool in. Just as biceps get strong when you lift weights, the anal muscles can get very strong with repeated use in this way. If this cycle is not broken, kids can go on to have problems for many years. However, with time and careful attention, kids can learn to use their muscles the right way and to have a healthy relationship with their body and bowel habits.
There are often tremendous social pressures on parents to toilet train their children. When parents come to see me in my behavioral pediatrics practice, they often have had ongoing conflicts with their child about sitting on the potty, but have recognized that this approach is not working. They may even wish to have their child take charge of the issue, only to be thwarted by pressures in the school setting. I am all for using motivation for encouragement when a child is ready. Pediatrician Barton Schmitt coined the term "poop candy" for rewards for pooping in the potty. But if a child is not ready, either physically or emotionally, even the promise of a trip to Disney World will not get him to poop in the potty.
Toilet training occurs at a time when children are taking ownership of their bodies. Eric Erikson referred to it as the stage of autonomy vs. shame and doubt. As much as is possible, its best to simply let a child take charge. If problems arise, short term use of Miralax to avoid stool holding while the underlying issues are addressed is certainly reasonable. But it should not be used for long-term treatment. I am not speaking to the safety of the drug, because its long-term risk is not known. Rather, using any drug for years without in- depth exploration of the cause of the problem, a trend far too common in our medication-happy culture, is not a good idea.
In my experience the cause of chronic constipation is usually not insufficient fiber in the diet, but rather a combination of a habit of stool holding with sometimes complex emotional issues around autonomy and control (the exception being an underlying neurologic or other medical condition.) I'm all for a healthy diet, but if you make this an issue about eating more fruits and vegetables, you may be simply shifting the battleground from one end to the other. It is best to avoid battles over either what goes in or what comes out, because in these battles the child, by using his body, will always win.
I hope readers don't mind some details-as a pediatrician I have to be comfortable talking about poop. On excellent use for Miralax is for a toddler who has a hard painful stool and then holds in his stool for fear of repeating this experience. This may be more likely to happen in a child who is sensitive not only to bodily sensations but also other forms of sensory input, such as sound and touch. This problem can occur whether or not a child is in diapers. It is best nipped in the bud. Miralax acts by drawing water into the stool. If you give the right amount, the stool is too soft for the child to hold it in. With time the child will forget the painful experience and then go back to normal stooling.
Stool holding and conflicts around toilet training may also occur if a child feels things are out of control in some other aspect of his life. For example, most parents intuitively recognize that toilet training a toddler around the time of the birth of a sibling is not a good idea. One child I took care of dug in his heels around potty training when his parents were going through a difficult divorce.
Parents who have dealt with this problem know that kids can be very adept at holding in stool. They may stand in a corner turning red in the face with effort. This may be interpreted as trying to push the poop out, but most of the time what is actually happening is that they are working to hold the stool in. Just as biceps get strong when you lift weights, the anal muscles can get very strong with repeated use in this way. If this cycle is not broken, kids can go on to have problems for many years. However, with time and careful attention, kids can learn to use their muscles the right way and to have a healthy relationship with their body and bowel habits.
There are often tremendous social pressures on parents to toilet train their children. When parents come to see me in my behavioral pediatrics practice, they often have had ongoing conflicts with their child about sitting on the potty, but have recognized that this approach is not working. They may even wish to have their child take charge of the issue, only to be thwarted by pressures in the school setting. I am all for using motivation for encouragement when a child is ready. Pediatrician Barton Schmitt coined the term "poop candy" for rewards for pooping in the potty. But if a child is not ready, either physically or emotionally, even the promise of a trip to Disney World will not get him to poop in the potty.
Toilet training occurs at a time when children are taking ownership of their bodies. Eric Erikson referred to it as the stage of autonomy vs. shame and doubt. As much as is possible, its best to simply let a child take charge. If problems arise, short term use of Miralax to avoid stool holding while the underlying issues are addressed is certainly reasonable. But it should not be used for long-term treatment. I am not speaking to the safety of the drug, because its long-term risk is not known. Rather, using any drug for years without in- depth exploration of the cause of the problem, a trend far too common in our medication-happy culture, is not a good idea.
25 Ocak 2016 Pazartesi
Is big pharmas grip on childrens mental health care loosening?
Is it possible that our culture's over-reliance on the quick fix of medication to treat complex problems is waning? That alternative models of care offering meaningful support for early parent-child relationships are gaining increased recognition? My inspiring weekend with the current group of fellows in the UMass Boston Infant-Parent Mental Health Post-Graduate Certificate Program gives me hope that this is in fact the case.
One person in the group, an experienced neonatologist, has in the course of her clinical work increasingly recognized that what makes some premature babies do well and others not lies in the quality of their early caregiving relationships. She sent the group an article as evidence of the above trend, writing:
Fonagy identifies the quality that makes us uniquely human, different from animals. It is the ability to interpret other's behavior as having meaning. Humans alone understand that behavior is driven by motivations, intentions, desires and beliefs.
But the thing is, babies are not born knowing how to make sense of their own and other's behavior. They learn it from the people who care for them. When a parent is attuned with her baby in such a way that says, "I understand you," that child learns to understand not only his own mind, but also the minds of others. This learning takes place at the level of structure and biochemistry of the brain. This ability to interpret other's behavior in turn allows that child to make sense of the wider social world.
Attuned early relationships of what Fonagy called "epistemic trust" are critical because they are "the superhighway for transmitting cultural knowledge." They are the means by which we learn about the world: how we learn to engage with others in a healthy and productive way.
Where does the motivation come from to shift from a quick-fix model of disease to one that promotes healthy relationships? The ACE study, which I have written about in previous posts, offers a kind of negative motivation. If we do not do something to change direction, there will be lots of bad outcomes in the form of such things as mental illness, violent crime, diabetes and heart disease. Fonagy offers more positive motivation. If we intervene early to promote secure safe relationships, we give children the tools to go out into the world, think creatively and move our society forward.
Fonagy points to three trends offering hope that things are changing in the way we as a society care for children and families. One is the increasing evidence of the impact of stressed early relationships on such long-term health outcomes as heart disease and obesity. The second is the decreasing influence of big pharma on mental health care, as evidenced by the marked decrease in development of new drugs to treat mental illness. And third is the role of the Internet in disseminating new information. I am hopeful that this blog is one small part of that trend.
One person in the group, an experienced neonatologist, has in the course of her clinical work increasingly recognized that what makes some premature babies do well and others not lies in the quality of their early caregiving relationships. She sent the group an article as evidence of the above trend, writing:
I am attaching a very short paper from this month's Journal of Perinatology that describes incorporation of relaxation techniques into perinatal counseling. It uses terms such as "being with," "connections," and "compassionate presence." Ten years ago, this paper would have been flatly rejected by a prestigious journal as being anecdotal and merely descriptive.Peter Fonagy, the weekend's featured speaker, a great mind who has been likened to a modern-day Freud in terms of the transformative nature of his ideas, offers an alternative model from that presented by the pharmaceutical industry. Relationships can change the brain in more specific ways than drugs.
Fonagy identifies the quality that makes us uniquely human, different from animals. It is the ability to interpret other's behavior as having meaning. Humans alone understand that behavior is driven by motivations, intentions, desires and beliefs.
But the thing is, babies are not born knowing how to make sense of their own and other's behavior. They learn it from the people who care for them. When a parent is attuned with her baby in such a way that says, "I understand you," that child learns to understand not only his own mind, but also the minds of others. This learning takes place at the level of structure and biochemistry of the brain. This ability to interpret other's behavior in turn allows that child to make sense of the wider social world.
Attuned early relationships of what Fonagy called "epistemic trust" are critical because they are "the superhighway for transmitting cultural knowledge." They are the means by which we learn about the world: how we learn to engage with others in a healthy and productive way.
Where does the motivation come from to shift from a quick-fix model of disease to one that promotes healthy relationships? The ACE study, which I have written about in previous posts, offers a kind of negative motivation. If we do not do something to change direction, there will be lots of bad outcomes in the form of such things as mental illness, violent crime, diabetes and heart disease. Fonagy offers more positive motivation. If we intervene early to promote secure safe relationships, we give children the tools to go out into the world, think creatively and move our society forward.
Fonagy points to three trends offering hope that things are changing in the way we as a society care for children and families. One is the increasing evidence of the impact of stressed early relationships on such long-term health outcomes as heart disease and obesity. The second is the decreasing influence of big pharma on mental health care, as evidenced by the marked decrease in development of new drugs to treat mental illness. And third is the role of the Internet in disseminating new information. I am hopeful that this blog is one small part of that trend.
23 Ocak 2016 Cumartesi
Educents First Grade Bundle is HERE!
Classroom routines are settling a bit, students are getting into the groove of things, and we are really starting to dig deeper into our curriculum! So I have teamed up with Educents and some other bloggers to offer you this great First Grade Literacy Bundle at a huge discount for a limited time! (And keep reading for an opportunity to win an item from my store!)
You get all these goodies for a grand total of $24.99!!
That's less than $1.50 per unit!!
This is my product that is featured in the bundle:
You can print and bind it, then place it in your Writing Center like I do.
Take a closer look:
There are 17 other products in our bundle to get your kids learning! Hop along to see all the goodies you will get!
But that's not all! I am giving you a chance to Pin It to Win It. Just pin the Educents image above and enter below for a chance to win TWO items from my Teachers Pay Teachers store.
a Rafflecopter giveawaySo head on over to Educents when you are ready and stock up on amazing literacy resources for first!
a Rafflecopter giveawaySo head on over to Educents when you are ready and stock up on amazing literacy resources for first!
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