Keep Mothers in Mind for Mothers Day and Mental Health Month

In recognition of May as National Mental Health Awareness Month, President Obama made a proclamation that included this statement

My Administration is also investing in programs that promote mental health among young people. 

While he went on to speak of working with teachers and students, my hope is that Obama will recognize that prevention starts with parents and babies. A social and cultural valuing of parents, as occurs in countries like Australia and Finland, is the path to a truly preventive model.

A recent issue of the journal Current Problems in Pediatric and Adolescent Health Care identifies the following:

The presence of parental psychological problems, such as depression or anxiety, can lead to prolonged periods of disorganized parent-infant social interaction, compromising long-term infant outcomes. A wealth of studies has shown that maternal depression is a strong predictor of infants' social, emotional, and cognitive problems throughout the lifespan.

Representative Ellen Story and her Postpartum Depression Commission have recognized this fact. While the initial focus of the group had been on screening for postpartum depression, it has expanded to focus on the emotional well being of parents during pregnancy and in the postpartum period. This includes supporting of strong, healthy parent-child relationships.

One of the initiatives is a new program MCPAP for Moms. The aim of the program is to provide statewide support for pediatricians, obstetricians and other clinicians who have the opportunity to identify and treat new parents who may be struggling with a range of perinatal emotional complications. MCPAP for Moms is partnering with the wonderful organization, MotherWoman, to integrate the community based perinatal support model, as well as the important and valuable program at the Massachusetts School of Professional Psychology,  the MSPP Interface Referral Service, that connects people in need of help with appropriate care.

D.W.Winnicott observed in his work as a pediatrician and psychoanalyst what he termed the "ordinary devoted mother." In the early weeks and months, when the infant is completely helpless, he relies on this devotion. When his caregivers are present in this way, development proceeds in a healthy direction. But when a parent is, in the words of Winnicott's biographer Adam Phillips, "preoccupied by something else," in the face of such things as social isolation, depression, anxiety or even PTSD, containing the helpless baby can be very difficult. Add a fussy baby to the mix, and this is where development can first get off track.

I am happy to be part of the MCPAP for Moms initiative because its leaders recognize the need to the focus is on the relationship. It is not only about treating the mother, but also bringing in the baby- identifying stressed early relationships and finding ways to support those relationships.

The baby is an active participant from the start. Crying, sleep and feeding problems often affect the emotional well being of new parents. The baby's mood can affect the parents, and the parents' mood can affect the baby. Parent and baby can interact in a way that causes worsening of each other's distress. This is the point at which help is needed- for the parent, for the baby, for the relationship.

By valuing the role of parents, and investing resources in the early weeks, months, and years when the baby's brain is most rapidly developing, we will be engaging in promotion of mental health and primary prevention of mental illness.

Music and mental health: a tribute to Pete Seeger

This morning while driving my son and two friends to practice for their high school singing group, we listened, as part of an NPR report on his death at age 94, to Pete Seeger tell the story of his song Where Have All the Flowers Gone. His voice, his message and his music together had a profound calming effect on me, and I suspect on my passengers as well. There was quiet, and perhaps even a tear shed by others besides me.

In my behavioral pediatrics practice I make a point of asking about a child's interest in music. Whether the presenting problem is one of anxiety, frequent meltdowns, inattention, hyperactivity, or a range of other concerns, I have found that music often has a calming effect.  One little girl, whose mother was under considerable pressure to have her diagnosed with ADHD and put on medication, stopped her scattered and frenetic play to sing me a song. Another, struggling with social anxiety, who for much of the visit refused to speak, at first with his back to me and then with increasing boldness, did the same. When parents see this effect of music on their child, they are moved to incorporate music in to our efforts to support development of emotional regulation. Problems with emotional regulation are central to all of these behavioral symptoms.

I was in need of emotional regulation myself this morning after spending the weekend embroiled in a difficult discussion about the subject of "ADHD." In a conversation on a list serve made up primarily of child psychiatrists, I pointed to a recent study about ADHD that showed very poor long-term outcome. I wondered if there might be an alternative explanation to that offered by the authors of the study, namely that ADHD is a chronic illness that requires lifelong treatment. Could it be, I asked, that the poor long-term outcome is because we are not properly treating the problem in the first place? That when we diagnose based on symptoms alone, and treat with behavior management and medication, we fail to address the full complexity of symptoms of dysregulation of attention, behavior, and emotion? I wondered how we would separate this issue from the possible long-term effects of stimulant medication itself.

I got a huge amount of push back, with a number of people implying that I was "unscientific," and that I might be affiliated with the church of Scientology. Given that there is extensive scientific evidence supporting an alternative paradigm for understanding symptoms of dysregulation of attention, behavior and emotion, this suggestion particularly got under my skin.

Not only music, but dance, martial arts, yoga and other activities have an important role to play in self-regulation. This is particularly true for children who have biological vulnerability to dysregulation, including those with problems of sensory processing. All of these activities occur in the context of important relationships, relationships that themselves are essential to development of emotional regulation. My little patients perform their songs in the context of a growing relationship with me.

But if we employ a purely medical model, diagnose ADHD, anxiety or any range of problems using the DSM ( Diagnostic and Statistical Manuel of Mental Disorders), we miss the relational and historical context of these symptoms. We need to offer room to hear the individual story of a child and his family in order to make sense of his symptoms. This story is itself can be a kind of music. Dar Williams incredible song "After All"  offers a beautiful example.

When children present with a range of behavioral symptoms, if we simply "manage behavior" and treat with medication, where is there room for the music?

Arlo Guthrie, who frequently performed with Seeger, in his song Alice's Restaurant, proposed that everyone being evaluated for the draft walk in singing the chorus of his song, and in doing so create an anti-war movement.

Borrowing the idea, espoused by both Arlo and Pete, of changing the world with music, what if every new evaluation of a child with a behavior problem included singing and/or listening to one of Pete's songs? It might help calm everyone down-parent, clinician, and child alike. If, in turn, the next generation were helped to develop in a healthy way, with an ability to think creatively and engage effectively in a complex social environment, it might change the world.

Postpartum Mental Illness: Ability to Soothe Baby Helps Mothers Most

Fascinating research at the Yale School of Medicine shows that in poor families who are under-resourced and overburdened (a more meaningful phrase replacing "high-risk,") "diaper need" or lack of reliable access to clean diapers, is the factor that most impacts on mothers' mental health. In a study published in Pediatrics, lead researcher Megan Smith found that 30% of mothers living in poverty report diaper need.

When mothers were worried about when they would be able to get the next diaper, self esteem was diminished in the face of their inability to soothe their baby, in turn negatively impacting their relationship with their baby, setting the stage for a downward spiral.

One take home message of this research is the importance of providing clean diapers. The National Diaper Bank Network, along with many local organizations, is making efforts to meet this significant need.

A second broader implication is the remarkable finding of how much the baby's well being impacts on the mother's mental health.

The converse of the finding that diaper need negatively impacts a mother's mental health, is that reliable access to clean diapers can improve a mother's mental health.

Generalizing this observation to a broader population of mothers with mental illness, the ability to soothe a baby, to take care of a baby's basic needs, may be integral to that mother's emotional well being. For that reason, the baby's behavior, including excessive crying, feeding issues, sleep issues should be an integral part of treatment of postpartum mental illness.

Traditionally treatment of postpartum depression focuses on the mother, often in the form of medication, but also support groups and psychotherapy. The baby's behavior is addressed separately, usually by a pediatrician. Innovative programs such as the Infant Behavior, Cry and Sleep clinic in Rhode Island explore the relational nature of these problems.

In a recent talk at the Austen Riggs Center Smith described a brochure addressing the question that many mothers ask- how can I prevent my baby from experiencing the effects of mental illness? Much of Smith's audience laughed at the brochures recommendations: "establish good relationships," reduce conflict," help with anxiety."

For families struggling to obtain life's basic necessities, these suggestions are laughable but certainly not funny. But for any family where a mother is struggling with mental illness, these goals may be unattainable without significant help.

In the new MCPAP for Moms program, a statewide initiative to improve identification and treatment for mothers who are struggling with perinatal emotional complications, efforts are being made to incorporate treatment of the mother and infant together.  Supporting a mother's efforts to effectively soothe and feed her baby by helping her to make sense of her baby's unique qualities and communications, is an integral part of preventing the negative impact of maternal mental illness on child development. A positive cycle of interaction can be set in place. This innovative research on diaper need offers evidence for the wisdom of this direction.

Moving beyond the DSM paradigm of mental health care

A paradigm is a way of thinking about things. For the past 60 or so years, our thinking about mental health and illness has been dominated by what can be referred to as the "DSM (Diagnostic and Statistical Manual of Mental Disorders) paradigm." What this looks like in everyday practice is that when a child is referred to my behavioral pediatrics practice for say, anxiety, the questions that parents, referring doctors, and teachers ask is, "Does he have anxiety disorder?" followed by  "How to we manage his behavior?" and "Does he need medication?"

The DSM paradigm has been useful as a way of organizing our thinking. But it is important to recognize that these "disorders" of anxiety, depression, ADHD etc, are simply lists of symptoms that tend to go together. They do not correspond to any known biological processes in the way that, for example, diabetes is a result of lack of insulin.

When the DSM system was first created, we did not have the powerful health insurance and pharmaceutical industries that we have today. Because of the existence of these entities, we are currently in a position of being forced in to a very narrow view of mental health and illness.

The DSM system is a black and white paradigm with only the possibility of "normal" or "disordered."
According to the DSM paradigm, if the answer to the first question about my anxious patient is no, and there is no diagnosis, there is no insurance coverage, and so no help. But clearly such a family is struggling.

 We need a paradigm shift, defined as a fundamental change in approach and underlying assumptions. A new paradigm is needed that gives room for the complexity that we have learned from the abundance of research at the interface of developmental psychology, neuroscience and epigenetics.

The child above may have a strong family history of anxiety traits. He may have a strong genetic vulnerability for anxiety. However, if a parent who shares these traits was slapped across the face for her "difficult behavior" when she was a child, she may become so overwhelmed with stress in the face of her child's challenges that she is unable to help him to manage his anxiety. Marital conflict, perhaps exacerbated by the stress of a child who is struggling, can further add to the complexity. The environment in which this child grows and develops will determine the way in which his genetic vulnerability is expressed.

As I described in a previous post, the field of infant mental health offers such a paradigm. It is relational, developmental and founded in the basic principle that behavior has meaning. It gives us a way to organize our thinking about the problems of the family I describe above.  It offers a path to treatment, namely to support the efforts of the child's parents to recognize the complex meaning of his behavior. Once parents feel heard and understood, and have the opportunity to make sense of their child's behavior, they will be better able to help him manage his anxiety. They might involve him in physical activities or creative activities that help him to feel calm in his body. They might get help for their own relationship. They might work together with the child's teachers to strategize about how to support him in the school setting.

Thanks to my book, Keeping Your Child in Mind, I had the honor of being invited to give the Paul A. Dewald lecture this week in St Louis.  My book is about the idea that rather than jump  "what to do" about a child's behavior, it is important to simply "be" with that child,  to think about that child. As I prepared the talk I came to recognize that the same holds true for our whole system of mental health care.  Before we can plan "what to do" to apply the wealth of research I refer to above, we must first recognize that we need to "think" differently. We need move beyond the DSM paradigm and embrace a new paradigm; to facilitate a paradigm shift. An important first step is to name it as such.

Mental illness and motherhood: lessons from Miriam Carey

We do not have medical records or diagnoses. The news is filled with speculation. What we do know is that Miriam Carey’s one-year-old daughter lost her mother, and that because the incident occurred in Washington D. C. in front of the White House, it is shining a spotlight on the subject of mental health and motherhood. And the message should be simple. Diagnoses don't matter. As part of our nation's health care system (another complex and fraught subject this week!) we must provide a safety net for mothers who are struggling emotionally in the weeks and months following the transition to motherhood.

Recently in my role as director of Newton-Wellesley Hospital’s Early Childhood Social Emotional Health program I have had the privilege of participating in a mother-baby group on a regular basis. During the 90 minute session, as these moms share feelings about such things as sleep deprivation, navigating new territory with a spouse, and going back to work, the babies cycle through sleep, alert interaction,  fussy periods, crying and feeding. These mothers, all of them doing this for the first time, intuitively guide their infants through multiple transitions while simultaneously engaging in meaningful conversation.

But it doesn’t always go well. Almost every session, there is a mother-baby pair who struggles. A baby may scream inconsolably, and his mother may leave, overwhelmed by helplessness and shame despite the reassurances from the other moms and group leaders.  A mother may break down in tears as she describes the way her own family is not supportive, and how alone she feels. The contrast between the easy attentiveness of the rest of the group, and the pain these mother-baby pairs are experiencing is striking. We expect motherhood to be a time of falling in love; a time of joy and bliss.  When it is not, the suffering can be profound.

There is nothing quite like the aloneness of mental health struggles in the setting of motherhood. I recall being startled by the story of  one mother in my behavioral pediatrics practice who had struggled with severe postpartum depression. She told me that she had experience relief when her father died when her daughter was about a year old. It was not that she didn’t love her father. But in sharing the grief with her mother and siblings, she no longer felt so terribly alone.

The Massachusetts Postpartum Depression Commission, led by Representative Ellen Story,  in collaboration with such organizations as MotherWoman and the Massachusetts Child Psychiatry Access Project, is working hard to provide a safety net for every mother-baby pair who is struggling in this way.

Through a combination of screening, support groups and a network of clinicians who are experienced in working with mothers and babies in the setting of perinatal emotional complications, the aim is to be able to identify and treat every one of these pairs.

This type of effort is also occurring on national level, through such organizations as the National Coalition of Maternal Mental Health. Perhaps the attention on the issue, due to the fact that an incident involving a car chase occurred on Capitol Hill, will give some meaning to Miriam Carey’s daughter’s loss.

To MA Gubernatorial Candidates on Mental Health: What About Children?

At last night's MSPP ( Massachusetts School for Professional Psychology) sponsored Gubernatorial Forum on Mental Health there was much talk among all of the candidates about how devoting resources to mental health care is a wise investment. But there was virtually not one mention of prevention in the form of children's mental health care. This was striking, as Nobel prize winning economist James Heckman has offered extensive evidence of how devoting resources to prevention in early childhood leads to decreased long-term costs of physical and mental health care.

Investing in early childhood also leads to decreased spending on prisons, a topic all of the candidates addressed in terms of decreasing the number of people in prison for non-violent crimes and first time drug offenses. They all correctly identified the high rate of mental illness in prison and the need to offer treatment, particularly substance abuse treatment.

The whole night I was thinking, "what about the children?" This might have been due to the format, and the fact that moderator Tom Ashbrook did not ask a single question about children.
I was struck by the contrast between this discussion and last week's American Academy of Pediatrics sponsored symposium on Child Health, Resilience and Toxic Stress.

All the best science of our time, in the form of research at the interface of neuroscience, genetics and developmental psychology, tells us that to invest in prevention means to invest in parents and children.

I was disappointed by Martha Coakley in a sense towing the NIMH party line, whose great shortcomings I describe in a previous post, by saying that mental illness is like any physical illness, such as diabetes. I am one hundred percent in favor of parity for mental health care, and decreasing the stigma of mental illness. But the only way to achieve this parity is to recognize that mental illness is not like diabetes.

Resilience and emotional wellbeing develop in the context of relationships. To both prevent and treat mental illness the focus of intervention needs to be on relationships. What makes us human is our historical and relational context. We need to value space and time to listen to each other.

The most important point of the evening, that was made in some form by all three democratic candidates, is that reimbursement for mental health care needs to increase significantly. When we place value, both cultural and monetary, on taking the time to listen, whether to parents of young children, teens struggling with substance abuse, or adults with a range of diagnostic labels, then we will be making meaningful steps not only towards mental health care parity, but also towards promotion of health and resilience.

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. 



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.

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. 

  

Adam Lanza and Preventive Mental Health Care

In keeping with my wish for continued meaningful dialogue in the wake of last week’s horrific events, I would like to expand upon what I mean by "preventive mental health care." I am referring to relationship-based care that focuses on young children and families. All of the best science of our time, at the interface of neuroscience, genetics and developmental psychology, tells us that by supporting parents and young children together we will have the best chance to promote both physical and emotional health.

This is not to say that when there are problems it is a parents "fault," nor certainly, as many parents fear, that a young child who is struggling is at risk for becoming a mass murderer. But the brain grows in relationships, and supporting relationships supports healthy brain growth. 

Early reporting suggests that Adam Lanza struggled with severe social anxiety from a young age. This is a description, not a DSM diagnosis.  His mother apparently had some kind of conflict with his school and ended up home schooling him (early reports that his mother worked at the school where the shooting occurred, that I refer to in my previous post, turned out to be incorrect.) 

I wonder if our best chance at preventing this horrific event would have been to carefully listen to these parents, including the father, when Adam was a young child, to understand their experience and find meaningful help for the whole family.

The  piece I Am Adam Lanza's Mother originally published in the Blue Review, that has now gone viral, offers a striking up-close view of how parents suffer in the face of a troubled young child. It offers evidence for the need for intensive help for parent and child together.  Simply labelling the child with a psychiatric disorder and prescribing medication is grossly inadequate care. 

Current standards of care in psychiatry, including both the focus on DSM diagnostic category, in psychiatrist and author Daniel Carlat’s words the “what” rather than the “why,” as well as over-reliance on psychiatric medication, is more narrow than my definition. Preventive mental health care consists of careful listening and support of parent-child relationships. 

On NPR this week there was a comment made that other countries with better gun control laws do not have these kind of events. But what if the important difference is that we are seriously behind in supporting young children and families with such things as parental leave for newborn care?

I wonder if there is some insight to be gained from the venom directed against me in some of the comments on my last post. I see similar venomous in comments on similar posts.They seem to represent an underlying rage (at least among those who comment on blogs) as well as the loss of the capacity to listen to each other.  Assumptions are made about me that are completely unfounded and could easily be dispelled by simply reading my bio and or most recent blog post.

We are as a society traumatized by this event, and by the continued horror of watching the funerals of these young children. To find a way to take meaningful action in the wake of this trauma, we all need to calm down and take a collective deep breath. Perhaps the opening point of meaningful dialogue would be an effort on all sides to take the time to listen to each other.

Gun control and preventive mental health care to honor the lost children of Newtown

For the families who lost children, their world as they knew it has effectively ended. Yet somehow the sun rises again and the next day is here. For the rest of us grieving along with these families, the only way to move forward is to take what President Obama called "meaningful action." I interpret this to be action that is radical and significant enough that it will somehow give meaning to this unimaginable loss.

The first and most obvious front is gun control. Without access to guns, apparently the same rifles used by troops in Afghanistan and Iraq, one individual could not have done this degree of harm. The politics of gun control is not my area of expertise, but certainly the politicians must now be motivated to, as Obama said, "put aside differences" and honor these children with dramatic changes to gun control laws.

The second front is preventive mental health care. This event is the result of a deeply disturbed individual with access to guns. My inbox this morning was full of emails from mental health colleagues referring to pieces they had written for other massacres such as Virginia Tech. I hope that this unspeakable horror will be  the one that will finally lead to real change in access to preventive mental health care.

One of these colleagues wrote of how these events are often perpetrated by young adults who have not been "acting out," but rather have been quietly bullied for years and seriously neglected at home. Their symptoms may be more subtle. Yet it is difficult to imagine that there were not people in this family's life who did not recognize that this boy/young man was mentally ill.

The emerging information speaks to  a deeply troubled relationship between the shooter and his mother as being at the root of the event. Apparently he first shot his mother and then went to the school to deliberately kill the children at the school where she worked. I wonder, was the hurt he experienced in his relationship with her magnified by his witnessing of the care she gave her young charges at her job?  Of course I don't know, and this is only theory as I struggle to make sense of something that doesn't make sense.

As I said to my editor when she asked for our thoughts on this event, the trauma is perhaps too fresh for an in-depth discussion of theory and policy change. However, I am hopeful that the coming weeks and months will be filled with meaningfully dialogue of how we as a society can honor the dead children, both through gun control and improved access to quality preventive mental health care.

Infant Mental Health and Child Protection: an Essential Partnership

Michael Bush, a bright, open-minded third-year student at West Virginia University College of Law, contacted me this past summer when, in his role as an editor of the Law Review, he was organizing a symposium on Child Protection in the 21st Century. In our subsequent email conversation he wisely observed that those in the legal profession are often in a position to decide what is "in the best interest of the child" with little substantive understanding of what exactly is in the best interest of the child.  He invited me to share my knowledge as an expert in infant mental health.

This week, his efforts and those of his fellow law review editors-a remarkable group of intelligent and thoughtful young people-came to fruition. It was an extraordinary experience that opened up many opportunities for meaningful collaboration.

 In my presentation I contrasted the historical view of Child Protection as a child-saving service designed to prosecute parents with the model of relationship-focused preventive intervention promoted by the field of infant mental health (those who are interested may see the talk in its entirety on the webcast.)


Rather than giving specific ideas about what to do, I offered a different way to think about work with very troubled families.  While many in the legal profession view their task as "proving what the parent has done wrong," (this is a direct quote from a CPS social worker) I encouraged them to think about creating a "holding environment" where there is room for non-judgmental curiosity about the meaning of behavior. I presented an overview of the research that supports this paradigm.

Many very important things came out of this trip. A number of people from CASA, a non-profit organization in Virginia that supports volunteer advocacy for abused and neglected children, attended my talk. Amber Moore, the editor-in-chief of the Law Review, told me that they had requested my PowerPoint because "they couldn't write fast enough." They want to use what I was teaching to train their volunteer workers. I discovered that people were starved for knowledge about contemporary research in child development in a form that they could understand.

I quoted from my book Keeping Your Child in Mind, explaining that while it was being marketed as a parenting book, it is actually a book about infant mental health written for a general audience. I wrote it with my pediatric and mental health colleagues in mind, but now I see how useful it could be to the legal profession, specifically those working in the area of child protection.

One of my co-presenters was a delightful judge from central West Virginia who has been doing child protection work for over 20 years. He openly admitted to his lack of knowledge on the subject of contemporary child development research and bought 5 copies of my book.

I met a remarkable young woman who, in addition to attending law school, works at the Industrial Home for Youth in Salem, where prior to a recent lawsuit, children as young as 13 were routinely placed in solitary confinement. As part of a law school class, she is drafting a bill to require multidisciplinary meetings every three months for these young offenders, who currently may not meet with anyone who is advocating for them for their entire stay. Because WVU is the only law school in West Virginia, the students' bills are presented to the state legislature, and a percentage of them actually become law. I am hopeful that she and I will keep in touch and that I can support her in her efforts.

As Keynote speaker of the symposium, I have been invited to write a paper for the West Virginia Law Review that will then be available for citation in legal work.  Another of my co-presenters, who spoke about the legal challenges of adolescent parents, already told me that she intends to cite my work.

This trip was well outside my comfort zone. I had never been to West Virginia (or even Pittsburgh-where I had to fly to get there) and certainly had never spoken with an audience of lawyers. My infant mental health colleagues are "my peeps." In a few weeks they will gather in Los Angeles at the wonderful Zero to Three National Training Institute. Sadly, I will miss it, in part because of this trip.

I have often said to my infant mental health colleagues that we need to work on communicating the wealth of ideas that will be presented at that conference widely beyond our borders.  It was like a dream come true to have the opportunity to speak to a group of bright young law students- the future lawmakers and policy makers of our country. The experience left me hungry for more.

Preventive mental health care for children falls through the cracks

The current issue of the Journal of the American Academy of Child and Adolescent Psychiatry has an excellent article, Integrating Mental Health Care Into Pediatric Primary Care Settings, identifying the causes of this problem.

Pediatric training provides limited experience in screening or intervening for mental disorders. In contrast, child psychiatry training emphasizes the treatment of children with established psychiatric diagnoses and typically offers limited experience with children at risk for mental disorders or children whose symptoms do not reach the threshold for diagnosis. 

In other words, the current structure of the health care system does not have room for prevention. Primary care clinicians, who have the main contact with young children and families, do not have adequate education in prevention, and specialists who children are referred to when problems arise only know how to treat identified "disorders." The article further elaborates on the reasons for this situation:

Current financing structures reward treating established diagnoses, not providing preventive services, because payment for visits, with few exceptions, requires a DSM-IV diagnosis.

This problem is currently being addressed in the refinement of the DC: 0-3, a classification of disorders of infancy and early childhood that recognizes the significant role of relationships in problems in this age group. If the DC:0-3 is "cross-walked" with a DSM diagnosis, then reimbursement is possible.  That word "disorder" is still part of the conversation, but it is a step in the right direction.

Another problem intrinsic to the system is that for billing purposes the child is the identified patient, making work with the family challenging.

Research on the treatment of child mental health conditions has strongly indicated the benefit of treating the child and the caregiver as “the patient,” but public and private plans frequently do not pay for family-focused treatment... the need to identify the child as the patient makes family-focused interventions difficult to support financially; likewise, payment for caregiver-only or collateral sessions is lacking.

Another problem identified is the lack of financial support for collaborative care. In my work with families in the Early Childhood Social Emotional Health program at Newton Wellesley Hospital I speak regularly with a child's primary care doctor. This is an essential part of care, as that person often has a longstanding ongoing relationship with the child and family and knows them well. In addition, if I refer a family on to more specialized care, such as with a psychiatrist, it is important that I fill them in on the work I have been doing with the family. Working as a team we can hold the family through a difficult time, and get development going in a healthy direction. I spend a lot of time on the phone because it is good care, and I know that many of my pediatrician and child psychiatry colleagues do the same. Yet none of this care is reimbursed.

The article offers this ray of hope:

The Affordable Care Act (Public Law 111-148) requires mental and behavioral health coverage in an essential benefit package at parity with medical benefits. This could incentivize the integration of care.

Of course for this to happen, President Obama must be reelected.

NYT on mental illness, talk therapy, drugs: what about children?

Last week there was an invitation to dialogue in the New York Times on this subject.  In today's Times there is a fascinating array of responses, but none addresses the issue as it relates to children, for whom there has been an exponential rise in prescribing of psychiatric medication in the last decade. Here is the letter I sent in.

We live in a culture of advice and quick fixes. Increasingly, understanding of human experience is reduced to lists of symptoms, diagnosis and medication. There is less curiosity, less careful listening to one another.

Talk therapy, which perhaps should be called “listening therapy,” offers space and time to create a meaningful narrative, including an opportunity to experience feelings of grief and loss.

This is particularly important in work with children. When symptoms are medicated away, the opportunity to tell stories that give meaning to behavior may be lost. Research has shown that a child’s knowledge of family narrative, both the ups and downs, is highly correlated with self- esteem, resilience and mental health. Giving a parents an opportunity to tell their story to a nonjudgmental listener, to integrate their own narrative,  is critical to treatment of childhood “behavior problems.”

I am not advocating for talk therapy for children. Rather, in order to help children who are struggling with a range of "behavior problems," it is essential to listen to their parents, to give them an opportunity to reflect on the meaning of behavior. The behavior is a symptom, perhaps even an adaptive response, to the underlying problem. There is extensive evidence, that I describe in my book Keeping Your Child in Mind, that when parents reflect on the meaning of behavior in this way, they have the opportunity to promote healthy development at the level of gene expression and structure and biochemistry of the brain.

In my practice, where I see children under the age of five, parents typically present with concerns like, "he never listens" or "she is defiant." But as we take the time to think about how the problem developed, meaningful shifts in understanding occur. For example, parents may recognize the way a child's behavior pushes their buttons because of their own history of abuse. Or serious marital conflict, that often has zeroed in on the child's behavior, comes to the fore.  Or the impact of an easygoing sibling may be recognized. Tantrums and meltdowns at birthday parties may be understood in the context of a child's longstanding difficulty with processing sensory input.

Creating this narrative, this story that makes sense of the problem, may only be the beginning of the treatment. Intensive work with parent and child together, to address the way the child's behavior provokes the parent, is often indicated. Marital counselling, or even working with a couple who are not together, to help them work together to support their child may be necessary. Quality occupational therapy can be invaluable to help a child to feel calm in his body. Parents may benefit from things such as yoga to help them to calm their own reactions.

Here is where the trouble really starts. Quality clinicians who offer these services are in short supply. Insurance is often a huge obstacle. But, creating perhaps an even bigger obstacle, is the cultural norm of the "quick fix" approach of medicating symptoms, even in children as young as 5.  Not only must parents overcome these obstacles of finding a provider, making the time, allocating funds, as well as doing the important but often challenging emotional work of addressing these issues. They must go against pressure from teachers, relatives, friends and  health care providers.

I will continue to offer parents space and time to be heard, to create meaningful narrative, because I am confident that telling stories, and working through the feelings of grief and loss that often accompany them, is the path to meaningful connection and healthy emotional development.  It causes me great heartache when these efforts are thwarted by a system that works in opposition to this approach.

To CDC on childrens mental health: consider office of homeland attachment security

Change is in the air for children's mental health care. The latest CDC (Center for Disease Control) special supplement to the MMWR (morbidity and mortality weekly report) is titled Mental Health Surveilance Among Children-United States 2005-2011. The report overview states:

Approximately $247 billion is spent each year on children’s mental health.  The mental health of children is critical to their overall health as children and as they grow into adults.

The report summary concludes:

More comprehensive surveillance is needed to develop a public health approach that will both help prevent mental disorders and promote mental health among children.

This report coincides with both the release of DSM (Diagnostic and Statistical Manual of Mental Disorders) 5, and a statement by the director of the NIMH (National Institute of Mental Health) that research funding would not be guided by DSM diagnoses, and that a new paradigm of mental health care is needed.

The time has come to recognize the overwhelming evidence regarding the importance of early relationships in healthy emotional development. The answer to the problem posed in the CDC report is in: invest in early childhood -from newborn to three- to prevent mental health disorders and promote mental health.

A huge part of this evidence comes from the CDC itself, with the ACES study, showing long-term negative impact on both physical and emotional health of a range of adverse childhood experiences.  An abundance of research coming from the discipline of infant mental health provides a more nuanced view of this issue. 

 When parents are supported and valued by society, they are able to be fully present with their children, in turn helping to grow healthy brains. Children who grow up in an attuned caregiving environment are flexible, resilient, and empathic.  In contrast, when children experience toxic stress, or stress in the absence of a safe, secure caregiving relationship, the parts of their brains responsible for emotional regulation do not develop normally. What results are symptoms that are then labeled "mental illness." 

I heard this phrase "office of homeland security of attachment" from Gerard Costa, director of the Center for Autism and Early Childhood Mental Health at Montclair State University. I was speaking at the 2nd annual Todd Ouida Children's Foundation Conference with the wonderful title: The Magic in Moments: Patterns of Early Relationships that Create Resilient Individuals and Peaceful Societies. While the phrase is meant to be humorous, the idea behind it is very serious.  

Our country is seriously lagging behind other countries in the care and attention we give to young children and their parents, with potentially devastating effects. A special government organization to take on this task would address this problem with the attention it deserves. This does not mean that the government has a role in parenting, which is a private, individual experience. Rather, such an organization could address such things as:

- parental leave policy

- comprehensive screening and treatment for perinatal emotional complications including 

depression and anxiety

- education of a workforce trained in working with young children and families

-  high quality child care, including supervision for child care workers 

Attending to early caregiving relationships will move us toward the goal of creating peaceful societies. Given that $247 billion is spent a year on children's mental health, focusing on early childhood is not only the right thing to do, it is also a worthwhile investment. 

  

DSM, NIMH on mental illness: both miss relational, historical context of being human

It seems that the National Institute of Mental Health (NIMH) may have dealt a death blow to the recently published Diagnostic and Statistical Manual of Mental Disorders (DSM 5) when the organization declared they would no longer fund research based on the DSM system of diagnosis. The views of NIMH director Thomas Insel were referenced in the recent New York Times article on the subject.

His goal was to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.

I am no fan of the DSM system, which reduces complex experience to lists of symptoms; focusing on the "what" rather than the "why."  However, the NIMH model has limits as well. There seems to be a wish to study mental illness in the same way we study cancer or diabetes. While I certainly have great respect for the complexity of the pancreas, or the process of malignant transformation of cells, trying to understand the brain/mind in an analogous way seems to be an unnecessary and even undesirable reduction of  human experience.

What is missing from both paradigms is recognition of the relational and historical context of being human. Fortunately there seems to be awareness that neither paradigm is complete. The Times article goes on to say:

Dr. Insel is one of a growing number of scientists who think that the field needs an entirely new paradigm for understanding mental disorders, though neither he nor anyone else knows exactly what it will look like.

The growing discipline of Infant Mental Health offers just such a paradigm. This discipline is characterized by four key components. First and foremost, it is relational, recognizing that humans (and that includes their genes and brains) develop in the context of caregiving relationships. Second, it is multidisciplinary. Experts in infant mental health offer different perspectives.  They come from many fields, including, among many others, developmental psychology, pediatrics, nursing, and occupational therapy.  Third, it encompasses research, clinical work and public policy.  The field looks at mental health within the context of culture and society. And last, it is reflective, looking at the meaning of behavior, not simply the behavior itself. The ability to attribute motivations and intentions to behavior is uniquely human, and research has shown that this capacity is closely linked with mental health.

Unfortunately when people hear the term infant mental health, they imagine babies lying on the couch.  In reality, the field offers a way of understanding all of human experience, well beyond infancy.  I recently taught a course on infant mental health to clinicians at the Austen Riggs Center, a hospital that offers intensive inpatient treatment for severely disturbed patients. None of them are infants- the youngest are in their late teens and most are well into adulthood.  My students found the insights from infant mental health very valuable for understanding and treating their patients.

The Center for Disease Control (CDC) Adverse Childhood Experience (ACES) study provides extensive evidence of the long-term effects of early exposure to a range of negative experience, including parental mental illness, divorce, abuse, and neglect, on mental health. The more severe the mental illness, the earlier in life disruptions to development probably occurred. Knowledge of infant mental health (that spans age 0-5) offers a textured understanding of this early experience.

Looking at an individual brain and/or genes, or listing the behavioral symptoms of an individual person, out of relational and historical context, how can one possibly understand the complexity of human experience? This complexity is represented by such things growing up in the home of a Holocaust survivor, a depressed parent,  in the setting of ongoing war trauma, with a physically and emotionally abusive parent, or some combination of all of these. A recent article on the blog ACES Too High,  "What motivated the Boston bombing suspects?" offers a fascinating look at the Tsarnaev brothers from an ACES perspective. The use of the word"motivation" in the title represents a curiosity about the meaning of behavior that is representative of an infant mental health perspective.

The ongoing research coming from the discipline of infant mental health offers growing knowledge about effective, primarily preventive, interventions. Not only do we need this research to continue, but we also need to grow a workforce trained in infant mental health to offer these interventions on a large scale. When the NIMH looks for a new paradigm towards which to direct funding, I hope they will look to the paradigm of infant mental health.

Postpartum Depression Rx Links Mothers Day and Childrens Mental Health Month

On Sunday we celebrate mothers- bringing breakfast in bed, going out to dinner, buying flowers. In my personal experience, one of the greatest pleasures of Mother's Day, in addition to having the "day off," is to take joy in my beautiful children as they grow and develop and make their way out into the world.

D. W. Winnicott, pediatrician turned psychoanalyst, famously said, "There is no such thing as a baby." What he meant  is that one cannot fully understand a baby without considering the relationship with the mother. Equally true is that without a child, there is no such thing as a mother. In order to understand a mother's experience, it important to consider the child and what he or she brings to the relationship.

I have been thinking about this a lot as I participate in the important work of Representative Ellen Story's Postpartum Depression(PPD) commission. Rep. Story originally filed a bill that mandated universal PPD screening in multiple settings (OB and pediatric), but it was amended to a law that calls on the Department of Public Health to issue regulations on best practices for PPD screening. The law also created the Commission, whose  job is to help DPH in its work to come up with a proposal for what the state should do on PPD. 

I think this was a good plan. Universal screening is important. Liz Friedman, program director at MotherWoman, an Amherst based non-profit that was instrumental in he bill's passage, addresses the issue in a recent article.

Friedman continues to believe in the crucial importance of screening all new mothers, rather than screening only those whom doctors suspect might be struggling—a practice that runs the risk of "profiling" women who might seem distressed while overlooking others who are suffering but don't show it as obviously. 

However, without a carefully thought through way to provide treatment for women with PPD, universal screening is meaningless. One excellent model of care, the Community-based Perinatal Support Model, developed by MotherWoman, has been implemented in Franklin county with great success, is currently being implemented in Berkshire and Hampshire counties. It will likely be the basis of the recommendations to the DPH. 

The Community-based Perinatal Support Model (CPSM) has been developed to address the gap between screening and services for mothers. CPSM aims to prevent, identify and facilitate treatment of PMD (perinatal mood disorders) by creating a comprehensive, community-based, multi-disciplinary safety net for women.

Winnicott again is helpful in understanding why such a model would be effective. He coined the phrase 'the holding environment" to describe the way in which a mother, by being present both physically and emotionally with her baby, helps him to manage and contain intense feelings.  Quoting Winnicott: 

It will be observed that though at first we were talking about very simple things, we were also talking about matters that have vital importance, matters that concern the laying down of the foundations for mental health

. 


The phrase "holding environment" has been used to describe other caregiving relationships, such as a therapist-patient relationship. In the CPS model, a network of people, including nurses, primary care clinicians, mental health professionals, and other parents in the group setting, provides a "holding environment" for mothers who are struggling emotionally in these early months with their baby. 

What makes postpartum depression different from other forms of depression is that it occurs in the setting of responsibility for a new life-with a person who is completely dependent, and brings his or her unique qualities to the relationship.  To fully hold the mother's experience, it is important to recognize the baby's contribution. For example, when a baby is born with difficulties settling to sleep, or  is not naturally cuddly, it will have significant impact on the mother's emotional experience. Sleep deprivation and feelings of inadequacy may compound an existing depression. In turn, the mother's state of mind, particularly if she is preoccupied with her own distress, may impair her ability to help the baby to contain and manage his experience. A recent study showing that mother's struggling with anxiety and depression often wake their babies at night offers an example of how a mother's emotional state may affect her child's development. 

How fitting that Mother's Day occurs in the middle of Children's Mental Health Awareness Month. The work of Representative Story and the PPD commission is a tribute to both.  When we as a society attend to the emotional needs of new mothers, we help them to emerge from pain and suffering to take joy in their children.  This not only promotes their children's healthy development, but it makes for a really great Mother's Day!!