Should pediatrics and child psychiatry marry for the sake of the children?

There is an interesting exchange of letters in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry between a prominent pediatrician and two psychiatrists regarding an article that recently appeared entitled "Is There a Child Psychiatrist in the House?" The pediatrician, William Carey, argues that pediatricians are well trained to manage such things as colic, sleep disturbances, toilet training and temper tantrums, perhaps more so than child psychiatrists. The authors of the original article reply that they are puzzled that Carey sees anything in the original article that threatens the role of the primary care clinician, and agree wholeheartedly with the proposed marriage.  Carey quotes a prominent British pediatrician, probably Winnicott, saying "many years ago" that "pediatrics and psychiatry have been living together long enough and its time we got married, if only for the sake of the children."

Here I would like to point out that Winnicott, a pediatrician turned psychoanalyst, practiced in a time before the explosion of psychiatric medications, and when psychoanalytic thought heavily influenced the practice of psychiatry. If that were still the case, I would agree with this marriage. However, in our current climate of mental health care, where the 15 minute "med check" is the most common type of visit, I think both fields would do well not to marry each other, but rather to marry the growing field of infant parent mental health.

I trained in both general and developmental and behavioral pediatrics, and work in a department of child psychiatry.  I know that for the most part neither discipline is exposed to the explosion of research and knowledge coming out of this new discipline, at the interface of neuroscience, genetics and developmental psychology. This knowledge has great bearing on preventive mental health care.

Here is a case in point. Prior to my own education in this new field, that came in part from my studies as a scholar with the Berkshire Psychoanalytic Institute and in part from a superb post-graduate training in infant parent mental health at U Mass Boston, I would not have known how to work effectively with mother-baby pairs in the setting of maternal mental illness.

Three-month-old Jenna sleeps peacefully in her mother’s lap. The cards seem stacked against her. Cara at 17 is struggling to finish high school. She has been diagnosed in the past with depression and anxiety, but currently is receiving no treatment. Her primary care doctor, who referred her to me, has been prescribing an anti-anxiety medication as a temporizing measure. Cara has been playing phone tag for over a month with the therapist at the community mental health center, whom she needs to see in order to get an appointment with a psychiatrist.

Cara is scheduled as my patient in my behavioral pediatric practice. I put anxiety as the diagnosis on the billing form. But in truth the aim of my work with this mother-infant pair is to protect her daughter’s developing brain from the well-documented ill effects of maternal mental illness on child development.

Cara talks in a rambling manner about a range of subjects- her older sister at 20 pregnant with her second child, but neglectful of the first, her father who abandoned the family when she was two. She is particularly focused on her difficult relationship with Jenna’s father, Ed. She tells of his drug use, his neediness and his difficulty accepting his role as father.

An infant’s brain makes as many as 1.8 million neural connections per second. The way in which these connections are formed is highly influenced by human relationships. As Cara responds to Jenna’s face and voice, is attuned with her rhythms and needs, both physical and emotional, she is literally growing her brain.

Important research has shown that when a mother can think about her baby’s mind and attribute meaning to his behavior, she helps him to develop a secure sense of himself and of his relationship with her. This security helps him to regulate himself in the face of difficult emotions. As he grows older he will have the capacity to think clearly and flexibly and manage himself in a complex social environment.

When I work with mother-baby pairs like Cara and Jenna, I focus on one simple thing. I listen to these mothers with the aim of helping them to reflect on their baby’s experience of the world and the meaning of their behavior. It never ceases to amaze me that with this singular focus, meaningful communication happens even in what appears to be chaotic and dismal circumstances.

As I listen to Cara’s rambling story, I know I need to help her start thinking about how all of this affects her relationship with Jenna. I use a technique I learned from leading researcher and clinician Peter Fonagy to help a person who is stuck in this kind of non-reflective thinking. I hold up my two hands. “Wait," I say. “I want you to help me understand how you think these problems with Ed connect with your relationship with Jenna.”

She pauses for a moment and then begins to cry. “When Jenna is so needy of me, it makes me think she’s just like her father, and I get so mad. Then I feel terrible for getting angry at her.” It’s a remarkable insight. But she isn’t done. She looks down at Jenna. “See how relaxed she is when I am calm. But when I get upset, she starts to cry.” Then she tells me of a time when she felt about to lose control, but somehow had managed to make Jenna laugh. “We were having a conversation,” she says joyfully, “even though she doesn’t say any words!”

After a year of visits like this every one to two months, despite having grown up in a quite chaotic environment, Jenna is a bright, curious well-regulated toddler. The research from infant-parent mental health clearly supports devoting this kind of time and attention early on to parent-child relationships as a model of preventive mental health care.

However, in order for a marriage between the two disciplines and infant-parent mental health to be successful, both need to divorce the current climate of health care where, under the influence of a powerful health insurance industry, there is no time for listening.

Pediatrics and Psychoanalysis: An Essential Partnership

D.W Winnicott, pediatrician turned psychoanalyst, has been among the most important influences on my work. Unlike him, however, I have been determined, in my professional life, not to "defect" from pediatrics to become a psychoanalyst. I have always felt it was important to bring the wealth of deeply meaningful ideas coming from the discipline of psychoanalysis to the practice of pediatrics.

For example, in my current position as a behavioral pediatrician at Newton-Wellesley Hospital I teach the pediatric residents and  medical students about colic by starting with Winnnicott's notion of "primary maternal preoccupation." I read to them from my book: Keeping Your Child in Mind, itself an effort to bring psychoanalytic ideas to a general audience:

Winnicott described the first weeks to months of motherhood as a period deserving of a name, a psychological state, which for both a newborn and mother is not only healthy but highly adaptive. The name Winnicott gave this state was “primary maternal preoccupation.” He referred to a mother who is preoccupied in this way with her baby as an “ordinary devoted mother.” This way of being in tune with the baby happens naturally and does not look like anything particularly dramatic. A mother knows what her baby feels through her intense identification with him. He is a part of her. Though her role is in this sense “ordinary,” it is in fact hugely important. Winnicott writes: “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.”

Rather than asking "what to do" to "manage" colic, I encourage them to think about the meaning of the behavior within the context of this intense infant-parent relationship. Similarly, when parents come to see me about how to "manage" their child's "behavior problem," I help them to recognize that they are engaged in a kind of "dance of dysregulation" with their child, and that they both need to learn a new way to dance that is calm and coordinated.

This weekend, however, I get to do exactly the opposite, namely bring my knowledge as a pediatrician to a group of psychoanalysts.  Just as psychoanalysts are experts in relationships, so pediatricians (and all professionals who provide primary care to children) are experts in babies.  We are immersed in child development in a way that is unlike any other profession.

I am speaking at a conference at the Austen Riggs Center, co-sponsored by the Yale Child Study Center: Development of the Parent as a Person: Psychological, Biological and Genetic Contributions. Within minutes of looking at the proposed lineup of presentations, I knew exactly what I had to add. My talk is titled: "The Development of the Parent: the Child's Contribution."

 After more than 20 years of listening to countless parents and seeing thousands of babies, I have no doubt that babies come in to the world with their own unique set of qualities and characteristics, that from the first moment have a significant impact on the development of the parent. Almost every parent who is struggling with their child's challenging behavior has shared some variation of, "we saw this from the moment he was born."

I will use the photographs from Kevin Nugent's book: Your Baby is Speaking to You, that so beautifully captures the way babies are engaged in complex communication from the start. I have a video clip of a baby at three days of age having a conversation with me. I will introduce the Newborn Behavioral Observation system, a clinical tool designed to bring out these qualities in the baby, and promote healthy relationships from the start.

A number of years ago I attended a conference entitled "Pediatrics and Child Psychiatry: an Essential Partnership." I was hopeful, but sadly it ended up being primarily about prescribing medication, with a little bit about "parent training" thrown in. The word "relationship" was not mentioned once.

Here we have two parallel relationships: the parent-child relationship, and the pediatrics-psychoanalysis relationship. In each pair, one has the opportunity to have a profound and positive effect on the development of the other.