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.

Antipsychotics for foster care kids with ADHD?

A recent study, one that received relatively scant media attention (compared with a concurrent New York Times piece about a new psychiatric diagnosis termed "sluggish cognitive tempo" that may be the "new ADHD") showed that antipsychotics are being prescribed to nearly one third of kids (age 2-17) in foster care who are diagnosed with attention deficit hyperactivity disorder (ADHD.)

This disturbing statistic brought to mind a common complaint I hear from parents about putting on shoes to go out of the house. A child will dawdle, ignoring multiple requests. The situation will escalate to the point where the parent becomes increasingly angry and frustrated, and the child descends in to an all out tantrum.

This kind of scene likely plays out in some form in every household with a young child. It can be useful to keep in mind as we aim to understand why a child who is in foster care might exhibit behavior that calls for bringing out these pharmaceutical big guns.

While there is a range of reasons for a child to be in foster care, one can assume that there has at minimum been some experience of trauma and loss. This might include physical and/or emotional abuse.

Research in the field of developmental psychology and attachment offers a way to understand this situation. Young children inevitably have tantrums. It is a normal healthy part of development. But if a caregiver herself has a history of trauma, her child's behavior may, as they say, "push her buttons." She may become flooded with stress in the face of her child's acting out. Unable to think clearly, she may respond with behavior that is either frightened or frightening. She may either become overwhelmed with rage, or shut down emotionally. In the language of psychology this is termed "dissociation." For the child, it is as if his caregiver suddenly isn't there. In this situation, the child learns to recognize his own emotional distress as a signal for abandonment.

Now put this same child in foster care and ask him to put his shoes on to go outside. What starts out as a "typical" parent-child interaction can quickly descend in to wildly uncontrollable behavior. I've heard parents who have adopted kids out of trauma say, "its like he's not even there." When the child was in this kind of situation with an abusing caregiver, he might, in a way that is in fact adaptive, responded to her dissociation with his own form of dissociation. Now he has learned that behavior. But out of context, in foster care with a non-abusing caregiver, it may look "crazy."

When this kind of "not listening" extends to other arenas, it may be reframed as "not paying attention."  This behavior often occurs together with the impulsivity. Impulsivity literally means to act without thinking. An inability to think in the face of strong emotions, as I describe in my book Keeping Your Child in Mind, can also be understood as part of the trauma, of not having been held in mind by caregivers early in development.  With problems of both inattention and impulsitivity the child may, according checklists commonly used to make the diagnosis, earn the ADHD label.

Perhaps this is how kids in foster care end up on antipsychotic medication for ADHD.

But by taking this path, we are essentially putting a muzzle on the child. The child's behavior is a form of communication. It says, "I have never learned how to manage myself in the face of life's inevitable frustrations." Rather than silence him with a powerful drug, that is well known to have serious side effects, we need to listen to that communication.

The first step is to recognize the meaning of the behavior. Once caregivers understand the "why" of the behavior, they can better support the child's efforts to regulate himself in the face of frustration. At first this might be in a very physical way. For example he might need to be held in a firm and loving embrace. Or he might need to run around the room. Or hit a punching bag. He might need a soft and gentle voice rather than a harsh and angry one. As a child gets older, regulating activities like dance, theater and martial arts can have a significant role to play. Once a child has developed the capacity to regulate his body in the face of distress, he can begin, perhaps in the setting of psychotherapy, to give words to his experience.

But if we simply silence him with medication, all of this opportunity for growth and healthy development may be lost.

Take new smartphone use study with a hefty dose of empathy for parents

A new study documenting the ubiquitous use of smartphones by parents at fast food restaurants with their young children is getting a lot of media attention. From Time magazine there is this headline: " Don't Text While Parenting- It Will Make You Cranky." "Put Down that Cellphone" from NBC. "Parents on Smartphone Ignore Their Kids," from ABC News.

I doubt that anyone is surprised by the findings of this study. People everywhere are on their smartphones all the time. In the arena of parenting, it is important to call attention to the impact of this behavior. There is extensive evidence that face-to-face interaction is critical for healthy emotional development. Mealtime offers an important opportunity for this type of interaction, especially in today's fast-paced culture.

However, I worry about the parent blaming tone of these headlines. Rather than saying, "This is bad, don't do it," perhaps we should be curious about why parents are using smartphones in this way.

One answer lies the increasing recognition of the addictive nature of these devices. Everyone, not just parents in fast food restaurants, is using smartphones all the time. The other may lie in the fact that parents, especially parents of young children, often feel alone, stressed and overwhelmed. Putting these two together and the allure of the screen becomes understandable.

The American Academy of Pediatrics press release states:

The study raises several questions for future research, including ...what are the long-term effects on child development from caregivers who frequently become absorbed with a device while spending time with their children.

I think we already know the answer to this question. I wonder if another important question might read: "How do we support parents in being more fully present with their young children, given the combination of high stress and an easy available, socially acceptable addictive device?"

ADHD, bipolar disorder and the DSM: A need for uncertainty?

A recent article in the New Republic, provocatively titled “ADHD Does Not Exist,” starts out well enough. The author, a psychiatrist with “over 50 years experience” points to the fact that ADHD describes a collection of symptoms, rather than their underlying cause. Using stimulants to control these symptoms, he argues, is analogous to prescribing pain medication for cardiac chest pain rather than addressing the underlying circulatory problem.  But my antennae went up when he applied his views to a case, and concluded that his patient, a 12-year-old-boy, was misdiagnosed with ADHD, when in fact he had bipolar disorder. My level of alarm rose when he went on to describe his treatment:

In William’s case, the family agreed to try medication first without psychotherapy, to see what kind of impact the pharmaceutical treatment could have. The first medication we tried, an anti-seizure drug commonly prescribed for bipolar disorder, reduced the boy’s mood and behavioral symptoms dramatically but resulted in side effects including upset stomach and dizziness. We started William on lithium, and within two months we found a dosage that worked well for him, reducing his symptoms to very mild levels, with no significant side effects.

There is no mention of developmental history or family relationships. There is no exploration of the context in which these symptoms occur, and certainly no evidence that William’s experience being bounced from medication to medication is being considered.  Dr. Saul in essence replaces one treatment of symptoms without determining the underlying cause with another treatment of symptoms without addressing the underlying cause.

The author points to a strong family history of bipolar disorder to support his diagnosis. Statistics from the National Institute of Mental Health indicate that when a parent or sibling has bipolar disorder, a child is up to six times more likely to develop the illness.

But when it comes to an individual child and family, not only are statistics meaningless, but they may also preclude exploration of the underlying cause of the child’s symptoms. These symptoms are usually due to a complex interplay of biology and environment. Statistics do not speak to the effect of early intervention in decreasing the risk. 

Consider Jacob, a five-year-old boy I saw recently in my behavioral pediatrics practice. He was adopted, and two biological relatives had bipolar disorder. A pediatrician, his adoptive parents and a neurologist suspected that he too had the disorder. But with space and time to hear the story, the following emerged.

Jacob had been an easy baby. Then when he was about two, he experienced a number of significant losses. A foster child with whom he was very close was removed from the home because of behavior problems. Just weeks after his adoptive mother, Alice, learned she was pregnant, her sister died suddenly of a cerebral hemorrhage. Jacob’s maternal grandmother, in the face of the loss of her own daughter, threw herself in to caring for Jacob’s baby sister. 

Jacob’s mother wept in my office as she spoke of her own loss, not only of her sister, but also of her mother who withdrew in the face of her grief. Shortly after these events, Jacob’s behavior problems began in earnest. He became alternatively clingy and aggressive. When I saw the family, no one had slept through the night for a long time.

Jacob might very well have a biological vulnerability to emotional dysregulation inherited from his parents who carried the bipolar label. But multiple losses, subsequent disruptions in attachment relationships, sleep disruption, and other factors had significant roles to play in development of his symptoms. Had he, like William, been prescribed medication for his symptoms, this story, and the meaning of his behavior, would not have been heard. For every child I see in my practice, there is a story, often equally complex, behind the symptoms. 

Rather than offer time and space for the nuances, complexities and uncertainties of human behavior and relationships, the DSM (Diagnostic and Statistical Manual of Mental Disorders) paradigm, with its diagnoses of disorders based on symptoms, often followed by prescribing of medication, creates an aura of certainty, as in “you have X and the treatment is Y.” But there is virtually no evidence of any known biological processes corresponding to either ADHD or bipolar disorder (or any other DSM diagnoses, for that matter.) This certainty implied in the giving of a diagnosis and prescribing of medication has a kind of comfort, but also a real danger. There is no room for curiosity, for wonder, for not knowing.  Jacob’s behavior was a form of communication. Giving medication to control his behavior is in effect a silencing of that communication.

A recent New York Times article, “The Dangers of Certainty,” addresses this issue in a very different context. The author describes how he was profoundly influenced by the 1973 BBC documentary series, “The Ascent of Man,” hosted by Dr. Jacob Bronowski. The article describes an episode in which Bronowski discusses Heisenberg’s uncertainty principle.  

Dr. Bronowski’s 11th essay took him to the ancient university city of Göttingen in Germany, to explain the genesis of Werner Heisenberg’s uncertainty principle in the hugely creative milieu that surrounded the physicist Max Born in the 1920s. Dr. Bronowski insisted that the principle of uncertainty was a misnomer, because it gives the impression that in science (and outside of it) we are always uncertain. But this is wrong. Knowledge is precise, but that precision is confined within a certain toleration of uncertainty….Dr. Bronowski thought that the uncertainty principle should therefore be called the principle of tolerance. Pursuing knowledge means accepting uncertainty. ..In the everyday world, we do not just accept a lack of ultimate exactitude with a melancholic shrug, but we constantly employ such inexactitude in our relations with other people. Our relations with others also require a principle of tolerance. We encounter other people across a gray area of negotiation and approximation. Such is the business of listening and the back and forth of conversation and social interaction. 

As he eloquently put it, “Human knowledge is personal and responsible, an unending adventure at the edge of uncertainty.”The relationship between humans and nature and humans and other humans can take place only within a certain play of tolerance. Insisting on certainty, by contrast, leads ineluctably to arrogance and dogma based on ignorance.

The episode takes a dark turn when the scene shifts to Auschwitz, where many members of Bonowski’s family were murdered. The article’s author, a professor of philosophy at the New School, offers this interpretation:

The pursuit of scientific knowledge is as personal an act as lifting a paintbrush or writing a poem, and they are both profoundly human. If the human condition is defined by limitedness, then this is a glorious fact because it is a moral limitedness rooted in a faith in the power of the imagination, our sense of responsibility and our acceptance of our fallibility. We always have to acknowledge that we might be mistaken. When we forget that, then we forget ourselves and the worst can happen. 

I can already hear the shouts of outrage that I dare to compare mental health care with Nazism. Having grandparents who survived a concentration camp, I know well that this is a highly fraught subject. But of course that is not what I am doing. I am simply pointing to this article as a beautiful articulation of the value of uncertainty, especially in the context of understanding human behavior.

The Time-Out Wars: A Case for Curiosity

Dan Siegel's new book No-Drama Discipline is calling attention to our innate need for connection. In his Time magazine piece provocatively titled Time-Outs Are Hurting Your Child he writes:

The problem is, children have a profound need for connection. Decades of research in attachment demonstrate that particularly in times of distress, we need to be near and be soothed by the people who care for us. But when children lose emotional control, parents often put them in their room or by themselves in the “naughty chair,” meaning that in this moment of emotional distress they have to suffer alone. 

Not surprisingly, his views are causing significant backlash from the pediatric community. This is from the Journal of Developmental and Behavioral Pediatrics

TIME magazine recently highlighted an editorial by Drs. Daniel J. Siegel and Tina Payne Bryson in their parenting section. In it, the authors claim that the time-honored tradition of time-out for discipline may actually be harming our children as a form of traumatizing experience. This has caused a wave of black lash from the behavioral health community, who retort that Drs. Siegel and Payne Bryson's claims are not only unsupported by research, but show a lack of understanding of proper use of time-out.

Extreme views generate publicity and lots of “hits” A more nuanced view is less popular in social media, as evidenced by this wise blog post on Psychology Today that got a meager 25 tweets:

To me, “time-ins” don’t solve it. But the concept does expose a nuance of giving time-outs that we don’t talk about enough. Namely, there’s a massive difference between giving your child a time out in anger and giving your child a time out in a loving, calm way. Too often we apply the technique, but not the spirit of technique. Time-outs are meant to deescalate a volatile situation and to help our children regain control, as much as they are to provide a consequence for unruly behavior.

The essence of Dan Siegel’s point is not to leave a child alone with out-of-control feelings. It is not the time out per se but rather the sense of abandonment that is potentially harmful. I articulate this point in a previous post entitled Never Leave a Child Alone During a Meltdown.

When a child is repeatedly abandoned both physically and emotionally in the middle of a meltdown, that experience in itself may be traumatic. In such a situation frequency and intensity of meltdowns often worsens.

A recent American Academy of Pediatrics document Bringing Out the Best in Your Child makes the important distinction between discipline, which means to teach, and punishment, which is rarely effective in changing behavior in a positive way. For young children, a matter-of-fact time out in the face of biting or hitting can help to teach them that this behavior is unacceptable. The shortcoming of this document is that it is very focused on the behavior, rather than the meaning of the behavior.

Taking time to listen to our child, and to take care of ourselves, is key. Rather than an either-or approach, a stance of wondering, of curiosity, will lead to the answer of “what to do.” We might ask the question, why is my child feeling out-of-control? Is he stressed from fatigue or hunger? Is he responding to tension in the home from marital conflict, a new sibling, or a parent’s new job with long hours? And what about my child’s behavior is provoking such anger, anxiety or some other intense response in me? Is it my fear that he will suffer as I did as a child with similar challenges? Is it my embarrassment, or even worse, shame, that I am not a good parent? Am I feeling alone and abandoned myself, by a spouse or parent, and so unable to tolerate my child’s need for me? When parents feel recognized and understood, they are better able to listen to their child. They are better able to connect with their natural intuition. They know "what to do."

Our ability to find meaning in behavior is essential to our humanity. Listening, being present in a way that supports connection, leads to healthy development. It is not so much about “what to do” as “how to be.” We are a culture of advice and quick fixes. Dr. Siegel's book is rich with important information and ideas. However, perhaps rather than spending precious free time reading another "how-to" parenting guide, taking a walk with a friend or going to a yoga class might be a better use of parents' all-too-limited time for themselves.

Antipsychotics for ADHD: A Big Unknown

Polypharmacy, or use of multiple psychiatric drugs, for treatment of Attention Deficit Hyperactivity Disorder(ADHD) is on the rise. A recent study compared treatment with "basic therapy"-stimulants plus parent training- with "augmented therapy" those two plus risperidone, an atypical antipsychotic. The study concluded that treatment with risperidone was "superior." 

When children show dramatic improvements in behavior on risperidone, now being prescribed with increasing frequency for ADHD and a range of other disorders that represent difficulty with emotional regulation, we need to ask ourselves one question. Does this change in behavior represent increased capacity for organization and self-regulation, or does it reflect a kind of compliance?

We have over 40 years of longitudinal research in developmental psychology showing that safe, secure relationships support development of the capacity for emotional regulation, cognitive resourcefulness and social adaptation. We have evidence from the field of epigenetics that these relationships, through changes to gene expression, change the structure and function of the brain.

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When children struggle with emotional and behavioral regulation, many evidence-based interventions can support development of these capacities. These include child-parent psychotherapy, DIR floortime, the Neurosequential Model of Therapeutics, and mentalization based treatment.  These relationship-based interventions foster our innate need for connection.

The mechanism of action of risperidone is to block dopamine receptors in the cortex. We do not know what changes in the lower regulatory centers of the brain, if any, are occurring. It is possible that these centers remain dysregulated, and that this dysregulated signal is blocked by the medication. The antipsychotic might promote compliance, with improvement in behavior, but the underlying disorganization might remain. If that is the case, then the medication is not changing the brain in the way that we know relationships can change the brain.

This is an important question to answer. It goes well beyond the known significant side effects of antipsychotics. For when medication is so effective at controlling behavior, the motivation for investing time and effort in relationship-based interventions may be lost. Prescribing medication takes much less time. With atypical antipsychotics the results are often immediate, and can be dramatic.

If risperidone is found to significantly alter the brain’s capacity for emotional regulation, then it might have a role to play. But if it does not, and we have well-established methods of intervention that do, then the possibility exists that by prescribing this medication to children, particularly in the absence of relationship-based interventions, we are actively interfering in their development. 

I am hopeful that all professionals who strive to promote healthy development in children can work to answer this question in a timely manner.

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

• Almost 50 percent of children enrolled in Medicaid who are prescribed psychotropic medications receive no identifiable behavioral health treatment.

This is a disturbing, though not surprising, statistic given that these medications are commonly prescribed by primary care clinicians. Children living in poverty often experience greater environmental stress and may have greater mental health care needs, and the study points to medicaid as a possible source for improved, and presumably preventive, care.

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.

Are iPad attachments for bouncy seats and potty seats a violation of infants rights?

I was contemplating writing a blog post about the movement by the Boston-based advocacy group Campaign for a Commercial Free Childhood urging Fisher-Price to recall the baby bouncy seat with an attachment for insertion of an iPad. When I then received an email from a colleague with a link for another product- a potty seat with an attachment for an iPad- there was no going back. I decided not to include the link to that product so as not to inadvertently be a source of free advertising, but it is easy to find. 

In our technology driven culture, a position maintaining that we need to put on the brakes is a challenging one to take. The force of "progress" is so powerful that one runs the risk of seeming out-of-touch or old fashioned. But in these two products I believe we have come face-to-face with exploitation of children ( and their parents) or what I have described in a previous post as a "prejudice" against children. I would even go so far as to say it is a violation of infants' rights.

In today's society, where parents are often living in a state of high stress, with little support, either practical or emotional, the appeal of these products is very understandable. The allure of the screen is equally, if not more powerful for the infant. So from a marketing perspective, from a moneymaking perspective, it is a recipe for success. 

I became aware of the concept of infants' rights in my role as a board member of the Massachusetts chapter of the World Association of Infant Mental Health. A preliminary version the Declaration of Infants' Rights, a work in progress, reads:

The young child’s capacity to experience, regulate, and express emotions, form close and secure relationships, and explore the environment and learn are fundamental to mental as well as physical and developmental health throughout the life span.

So how do these products violate these rights? Lets start with toilet training. Recently I had the opportunity to write the parent guide for a new children's book, Potty Palooza. I identify the relational nature of toilet training:

Toilet training occurs in relationships. This includes a child’s relationship with his body, as well as his relationship with you. Toilet training will occur under the influence of a child’s inborn desire for mastery in relation to his body. A normal developmental movement toward separation and independence, together with your child’s wish to be like you and to please you, will move the process forward.

I do not know what will happen if you insert a screen between parent and child as part of this process (and sitting on the potty with a book is an entirely different experience.)  It is likely that the draw of the screen will interfere with a child's ability to read his body's natural signals.  The desire for treasured "screen time" will become the motivation for sitting on the potty, replacing his natural motivation to please his parents and to gain mastery over his body in a healthy way.  

Turning to the Ipad in the bouncy seat, the possible effects are more insidious and diffuse. Sitting in the bouncy seat in kitchen watching mom or dad prepare dinner is a time of great learning; a time of significant brain development. This learning occurs both through direct interactions with adults and older siblings, as well as through observation. The iPad interferes with both. As CCFC writes:

The Apptivity Seat is the ultimate electronic baby sitter. Because screens can be mesmerizing and babies are strapped down and “safely" restrained, it encourages parents to leave infants all alone with an iPad. To make matters worse, Fisher-Price is marketing the Apptivity Seat—and claiming it’s educational—for newborns. Parents are encouraged to download “early learning apps” that claim to “introduce baby to letters, numbers and more.” There’s no evidence that babies benefit from screen time and some evidence that it might be harmful. That’s why the American Academy of Pediatrics discourages any screen time for children under two.

Extensive evidence at the interface of neuroscience and developmental psychology shows how the brain is wired in relationships, with the most rapid brain growth occurring in the first three years. Instead of making products that come between parent and infant, our focus needs to be on supporting early caregiver-infant relationships, in the form of such things as parental leave, quality childcare and screening for and treatment of postpartum depression.

On Rising Disability Benefits for Children: Distribute Diapers, Not Drugs

Children who grow up in poverty are at risk for problems of emotional, behavioral and attentional regulation. Today's Globe reports that SSI (Supplemental Security Income) for disabilities has surpassed traditional welfare as a source of support for poor families. The vast majority of these disabilities are mental health problems such as ADHD ( attention deficit hyperactivity disorder.) In her brilliant three part series that led to this current study, Patricia Wen uncovered some complex questions.  What does it mean for children and families that in order to receive financial support, there is incentive to get children diagnosed with psychiatric disorders and medicated with psychiatric drugs?

Current research at the Yale Child Study Center offers a novel look at this problem, literally from the other end. In a study published in Pediatrics in 2013, researcher Megan Smith showed that 30 percent of families living in poverty report diaper need.

Extensive research has  shown that when parents are fully emotionally present with their infants, they support development of emotional regulation, cognitive resourcefulness and social adaptation. But what if her baby is screaming in a dirty diaper, uncomfortable or in pain, and a mother can't reliably have access to a clean one? The stress of this predicament may make emotional regulation, both for parent and child, impossible. Smith concludes:

Although a majority of studies have examined family socioeconomic status as income and educational and employment status, emerging research suggests that indicators of material hardship are increasingly important to child health. This study supports this premise with the suggestion that an adequate supply of diapers may prove a tangible way of reducing parenting stress, a critical factor influencing child health and development. 

Next weekend, Smith will be presenting her research at the Austen Riggs Center, in conjunction with a community diaper drive sponsored by the Berkshire Psychoanalytic Institute. 

Wen's current Globe piece quotes Rebecca Vallas of the Center for American Progress; "Cash is what actually matters for these families, as a baseline, before you can even start talking about supports and services."

The point of juxtaposing these two studies is not that we should distribute diapers in place of cash. Rather it raises the question of whether it makes sense to invest in infants, rather than waiting until problems of emotional and behavioral regulation are so great that children meet diagnostic criteria for a psychiatric disorder. 

The infant brain makes as many as 700 synaptic connections per second. By investing resources in infancy, not only with diapers, but also such things as quality child care, paid maternity and paternity leave, and identification and treatment of perinatal mental health problems such as postpartum depression and anxiety, we literally have the opportunity to grow healthy brains. 

The current SSI system seems to be an investment in illness. In contrast, concrete support with clean diapers, as well as the broader support of parents and young children, is an investment in prevention and health. 

Rising incidence of "ADHD" calls for radical rethinking

When the American Academy of Pediatrics changed the guidelines for ADHD to expand age of diagnosis to include children from age 4-18 (from 6-12), that the number of cases would rise was, by definition, inevitable. The recent survey by the CDC, published in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry, indicating that one in 10 children in the US carry a diagnosis of ADHD, confirms just that.

I felt re-energized and hopeful in ongoing efforts to, in my colleague's words "move the mountain of ADHD,"  when I received a request to speak at an international child psychiatry conference as part of a panel with a working title: "The ADHD Diagnosis: a Deconstruction from Developmental, Psychoanalytic, Infant Mental Health and Neuropsychiatric Perspectives."

 "Deconstruction" is a brilliant word, and captures well what I do in my clinical practice. Consider 4-year-old Max, whose parents brought him to my behavioral pediatrics practice to "see if he has ADHD." His preschool teacher had recommended the visit, suggesting that he might benefit from medication.  I asked his parents, Ann and Peter, if we might, acknowledging that Max did have symptoms of inattention, hyperactivity and impulsivity, take the time (we had an hour) to ask why he had these symptoms: to make sense of his behavior. While they had been hopeful that they would leave the visit with a prescription, reflecting Max's teacher's concern that he might "fall behind" without treatment, they were overjoyed to consider another approach.

Max had been adopted at age 3 months. Prior to this he had lived with his biological parents who were actively using drugs. They reportedly had a history of ADHD as did some biological siblings. Ann and Peter had been struggling in their marriage in the face of caring for this challenging child, and had recently separated. While Max had been a good sleeper, for the past several months he had been getting up multiple times a night and the whole family was chronically sleep deprived. Max had multiple sensory sensitivities. He cried with the sound of the vacuum cleaner; getting dressed was an ordeal because he could not find a pair of socks that was comfortable. He had difficulties with "personal space."

We had, in a sense, "deconstructed" the "symptom" to examine its various parts. We identified a genetic vulnerability for problems of attention, early neglect, ongoing family stress, sleep deprivation, and sensory processing challenges.

At age 4, there are multiple avenues of intervention. I usually start with sleep, as chronic sleep deprivation is inextricably linked with emotional and attentional dysregulation. Child-parent psychotherapy, where a clinician works with parents and child together,  has been shown to be effective in helping children develop capacities for emotional regulation, even in the face of early developmental trauma. A good occupational therapist, who addresses sensory processing challenges in the context of relationships, can help Max to use his body to manage his symptoms. Ann and Peter could examine the effects of their marital conflict on Max, and perhaps consider couples therapy.

The preliminary write up for the panel I refer to above speaks of what is now called "ADHD" as a valid symptom complex. But it proposes that

this terminology should not ever be used in our clinical thinking.  "ADHD," used as a primary diagnosis, has no etiologic significance, is conceptually and diagnostically distracting, leads to a paucity of thinking about a patient's early developmental history and trauma, and is therapeutically misleading.

 I hope that there will be a large scale movement to "deconstruct" the ADHD diagnosis. In essence deconstructing the diagnosis means eliminating the diagnosis.  Instead we would understand and treat the multiple parts that make up what is now called "ADHD." Such a process would result in  effective early intervention and prevention.

If I were to diagnose Max with ADHD and start him on stimulant medication, it would be in keeping with the current standard of care. Stimulants are powerful medications that have been shown in the short term to eliminate symptoms. But such an approach is simply a silencing of children. It would be a great disservice to  Max and his family.

Just as expanding the age range for diagnosis inevitably led to a rise in cases, "deconstructing" the diagnosis would lead to a significant drop in cases. The difference is that this change would reflect, not silencing of children, but rather improving access to meaningful help.

Dancing Lessons: Metaphor for Healing Through Relationships

Dancing Lessons, a new play recently premiered at Barrington Stage Company, is ostensibly about an actual dancing lesson. An injured dancer reluctantly agrees to give a one-hour dance lesson to a young man with Asperger's syndrome who lives in her apartment building.

At first the two characters are cast in conventional roles, he awkwardly defining himself by DSM criteria and she drinking too much while spewing bitterness over her sudden unexpected disability. Over the course of the play's single act, as their relationship deepens, we appreciate the complexity of their characters. As they grow closer, sharing painful stories of loss from their past, they discover they are in many ways not that different from each other. In a wonderful fantasy sequence at the end, the two shed their respective disabilities and dance gracefully together.

The play, itself an act of creativity, can be seen as a metaphor for the value of play and creativity in healing. 

D.W. Winnicott, pediatrician turned psychoanalyst, is known for the playfulness he introduced to his work with children and families. I am not referring to "play therapy" but rather time and space to sit on the floor and see what unfolds.

Every summer the Austen Riggs Center in Stockbridge, MA hosts a creativity seminar in which mental health clinicians and a range of artists come together to explore the creative process. In the introduction to A Spirit That Impels, a collection of essays that grew out of the yearly seminar, editor M. Gerard Fromm shares a vignette told to him by a colleague who had the good fortune to observe Winnicott at work.  

Winnicott would see a family for one or two consultations; this one involved a young mother and her 3-year-old son.

He sat on the floor playing with the child, while also talking with the mother, who was sitting on the couch. She told Winnicott that her ordinarily sweet little boy had suddenly become quite ill-tempered and obstreperous. Worst of all, toilet training was completely set back, and the lad was now worrisomely constipated. The father in this working-class household spent long hours at two jobs, and the boys mother was at her wit’s end.

The trainee described to Fromm how she had no idea what was going on, but at the end of the visit Winnicott turned to the mother and said, “So how long have you been pregnant?” She revealed that she had not told anyone, but Winnicott suggested that the boy did in fact know and suggested she speak with him about it. When the mother returned a few weeks later, she reported that not only was her son “great fun again,” but his constipation had completely resolved.

In his book Playing and Reality, Winnicott writes:

This gives us some indication for therapeutic procedure- to afford opportunity for formless experience, and for creative impulses, motor and sensory, which are the stuff of playing.

This playfulness that Winnicott employed in his clinical work stands in start contrast to today’s system of mental health care replete with assessment tools and standardized forms.  Our reliance on DSM classification and medication may not leave room for this kind of creativity and healing through relationships.  

For example, in standard treatment of postpartum depression, the "problem" is seen as residing squarely in the mother, who may be offered nothing more than psychiatric medication. The role of the baby, the way fussiness, sleep and feeding difficulties affect the mother, may not be addressed. Similarly when we diagnose ADHD based on standard symptom checklists, and treat with "behavior management" or medication, there may be no room for creativity, either in making sense of or in treating the "problem." In the play space there is opportunity to understanding the meaning of behavior in the context of relationships.

Parent-child relationships are a complex intricate dance. At times this dance can be full of mismatches and stepped on toes. Sitting on the floor with parent and child together, rather than diagnosing disorders or managing problems, I prefer to think of my work as a form of dancing lessons.  Through playfulness and creativity, parent and child learn to dance gracefully, and as St. Germain’s characters discover in the final scene, to find beauty and joy in their relationship

What might redefining "term pregnancy" mean for parents and babies?

So far the discussion on the policy change by the American College of Obstetrics and Gynecology (ACOG) has focused on the implication for timing of delivery. While previously babies had been considered "term" at 37- 42 weeks, the new policy defines term as 39-40 weeks. Babies born at 37-38 weeks are considered "early term" and those born at 41-42 weeks "late term."

The main consequence of this policy change is an official recognition that babies at 37-38 weeks are still not optimally mature for delivery.  The main objective of the policy is to "expand efforts to prevent nonmedically indicated deliveries before 39 weeks gestation*." In other words, doctors should not electively induce delivery or perform c-sections before 39 weeks. An article in Time magazine on the subject refers to a recent study showing an increased incidence of medical complications in what are now officially "early term" deliveries.

But given my interest in the parent-baby relationship and its impact on healthy development after birth, I had a different take on the significance of this change. Many babies born at 37-38 weeks are not induced or delivered by c-section. For a range of reasons, most of the time not an identifiable one, a mother may spontaneously go in to labor at 37 weeks. And, in contrast to the babies in the above study, the vast majority of these babies do not end up in the neonatal intensive care unit. They are in the regular nursery for the typical 48 hour stay.

My hope is that the policy change will focus more attention on the vulnerabilities of these babies.  The important question is,  "What is the implication for these babies who are not at optimal states of maturity, yet are cared for along side the now "term" babies and treated by professionals as if they are no different?" I put this question to a colleague of mine who is a hospitalist in a major teaching hospital in Boston. Her full time job is to care for newborns and parents following delivery and up to discharge in the regular nursery.

Personally I think this more nuanced classification of who the "full-term" baby is will be important for the parents and other professional who are supporting and teaching the family in the early weeks of life - eg. nurses in the well nursery, lactation consultants and medical providers.  Currently, unless a baby is under 37 weeks, they are all seen as fairly similar in their capabilities with differences being attributed to temperament or "personality" rather than gestation maturity.

There's a continuum to observed physiological parameters that may not be appreciated or fully noticed when babies are lumped together as full-term between 37-42wks; these include degree of sleepiness, subtlety of feeding cues, amount of energy reserves, ability to regulate state changes, muscular tone to name a few.  All of these impact the newborns' behaviors; especially feeding which is a primary focus for parents with their newborns.

Understanding that their infant's capabilities are related very often to his/her gestational age will reassure parents about their own capabilities as they learn to observe/make sense of their new infant's behaviors/cues with a more informed/understanding eye and less self-blame when trying (or struggling) to feed or to calm or to awaken their newborn.  

As my colleague wisely points out, what it looks like in real life when a baby is not "optimally mature," is that the baby may be difficult to arouse,  cry more or in general be more challenging to care for. Much of a new parent's sense of competence comes from successfully feeding her baby. If the baby's challenges with feeding are not identified and linked to his early gestational age, a parent may experience feelings of frustration and failure. She may abandon breast feeding or slide in to depression as she struggles to meet the needs of her baby.

In previous posts, I have referred to a wonderful tool, the Newborn Behavioral Observation System, that offers the opportunity to identify a baby's unique strengths and vulnerabilities.  This video of a brief excerpt of the NBO with a 3-day-old infant shows the newborn's tremendous capacities for communication. The NBO offers the opportunity to look at these qualities in a systematic way.

My hope is that now that the ACOG has officially identified these "early term " babies as vulnerable, professionals who interact with these families will offer parents the opportunity to identify possible challenges and develop strategies to manage these challenges, which with care and attention will resolve in a short time as the baby matures.

*Gestational age refers to the number of weeks since a mother's last normal menstrual period.

Protecting a space for parenting in an age of expert advice

In my behavioral pediatrics practice, it never ceases to amaze me how, given the space and time, parents come around to making sense of their child's "difficult" behavior without my giving "advice" about "what to do." They may recognize that they share a trait with their child that has troubled them their whole life. They may become tearful, thinking of how that child represents a lost loved one.  There are countless variations. The process of telling the story, of finding the meaning in the behavior, is often itself the treatment. Once parents have these insights, "what to do" follows naturally. In contrast, if I give advice without a full understanding of the story, things may not go well.

Recently in working on a new book, I have had the pleasure of returning to a close look at the work of D. W. Winnicott, pediatrician turned psychoanalyst and a kind of British Dr. Spock. In my review of his writings on the subject of advice, I came across a wonderful piece from this past spring in The Guardian: Mothers on the naughty step: the growth of the parenting advice industry, that references Winnicott.

Winnicott abhorred the idea of giving advice. He believed that when mothers tried to do things by the book – or by the wireless: "They lose touch with their own ability to act without knowing exactly what is right and what is wrong." Yet today there are far more parenting advice books (each with their own regime to promote) than 30 years ago, and the radio and TV schedules are full of programmes such as Supernanny, which train a critical eye on what are generally called parents but most of us understand to be mothers. It sometimes seems it is mothers, rather than children, who are being dispatched to the naughty step...

Winnicott feared that focusing on pathological families rather than "the ordinary devoted mother and her baby" (the title of his most famous series) could excite anxiety in listeners without access to therapy. "I cannot tell you exactly what to do," he said, "but I can talk about what it all means." And so he did, extolling the role of the good enough mother – one who can be loved, hated and depended on – in enabling the baby to develop into a healthy, independent, adult. While many of today's parenting gurus focus on a child's deviant behaviour and the contribution of supposed misparenting, Winnicott tried to help mothers understand the significance of their child's behaviour, whether it was "cloth-sucking" or a display of jealousy, and the ways that they instinctively contained their child's anxieties.

The author refers to the British program "Supernanny," the "high priestess of behaviorist parenting."

Tracey Jensen, lecturer in media and cultural studies at Newcastle University, says Supernanny reverses Winnicott, offering up the spectacle of the "bad enough mother", usually working-class, who is shamed before she is transformed. Jensen watched the programme with a group of mothers, relieved that it was not their parenting practices being scrutinised, but those of someone else onto whom all their own worries and fears could be displaced. But they also shouted back at the programme, discomfited by the judgment and humiliation meted out to the mothers featured. Such series foster the very anxiety they claim to assuage, and substitute "training" for thinking and feeling.

This last phrase captures the essence of the issue. I shudder whenever I see the term "parent training."  But this phrase, as well as others such as "management of symptoms" or "parent education" are pervasive in our culture. These kinds of interventions may improve behavior in the short term. But if they substitute for "thinking and feeling" it is likely that symptoms will re-emerge at a later date, in a different form. 

When we talk about parents and children, we are talking about passionate love relationships. The feelings are deep, intense and sometimes painful. It makes sense that we might choose to avoid them. But this is not a long-term solution.  We would do well to instead make a space for them, starting from birth.

I borrowed this phrase "protecting a space" from my good friend Gale Pryor, who's wonderful book Nursing Mother, Working Mother was also heavily influenced by Winnicott. In such a space parents can connect with their natural intuition. It is in this space that we give room for healthy development of parent and child together.