Rising numbers of kids expelled from preschool and diagnosed with autism: are they linked?

Two alarming news items compete for attention. The first,  a New York Times editorial entitled Giving Up on Four-Year-Olds describes a recent report showing expulsion from preschool as a form of discipline occurring in increasing numbers. A second speaks to the new CDC statistics indicating that 1 in 68 children have autism, a change from 1 in 88 just 5 years ago.

Perhaps both represent a lack of value of space and time for listening, in particular for listening to children and parents. Elizabeth Young-Breuhl might refer to both phenomena as prejudice against children. 

Each child who is expelled from preschool has a story. Similarly, every child diagnosed with autism has a story. It takes time, and a safe non-judgmental environment to bring these stories to light and so make sense of a child's behavior.

There may be witnessed domestic violence. When  a child lives in fear, he may respond to the "threat" of a child standing too close to him in line by pushing him. A reprimanding voice may lead to escalation of stress and even the development of a "fight-flight reaction." Being sent to the principal's office leads to further disorganization. 

Sensory processing challenges are often prominent. A withdrawal from social interaction makes sense from the perspective of a child who is flooded and overwhelmed by a busy classroom. Crawling under a desk may not be something "wrong" but rather an adaptive response.

Increasingly structured school environments, with little room for variation and high student:teacher ratios may exacerbate both of these problems. 

However, once we have the opportunity to hear the story, what to do to help the child becomes clear. One boy whose behavior had escalated to the point where he was throwing things at the teacher felt calm if he could start the day with a few minutes buried under the plastic balls in the ball pit. Another who would run in circles much of the day discovered music. When she was invited to sing or play an instrument she could sit calmly with the other children. Another family recognized how the level of chaos in the home was particularly problematic given their son's vulnerabilities, and took steps to change that environment.

A recent New York Times article describes a wonderful school program, Head Start Trauma Smart, an example of an innovative program that takes time to listen to the story, make sense of a child's behavior and respond appropriately. In contrast, expelling children for "acting out" may result in a cascade of worsening behavior problems.

The massive rise in autism numbers may reflect a need to name a problem with certainty, rather than taking the time to let the story unfold, to let a child grow in to himself. Perhaps if parents, teachers and clinicians had the opportunity to get a child the help he needs without pressure to name the problem, the numbers would be much lower.

Clearly there are significant differences between these two issues. But an underlying theme emerges. 

Lessons from Adam Lanza: Listen Early and Listen Well

The just released report, Shooting at Sandy Hook Elementary School, from Connecticut's Office of the Child Advocate offers a searing account of the holes in our mental health care system. The report is careful to point out that no causative link exists between their findings and the events at Sandy Hook. However, this in-depth investigation offers an opportunity, if we are able to hear and take action on its recommendations, to begin to fix a system that without significant attention may lead to an ever growing epidemic of serious mental illness.

I highlight 4 key points addressed in the 114-page report:

1) Early means early.

When significant problems in social-emotional development are identified, the greatest investment of resources ideally should come well before age three. In this time period, when the brain is rapidly growing and changing,  opportunity exists to set development on a healthier path. The report states:

A review of information regarding AL’s early years with his family does not reveal any profound tragedies or traumas. However, records clearly indicate the presence of developmental challenges and opportunities to maximize therapeutic and intensive early intervention. These observations underscore the importance of parental and pediatric vigilance regarding children’s developmental well-being. AL was referred for early intervention late in his toddler years, when he was almost three. By this time, he presented with several developmental challenges, including significant speech and language delays, sensory integration challenges, motor difficulties, and perseverative behaviors.

I would also like to highlight the report's important statement:" Research-based intervention to support improved sensory processing through occupational therapy is a critical service for these children."

2) The problem is located not exclusively in the child, but in parent-child relationships.

The report describes significant ongoing marital conflict, with Adam's father described as a "weekend father" who was not involved in the emotional lives of his children. There is evidence that Adam's mother might have had significant emotional illness. She was preoccupied with her own health and mortality despite the fact that her doctors reports do not show signs of physical illness.  While these findings do not represent " profound tragedies or traumas," the story is one of a biologically vulnerable child with two parents preoccupied and emotionally unavailable.

When a problem is placed squarely in a child,  the relational nature of these problems may be missed. Perhaps by addressing the issues in the marriage and the mother's mental health, room could have been made in their minds for thinking about the meaning of Adam's increasingly disturbed behavior.

3) Need for collaborative care with adequate reimbursement. The report states:

Pediatricians’ offices must have resources to conduct comprehensive and ongoing
developmental and behavioral health screening for youth, with appropriate reimbursement strategies to support this work.

 Children and their families should have access to quality care coordination, often reserved only for children with complex medical needs, but beneficial for children with developmental challenges and mental health concerns. Care coordination should facilitate more effective information-sharing between medical, community, and educational providers.

When people are stressed and vulnerable, they will share what is important only when they feel safe. Parents may experience terrible shame in the face of a child who is struggling and a marriage that is collapsing. Clinicians need to be reimbursed for time spent listening to parents. Time spent in coordination of care, a critical part of comprehensive treatment, also should be reimbursed.

4) Listening, not placing blame, will lead to meaningful change.

The report concludes by emphasizing that it "in no way blames parents, educators or mental health professionals for AL's heinous acts." I remain hopeful that blame can stay out of the conversation. Already media coverage has focused on the one adversarial aspect of the report that suggests the school "appeased" his mother, perhaps because she was white and wealthy.

All the accumulated evidence points to extreme suffering in the Lanza home over many years; suffering that went unheard and unrecognized. Blaming the school or the mother is not only unhelpful but also diverts attention from the critically important recommendations in this report.

 We are in the midst of an epidemic of violence and mental illness. The recommendations, particularly those I have outlined above, may offer a way off that path. I hope that those in a position to effect these changes will be open to listening. If this comprehensive report can be used to make substantive changes in the education, health care and mental health care systems, then some meaning may be found in the senseless, tragic loss of life at Sandy Hook.

Lessons from Atticus: is "ADHD" a problem of not listening?

Recently I reviewed my son's high school essay on To Kill A Mockingbird. I was surprised and pleased to rediscover, or perhaps discover for the first time now that I was viewing it from the perspective of over 50 years of life experience, the profound wisdom of the book.

In one of the novel's most famous quotes, Atticus tell his daughter Scout, "you never really understand a person until you consider things from his point of view, until you climb in his skin and walk around in it."

I now understand this as a description of the essence of being human, namely the capacity to be curious about the meaning of another person's behavior. Peter Fonagy, whose research has shown how the development of this capacity is intimately linked to healthy emotional development, argues, in a way analogous to Bowlby's description of attachment behavior, that this capacity has evolutionary significance, and is essential to survival. My book Keeping Your Child in Mind presents this research for a general audience, showing its application to parenting.

I wonder if our current epidemic of "ADHD" is related to having lost sight of this essential human quality.  The most common phrases I hear from parents who come to my office with concerns of problems of inattention and  impulsivity are, "he never listens," followed by "tell me what to do to make him listen."

Perhaps ADHD is a problem of not listening. But it is the adults who are not listening to each other. In our fast-paced, technology driven age, we rarely take the time to listen to each other, to put ourselves in another person's skin.

When Scout comes home from her first day of school upset with the teacher, her father tells her, "she's new too." He is helping Scout to understand her teacher's perhaps impatient behavior from a different point of view, to appreciate that the teacher herself may have been stressed and overwhelmed.

Recently parents of 4-year-old Sam, who was having problems of impulsivity in the classroom, spent a good portion of our visit expressing anger at his teacher, who they were convinced just didn't like their child. But with a full hour, and a quiet space to tell the story, they came to recognize that just as they could get overwhelmed at times by their son's behavior, so could the teacher be overwhelmed. Perhaps she felt defensive when the parents got angry, as she was trying her best in less than ideal classroom setting, with a low teacher: student ratio.

In turn, with the parents and teacher listening to each other and not behaving defensively, they could reach a new level of understanding of what set Sam off, and to develop strategies both at home and in school to help him to feel calm.

I wonder if the current epidemic of what we call "ADHD" represents a loss of this capacity to put ourselves in another person's skin. I have had the pleasure of an email exchange with the New York Times journalist Alan Schwartz, whose multiple superb article, most recently The Selling of ADHD, have served to bring the subject to the forefront of public discourse. I am hopeful that he will help us to see the big picture, rather than to place blame.

I have wondered in conversation with him if the whole phenomenon of "ADHD" is itself a symptom of larger social ills, particularly in the education and health care systems as well as the medical education system. People, including parents, teachers, pediatricians and mental health professionals, are feeling overwhelmed and not heard.

The large scale medication of a whole generation of children has potential serious and profound long-term effects. These include the silencing of children whose symptoms represent complex underlying problems, as well as abuse of stimulant medication by high school and college students.

We will never go back to the slow pace depicted in the 1960 novel, where there are large expanses of time to listen. But we need to be very careful not to give it up completely. For it does take space and time to put yourself in another person's skin. If that is the essence of what makes us human, we need to value that space and time.

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.

Eliminate shame and blame from parenting: new study sheds light

In my behavioral pediatrics practice, it is not  uncommon for parents to go to great lengths to put up a good front. They feel terrible shame about moments of out-of-control behavior, and also fear that I will blame them for their child's troubles. They focus primarily on "what to do" about their child's difficult behavior. However with time, and the realization that I am interested in understanding, not shaming or blaming, they begin to open up about their own life and the enormous stress they experience in their parenting role. They acknowledge that this stress has often led them to yell at their kids or even remove themselves emotionally.

An important new study published in the current journal of the American Academy of Child and Adolescent Psychiatry provides evidence that a parent's early life stress, such as abuse, emotional neglect, or emotional abandonment, lives in the parent's body. The reactions mothers (the study is just about mothers, though fathers certainly face similar challenges) may have in the face of a child's aggressive or clingy behavior are biologically based. It is not simply that they are hitting because they were hit. The authors of the study draw on extensive animal research showing biological mechanisms for transmission of parenting behavior.

For example, when a child behaves aggressively in a way that is developmentally normal (though limits must be set) a parent with a history of early life trauma may have a surge of stress hormones that affect the functioning of his or her brain. Thinking is impaired. He or she may have a kind of fight-or-flight reaction, which may lead to aggression in return.  Another alternative is to shut down, or in psychological language to "dissociate." This leads to that sense of being emotionally disconnected. Neither are good for a child.

This study has major implications for understanding as well as treatment.  If a parent is frequently out-of-control, and is yelling at or hitting a child, or emotionally removing him or herself, it must be addressed. Focusing exclusively on the child's behavior will accomplish little in this situation. Repeated exposure to an angry, out-of-control or emotionally removed parent has significant impact on development.

If  parents can recognize that early life trauma has led to this kind of biological reaction, it may eliminate some of the guilt and shame. It may encourage them to acknowledge and address the problem. When children are young, there is ample opportunity to turn things in a better direction.

Second, if the problem is in the parents' body,  treatment needs to involve working with the parents body. Psychotherapy can be important as a way to develop insight into the impact early life experience. But this kind of work can take time. A more immediate intervention involves helping a parent to recognize the stress reaction and then to develop tools to combat it.

I am not talking about medication. While medication may calm a parent down, and may be necessary in  some cases, the hope is to identify the way a child's behavior provokes a parent, and develop strategies for remaining calm  in the moment. The mindfulness movement has much to offer in this regard. Deep breathing, yoga or simply a short walk can help to calm the body down. Music or art will work better for others.

When parents come to my office asking what to do about their child's "problem behavior," I don't think they expect that my answer will be "go for a walk." I am pleased that this current study will support me when in fact I do say something like that.

Possible Lessons From a Teenage Suicide

About three years ago an eighteen-year-old girl committed suicide several days after being admitted to a Boston area psychiatric hospital. A year later her family filed suit against her psychiatrist, who had seen her for one and one half sessions. The case went to trial this winter, and he was exonerated. Recently I was speaking with his wife about the case. "Nothing good came of it," she said. The girl is still dead, huge amounts of money were spent, and three years were taken from the life of my friend and her young family.

The case became public record once the suit was filed. My friend, a minister, spoke about the experience in her sermon at the time of the trial, hoping perhaps to find some life lesson in the experience. As I listened to her describe the event, her emotional pain still so fresh in her telling, I, too, was moved to try to capture it in writing.

I start by borrowing from her sermon. She poignantly describes her husband two days after the girl killed herself. He was at a party, "surrounded by friends and holding our newborn son and nonetheless looking stricken." The real tragedy of the story is, of course, the death itself. But unfortunately it became a story about other things, namely guilt, blame and responsibility.

In her sermon my friend vividly portrays her efforts to find empathy for the girl's mother.

I spent most of this past week in court with Jim, and I’ve searched my heart for the gesture Jesus hands down to us, a gesture of compassion: “My heart goes out to you.” It was there early on, but following her testimony, by which it’s become clear (at least to me) that Jim was not the problem, I can only muster such compassion when I’m removed from the situation, physically out of that courtroom: “My heart goes out to you.” But when I’m there, sitting close enough to touch her, where she sits in front of me, shoulder-to-shoulder with her gentle-faced second husband (her first having himself died from self-hanging), I haven’t got it. I haven’t got it to offer.

My friend told me of her sense that this mother was unable to think about her daughter. The mother seemed to have an image of what her daughter was or should be that did not consider her child's perspective. As an example, my friend told of the mother's insistence that her daughter's private journal be admitted as evidence in the trial.

Even though I don't know any of these people, I felt this overwhelming wish to have had time with this mother before her daughter died. Would empathy then have helped her to hold her child's mind in mind ? What in her life had caused her such pain that she was unable to do this?

For I am certain that mothers never want to hurt their children. No matter how horribly a mother speaks about or behaves towards her child, given the time and space to be heard, I believe it is possible to uncover the hurt in her own life that is making this task of holding her child in mind so difficult. But the staff at the hospital didn't have time to even try. As my friend said, "They didn't know they were working on a deadline."

But now it was too late. The girl was dead. And because the mother was on the attack, specifically attacking my friend's husband, empathy was not an option. If blame must be laid for this sad situation, I would place it on the lawyer who took the case. How could someone who saw her for less that two hours possibly be responsible for a eighteen year life?

My friend described the cross-examination of her husband. The girl had missed her last session. She had also missed the previous session, and he had gone to find her. The second time he chose not to go after her, because, as he explained to the court, she had said she didn't trust him. She probably wouldn't feel comfortable being actively chased down by a man she didn't trust.

The plaintiff's attorney asked him what he had done during that time. He answered that he had reviewed her chart and thought about her. The lawyer asked, with a sneer that my friend vividly conveyed, "You thought about her?' Her husband calmly looked him in the eye and said simply, "Yes."

42 Freebies on the 4th from your Kinderland Friends!!!

Happy 4th of July!!! I am so excited to finally be able to reveal the BIG SECRET!!! 

My Kinderland friends & I have some goodies in store for you!! 

42 goodies to be exact!

All you have to go to my FB page and click on this image at the top:

 After clicking on this image on my FB page, you will see this image:

After you grab my freebie, be sure to click on the circle to take you to the next participating member. If you make the full hop you will have grabbed 42 freebies in all!
 

Here is a sneak peak of my freebie!! 

Only available on my FB page & only available for 24 hours!! 

Happy Clicking!

I get by with a little help from my friends.....

Today my dear friends, I was visited by the "Curriculum Police" who walked into my class along with my Principal. THANK- GOD I wasn't in the middle of taking pictures for my blog...LOL!!! 

I had Deanna's Common Core Standards Posters up which caught their eye....thank- you Deanna! They were impressed with this :)

They stayed for what seemed like an eternity!! Here are the things we were working on:

My Spring Math Journal Pack

 {click on the picture to purchase} 

Rachelle's {What the Teacher Wants} Handwriting Fairy Unit
(Several kids were finishing this up- we started it the day before)

{click on the picture to purchase}

Christie's {First Grade Fever} What's Hatchin' Chick?

{Click on the the picture to purchase}

& we just had to begin our "Waddle we do if it rains?" craftivities from the awesome Teri aka Mrs. Cupcake.

{click on the picture to purchase}

What in the world would I do without teacher BLOGS?!! ;)
And don't forget to enter my giveaway...ends on March 27th. GOOD LUCK!!!

More from John on Breast milk!