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.

Huge increase in ADHD diagnosis in young women a worrisome trend

"I know its my ADHD acting up," a mother of three young children recently said to me as an explanation for her inability to recall a particular piece of information. My observation, in the setting of my behavioral pediatrics practice, of increasing numbers of mothers of young children being diagnosed with ADHD is in keeping with a recent report from Express Scripts. This report, based on pharmacy claims data, showed a 53% rise in writing of prescriptions for ADHD in adults from 2008-2012, with "the largest gains seen in women age 26-34, climbing 85%."

A psychiatrist colleague of mine took this data at face value, saying that "ADHD is genetic" so with the rise in diagnosis in children, it makes perfect sense that there should be a parallel rise in diagnosis in adults. 

But there are big holes in this argument. Certainly problems of regulation of attention, behavior and emotion, that are all called "ADHD," have a familial component. But we are far from identifying a specific genetic cause. These qualities, both in children and adults, represent a complex interplay between genetic vulnerability and environmental effects.  

So how else might we explain this rise in writing of prescriptions for this group, many of whom are young mothers? In today's fast-paced society, parents of young children are often overextended and overwhelmed. In my practice many fathers work very long hours, leaving mothers alone to manage everything. In the absence of extended family this can be highly stressful. Physical activities such as yoga, running or even walking have a calming organizing effect on the brain, but often these mothers are unable to carve out time for themselves during the day. Sleep deprivation has a huge role to play. There is a well-established link between sleep deprivation and symptoms of distractibility, inattention, and hyperactivity. This may be an inevitable part of parenting young children. But often there are ways to improve sleep if parents have the opportunity to make sense of the situation and take the time to fix it. But often there is not this time, so families get stuck in a reactive mode, with a vicious cycle setting in as lack of sleep makes them increasingly less able to think clearly.

I have concerns about this trend of diagnosing and treating ADHD, particularly in this population of young mothers. If we label this behavior as a disorder and prescribe a pill, we are not placing responsibility (blame) squarely on the mother? Do we not have a responsibility as a society to care for mothers to support their efforts to care for the next generation? Will the motivation to find more creative solutions, such as flexible parental leave, and valuing of self-care (the airlines recognize this need in the instruction to adjust your own oxygen mask before your children's) be lost?

These medications are not without harmful effects. About a year ago, a young woman, not a mother but in this age group, wrote poignantly in the New York Times of her struggle with Adderall addiction that took hold in an environment of ever increasing demands for productivity.

I am probably not alone in wondering about an alternative explanation to that of my psychiatrist colleague. Clearly this trend is a boon for the pharmaceutical industry. Could it be that some very clever people in marketing saw an opportunity, and set about selling "Adult ADHD" to both a general and a professional audience? If so, they have certainly been very successful.

ADHD, the aggressive child and the elephant in the room

(Three recent news items lead me to republish a post that predated my Boston.com days. The first is a new study showing that antipsychotics and stimulants can be used together in treatment of aggression associated with ADHD. The second is a recent New York Times article, The Selling of Attention Deficit Disorder, the third an article from today's New York Times: ADHD Experts Re-evaluate Study's Zeal for Drugs. I am hopeful that 2014 will be  a year of radical rethinking about what we now call "ADHD.")

In the Tony award winning play God of Carnage two couples meet in an elegant living room for an ostensibly civilized conversation about the aggressive act of one couple’s child against the other’s. The meeting soon degenerates to reveal the underbelly of conflict in the two marriages. Husband and wife hurl insults, precious items and even themselves with escalating rage. We see, as they attempt in vain to focus on the children’s behavior, the proverbial “elephant in the room.” 

It brought to mind another depiction of the nature of the elephant, presented by the pharmaceutical industry. A recent issue of The Journal of Developmental and Behavioral Pediatrics features prominently a two page ad from Shire, makers of drugs commonly used for treatment of Attention Deficit Hyperactivity Disorder (ADHD). A mother and her son sit at the desk of a doctor in a white coat. Behind them is a large elephant draped in a red blanket on which is printed the words, “resentful, defiant, angry.” The ad recommends that these symptoms, in addition to the more common symptoms of inattention and hyperactivity, should be addressed. This is the message: doctors should be treating these symptoms with medication.

From my vantage point of over 20 years of practicing pediatrics, where I sit on the floor, not in a white coat, and play with children, I believe that the play’s depiction of the nature of the elephant is much more accurate and meaningful than that of the pharmaceutical industry. In the play the elephant is the environment of rage and conflict in which the aggression occurs, while in the ad the elephant is the child’s symptom. Consider these two stories from my pediatric practice (with details changed to protect privacy.)

Everything was a battle with six year old Mark. Though I asked both parents to come to the visit, Mom came alone. She was furious.”Tell me what to do to make him listen.” We had a full hour visit, and as she began to relax, she shared a story of constant vicious fighting between herself and her husband. Mark, who had been playing calmly and quietly, took a marker and slowly and deliberately made a black smudge on the yellow wall. His mother was too distracted by her own distress to stop him. I said, “You cannot draw on the wall, but maybe you are upset about what we are talking about.” He came and sat on his mother’s lap. She reluctantly revealed her suspicion that his angry behavior was a reflection of the rage he experienced at home. She agreed to get help for her marriage, and Mark’s behavior gradually began to improve.

Jane’s parents became alarmed when her aggressive behavior began to spill over into school. Her third grade teacher told them that not only was she distracted and fidgety, but she seemed increasingly angry. At our second visit, Dad became tearful as he described his cruel and abusive father. He acknowledged being overwhelmed with rage at Jane when she didn’t listen. He yelled at her and threatened her. He longed for a positive role model to learn how to discipline her in a different way. He realized he needed help to address the traumas of his own childhood in order to be a more effective parent for Jane. 

If the elephant in the room is the child’s symptoms, as the drug companies would have us believe, then medication may be the solution. Children taking medication for ADHD often tell me that it makes them feel calm. The full responsibility for the problem then falls squarely on the child’s shoulders. 

For Mark and Jane, and countless children like them, the elephant in the room, however, is not the child’s symptoms. It is the environment of conflict in which the symptoms occur. If the family environment is the elephant, the treatment of the problem is not as simple as prescribing a pill. Families must acknowledge and address seemingly overwhelming problems. The parents’ relationship with each other, and each parent’s relationship with his or her own family of origin, often contributes significantly to this environment. 

In the supportive setting of my office, Mark and Jane’s parents were freed to think about their child’s perspective and experience. Rather than focusing on “what to do” they understood what their children might be feeling growing up in an environment of conflict and rage. This ability for parents to think about their child’s feelings has been shown, in extensive research at the intersection of developmental psychology, genetics and neuroscience, to facilitate a child’s development of the capacity to manage strong emotions and adapt in social situations. 

In another interesting link between this ad and God of Carnage, one of the fathers is an attorney representing a drug company. He speaks loudly on his cell phone, seemingly oblivious to the effect of his behavior on the other people in the room. His conversation reveals the profit motive of the drug company taking precedence over the well being of the patient. 

God of Carnage was written by Yasmina Reza, a French playwright. While the play itself is hugely entertaining as a witty farce about family life, an important message was in a brief scene at the very end. The telephone rings. The mother answers. It is her daughter, all upset about the loss of her pet hamster, which the father had “set free” one night because he was annoyed by the animal’s habits. Suddenly the mood of the play, which was lively with scintillating dialogue throughout, becomes serene as the mother speaks lovingly to her distraught daughter. Perhaps most of the audience was barely aware of the sudden mood change. Yet it lifted this delightful play into universal significance. Freeing herself from the preceding chaos, she calmly gives her full attention to her daughter’s experience.

The popularity of the play gives me hope that people are hungry for a different way to think about children and families than that offered by the pharmaceutical industry, which, with the money to place an attention getting ad, has a very loud voice. It is joined by the equally loud voice of the private health insurance industry, which supports the quick fix of medication over more time intensive interventions. In contrast, Mark, with his black smudge on my yellow wall, has a very small voice. His voice says “Please think about my feelings, not just my behavior.”

His voice is particularly critical now, as our country strives to create social policy and a health care system that values prevention and primary care. Parents, if they are supported and nurtured, know what is best for their children. We as a culture must demonstrate that we respect both the difficulty and the critical importance of being an effective parent. In this way we will be able to help children, not only by treating their symptoms, but giving an opportunity for deeply rewarding changes in the important relationships in their lives.

How Yoga Informs Parenting: Value in Not Knowing

In yoga, a pose referred to by my teacher as "how wonderful" involves a lifting of the head and chest, and opening of the arms out to the side, with a bend in the elbows.

In her introductory words of wisdom to a class in which that pose was to be the theme of the day, she asked us, "Do you ever make up stories?" She shared that she may in response to a distracted expression from a friend think, "She's mad at me," or from her 3-year-old child who refuses to put on his shoes, "He's trying to drive me crazy!" She identified how this ability to try to make sense of other's behavior has evolutionary significance. It helps us navigate a complex social world- otherwise, she said, we would have no idea what was going on. But sometimes this kind of assuming of meaning, this making up stories, can get us in to trouble.

What if instead, we employ the open stance of  "I don't know?"-words she demonstrated fit perfectly with the pose of "how wonderful."

In my behavioral pediatric practice, I find parents often driven by a  need to know. "Is there something wrong with him?" they ask. There are tremendous pressures -from teachers, from family, from insurance companies, to name the problem. There is a kind of certainty in this approach, a kind of professional declaring of "I know whats wrong with you."

What if, rather than being guided by diagnostic instruments, that ask questions with the aim of getting an answer, we approach the situation with a stance of curiosity, of inquiry, of "not knowing."

I find if, in a way not dissimilar to the hour-long yoga class, I offer space and time to let the story unfold, we uncover complex meaning in "problem" behavior. There may be a number of relatives with similar traits, suggesting a genetic component. There may have been significant stresses in a family that, even with parents' best efforts to shield a child from the effects, have been noticed and absorbed. A child may have a range of sensory sensitivities that he can manage, but under the stress of separation, often at bedtime or in the process of getting out the door, these sensitivities are magnified. "Problem" behavior may be both cause of and result of family conflict between parents, among siblings, between generations.

There is courage in a stance of not knowing. In yoga, we trust our teacher to guide us in the backbends that evolve out of the "how wonderful/I don't know" pose. The work is hard.  She challenges us while taking care to protect us from harm.

Perhaps professionals who care for children with "behavior problems" -pediatricians, psychiatrists, teachers- could learn a lesson from my yoga teacher (support from the health care system that decided what is and is not "covered" would be essential to this kind of approach.) Rather than being guided by a need to make a "diagnosis," we would support parents in a safe, holding environment through a time of not knowing, on a journey to find the true meaning of behavior.

This kind of journey might not only serve to decrease the number of children receiving psychiatric diagnoses, but also help us to discover creative solutions. We would have the opportunity to uncover both weaknesses and strengths, and to support development of resilience.  In the words of pediatrician turned psychoanalyst D.W. Winnicott, we would be promoting development of a child's "true self."

How wonderful.

Supporting Parent-Baby Pairs in the Wake of Infertility

A new study in Denmark demonstrated a 33% increased risk of a range of psychiatric disorders in children whose mothers were treated for infertility. The authors do not offer a cause, but postulate that the increased risk is related not to the treatments, but to the infertility itself.

These findings echo research showing increased risk of psychiatric problems in children whose mothers have struggled with perinatal emotional complications such as anxiety and depression.

How can we make sense of this?

Mental health, including the capacity for emotional regulation, empathy, resourceful thinking and resilience, develops in relationships. So the answer to this question lies in the way infertility impacts on parent-child relationships.

I recently came upon a beautiful expression in a work of literature that captures pediatrician D.W. Winnicott's concept of primary maternal preoccupation, that he identifies as central to a child's healthy emotional development.

The book is James Agee's A Death in the Family. In this early scene, the father is awakened during the night because his father is ill. As he dresses to leave the house, his wife, on her way downstairs to make him breakfast, whispers to him to bring his shoes in to the kitchen.

"He watched her disappear, wondering what in hell she meant by that, and was suddenly taken with a snort of silent amusement. She looked so deadly serious, about the shoes. God, the ten thousand little things every day that a woman kept thinking of, on account of children. Hardly even thinking, he thought to himself as he pulled on his other sock. Practically automatic. Like breathing."

The experience of infertility may get in the way of this breathing. Without appropriate support, a mother may feel that she is suffocating.

A mother, and also a father who, while not experiencing the physical assaults of infertility treatments, certainly shares in the emotional trauma, may come to the experience of parenthood with a range of significant vulnerabilities.

Anxiety over the well being of a new baby, no matter how much reassurance well meaning clinicians offer, may be unrelenting. In the face of repeated loss, as occurs in the process of infertility treatment, not only with every period, but sometimes with early pregnancy loss, may lead a parent to, in an adaptive effort to protect themselves from further loss, disengage emotionally. A parent may not fully surrender to the falling in love that accompanies the birth of a baby. And parents may be simply emotionally exhausted.

The baby also may have a role to play. There is evidence that stress in pregnancy, as is almost inevitable in a pregnancy that follows infertility treatments, is associated with what is termed "behavioral dysregulation" in the baby. That is, the baby may be more difficult to feed, may cry more or have irregular sleep patterns.

The good news is that, having identified infertility as a risk factor in development of mental illness, there is ample opportunity to set these vulnerable parent-baby pairs on a healthy path. One option is suggested in a recent article in the Atlantic, How Supportive Parenting Protects the Brain, where the possible role of the pediatrician is addressed.

What if every parent-baby pair, in the aftermath of infertility treatment, got some extra time and attention? An extra hour-long visit-with clinicians reimbursed for their time- to meet with parent and baby together, to listen to them both? Even better, as pediatricians have variable interest/expertise in this kind of work, have an infant mental health specialist, physically located in the pediatrician's office. The Newborn Behavioral Observation system is a wonderful tool for listening to parent and baby together in a way that sets development on a healthy path.

The idea is to normalize, rather than stigmatize.

This study might cause alarm for parents who are already stressed by the process of infertility treatment. I was alarmed myself by the statement by one of the study's authors that "this knowledge should be balanced against the physical and psychological benefits of pregnancy." To even entertain the idea of not getting pregnant because of this potential risk to the child is absurd, and feels almost punishing.

But if instead we use this study as further evidence of the value of protecting space and time to listen to parents and babies, then alarm could be transformed in to hope.

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.

In the age of DSM 5, what is normal?

In an interesting coincidence, a couple of weeks ago I received two emails on the same day asking me to write about books that are about the same subject. One is  Child Temperament: New Thinking About the Boundary Between Traits and Illness,  the second Back To Normal: Why Ordinary Childhood Behavior is Mistaken for ADHD, Bipolar Disorder, and Autism Spectrum Disorder.

The first was written by David Rettew, MD a child psychiatrist at the University of Vermont College of Medicine, where at the Vermont Center for Children, Youth, and Families ( VCCYF) they have an innovative family centered, strength-based approach to children's emotional and behavioral problems.

In a language that is based in science and research,  Rettew explores the overlap and interplay between the concepts of "temperament" and "psychopathology. He tackles the complex science of behavioral epigenetics- the impact of life experience on gene expression and subsequent behavior and development. He then describes how he integrates these ideas in to his care of children and families. For example, he describes how he might speak to a child patient:

I've heard a lot about you today and one of the things that I hear from you and your parents is that you are a very kind person who can really tune in to other people.  That is a wonderful quality that will serve you well in the future. At the same time, I also hear that you can get so concerned about what others think about you that you avoid things you like doing just so there is no chance you will feel embarrassed. Doctors sometimes use the term  social anxiety disorder to describe this situation, and if you are willing there are things we can do to help you feel more at ease in social situations.

He masterfully takes on very complex issues, including the way a child's behavior may provoke a parent's negative response.

A father of a temperamentally irritable boy who is prone to shout at the boy for  relatively minor infractions is certainly not relieved of responsibility for his behavior, but can be understood from a prespective that some of his suboptimal responses are evoked by the child's behavior, partially influenced by shared genes that cause both of them to escalate in negative ways.

The second book is organized around examples from the practice of the author Enrico Gnaulati, PhD, a clinical psychologist specializing in child and adolescent therapy. He examines our cultures rush to diagnose and medicate, and what he terms the "casualties of casual diagnosis." He writes:

In the past four decades we have gone from blaming parents for kids' problem behavior to blaming kids' brains....yet rarely can a child's behavior be explained exclusively in terms of child rearing or brain chemistry. In most cases, it is causes- plural, not singular- that explain why a child behaves the way he or she does. 

The underlying problem both authors address is embedded in the paradigm of mental health in which they practice.  Rettew seems to be trying to wrestle out of the paradigm in the last section where he describes an evaluation process that makes use of other tools besides DSM. However, the above example shows how the language of DSM permeates care, when albeit reluctantly, he uses the term "social anxiety disorder." This "disorder" may be in the DSM, but it is not a "real" disorder in the way, for example, diabetes is.

Earlier this year, the head of the National Institute for Mental Health tried to discredit DSM 5 by saying that they would not fund research based on the DSM system but rather aim to find the underlying "cause" in the realm of neuroscience and genetics. But as Gnaulati points out, we will never find the cause by just looking at the brain.

Gnaulati is similarly trying to find another way to think about this paradigm that offers oversimplified labels. But I am concerned that framing the issue as "normal" vs "disordered" is  misguided, and a result of the author being unable to see his way out of the DSM paradigm.

If a child and family are seeking help, then by definition the behavior is not "normal." Given the continued stigma associated with mental health problems, for a family to make the effort to call, make an appointment and actually show up, they are likely to be struggling in a significant way. Thus to call this "normal," even though the intention may be to be reassuring, is actually dismissive of the family's suffering. I wrestle with this dilemma every day in my clinical practice. Parents come to me and ask, "Is my child normal?"

I speak to this issue in a previous post: Answering the question: is something wrong with my child?
I refer to an article by Daphne Merkin on the question of whether depression is inherited:

The concept of "being attuned to your child's nature, especially when it differs from your own,"  is the essence of healthy parenting. She is describing a parent's recognition of what D. W, Winnicott termed the child's "true self." It involves recognizing a child as a person with thoughts and feelings that are his own. It is an excellent goal to work towards, though not always easy.   Issues that get in the way of recognizing the child's true self, including stresses in a parent's life and other relationships, may need to be addressed.

When viewed from this perspective, the question becomes not "is there something wrong with my child?" but rather "Who is this child, and how is he or she both alike and different from me?"

I wonder if Rettew and Gnaulati are so much a part of the prevailing paradigm that they do not recognize that what they are actually doing in their books is questioning the very paradigm in which they practice. If they were to step outside of the paradigm, they might, rather than asking the question "does a child have ADHD?" , asking the more salient question, "Is ADHD ( or autism or bipolar disorder or OCD for that matter) the way we as a culture use the term, a "real" thing, or is it an artificial construct defined by the DSM system and perpetuated by the pharmaceutical and health insurance industries?"

I believe that what both of these authors are actually doing is describing a new paradigm of mental health care that recognizes the relational nature of human development and offers opportunity for curiosity about the complex meaning of behavior. I'm calling them on it.

Investing in early childhood means investing in infants

Why is this so difficult for us to see? The United States has one of the most restrictive parental leave policies in the world, as my fellow blogger Claire McCarthy accurately described in a recent post. We fail to recognize the importance in investing in early relationships. The closest we seem to be able to get is age four. But the abundance of research at the interface of developmental psychology, neuroscience and genetics tells us that 4 years may be too late.

I wonder if the answer lies in child development researcher Ed Tronick's  still-face experiment. I remember well when I first learned of his research. I felt a kind of outrage, asking "how did he get this past the IRB( institutional review board for human subjects)?" In his well-known experiment, a mother plays with her infant in a usual way, then presents a still-face for a specified period of time, and then resumes normal interaction.

I now work closely with Dr. Tronick and well recognize the brilliance of his work. He sometimes remarks that it is his students in his Infant Parent Mental Health program at UMass Boston who seem to have the most initial outrage at seeing the experiment. I now understand that as a kind of deep empathy with the experience of both the mother and the baby. With that comes a passion for protecting this relationship, a passion that drives those of us who chose this field.

There is a great poignancy to recognizing the tremendous capacity of the newborn to communicate when we have a system that fails to support stressed early parent-child relationships. The Newborn Behavioral Observation System developed by T. Berry Brazelton and Kevin Nugent beautifully brings out these capacities.

But if a parent is stressed in the setting of such things as emotional distress, her own history of abuse, marital conflict and domestic violence, social isolation and poverty, being available to her infant in the way he needs is difficult. This is where the investment needs to be. Not 4 years, but 4 months, 4 days, 4 hours.

In Sunday's New York Times Nobel prize winning economist James Heckman has an op ed Lifelines for Poor Children where he again speaks to the need to invest in early childhood. He refers to Obama's policy proposal. However in the actual text of Obama's proposal there is relatively little for infants. The emphasis is on the four-year-old.

All we know about the science of early childhood tells us that the brain grows in relationships. The volume of the brain doubles in the first year. The brain makes millions of synaptic connections every minute. It is in infancy that the parts of the brain responsible for emotional regulation have the most rapid development.

 A startling article in the New York Times Can Emotional Intelligence Be Taught? begins with a vignette from a Kindergarten classroom where a child says, "My Mom does not like me," When he describes how his mother screams at him every day, he is taught how to handle the situation in a calm way. Somehow the tables are turned and it is the child's responsibility to manage his out-of control mother. The answer is not to teach this child emotional regulation, but to help this parent-child pair to grow together in a healthy loving way. And this help needs to start in infancy.

This week I will again attend a meeting of Representative Ellen Story's postpartum depression commission at the State House. It is always an uplifting experience as leaders in the field grapple with the question of how best to support parents and young infants. The commission recognizes that this work occurs primarily in the realm of health care, which is where young infants and their parents can most reliably be found.

Can we stem the rising tide of serious psychiatric illness in college?

Last week I "launched" my oldest off to college. As anticipated, it was an intense emotional experience full of joy, sadness, and many things in between. (I have to tip my hat to fellow Globe writer Beverly Beckham for her piece I was the sun, the kids were my planets that was very helpful. However, I might have written that my child was the sun, a burst of light in our household, and the experience of leaving her is like being temporarily knocked out of orbit as our family re-orients to life without her.)

The same week I received in the mail, in exchange for filling out a questionnaire about a study on diversion -use of ADHD medications by individuals for whom it was not prescribed- this pretty laminated poster of all the drugs currently available for treatment of ADHD.

Statistics indicate that serious mental health problems in the college community are growing at rapid rates. Some optimistically speculate that this is because of decreased stigma for getting care. But I wonder at the paradox of the parallel increase in availability of new psychiatric drugs- I counted 22 different formulations for ADHD medications on that poster- and the rise of serious mental health problems. Could it be that the drugs themselves are responsible for this increase? If the drugs were effective in childhood, shouldn't we see a significant decline in serious mental illness in college?

How would this work? Starting at a young age, rather than learning to manage stress in the context of supportive relationships, the symptoms are medicated away. The brain is actually wired in relationships, and in the absence of this kind of co-regulation of emotion, the areas of the brain responsible for emotional regulation do not develop properly. All forms of mental illness, including depression, anxiety and attention problems are essentially problems of emotional regulation. Then as the challenges of life increase in complexity, the medications often increase in strength and complexity. Children learn to be defined by their medication and are further estranged from a core sense of self. Add to that unknown side effects on the developing brain, and it is no wonder that there is a significant increase in serious mental illness by the time a child gets to college.

But what about that issue of decreased stigma? That also is likely true. At a superb talk given by a psychology professor at our child's orientation, we learned about the school's  "invisible safety net." It is made up of an elaborate interconnected system of students, faculty and mental health professionals to monitor the emotional well-being of the students. It is all about relationships and connection.

The very existence of this net reduces the stigma of emotional struggles. The fact that the school goes to the trouble to train such an elaborate system of care (sophomore advisors- or "SA's" the front line of this system, must apply in January of their freshman year, and they get several weeks of training prior to the start of the school year), conveys to both students and parents that it is normal and expected that people will struggle and need help.

I believe there is something to be learned from this "invisible safety net" model. If we as a country were to implement a model of preventive mental health care, we would have in place a net made up of primary care clinicians, early childhood educators, childcare workers, mental health care professionals, as well as others who come in contact with young children and families. There would be open and expected lines of communication. (At this college, if a parent calls with a concern about their child, within the hour there is a person making face-to-face contact with that student, even if it is just inviting them out for a slice of pizza- and that person is trained to recognize when it is necessary to call in a higher level of intervention.)

If such a net were there from infancy-including a system for identification and treatment of perinatal mental health problems- through adolescence, then maybe kids wouldn't need all those pretty little pills to take to college.

A happy story in stressful times

It was quiet on the mountain. My husband and I were on an early morning hike with our dog up Monument Mountain. As we approached Inscription Rock, a landmark near the top, we saw a man and woman who looked to be in their late 60's, healthy outdoorsy types. The man was asking the woman to sit on the rock so he could take her picture.

As we passed by, the man walked towards me and asked me to take their picture. "Sure," I replied, taking his camera. Then, as the woman got settled on the rock, he whispered to me, "I'm about to ask this woman to marry me." Signaling to my husband to stay back with the dog, I began clicking away. He approached her and got down on one knee, pulling a small box out of his jacket pocket. There was much laughter and embracing. When the deed was done, they turned to face me, arms around each other, and asked me to take their picture together.

"It was meant to be," I said, referring both to our arrival at this spot at the exact moment of the proposal, as well as, I hope, their marriage. My husband and I continued over the top of the mountain and down the other side, exhillarated by this chance encounter with new love.

( Between the elections, hurricane Sandy and my preparations for two major presentations in the next two weeks-more about those soon- a relevant and meaningful blog post has not been forthcoming. I hope readers enjoy this little tale instead!)

Asynclitism resolved in Brazil!

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My 13 in 2013 Linky Party & a SALE!!

2013!!! Yikes, where did you go? I guess it's true that time surely flies when you're having fun!

I'm linking up with Hadar, Kristin, and Tracy to bring you my 13 in '13!

Gosh, I can go on and on about clothing! I secretly always wished to be a fashion designer, but my overly conservative family couldn't handle my "trends" when I was younger…lol! My favorite piece of clothing that I simply can't live without are my Tory Burch eddie flats!! 

I received them from my sister last Christmas, 2012 so you can definitely say I lived in them for most of 2013!! They are super soft and comfy!

I am slightly obsessed!! 

I'm going to cheat here and add just one more piece of clothing I can't live without ,which are my cropped boyfriend jeans from Joe's Jeans. Super soft and comfy just like my flats.

Don't laugh, but I lovvveee them! I own 4 pairs and 2 dark denim pairs. My hubby won't be caught dead with me when I rock them! He constantly asks "why do your pants have holes?". Ugh, MEN! I guess when you live in pants & skirts M- F you want to loosen up a bit on the weekends. Yep, I married a conservative one as well. Boo. 

I can't remember the last time the hubs and I watched a "grown up" movie together so I have to choose,

hands down Despicable Me 2!!!! This movie had me practically choking on my popcorn!!! 

Okay since HGTV, Food Network and Oprah's Channel might not  count, I'm going to have to say GLEE! 

I was definitely saddened by the death of Cory Monteith. The pressures and the demons these celebrities battle is just a shame and a huge tragedy.

This one's kinda hard because my family and I love trying new food. From Indian to Chinese to Japanese, we're not afraid to try it. I blame my mom, who always said to me at the dinner table "you need to at least TRY it". Hubby is yelling Ihop (don't ask), but if I had to choose one, it would probably be the Olive Garden. I've always experienced great service there and their food has been delicious each time. 

When school started in August, I began to get really stressed out. We were short a Kindergarten teacher, and the group of kids we got this year literally came from all walks of life. Yes, each year has its challenges, but I don't think I've had a year like this. It has made me question my choice to teach, and it has made me question being at the school I've called home for the last 13 years. Not to mention the constant, sometimes overly- outrageous demands of my admin. Everything started to get the best of me, and I started to break out around my chin. I hated it. I've never really had breakouts growing up so I was a bit freaked out. Let me tell you friends, when your 10 year-old sees a Proactiv commercial and says "Mom, you should try that"…then you really need to take their advice. So far it is working and I love it. I just wish there was just one bottle and not 4. With the busy lives teachers lead, I sometimes forget to do the last two steps…sigh. 

My favorite gift was a handmade card from my 10- year old. Wish I had a picture of it but sadly I don't. She made it in her class and it's sitting proudly on my desk at school now :)

This art activity is one of my favorite pins!  

{original source here}

My favorite blog post this year was about the First Grade Educents bundle! I was so excited to have my product featured! 

Definitely organizing my teacher files and center games. Looking back, I think I have a serious addiction to TPT!! Yikes!

You can see the picture on Instgram here: http://instagram.com/p/g60VAQw8qe/

I can't seem to copy it directly from instagram :(

My favorite picture will tie in with my #3….the time when I made 100 cookies for the staff at my school. You can see it here on instagram:

 http://instagram.com/p/g-Vcmsw8me/

For the life of me, I don't know how to copy images from instagram…aaggg!!

My favorite memory this year was baking over 100 cookies for the staff at my school during Staff Appreciation Week. They truly are the unsung heroes that don't get as much credit as they should sometimes. 

My goal for 2014 is to make enough money on TPT to pay off my student loans!! HA!! I wish!! 

Breathe. Just Breathe. I've set it as my screensaver as a constant reminder. This coming year I need to learn how to just breathe and move on. I can't change the world, I can only change myself. I need to have faith that God is in control and he will continue to guide me through this journey called life. 

Thanks for sticking with me. This is probably my longest post yet. Cheers to peace, love, joy, and a ton of blessings and happy moments for your family and mine this New Year!! 

OH, aaannnddd, I'm having a New Year's Sale. I'm currently working on adding a TON of products to my store, so please check back soon! One of my New Year's Resolutions is to finish all these products that have been "in the works" for forever now! lol! 

Christmas in Paradise Giveaway!

I'm teaming up with my favorite Hawaiian teacher bloggers to bring you a very special giveaway!

You could win seven different holiday/tropical goodies, plus a fancy new pencil sharpener from Classroom Friendly Supplies!  Click on the images to check out their descriptions on TpT {and to add them to your wishlist in case you don't win!!}

Good Luck!

a Rafflecopter giveaway