A recent article in the New York Times identifies the possible overuse of Miralax for treating chronic constipation in children. Many take it on a daily basis for years, despite the fact that it is only approved for use in adults. As a pediatrician I have prescribed Miralax many times, and find it to be a very useful medication. The problem comes when only the symptom, and not the underlying cause, is treated.

In my experience the cause of chronic constipation is usually not insufficient fiber in the diet, but rather a combination of a habit of stool holding with sometimes complex emotional issues around autonomy and control (the exception being an underlying neurologic or other medical condition.) I'm all for a healthy diet, but if you make this an issue about eating more fruits and vegetables, you may be simply shifting the battleground from one end to the other. It is best to avoid battles over either what goes in or what comes out, because in these battles the child, by using his body, will always win.

 I hope readers don't mind some details-as a pediatrician I have to be comfortable talking about poop.  On excellent use for Miralax is for a toddler who has a hard painful stool and then holds in his stool for fear of repeating this experience.  This may be more likely to happen in a child who is sensitive not only to bodily sensations but also other forms of sensory input, such as sound and touch.  This problem can occur whether or not a child is in diapers. It is best nipped in the bud. Miralax acts by drawing water into the stool. If you give the right amount, the stool is too soft for the child to hold it in. With time the child will forget the painful experience and then go back to normal stooling.

Stool holding and conflicts around toilet training may also occur if a child feels things are out of control in some other aspect of his life. For example, most parents intuitively recognize that toilet training a toddler around the time of the birth of a sibling is not a good idea. One child I took care of dug in his heels around potty training when his parents were going through a difficult divorce.

Parents who have dealt with this problem know that kids can be very adept at holding in stool. They may stand in a corner turning red in the face with effort.  This may be interpreted as trying to push the poop out, but most of the time what is actually happening is that they are working to hold the stool in. Just as biceps get strong when you lift weights, the anal muscles can get very strong with repeated use in this way.  If this cycle is not broken, kids can go on to have problems for many years. However, with time and careful attention, kids can learn to use their muscles the right way and to have a healthy relationship with their body and bowel habits.

There are often tremendous social pressures on parents to toilet train their children. When parents come to see me in my behavioral pediatrics practice, they often have had ongoing conflicts with their child about sitting on the potty, but have recognized that this approach is not working. They may even wish to have their child take charge of the issue, only to be thwarted by pressures in the school setting. I am all for using motivation for encouragement when a child is ready. Pediatrician Barton Schmitt coined the term "poop candy" for rewards for pooping in the potty. But if a child is not ready, either physically or emotionally, even the promise of a trip to Disney World will not get him to poop in the potty.

Toilet training occurs at a time when children are taking ownership of their bodies. Eric Erikson referred to it as the stage of autonomy vs. shame and doubt. As much as is possible, its best to simply let a child take charge. If problems arise, short term use of Miralax to avoid stool holding while the underlying issues are addressed is certainly reasonable. But it should not be used for long-term treatment. I am not speaking to the safety of the drug, because its long-term risk is not known. Rather, using any drug for years without in- depth exploration of the cause of the problem, a trend far too common in our medication-happy culture, is not a good idea.

Is it possible that our culture's over-reliance on the quick fix of medication to treat complex problems is waning? That alternative models of care offering meaningful support for early parent-child relationships are gaining increased recognition? My inspiring weekend with the current group of fellows in the UMass Boston Infant-Parent Mental Health Post-Graduate Certificate Program gives me hope that this is in fact the case.

One person in the group, an experienced neonatologist, has in the course of her clinical work increasingly recognized that what makes some premature babies do well and others not lies in the quality of their early caregiving relationships. She sent the group an article as evidence of the above trend, writing: 

I am attaching a very short paper from this month's Journal of Perinatology that describes incorporation of relaxation techniques into perinatal counseling. It uses terms such as "being with," "connections," and "compassionate presence." Ten years ago, this paper would have been flatly rejected by a prestigious journal as being anecdotal and merely descriptive. 

Peter Fonagy, the weekend's featured speaker, a great mind who has been likened to a modern-day Freud in terms of the transformative nature of his ideas, offers an alternative model from that presented by the pharmaceutical industry. Relationships can change the brain in more specific ways than drugs.

Fonagy identifies the quality that makes us uniquely human, different from animals. It is the ability to interpret other's behavior as having meaning. Humans alone understand that behavior is driven by motivations, intentions, desires and beliefs.

But the thing is, babies are not born knowing how to make sense of their own and other's behavior. They learn it from the people who care for them. When a parent is attuned with her baby in such a way that says, "I understand you," that child learns to understand not only his own mind, but also the minds of others. This learning takes place at the level of structure and biochemistry of the brain. This ability to interpret other's behavior in turn allows that child to make sense of the wider social world.

 Attuned early relationships of what Fonagy called "epistemic trust" are critical because they are "the superhighway for transmitting cultural knowledge." They are the means by which we learn about the world: how we learn to engage with others in a healthy and productive way.

Where does the motivation come from to shift from a quick-fix model of disease to one that promotes healthy relationships? The ACE study, which I have written about in previous posts, offers a kind of negative motivation. If we do not do something to change direction, there will be lots of bad outcomes in the form of such things as mental illness, violent crime, diabetes and heart disease. Fonagy offers more positive motivation. If we intervene early to promote secure safe relationships, we give children the tools to go out into the world, think creatively and move our society forward.

Fonagy points to three trends offering hope that things are changing in the way we as a society care for children and families. One is the increasing evidence of the impact of stressed early relationships on such long-term health outcomes as heart disease and obesity. The second is the decreasing influence of big pharma on mental health care, as evidenced by the marked decrease in development of new drugs to treat mental illness.  And third is the role of the Internet in disseminating new information. I am hopeful that this blog is one small part of that trend.

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

Mindfulness means paying attention in a particular way; On purpose, in the present moment, and nonjudgmentally.

"People have to feel something in order to change the way they think and behave." This is a quote from my book Keeping Your Child in Mind. The right brain is the seat of emotional regulation. Most, if not all, emotional and behavioral problems are intrinsically tied to the ability to regulate emotions. Changes in the brain can occur only if the right brain centers that regulate emotion are actually firing.

I was thinking about this idea when I attended an amazing conference at the Picower Institute for Learning and Memory at MIT, New Insights on Early Life Stress and Mental Health. Leaders from a range of disciplines presented the explosion of scientific evidence showing that early caregiving relationships have a significant long term impact on both mental and physical health.

MIT is a particularly left brain place, and there was a lot of hard core science at this talk. One speaker, Robert Anda, did inject a bit of right brain experience. Anda is one of the main authors of the ACES study, a powerful longitudinal research project that shows the cumulative effect of adverse childhood experiences, including parental mental illness, divorce, neglect and abuse, on many outcomes related to physical and emotional health. He used art to make our right brains fire. In a painting he showed, a little boy of about seven sat at the dinner table as his parents engaged in an argument, his father holding a knife and his mother's face distorted by rage. The terror on the boy's face was palpable.

The conference was very much framed around the concept of adversity. Anda kept apologizing for making us depressed. Consider the conference description:

Within the last two decades, scientists have begun to examine the biological repercussions of early childhood stress, and have uncovered clues as to how these early life experiences cause lasting changes in DNA and the brain that predispose individuals to disabling behavioral and psychiatric disorders in adolescence and adulthood.

The whole day I found myself thinking that what was missing was a right brain experience of what it feels like when things go well. We know it is bad for kids when they do not have a secure safe relationship. But what does it feel like when parents and children do connect in a way that makes a child feel safe and secure? Earlier in the day I had had the opportunity to share just such a right brain experience.

I had given Pediatric Grand Rounds at Newton-Wellesley Hospital, where I was introducing the scientific basis of my new Social Emotional Health program, where I see families of children under age six. When families come to see me, parents and children feel sad, angry, and out-of-control. By carefully listening to parents' own experience I help them to reflect on the meaning of their child's behavior, rather than responding to the behavior itself. This approach is founded in decades of longitudinal research at the intersection of developmental psychology, neuroscience and genetics that I describe in my book.

I told my audience the story of a visit with a mother who experienced her 3-year-old son's behavior as an assault. I had reframed the child's behavior in these out-of-control moments as helpless rather than defiant. She said, "I know what you mean." She described one moment when, rather than getting angry, she had held her son firmly on her lap and said gently "What's wrong?" She told me how her son "melted in my arms" and replied softly, "I don't know."

This mother felt this change not only in her brain, but in her body. It is not uncommon for parents to have themselves experienced trauma in early relationships. They react to their child's provocative behavior on a physical level that is related to their own history, not to the child. By carefully listening to parents, in a visit that is not fifteen minutes but an hour, I help them to make these connections. Once their own issues are in a sense moved out of the way, they are free to reflect on their child's experience in a way that is not encumbered by their own trauma history. When a child feels understood in this way, his behavior improves. A positive cycle of interaction is set in place.

When I told this story during Grand Rounds, I felt a tingling in my arms as I spoke of this mother's transformation in my office. The visit with that family had been a powerful experience for me. The fact that I felt something in the telling makes me hopeful that I was able to convey this to my audience. Maybe they understood how this kind of careful listening may actually change brains.

My book is full of stories like this one. If we are going to change this path that was described at MIT, of early childhood stress leading to terrible outcomes, these conferences need to include stories of what goes right; when clinician-parent-child connect in a meaningful way. Once we know what this feels like, we will be closer to understanding what we need to do to set children and families on a better path.

Two things most stood out for me in Kaitlin Bell Barnett's new book Dosed: The Medication Generation Grows Up. The first is the stories of women struggling to get off of SSRI's (selective serotonin reuptake inhibitors), started in early adolescence, when they decide to get pregnant. The second is Bell Barnett's review of the literature regarding sexual dysfunction as a side effect of SSRIs in adolescence.

The book as a whole has much to say that is very important. As I write in my blurb for the cover:

Dosed is a fascinating, well-researched, and very important book. After reading it, I hope that no parent, pediatrician or psychiatrist will give psychiatric medication to a child or adolescent without very careful consideration of the potential long-term consequences. Bell Barnett shows that these medications are often not a ‘quick fix,’ but rather have deep, lasting impact, not only on physical and emotional health, but also on a person’s core sense of self.

Bell Barnett is a journalist who was herself started on SSRIs as a teenager. Her book intertwines in depth interviews with people who were started on psychiatric medication in childhood and are now young adults, with a journalistic study of the history of psychiatric medication use in children. I could probably write several posts covering all the important issues she addresses, but have chosen to focus on these two.

I first learned of the emerging evidence that SSRIs may cause long term sexual dysfunction last fall when I attended a talk by Robert Whitaker, author of the controversial book about psychiatric illness and medication Anatomy of an Epidemic. I was so alarmed about this data that I wanted to immediately write a blog post about it. But shortly after that talk I received the galleys of Bell Barnett's book. I discovered that she has a through review of the rather scant literature on the subject along with some very poignant stories, so I decided to wait until her book came out. I recommend that anyone who is concerned about this issue (as anyone who takes or prescribes these drugs should be) read her book. The subject is covered in the chapter entitled "Side Effects." Here are a few sample quotes.

A comprehensive review of the literature conducted in 2004 found just one clinical trial that reported erectile dysfunction in a teenager; most clinical guidelines and reviews of SSRIs didn't mention sexual side effects at all.

This is pretty shocking since, as the authors of the study cited above noted, anywhere from 30-40 percent of adults experience some kind of SSRI induced problems with libido, arousal, or orgasm.

And this important point:

Despite the lack of formal studies involving young people, anecdotal evidence suggests that drugs causing decreased libido and sexual dysfunction do sometimes pose a real problem, psychologically and socially, both for teenagers who are in the process of developing a sexual identity and for young adults testing out long-term intimate relationships.

And this from Elizabeth, who started taking SSRIs in 9th grade:

I am not sure I can [over]state the extent to which it impacted things. I didn't grow up with a normal sex drive, and that was obviously due to a combination of factors, but being on and off antidepressants whose impact I really couldn't understand back when I didn't have any real understanding of my sex drive or sex in relationships to begin with means I basically went through adolescence without experiencing anything in that realm in a "normal' way.

There's more, but the bottom line is that this issue is not well studied and yet of major significance in adolescent development.

Bell-Barnett poignantly captures the challenges faced by her interviewees who were started on SSRIs in childhood and now want to have children. Aware of the potential effects on the developing fetus, they try to get off the medication, but rebound with debilitating symptoms of depression. SSRIs are one of the most common medications prescribed in pregnancy. Yet we really do not know what the effects are on the developing fetus. A policy statement put out by the American Academy of Pediatrics earlier this year points to evidence that SSRI use in the third trimester is linked to a constellation of neonatal signs and symptoms. We do know that maternal depression itself can have a negative impact on the developing fetus. So if a woman is already on SSRIs and develops symptoms of depression without them, it may be best to stay on them during pregnancy.

The take home point of Bell Barnett's book, however, is that this issue needs to be considered by parents and clinicians when girls are prescribed these medications in childhood and adolescence well before having children is on their minds. These medications have a great allure as they may very quickly resolve symptoms. But one thing that Bell Barnett makes clear, and that is also supported by the literature, is that getting off these medications is very difficult.

Certainly these children and teenager should get help if they are struggling with depression. But other forms of intervention, including psychodynamic psychotherapy combined with self-regulating activities such as yoga, offer an alternative to medication. There is a severe shortage of quality mental health services due in part to the influence of the health insurance industry. It is a complex issue that must be addressed at the level of health care policy.

Large-scale use of these medications has major life-long impact on identity and sense of self of the current generation, referred to as "Generation Rx." Considering the complex issue of SSRIs in pregnancy, there is also potential for significant impact on the next generation. The time to pay attention to this problem is now. Reading Bell Barnett's book is a good place to start.

Respiratory rate, heart rate, blood pressure- these are the three vital signs that those on the front lines of health care are well trained to measure as initial assessment of a patient. Given the explosion of knowledge emerging at the intersection of neuroscience, genetics and developmental psychology about the essential role of early caregiver-child relationships on lifelong health, it is time to add a fourth vital sign- relationships. I first learned of this idea from a colleague, David Willis who is Chair of the American Academy of Pediatrics (AAP) Early Brain and Child Development Initiative. He in turn learned it from Colleen Kraft. Adding this fourth vital sign puts assessment and support of early relationships front and center.

The recent AAP policy statement Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health captures the critical role of relationships in healthy development.

In contrast to positive or tolerable stress, toxic stress is defined as the excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships..toxic stress early in life plays a critical role by disrupting brain circuitry and other important regulatory systems in ways that continue to influence physiology, behavior, and health decades later.

A remarkable study coming out of the Yale Child Study Center and described in the New York Times last week shows the wisdom of this focus on relationships. It was a randomized control study of the Child and Family Traumatic Stress Intervention(CFTSI). Children who received the intervention were 65 percent less likely than those in the comparison group to have developed full-blown post-traumatic stress disorder and 73 percent less likely to experience partial post-traumatic stress disorder. These are the kind of numbers that make one stand up and take notice.

What makes this intervention different is that it specifically works with caregiver and child together to support the caregiver's efforts to understand the meaning of the child's behavior.

Unlike traditional counseling, which is often unstructured and prolonged and may not involve both child and caregiver, this program follows a proven pattern: first a session with the caregiver, then one with the child, then two sessions with them together.

Steve Marans, lead author on the study, explains the results.

When children are alone with and don’t have words to describe their traumatic reactions, symptoms and symptomatic behaviors are their only means of expression. And caregivers are often unable to understand the connection between the traumatic event and their children’s symptoms and behaviors. To heal, children need recognition and understanding from their caregivers.

These remarkable results make perfect sense to me. Children want to be understood by their parents, not their therapist. This is the model I have been using for years in my pediatric practice to address any behavioral symptom, not only those associated with trauma, and I too have had remarkable results. It is wonderful to see this approach validated by a high quality randomized control study. As I write in my book Keeping Your Child in Mind

Being understood by a person we love is one of our most powerful yearnings, for adults and children alike. The need for understanding is part of what makes us human. When our feelings are validated, we know that we’re not alone. For a young child, this understanding helps develop his mind and sense of himself. When the people who care for him can reflect back his experience, he learns to recognize and manage his emotions, think more clearly, and adapt to his complex social world

This concept of supporting parent's efforts to reflect on the meaning of a child's behavior comes out of decades of research showing how this kind of understanding promotes healthy development at the level of gene expression and biochemistry of the brain.

When baby is born, if heart rate, respiratory rate and blood pressure are OK, our next priority is to support the primary relationships by carefully listening to both caregiver and baby. One way to accomplish this is to use a wonderful tool- the Newborn Behavioral Observation system, developed by J.Kevin Nugent, colleague of T. Berry Brazelton. If problems are identified, such as a biologically vulnerable child whose cues are hard to read, or postpartum depression, or lack of social support for mother, we can address them. We will then be setting this new life out on a course of healthy development from the start.

Recently there was a beautiful article, Wonder Dog , in the New York Times magazine about an emotionally troubled boy who was helped significantly by a devoted dog. I thought about this story this past week when my beloved dog, a lab-border collie mix who we adopted 9 years ago at the age of two , died rather suddenly. It turns out he had a tumor on his spleen and bled internally-at least it was quick and painless.

The thing is- he really helped me out with my emotional regulation, especially in my role as mother to my daughter, who as a young teenager had an incredible capacity to push my buttons. In the interests of full disclosure, I also had a lot of help from a wonderful therapist in understanding the roots of this issue. But Jasper was there with us on the front lines.

Whenever we would get into any kind of conflict and I would start to raise my voice, Jasper would immediately get up from his dog bed and come and lie right next to me. At once I would feel calm. My breathing slowed and I am quite sure my blood pressure went down. Rather than continue to butt heads with her, I would be able to think more clearly about what was happening and to reflect on the meaning of her behavior. Often I could identify some event in her life that was causing her stress and anxiety that she was now taking out on me. I was able to remain calm in the face of assault. Jasper helped me to much more rapidly defuse these encounters.

Now that he is gone, I think of his beautiful soulful eyes and his oh-so soft head, and I hope that I have internalized his presence enough that I can just think of him to gain that calm feeling. My daughter is older now and she herself has learned to regulate her own emotions. Part of this is simply development and maturation. But to some degree I believe she has learned this from me, and I in turn learned it in part from Jasper.

In my book, Keeping Your Child in Mind, I talk about how parents themselves need to find ways to manage their own emotions in order to be present with their children in a way that promotes healthy development. This involves having someone to hold them in mind, be it a spouse, friend, family member or therapist. I should add animals to that list.

The therapeutic value of animals for children is well known. I often recommend horseback riding as an activity for children with problems of emotional regulation. Child psychiatrist Bruce Perry, in his description of the Neurosequential Model of Therapeutics that he developed for working with traumatized children, writes:

Dogs have the capacity to provide the unconditional accepting and repetitive nurturing experiences required to help some of these children.

The wonderful documentary film Buck, clearly demonstrates how Buck's close relationship with horses has helped him to recover from the severe physical and emotional abuse he experienced as a child. He now uses this experience to help others. In training workshops he runs all over the country he shows the importance of managing your own emotions in order to be present with your horse in a way that helps him to manage his. It's an amazingly similar concept to my book!

If your child wants a dog, and you worry that you will "get stuck" taking care of it, remember that the dog can be a wonderful asset for the whole family. I know it will take our family a long time to heal from this terrible loss. I would often say to Jasper, "You are truly a good person ( as dog)." I hope that in writing this I can to some degree immortalize his gifts to us.

About three years ago an eighteen-year-old girl committed suicide six 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 and her 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."

If my book, Keeping Your Child In Mind, were to have a theme song/video, it would be Taylor Swift's The Best Day. I have included the lyrics below, but suggest watching and listening (with tissues!) It offers a "right brain" emotional experience of what D.W. Winnicott termed the "holding environment." As I write in my book:

Winnicott describes this way of being with a baby as the “holding environment.” The mother’s ability to tolerate and contain her baby’s distress helps him to make sense of and learn to manage his experiences. Even though holding a baby may seem to be simply a physical act, it is her emotional presence that is important to the baby.

The video speaks for itself, but here are a few points that stood out for me.

As a young child Taylor's mother physically contains her after a long day playing outside: "I hug your legs and fall asleep/
on the way home" She feels safe and secure with her mother who is "not scared of anything at all."

The video captures the way in which she was included in the arrival of her baby brother. Her love for him is clear in the later lyrics, "Inside and out, he's better than me."

At thirteen she experiences inevitable social trauma, with her friends being "so mean.". Her mother does not try to fix it. Rather, Taylor receives her mother's undivided and playful attention as they go for a ride in the car. One feels confident that though, as she says, "Don't know how long it's gonna take to feel okay," Taylor, refueled and fortified by mother's love, will work it out herself.

While the song is primarily about her mother, Swift brings in her father "whose strength is making me stronger."

Overall, the video perfectly captures the great value of simply being present with our children. In our culture of "advice" about "what to do" about any range of problems, this is a breath of fresh air. The challenge is clear our own minds and lives enough to offer our children this kind of holding. If we can, we are setting the foundation for their healthy emotional development and future success, in every sense of the word.

The Best Day

I'm five years old
It's getting cold
I've got my big coat on

I hear your laugh
And look up smiling at you
I run and run

Past the pumpkin patch
And the tractor rides
Look now -- the sky is gold
I hug your legs and fall asleep
On the way home

I don't know why all the trees change in the fall
I know you're not scared of anything at all
Don't know if Snow White's house is near or far away
But I know I had the best day
With you today

I'm thirteen now
And don't know how my friends
Could be so mean

I come home crying and you hold me tight and grab the keys

And we drive and drive
Until we've found a town
Far enough away

And we talk and window-shop
Until I've forgotten all their names

I don't know who I'm gonna talk to
Now at school
I know I'm laughing on the car ride home with you
Don't know how long it's gonna take to feel okay
But I know I had the best day
With you today

I have an excellent father
His strength is making me stronger
God smiles on my little brother
Inside and out
He's better than I am

I grew up in a pretty house
And I had space to run
And I had the best days with you

There is a video
I found from back when I was three
You set up a paint set in the kitchen
And you're talking to me

It's the age of princesses and pirate ships
And the seven dwarfs
Daddy's smart
And you're the prettiest lady in the whole wide world

Now I know why all the trees change in the fall
I know you were on my side
Even when I was wrong
And I love you for giving me your eyes
Staying back and watching me shine

And I didn't know if you knew
So I'm taking this chance to say
That I had the best day
With you today

Recently I went to a talk given by a local "ADHD (attention deficit hyperactivity disorder) expert" to a group of primary care pediatricians. The aim of the talk was to guide these practitioners in doing "ADHD evals" given the time constraints of primary care practice.

"Its all about the rating scales," he said. "You need to train your staff to give out the right scales. The key to working kids up is getting the scales done ahead of time. Nothing happens in the office."

This doctor proudly displayed his version of the main rating scale, the Vanderbilt, which he has divided into two time slots, because "kids have different symptoms at different times of day." Evaluation and treatment of ADHD consists primarily of scoring rating scales, making a decision to use medication, and once the decision is made, having follow-up visits every three months to adjust medication dose according to symptoms and side effects.

One pediatrician, someone for whom I have great respect as a clinician, was alarmed about a 5-year-old who was placed on a very high dose of medication by another doctor. When I asked her what was going on in the child's life that might cause him to have so much trouble, she didn't know. She had changed the medication, which did in fact improve the child's symptoms. Her approach is the standard of care in pediatrics.

In other areas of medicine, we treat the underlying cause, not just the symptom. In treating bacterial pneumonia, for example, we use an antibiotic, not a cough suppressant. The Vanderbilt lists symptoms of problems with regulation of behavior, emotions, and attention, which together may be labeled as ADHD. The question should be not “How do we control the symptoms?” but rather “What is making self-regulation difficult for this particular child?” followed by “What can we do to help promote self-regulation?”

Recently I saw several children who had been diagnosed with ADHD but medication "didn't work". One mother told me about her own struggles with untreated depression. Another child spent weekends with an actively drinking alcoholic father. A third child quietly spoke with her mother of being frightened when she pulled her hair and hit her.

Nowhere on these rating scales does it ask about family history or life stressors. According to the current standard of care it is possible to diagnose and treat ADHD without ever learning about any of this history. Detailed family history (see previous post), as is well described in the book A Lethal Inheritence, is essential to diagnostic evaluation. In addition, detailed early developmental history may reveal significant sensory processing problems that have been unrecognized.

When I have written about ADHD in the past, I usually get a number of angry responses from parents who say everything is fine in their family and I shouldn't blame them for the problem. In my experience, about 10 % of kids have what I refer to as "straightforward ADHD." They have symptoms and an extensive family history of inattention and/or hyperactivity with no other issues. If you are in that 10%, this blog post is not about you.

Giving a list of therapists does not solve the problem, because the child is usually the "identified patient." Family therapy can be an important component of treatment when a child struggling with self-regulation, as is well described in the recent book, Suffer the Children: The Case against Labeling and Medicating and an Effective Alternative. Furthermore, once a child is placed on medication, his behavior is "better" for the short term and the motivation to do the more challenging, time intensive work to uncover the cause is lost.

The term "ADHD eval" implies only two options- a child does or does not have ADHD. It leaves no room for curiousity about the meaning of behavior. Then there is the term "co-morbidity." This simply offers the opportunity for more labels without exploring the cause of symptoms.

There is a reason why, as one of the pediatricians at this presentation bemoaned, a parent may say, "by the way" just when when a doctor has his hand on the doorknob to leave. It takes time to develop sense of safety and trust to be able to say what's really important.

Fortunately I work in a practice that is open to a different approach. Here are some initial changes I propose:

1) Schedule the visit as "evaluation of problem of attention, behavior and emotion," or more simply "behavior problem,"rather than "ADHD eval"

2) Have a minimum of two 50 minute visits for an evaluation

3) See parents alone without the child for the first visit. Aim to include both parents whenever possible

4) Goal of initial evaluation is to get detailed family and social history, and to offer parents an opportunity to be heard. Very often the parent and/or couple need support and possibly referral

5) Medication may be considered for an older child if he is unable to learn or function in a social environment without it. Equal attention must be given to other interventions, including addressing diet, sleep, and physical activity

Such an approach involves a change in expectation on the part of parents, teachers and clinicians. Parents are often under tremendous pressure from teachers to get a prescription for medication.

Stanley Greenspan's book Overcoming ADHD: Helping Your Child Become Calm, Engaged, and Focused--Without a Pill offers an excellent holistic approach that is founded in quality scientific research. One key component of his treatment is to support "reflective thinking." This involves helping a child to recognize both his strengths and challenges, and to develop strategies to manage his own unique vulnerabilities.

"We don"t have time" is not an acceptable answer. Changes must be made in our healthcare system to insure better reimursement for time spent listening in this way, and to improve access to quality mental health care services.

This is child's life we are talking about. If the root cause of the problem is not addressed, there may be years of medication adjustment until something bad happens- car accident, school failure, violent crime, prison. If I sound alarmist, it is because I am alarmed. The current standard of care of ADHD treatment, particularly now that diagnosis is extended down to age 4, effectively silences huge numbers of children. We need to give these children a voice.

Lately, following conversations with colleagues and patients, I have been doing a lot of thinking about pregnancy loss. In particular I've been wondering about its effect on subsequent term pregnancies, and relationships between parents and these children. In researching this subject, I came upon a study from 2011 in the British Journal of Psychiatry showing that depression and anxiety following a miscarriage may last for almost three years, even after the birth of a healthy baby. Researcher Emma Robertson Blackmore, PhD, an assistant professor of psychiatry at the University of Rochester Medical Center said of the study:

Health providers and women themselves think that once they have a healthy baby after a loss, all would be fine and that any anxiety, fears, or depression would go away, but that is simply not the case. I honestly thought that once a woman had a baby or had gone past the stage of her previous loss, the anxiety and depression would go away, but these feelings persist.

As a culture we often do not recognize the deep significance and impact of pregnancy loss. I still vividly recall my own family's well meaning reassurances of "don't worry you'll get pregnant again," that seemed so remote from the pain I felt following an early miscarriage.

In my work as a behavioral pediatrician, I frequently hear stories (identifying details, as always, have been changed to protect privacy) from mothers who have not had the opportunity to mourn the loss of a pregnancy. One mother told me about of having lost a baby at term and then suffering with severe postpartum depression (PPD) when her healthy child was born a year later. A five-year-old girl I saw struggled with severe separation anxiety. At first the focus of our work was on what to do to get her to sleep in her own room. But as we got to know each other, her mother, for the first time, spoke openly about her grief over a miscarriage when her daughter, an only child, was three. The little girl, it turned out, was worried about her mother. At the root of her separation anxiety was a wish to to protect her mother from feeling sad.

Mental health professionals who work with adults describe the phenomenon of the "replacement baby." These are adults who were born following the death of a previous child. When parents have not spoken of this child, or have not been able to fully grieve this loss, it may have significant long-term effects on the mental health of subsequent children. These effects may, in fact, persist for generations. One mother I worked with was such a "replacement baby." Her older brother had died at birth several years before she was born. When I saw this family, her son was 8 years old and the whole family was struggling. Separation anxiety was again the presenting problem. The marriage was strained because this mother had such an intensely close relationship with her son that her husband felt excluded. I learned that this son was named after her dead brother.

Interestingly, when I googled "pregnancy loss and postpartum depression" most of what I found asked if women could have postpartum depression following pregnancy loss. I think that both in terms of how we understand and how we treatment of these problems, it is important to think of them as two distinct and different phenomena.

Certainly a woman may slide from grief into depression following the loss of a baby. This may occur if the loss triggers memories of other losses, if she does not have an adequate support system, or there are other significant stressors in her life. But postpartum depression, as I describe in my previous post, is specifically a problem in a relationship. Untreated PPD often has significant long-term sequelae for the baby. Treatment of pregnancy loss focuses on the mother, while treatment of PPD needs to include the baby from the beginning.

What can we learn from these stories? As Massachusetts is currently working to address the issue of postpartum depession via the PPD commission, one very concrete we can do is to identify mothers who have had previous pregnancy loss as being at high risk for developing PPD. We can make sure that these mothers do not "fall through the cracks." One mother poignantly told me that because of a change in health insurance plans when her child was an infant, she was forced to give up the relationships with her health care providers that were very important to her, just at a time when she was most vulnerable.

Even before that, friends, family members, religious organizations and health care providers can be attuned to the nature of the trauma of pregnancy loss. Women themselves need to feel the right, and be given the space, to grieve a pregnancy loss. While the effects of such a loss can linger in any circumstances, it is unacknowledged and unprocessed grief that has to potential to have the tightest grip on people for years to come.

I recently had the privilege of being appointed to the Massachusetts Commission on Postpartum Depression (PPD). The Commission, co-chaired by Rep. Ellen Story (Amherst) and Senator Thomas M. McGee (Lynn), is charged with making recommendations to the Department of Public Health and the MA State Legislature on advancing best practices regarding PPD screening, treatment and public and professional education. I am on the public education subcommittee.

Lately I have been writing a lot about love, and this new role brings me again to this subject. When we support caregivers (I use this word rather than mother, as while the primary caregiver is usually the mother, it may be the father or another relative) who are struggling with postpartum depression, we are dealing with disruptions in passionate love relationships. Depression is, in fact, only one potential cause of such disruption. Perhaps our conversation should focus on relationships from the beginning. Education material about PPD does address the impact of PPD on child development, but the language is often focused on the caregiver, rather than the caregiver-child relationship.

Across the ocean in Scotland my friend and colleague Suzanne Zeedyk has had a good deal of success in calling attention to the need to support early parent-child relationships. The departments of education, health care, finance and even law enforcement are on board in recognizing this need. On her website under "what I do" she writes:

Science is helping us to better understand how relationships shape the development of human brains and human communities. I make this knowledge understandable for parents, professionals and policymakers

Suzanne has created a beautiful DVD, The Connected Baby. There is a live streaming of the film today March 1st on the blog Mothering.com. One segment entitled "The Dance of the Nappy" films a mother changing her baby's diaper, interspersing commentary. In this simple and elegant way she shows the exquisite attunment between mother and baby that goes on in countless minute to minute interactions throughout the day. It is in this relationship that a baby's brain grows and develops. It is how he develops a sense of himself.

Her film does not address disruptions in relationships. But it is only a small step from there to understand that if a mother is depressed or anxious, or in some other way preoccupied, this dance will be significantly altered. Equally important to consider is the way in which qualities in the baby may disrupt the dance. In my previous post I wrote about regulatory and sensory processing difficulties. A baby may be sensitive to touch or sound, or struggle going from awake to asleep, or any of a range of qualities that may make negotiating the big, loud, complex world more challenging. If, in addition, his caregiver is struggling with depression, the dance may be further disrupted. Or the problems in the baby may cause depression in the mother, as when the baby cries all the time and the mother never sleeps.

When these disruption are not addressed early, significant problems may develop. As I write in my book Keeping Your Child in Mind:

When I see older children for behavior problems, I often hear stories from mothers who struggled terribly when their children were very young infants. Sometimes the memories are vague, but these mothers often recall vividly the sense of being completely alone. The most dramatic example of this was a mother with severe postpartum depression whose father suddenly died when her baby was three months old. Much to my astonishment, she described being relieved by this event. It wasn’t because she didn’t love her father. Rather, in sharing the grief with her siblings, mother, and extended family, she no longer felt so terribly alone. In order for mothers to be available for the kind of preoccupation their newborns need, they must not be left alone. If I were to give one piece of advice to mothers, families, and our culture as a whole, it would be to recognize that although what a mother does with her newborn may look ordinary, it is in fact extraordinary and deserves to be valued as such.

The MA commission is doing important work to call attention to this issue of PPD that is so critical not only for the health and well being of new mothers and fathers, but for the next generation as well. This commission offers an important opportunity to broaden the conversation. An investment in resources that support early caregiver-child relationships is an investment in the future of our country.

In a new study, neurologists at the University of California, San Francisco who surveyed new mothers at their pediatricians office found that mothers who suffer migraine headaches are more than twice as likely to have babies with colic than mothers without a history of migraines. Proposing a genetic link, they hypothesize that colic may represent an early form of migraine.

Before we can launch any meaningful conversation about colic, it is essential to recognize that when we talk about mothers and infants, we are talking about an intense passionate love relationship (see my previous post). When all goes well, the caregiver, who is usually the mother, is highly attuned to the needs of her infant, who in these early months is completely helpless. In a natural and healthy way that accompanies this state of falling in love, a mother is, to quote D. W.Winnicott,, "preoccupied" with her baby. They are engaged in a beautiful dance, in which the mother, by supporting and containing the baby, helps him to learn to regulate himself in the face of all the new experiences he has out in the busy, bright, loud world.

It is not as simple as "the mother has migraines, so maybe the baby has migraines." The exquisite dance of mutual regulation, that goes on naturally when both mother an baby are well, is severely disrupted. It is replaced by a dance of mutual dysregulation.

The baby may be more sensitive to sensory input, as the authors postulate. This difficulty with sensory processing is thought to be a significant component of colic, even if the mother does not have migraines. But the other person in the dance, far from being "preoccupied" with her baby, may be" lying prostrate on the couch for 10 hours," as one migraine sufferer wrote on her blog in response to this study. Certainly her ability to respond to her baby will be in some way impaired by her own distress. The crying, in turn, may worsen the migraine. This is not meant to be a judgment, but simply a fact.

The growing discipline of infant mental health looks at colic not only as a problem in the baby, who may have a variety of biological vulnerabilities, (sensitivity to sensory input being one of them) but as a problem in a relationship. For a new mother, who had anticipated this period as a time of bliss but is instead faced with baby who is either crying or sleeping, with few moments available for gazing adoringly into each others eyes , colic can be a devastating experience.

Recently I had the privilege of teaching about infant mental health to a group of psychologists and psychiatrists who work with very troubled adults, many of whom had significant disruptions in relationships starting in infancy. My students wanted to know what questions to ask when taking early developmental history. I found that they know what to ask, as in "did he have colic?" but they don't know what to listen for in the answers. I told them that my aim was to give texture to colic -to give them sense of what colic felt like, how it was experienced by both the baby and caregiver.

Interestingly this word "texture" came up again last week. I have been taking a wonderful online course on regulatory and sensory processing disorders taught by Rosemary White, who worked closely with the late Stanley Greenspan. White used the word "tailor" to describe how mothers are attuned to their babies, preferring this word to the word "calibrate" that she has used in previous courses. She said that the word "tailor" gives more "texture" to the experience.

There is yet another layer to the "texture" of colic. Mothers, even in the absence of migraines, may struggle with intense feelings of inadequacy in the face of a baby who cries all the time. Add to that chronic sleep deprivation along with an illness like migraines, and there may be a slide into depression.

Recognizing and exploring this "texture" of colic has significant implications for treatment. Rather than exclusively focusing on the baby, it is important to listen to the mother. A mother will need to know that another caregiver who she trusts, be it a spouse, close friend or relative, can watch the baby when she has a migraine. If she can count on such a person, it may lessen the guilt she will likely be experiencing. She may need to attend a group with other mothers facing similar challenges so that she does not feel so isolated. She may need to work on-on-one with an infant mental health specialist who can help the "couple' to manage the stresses on their relationship.

Even in the absence of colic, a mother needs to feel heard, valued and not alone in order to be free to provide that "primary maternal preoccupation." But when she is not well, and her infant is crying all the time, that kind of supportive environment is even more essential. When a mother has such a "holding environment," to again quote Winnicott, she is better able to provide that holding environment for her baby. Together they can make their way thorough these early months when the baby is totally dependent and helpless. It is important in those difficult months, to keep in mind that by "hanging in there," the time will come when a baby can reach for a toy, bring his thumb to his mouth, and begin to learn to comfort himself. This is a skill he will, with the help of his caregivers, continue to develop and refine as he grows increasingly more independent.

The central thesis of an important new book, A Lethal Inheritance: A Mother Uncovers the Science behind Three Generations of Mental Illness, is that the answer to this and other similarly painful questions about family history are critical to the mental health of future generations.The author, Victoria Costello, is a science journalist and mother of two sons diagnosed with serious mental illness, one schizophrenia and the other major depression, in their late adolescence.

As her own survival mechanism kicks in the face of such devastating circumstances, Costello explores the skeletons in her own closet, while using her considerable skill as a investigative reporter to weave her personal story with the last several decades of mental health research at the interface of psychiatry and genetics. Costello learns that her sons are the fourth generation of serious mental illness that has been previously been shrouded in secret. Capturing this well-recognized phenomenon of of intergenerational transmission of trauma and mental illness, she writes:

I've come to think that whoever is denied their rightful place in a family's collective memories will possess the hearts and minds of those left behind, unless and until he is acknowledged.

I found the book to be hopeful and refreshing, essential reading for parents, professionals and policy makers. In my behavioral pediatrics practice it is not uncommon for me to see a young child for "ADHD" evaluation who is described by parents in highly negative terms. As the "identified patient" he may have already been placed on medication by other clinicians. However, when parents are given the time and space to be heard by a person who is interested but not judgmental, they often reveal a history of family mental illness and significant trauma that has been kept secret for years, sometimes for generations. This information is essential for the family members suffering from mental illness who may now seek treatment. Equally importantly, when the child is released from carrying the burden of these secrets, her "true self," in the words of pediatrician turned psychoanalyst D.W. Winnicott, is free to emerge. This is the kind of honest family exploration Costello is advocating for. She writes:

I argue in this book that this stance of silence and secrecy is no longer a viable option, least of all for parents of young children in a family with a pattern of mental illness and addiction. Secrets can cause harm and even kill.

Costello takes on the highly charged question of "blame," She is in an excellent position to address this issue, as she took responsibility for her own lifelong struggle with depression and alcohol abuse in her journey to help her sons. She says:

If it's beginning to sound like I'm getting dangerously close to the historical tendency to blame parents for the psychological ills of a child, my answer is that to a certain degree, I am. In so far as I believe we've gone too far in the direction of "blaming" biochemistry and not taking responsibility for our own roles in shaping the health of our children's brains, I think we have to back up and reconsider. I'm advocating transparency and taking of greater responsibility by everyone-parents, extended family members, mental health practitioners, and our larger communities, including corporate healthcare and government-administered services-for the mental health of our children and future leaders.

She goes on to say that this translates into giving parents more support. Heading off the objection that "we cant afford it,"she offers stark numbers to depict the economic implications to failing to do so.

If we reduce the proportion of young people who become mentally ill by even one quarter, that would mean about 3.8 million saved each year from what can turn into a lifelong and expensive struggle. How expensive? The National Academies estimates that the total economic cost of mental disorders just among Americans under twenty-five was $247 billion in 2007.

Costello has a judicious approach to the contentious issue of psychiatric medication , showing how medication in the face of severe psychiatric illness may at times be essential not only for daily functioning but also for accessing other forms of help, such as insight oriented psychotherapy.

Costello does not address the issue of psychiatric medication in young children, but her view is implied in advocating for prevention. Starting as early as infancy, effective treatment for postpartum depression can give parents the opportunity to promote a child's health brain development, even in the face of a strong genetic vulnerability. She writes:

I've learned that although we're each born with with inherited liabilities and assets, throughout our lives, our minds become largely what we make of them. Put simply, nurture can trump nature. In some cases, it can turn even an inherited liability into a possibility-yes-an asset.

Costello vividly captures her own childhood experience which was "typically middle class."

But the visceral experience of growing up in my family consisted of thousands of moments of bone-chilling fear with no adult to help me cope.

In the concluding chapter, Costello outlines the top ten things a parent can do to safeguard a child's mental health. Costello is arguing that we as a society must work to support parent-child relationships. Every child should have the opportunity to grow up with an adult who can provide safety and security in the face of fear and stress. She advocates for a "fundamental shift in our orientation from doing things for our children to being there for them and us." Costello's recovery and the current successes of her two sons offer heartwarming evidence for the wisdom of this approach.

She gazes into his eyes and speaks to him in soft murmuring tones. He follows her every move with rapt attention. For both, the other is a person full of light and color, while the rest of the world has faded to a kind of uniform pale background. She is obsessed by thoughts of him and worries that something terrible may befall him. He is constantly attuned to her whereabouts.

In this week of Valentine's Day, you might think I am describing romantic love. But I am, in fact, describing a mother and her newborn son. Physicians, nurses and other professionals who work with pregnant women and newborns have the frequent privilege of bearing witness to people falling in love. When all goes well, the period of time when a newborn, who is wired for successful communication from the start, meets his or her caregivers, is a time of joy and bliss.

It is particularly devastating, therefore, when this first communication, this early developing relationship, is less than successful. When this happens, it is often because of postpartum depression and/or anxiety, a very fussy baby, or both. In fact, these problems often go together, as stress in pregnancy, as well as psychiatric medication use in pregnancy, may be associated with irritability, poor sleep, and feeding problems in the newborn.

Traditionally, help for postpartum depression and anxiety has been aimed at treating the caregiver (usually the mother) with psychotherapy, psychiatric medication and support groups. Problems seen as residing in the baby are treated separately, usually by the pediatrician.

But if one thinks of these problems as disruptions in a love relationship, it makes sense to work with parent and child together (to continue the analogy- it's kind of like couples therapy.) Recent research suggests that working with mother and baby together, with the specific aim of supporting successful communication, may be effective in preventing long-term negative effects on child development. Among the most well studied of these interventions is the Newborn Behavioral Observations (NBO) system.

This tool was developed by J. Kevin Nugent and colleagues as a practical, clinical application of T. Berry Brazelton’s Neonatal Behavioral Assessment Scale (NBAS) Brazelton was among the first, in the early 1970's to recognize the range of capabilities of the newborn, and their contribution to the parent-child relationship.

I am in the process of introducing this intervention at Newton-Wellesley Hospital as part of the new Social Emotional Health Program. It is ideally done in the hospital when often both caregivers are present, and there is less time pressure and external stress than in an office visit. It can also be done in the home setting by home visitors. In addition, it can be done in the office setting up to about 3 months of age.

When I am consulted to do the NBO with a mother-baby pair, it never fails to be an exhilarating experience. I have been thinking about the reason for my intense reaction. When I am with a mother, particularly one who has been worried about her connection with her baby, as she experiences the way her baby responds to her voice, or learns about his ability to calm himself, or any other of a number of abilities revealed by the NBO, I am in the presence of a profound and deepening love relationship. No wonder it is a kind of a high that eclipses all other events of the day!

Yesterday I listened to an important webinar from the Harvard School of Public health: Toxic Stress and Early Childhood Adversity: Rethinking Health and Education Policy. The forum centered on growing evidence that when young children experience a constant state of internal stress, it leads not only to mental health problems but long-term poor health outcomes in the form of asthma, obesity, diabetes and other chronic illnesses. Jack Shonkoff, a pediatrician and Director of the Center on the Developing Child at Harvard University, summed up the problem well when he said, in response to a question about growing and new external stresses like cyberbullying and the recent economic crisis, that "Toxic stress happens in the body." He went on to say that prevention of toxic stress is dependent on a child growing up in the company of a relationship with an adult/adults who offer a sense of safety in the face of external stress."

These words could have come straight from John Bowlby, considered to be the father of attachment theory. I summarize his work in my book Keeping Your Child in Mind as follows:

In England during World War II, as in most Western societies at that time, a mother was thought of mainly as a provider of the physical necessities of food and shelter. The mother–child relationship itself was accorded little value; children were routinely removed from their families to keep them safe, and hospitalized children were separated from their parents for long periods of time. D. W. Winnicott, a pediatrician turned psychoanalyst, was among the first to introduce a different way of thinking. He saw that children developed a strong, healthy sense of self when the people close to them accepted their feelings and helped to manage their emotional experiences. To describe this ideal situation, Winnicott coined the phrase “the holding environment.” The way in which a mother makes sense of her infant’s expression gives rise to what Winnicott referred to as the child’s “true self.”

John Bowlby, a British psychoanalyst and contemporary of Winnicott’s, observed the devastating effects of separating mother and child. He described the way a child keeps close to his mother in times of stress and fear as “attachment” behavior. Greatly influenced by Darwin, Bowlby postulated that this attachment relationship was essential to the survival of the species.

Shonkoff is saying the same thing, only now we have the scientific evidence, not available to Bowlby, of exactly how the species will become extinct if children do not have these secure, safe relationships. It will be through violence associated with mental illness, and death from chronic illness.

This is not a matter of shifting funding sources. This is a matter of survival of our species. As Shonkoff wisely said, "we find money to build prisons and cure cancer." Why then is it so hard to recognize the need to support young children? I believe it is linked to another phenomenon that I address in a previous post, namely prejudice against children. This phenomenon is described in the book by the late Elizabeth Young Breuhl, Childism: Confronting Prejudice Against Children. One particularly striking statement came from the moderator of the forum that could be seen as a reflection of this societal prejudice. Wondering about how pediatricians will be paid in keeping with the importance of their role in promoting early caregiver- child relationships, she said "the orthopedists aren't going to say "I'll get a paid less."" So now our survival is up to the orthopedists? Actually that is now in a sense true, as currently reimbursement is decided by the Specialty Society Relative Value Scale Update Committee, commonly called the RUC, which as was described in a recent New York times article, How One Group Sets Doctor's Pay. This committee has very few primary care clinicians. When it comes to policy changes, this might be a good place to start.

The policy statement upon which this forum was based comes from the American Academy of Pediatrics and calls upon pediatricians to take up this role as protectors of children from toxic stress. Over 40 years of attachment research that followed Bowlby's original observations offers solid evidence that secure attachment relationships develop when caregivers are able to listen carefully to their children, to reflect on the meaning of behavior, to, as I also describe in my book "hold their child's mind in mind." In order to support parent's efforts to be present with their child in this way, there must be a place for them to be heard, for their struggles to be recognized and understood. The primary care clinician's office can be such a place. As Dr. Block, president of the American Academy of Pediatrics, stated during the forum, a pediatrician should be able to spend 25-30 minutes instead of 10 listening to a parent. This is an excellent, very concrete plan (though 50 minutes would be better.) Next would come changes to our medical education system to value the role of taking time to listen as a form of healing. These would be small but important steps in the direction of insuring survival of our species.

Recently my teenage daughter presented me with a moral dilemma. Up to one third of the kids in her high school are prescribed some kind of psychiatric drug, most of them stimulants like Ritalin. Many of the others students buy drugs from those who are getting them by prescription. If a person who has not been prescribed the drug takes it for the SAT's, is that cheating?

My reflexive response was "yes," but on further thought I wondered: If it has become so much the norm to be on stimulants, are the kids who are not taking them at a disadvantage? As my daughter wisely observed, anyone has trouble paying attention when sitting for a 5 hour test.

The point of this story is that there are serious long-term consequences to prescribing stimulant medication to large numbers of children. In addition to the above dilemma, by controlling symptoms with medication, the motivation to provide more comprehensive treatment is lost.

To the statement that they "work" I answer that yes, the drugs, at least in the short term, reduce symptoms of inattention and hyperactivity. They make a child conform to society's expectations. If medication helps a child to learn, then in our current educational and social system prescribing may be necessary. But is it right?

Bruce Perry, a psychiatrist who has developed a comprehensive treatment approach based on brain development captures this dilemma well when he writes:

Human beings are biological creatures. Of the 250,000 years or so that our species has been on the planet, we spent 245,000 years living in small transgenerational hunter-gatherer bands. The human brain has evolved specific capabilities that are hominid and pre-hominid adaptations to the millions of years of living in the natural world in groups of 40-50 individuals in these transgenerational groups.

The relationally-enriched, developmentally heterogeneous environment of our past is what our brain "prefers." Our brain is not well-designed for the artificial light, pervasive visual over­ stimulation from television, the distracting sounds, images, anonymous social interactions and host
of other phenomenon related to life in the modern Western world. The impact of the changes in the way we live, work and raise our children has not been completely examined. While well­ intended, many of our current lifestyle choices are likely contributing to the emotional, social, cognitive and physical health problems in our children. The most alarming is the relational poverty that many of our children are experiencing. This is most disturbing because humans are fundamentally relational creatures.

Relationship-rich interventions include such things as martial arts, music, and team sports (Michael Phelps had severe ADHD), activities that foster relationships and also promote self-regulation. Family systems are often severely strained when a child is struggling, and interventions aimed at supporting the family as a whole are very important. Careful examination of the school setting and accommodations to decrease over-stimulation are similarly necessary. But if the drug makes the symptom go away, there is no motivation to devote effort and resources to make these kinds of changes.

Obama's health care reform takes a small step in the right direction. ACO's (accountable care organizations), if they work the way they are intended to work, will encourage primary care clinicians to take the time to carefully listen to patients stories. In building relationships with parents, these clinician have the opportunity to support healthy development of the next generation in a preventive model.

Last week there was a little noticed news item about reports of the possible association between suicidal ideation and Focalin, a stimulant medication used for ADHD.

The FDA said it received eight reports of suicidal thoughts for children or adolescents who took the drug over the past six years, and four of the cases appeared to be linked to the medicine. The link for the remaining cases was less clear.

Kaitlin Bell Barnett, a journalist who writes very intelligently about psychiatric medication, asks on her facebook page "Based on 8 cases of suicidal thoughts ever reported?" I'm not sure what she meant by this question. But it seems to me that even 4 cases is enough to make us seriously rethink this path we are on to medicate away symptoms rather than address "relational poverty" in a meaningful way.

In yet another New York Times op ed, The DSM's Troubled Revision, on this controversial issue of diagnostic labeling, the author makes the argument that categories in the DSM (Diagnostic and Statistical Manual of Mental Disorders) are not actual diseases in the way that measles or hepatitis are, but rather offer a way of "categorizing suffering." I like this idea, in that it comes closer to trying to capture experience rather than pathologize. But, as he also goes on to say, our culture takes DSM too seriously, treating these categories as if they were "real." The health insurance industry contributes to this phenomenon by requiring a diagnosis in order to have treatment covered. While I agree with much of what he says, I was alarmed to find this statement:

The D.S.M. is the offspring of odd bedfellows: the medical industry, with its focus on germs and other biochemical causes of disease, and psychoanalysis, the now-largely-discredited discipline that attributes our psychological suffering to our individual and collective history (italics mine.)

While lying on the couch 5 days a week may not be a realistic treatment for most people, the discipline of psychoanalysis as a whole is most certainly not "discredited."

Most of the best ideas that I use in my work come from psychoanalysts-John Bowlby, D.W. Winnicott, Peter Fonagy -to name a few. I first learned about gene-environment interactions, expressed in my letter about ADHD published today in the New York Times , from another psychoanalyst, David Reiss, of the Yale Child Study Center, when he was the Erickson Scholar at Austen Riggs, a psychiatric hospital where intensive inpatient treatment is grounded in psychoanalytic thought. Reiss and his colleagues are on the forefront of collaborative research in neuroscience, child development and parenting. My recent piece, Mothers, Babies, Psychoanalysts, Pediatricians, shows how contemporary research in this discipline is making significant contributions to our understanding of how to promote healthy development in children at risk. Bruce Perry, a psychiatrist and psychoanalyst, is leader in the field of trauma research and treatment. In describing his model of intervention, he writes of the way brains develop in relationships. Healing from trauma must occur in the context of relationships.

Relationships between parents and children are among the most passionate. We fiercely love our children, though at moments are filled with unimaginable rage at them. Psychoanalytic literature that explores parent-child relationships, in my opinion, has poetry and feelings, in keeping with the subject matter. This is in contrast to much of the literature coming out of other disciplines that address this subject. Perhaps this is because, as Freud said in a letter to Jung, "psychoanalysis is in essence a cure through love."

There is an interesting discussion going on now on the list serve of the American Psychoanalytic Association about love. Because relationships between analyst and patient are so intense and intimate, much attention, rightfully so, is paid to the importance of maintaining boundaries. Boundary violations are destructive to patient, analyst and the therapy. Yet there must be a place for love. One analyst, Jane Hall, writes of the relationship:

It involves constancy, trust, compassion, patience, impatience, fury, empathy, consistency, amazement, attraction, disappointment, and regard among other things. This experience defines love for me.

Hypothesizing about the ability of love to change the brain, she writes "love is more powerful that we know. After all, it does make the world go round."

When I feel stressed, caught up in the whirlwind of intense controversy around how to best help young children develop in a healthy way, I return to these psychoanalytic roots. I find that they keep me grounded.

"A diagnosis tells that there is a reason for that other than that they are bad."

This quote is from a blog post written in criticism of my most recent post about the controversy over the autism diagnosis. The intense and widely varied response to that post has prompted me to further explore this complex and highly emotionally charged issue.

The wish to be recognized and understood by those who love us is an essential human quality. We want to have our experience validated. In my work with parents, my main objective is to listen and validate their experience, with the hope that they will be more free to do the same for their child. For parents whose child is struggling in a variety of ways, a diagnosis may say to them "You are not a bad parent." In this way, I understand that a diagnosis is of value.

Speaking from the child's perspective, there is a similar wish to have his experience validated and understood. When, in that previous post, I describe an occupational therapist "giving words to his experience' I did not mean teaching the child to talk. I meant literally giving words to his experience, as in saying "I know its hard for you when its so loud and other kids are too close to you." This kind of giving voice can go a long way in helping a child make sense of his experience. The aim is to avoid having him feel that there is something "wrong with him."

The same blog post goes on to say:

"Dr. Gold simply does not understand that autism is not a psychiatric disorder."

It took me some time to wrap my mind around this criticism. The autism diagnosis or preschool depression or any other psychiatric diagnoses are in the DSM, the Diagnostic and Statistical Manual of Mental Disorders (italics mine.) In essence, you can't have a diagnosis without having a disorder, because it is by definition a diagnosis of a disorder.

So the question becomes: Can we validate a child's or a parent's experience, recognize that there is nothing "wrong with him," that his experiences are "real", without giving it a label?

Psychotherapists run in to a similar challenge when they work with adults whose primary caregivers had significant depression. These adults have often, over the years, internalized a sense that they are bad, that there is something wrong with them. Helping them to recognize that their caregiver was in some way emotionally unavailable to them can validate their experience. It can be enormously helpful in shaking that crippling sense of being damaged in some way. In this setting, the "diagnosis" may only be relevant for the insurance company, and has no real meaning in terms of helping the person to feel better about himself.

While I don't have an answer to this dilemma, I do, thanks to the responses of my readers, have a clearer sense of what the problem is. We don't listen to each other enough. Careful listening, and with that the ability to understand another perspective, is one of the qualities that makes us human. Cultivating this skill will be good for everyone.

Child's voice. " I am very smart and tuned in to everything happening around me. I get overwhelmed when there are a lot of people. I love music, but I hear every sound so intensely that I need to cover my ears. Sometimes I run around in circles to help myself calm down. When grown-ups make me go somewhere that is too loud or confusing, I lie down on the floor and scream. When people get too close I cant' stand it. Sometimes I hit the other kids when this happens and now I can't go to preschool. My parents fight all the time about what to do about my difficult behavior. My little sister is very quiet because she knows to get out of the way when I am having trouble"

Adult's voice. "He has Autism"

Certainly this child and his family need help. An occupational therapist consulting in the school setting would be able to help this child give words to his experience. She could support both the teachers' efforts to understand what environments are challenging and how to manage these challenges. She might even recommend a different school setting that is more compatible. A therapist working with parents and child together would similarly help them as a family to manage this child's unique biological vulnerabilities.

If the proposed changes to the diagnostic criteria for autism in DSM V, the newest version of Diagnostic and Statistical Manual of Mental Disorders, result in children like this not getting the help they need, as a recent article in the New York Times suggests, it will be a terrible loss for these families. It will result in increased costs to society when these unaddressed problems grow into bigger problems in later childhood and adulthood, as they inevitably will.

This fear was expressed by Lori Shery, president of the Asperger Syndrome Education Network, when she was quoted in the article saying “If clinicians say, ‘These kids don’t fit the criteria for an autism spectrum diagnosis,’ they are not going to get the supports and services they need, and they’re going to experience failure."

But the real question is this: Why have we created a health care system where the insurance industry, a for-profit business, is allowed to dictate our children's experience in this way?

The need for a diagnosis is primarily driven by the health insurance industry. Clinicians need to have something to bill for, so that services are "covered.". " As I state in my book Keeping Your Child in Mind," [This] is a dangerous example of the tail wagging the dog."

From the young child's perspective, there is a significant downside to receiving such a label. As my book states:

Parents who receive a label of a major psychiatric diagnosis for their child inevitably go through a period of mourning. The child they had is gone and has been replaced by a child with a “disorder.” As D. W. Winnicott so wisely observed, a child develops a healthy sense of self when the people who care for him recognize the meaning of his behavior, rather than substituting their own adult meaning. Parents often begin to regard behaviors as “symptoms” of the “disorder.” For a very young child whose development is unfolding, his “true self” might be lost in the face of such a frightening label. It is my hope that we can move from an emphasis on diagnosis and labeling to an emphasis on prevention. We need to ask not “what is the disorder?” but rather, “what is the experience of this particular child and family?” and “what can we do to move things in a better direction?”

From a young child's perspective, the diagnosis with a psychiatric disorder reduces the complexity of his experience to a label that by its very nature indicates that there is something "wrong with him."

I had a similar discussion with a child psychiatrist who is advocating for the diagnosis of "preschool depression." Certainly young children can struggle with disturbances of mood, and, as is the case with the above child, these families need help, and early intervention is essential to prevent more significant and deeply entrenched difficulties.

But as is the case with the diagnosis of autism, the diagnosis of depression in a young child reduces the complexity of his experience to a disorder, and clearly locates the problem within the child. Often there is a complex interaction between the child's unique biological vulnerabilities and his environment. Qualities that are problems in early childhood may, with the right help, be transformed into adaptive assets as he grows up.

In a previous post I wrote about a new book, Childism, that calls attention to a kind of prejudice against children that exists in our culture. In a sense this kind of labeling can be seen as a manifestation of that prejudice.

Many parents of children with the diagnosis of autism object to my perspective, describing relief that the things they were struggling with had a name. But what if teachers, friends, grandparents, and clinicians were respectful of their struggles and provided help without having to burden their child with a "disorder?" I suspect that these same parents would prefer the latter scenario.

By focusing the discussion on the question: "what are the diagnostic criteria for autism,", we are failing to see the forest for the trees. The real question is "Why are we as a society willing to give the insurance industry so much control over our children's lives?"

For many people the word "psychoanalyst" conjures up an image of a man sitting silent behind a patient lying on a couch. In stark contrast to this image, the National Meeting of the American Psychoanalytic Association(APsAA) this past week prominently featured women analysts presenting their work with mothers and infants.

Among the most striking presentations was a pair of videos shown as part of the main research symposium by Nancy Suchman, PhD of the Yale Child Study Center. Substance abusing mothers who had histories of significant emotional trauma received an intervention that specifically aimed to listen to the mother and support her efforts to listen to her child. This is known as "mentalization based therapy." In my book Keeping Your Child in Mind, I show what mentalization, or holding a child's mind in mind, looks like in everyday parenting moments as well as in the clinical setting of a pediatric practice.

In the first video, before treatment, the mother was tense and angry, describing her infant's clingy behavior and night wakings as his attempts to make life difficult for her. After the 6 week intervention, she was calm and thoughtful, wondering about the meaning of her baby's behavior. She recognized how much her baby needed and loved her. In a related study, part of the Minding the Baby program at Yale, children of mothers who were similarly at risk but without the history of substance abuse received this mentalization based treatment. Their children showed fewer behavior problems, and the mothers reported less parenting stress several years after the intervention. Another researcher, Dana Shai, PhD, spoke of how a parent's ability to hold her baby in mind is reflected in her body and the way she physically interacts with her baby. This "embodied mentalization" was clear in the second video, when not only the mother's words and tone of voice were different, but her whole body was relaxed and welcoming. This was "evidence based medicine" at its best -an intervention founded on a solid conceptual framework, used in a high quality research design, demonstrating meaningful and significant improvement in developmental outcome.

When I was being interviewed on the Diane Rehm show about the new AAP guidelines regarding diagnosis of ADHD in children under age six, one of the other participants, a professor of pediatrics who clearly supported the new guidelines, identified behavior modification followed by medication as an evidence based intervention. I responded that there were in fact other quality interventions, citing the Minding the Baby program as an evidence based practice. As they had not heard of it, and didn't have any idea what I was talking about, I'm afraid my comment got lost. Here is the actual exchange.

GOLD
I want to just address this issue of behavior therapy because, again, when you start with the much younger children when they're two or three, there are a number of very well-established interventions, such as the Minding the Baby program at Yale, Circle of Security, Promoting First Relationships, that work with parents and children together to promote the ability to self regulate, which is really what ADHD is a problem of, self regulation.

So there are other forms of intervention besides behavior therapy. And, again, that kind of undermines the parents' natural authority if you give them training. But there aren't that many services. The problem is if the AAP kind of endorses medication in very young children, it will decrease the motivation to improve access to other interventions. And that's my biggest worry in very young children.

REHM
What do you think, Dr. Ostrander?

OSTRANDER
Well, I think that, you know, by far measure, the behavioral therapies tend to be the ones that has the greatest empirical support. Now, I'm not to say -- that's not to say that there are not other interventions that are not effective. But, you know, if -- what you -- it seems to me, the most prudent course is to take the medications that have the greatest demonstrated efficacy and try those first.

In another APsAA program, two psychoanalysts from the Parent-Infant Psychotherapy Program at Columbia University, Talia Hatzor and Christine Anzieu-Premmereur, described beautiful individual work with mother-baby pairs. The settings included both private practice and an early head start program, with mothers dealing with poverty and their own abuse histories. The presenters bemoaned the fact that pediatricians do not refer to them. We talked about the gap between primary care clinicians, who are seeing mothers and young infants, and the wealth of knowledge coming out of the discipline of psychoanalysis.

I have been writing about the new AAP policy statement on Early Childhood Adversity and Toxic Stress which emphasizes the need for pediatricians to intervene early to support parent-infant relationships. As I have said, the policy statement is lacking in specifics what such intervention actually looks like. After being at this meeting, it is my wish (fantasy) that there be a combined meeting of pediatricians and psychoanalysts to share experiences and ideas. I would also include health care policy makers, for to do this important work clinicians need freedom from the current restrictive environment imposed by the health insurance industry. The pediatricians (as well as other primary care clinicians) are in the right place at the right time. The psychoanalysts have a great deal to teach us about how to make use of this privileged position.

Tears ran down Elena’s cheeks as she described being so overwhelmed and full of rage that she forcefully held her fully clothed 4-year-old son, James, under the shower when he wouldn’t go to bed. Later in the same 50-minute visit she revealed that she had suffered years of physical and emotional abuse as a child. As is typical of visits to my behavioral pediatrics practice, she had brought James because he was “defiant.” “Something must be wrong with him,” was followed by, “Tell me what to do to make him listen.” James’ preschool teachers, who were having trouble managing his behavior, had suggested that he might have attention deficit hyperactivity disorder (ADHD.) They recommended to Elena that medication be considered. They knew nothing of this history. My wish in listening to this story is not to judge, but rather to understand the experience of both mother and child.

A great tragedy of 2011 was the sudden death of Elizabeth Young-Bruehl a month before the publication of her book, Childism: Confronting Prejudice Against Children, released January 10th. Not only was this the loss of a great mind, but also the opportunity for her to represent her very important ideas, ones that are likely to cause some controversy, in public discussion.

Young-Breuhl, an analyst, political theorist and biographer, calls attention to the way human rights of children are threatened. Childism is defined as “a prejudice against children on the ground of a belief that they are property and can (or even should) be controlled, enslaved, or removed to serve adult needs.”

Elena’s story offers a microscopic view of the macroscopic phenomenon Young-Breuhl so brilliantly articulates. Following the history of the field of Child Abuse and Neglect (CAN) studies, she finds that “from the start [this field] took attention away from abusers and their motivations; and it implied that children could be helped without their abusers being helped.” Furthermore, she describes Child Protective Services (CPS) as a “rescue service-a child saving service-not a family service supporting child development generally and helping parents…” Rather than setting up a system of treatment, CPS became "an investigative service...a situation in which bad families suspected of making their children bad will be invaded and infiltrated." Young- Breuhl has empathy for both parent and child, arguing that failure to support families is a manifestation of childism.

While Young-Breuhl does not write about ADHD, such as James is believed by his teachers to have, she writes of “a childism of the sort that is now fueling an epidemic of diagnoses of bipolar II disorder and the prescription of medications to children who are, in effect, being doped into acquiescence.”

I wonder if Young-Breuhl would have considered the new American Academy of Pediatrics (AAP) guidelines recommending the diagnosis of ADHD in children under age 6 (in contrast to the previous guidelines that covered age 6-12) to be a manifestation of childism.

According to the new AAP guidelines, if a child in this age group meets diagnostic criteria for ADHD, he is first treated with “behavior management techniques” and if these fail, medication is prescribed. The guidelines do not offer opportunity to explore the meaning, or motivations, of behavior, which is often due to a combination of biological vulnerability and environmental stress. One could argue that inherent in this approach is the phenomenon of childism; the idea that children are property of adults, who have the right to control them for their own self-interest.

Rather than blaming individual parents, my aim, as Young-Breuhl does, is to call attention to the way we as a society approach problems involving children and families. For childism is a societal phenomenon. Most individual parents, given the opportunity to be heard and supported, are not childist. They long to help their children, not merely control them.

Elena, once she had the chance to tell her story, was eager to address her own trauma. She wanted to learn to regulate her emotions and help her son to manage his. She did not want to medicate away his symptoms. But getting such help is not easy. There is a severe shortage of quality mental health care services. Pediatricians are under enormous time pressures in the current system of health care, in which a practice must accommodate demands of multiple different insurance carriers. Visits are on average 10 minutes in length, not offering a chance for a clinician to listen to a story like Elena’s.

The problem of improving access to care is a political one. Young-Breuhl describes an attempt in 1970 to pass the Comprehensive Child Development Act. Its creators were accused of being “anti-family.” Young-Breuhl writes, “To this kind of childism, in which trying to ensure that parents were responsive to their children’s developmental needs was seen as anti-family, the framers and supporters of the act could not reply, “this is childism.” They lacked the concept of childism to address the root of the controversy and so remained on the defensive, trying to win a “disinformation” propaganda war. A futile project.” Current efforts to provide services for young children and families similarly come up against “family values” propaganda.

Young-Bruehl compares the situation in our country with that of comparably developed countries that have lower rates of child abuse and neglect. There, “children have a range of preventative and development-oriented services: universal health care, health services, and parent support services in homes after the birth of a child; maternal and parental leaves for infant care; developmental preschool programs; after-school programs; and economic supports of various kinds.”

Young-Breuhl wisely recognizes that “children whose development is not being supported cannot be protected.” She proposes a new Comprehensive Child Development Act. I think she would be heartened by the recent policy statement of the AAP: Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health. This policy statement seeks to use the explosion of research at the interface of neuroscience, genetics and developmental psychology to support early parent-child relationships. It is a preventive model designed to promote healthy development.

Access to care is a significant obstacle to implementation. I believe Young- Bruehl would say that childism is the reason why pediatric primary care clinicians and mental health care workers are among the lowest paid professionals. She would point to childism to explain why the health insurance industry and pharmaceutical industry have together been able to create a system where children are more likely to be medicated than listened to. She would say that medicating James (or even using "behavior management") without addressing either his mother's history of abuse or his experience of her out-of-control behavior would be a manifestation of childism.

Atthe time of her death, Young-Breuhl was in the process of editing the complete works of D.W.Winnicott, pediatrician turned psychoanalyst. His notion of the need to recognize a child's "true self" to facilitate healthy development fits seamlessly with her ideas.

Pediatrician T. Berry Brazelton, whose work is featured as an antidote to childism, endorses the book, recommending that all who are involved with children and families should read it. This book has helped me, like nothing else I've read, to understand why it is so hard to get the kind of help for children that all the best science of our time is telling us they need. I hope everyone reads it. As Young-Breuhl states, “prejudice has to be recognized in order to be overcome.”