A member of the American Psychoanalytic Association posted the following on an internal email list, and I am reproducing it with permission. It captures the kind of circular reasoning behind the current paradigm of psychiatry as represented by DSM 5. As in "we define the disease by these symptoms, therefore if you have these symptoms, you have the disease."

The following two questions were published in a recent (June 8) issue of Psychiatric News and also distributed by APA in an email message, apparently as part of a PR quiz program to popularize the DSM-5.  However, I'm posting them here to convey an idea of what many of us feel has gone wrong in American Psychiatry in the last decades.  Each of these clinical vignettes describes a patient with some kind of mental disorder.  Each vignette ends with a quiz question. Fair enough.

However, I have changed to UPPER CASE some words in the two questions to which I'd like to call your attention.  Note in both cases, the question is phrased in such a way that the task is to decide which of the listed DSM-5 entities CAUSED the patient's symptoms and clinical "picture" described in the vignette.  However, the real task is to try to guess which set of symptoms listed in the DSM-5 most closely matches the patient's symptoms.

Framing the questions as they are indicates a mind set that these DSM-5 "disorders" are "real" things which are somehow present in the patient (like a bacteria) and which then CAUSE the patient's symptoms.  In actual fact, because there are no such entities other than in the DSM-5's attempt to classify the myriad variations of human mental disorders into convenient slots, the actual meaning of psychiatric diagnoses in the current state of our knowledge is being turned on its head in the minds of contemporary (biologically based) psychiatric thinking. As you know, in the DSM-5 all "disorders" supposedly reflect an "underlying psychobiological dysfunction" which then leads to the conclusion that all one has to do is to discern the biological mechanism underlying the disorder, find the right pill, and voila!  Cured! What a great doctor!  What a great specialty!!

He then quotes the two quiz cases.

 A 65-year-old woman reports being housebound despite feeling physically healthy. She reports falling while shopping several years ago; although she sustained no injuries, the situation was so distressing to her that she becomes extremely nervous when she has to leave her house unaccompanied. She has no children and few friends. She is very distressed by the fact that she has few opportunities to venture outside her home. Which of the following disorders BEST ACCOUNTS FOR her disability?

a) specific phobia*situational subtype

b) social anxiety disorder

c) posttraumatic stress disorder

d) agoraphobia

e) adjustment disorder

 A 35-year-old man is in danger of losing his job; the job requires frequent long-range traveling, and for the past year he has avoided flying. Two years prior, he traveled on a particularly turbulent flight, and although he was not in any real danger, he was convinced that the pilot minimized the risk and that the plane almost crashed. He flew again one month later, and although he experienced a smooth flight, the anticipation of turbulence was so distressing that he experienced a panic attack during the flight. He has not flown since. Which of the following disorders IS THE MOST LIKELY CAUSE of his anxiety?

a) agoraphobia

b) acute stress disorder

c) specific phobia*situational type

d) social anxiety disorder

e) panic disorder

He references a commentary in the very same issue of Psychiatry News entitled New Evidence Said to Challenge Psychiatry's Basic Paradigms that calls attention to the lost state of the discipline.

Psychiatry is at a crossroads, according to Patrick Bracken, M.D., Ph.D., clinical director of the West Cork Mental Health Service in Ireland, at APA’s annual meeting in San Francisco in May.

“Accumulating evidence challenges the current paradigm underlying psychiatric thinking and practice,” said Bracken. The problem lies deeper than just “too many drugs....”

Psychiatry is not like cardiology, he said. The mind is not simply another organ of the body, but encompasses relationships, values, and meaning.

Clearly a new paradigm is needed.  

Allen Frances, professor of child psychiatry at Duke University and chair of the DSM IV(Diagnostic and Statistical Manual of Mental Disorders) task force hit the nail on the head in a recent commentary "Why So Many Epidemics of Childhood Mental Disorders?" in the Journal of Developmental and Behavioral Pediatrics. Because he makes his argument so clearly and persuasively (and the full article is only available to those who subscribe to the journal) I will quote it at length.

Since the publication of DSM-IV in 1994, the rates of 3 mental disorders have skyrocketed: attention deficit disorder (ADD) tripled, autism increased by 20-fold, and childhood bipolar disorder by 40-fold. It is no accident that diagnostic inflation has focused on the mental disorders of children and teenagers. These are inherently difficult to diagnose accurately because youngsters have a short track record; are in developmental flux that makes presentations transient and unstable; are sensitive to family, peer, and school stresses; and may be using drugs. If ever diagnosis should be conservative, it should be in kids. Instead, we have experienced an unprecedented diagnostic exuberance encouraged in part by DSM-IV, but mostly stimulated by the powerful external forces of drug company marketing and the close coupling of school services to a diagnosis of mental disorder.

He gives the example of ADHD, describing how the revisions to DSM IV had anticipated a jump in diagnoses in girls with the additon of an "inattentive" subtype. But in fact there was an unexpected tripling of ADHD rates and parallel increase in use of psychiatric medication. He writes:

Three years after DSM-IV was published, drug companies introduced new and expensive on-patent drugs that provided the incentive and resources for an aggressive marketing campaign to psychiatrists, pediatricians, and family doctors. Simultaneously, successful drug company lobbying gave them unrestricted freedom to advertise directly to consumers. Parents and teachers were inundated with the message that ADD was terribly underdiagnosed and easily treated with a pill. Sales of ADD drugs ballooned to an astounding $7 billion.

He then moves on to bipolar disorder:

Childhood bipolar disorder is an even more chilling case. DSM-IV had wisely rejected a proposal that there be a separate and much looser definition of bipolar disorder in children. The argument for inclusion rested on the unreplicated findings of just 1 (albeit very influential) research group suggesting that kids present a developmentally different prodromal form of bipolar disorder characterized by ambient irritability, impulsivity, and temper outbursts, rather than the typical cyclical mood swings of adults. Rejection by DSM-IV did not stop charismatic thought leaders (who were heavily financed by drug companies) from spreading the gospel of childhood bipolar disorder. The 40-fold increase in rates was accompanied by an increase in antipsychotic spending up to $18.2 billion in 2011. These drugs frequently cause massive weight gain in children. The overuse of antipsychotics in kids was not deterred by the fact that childhood obesity is an important risk factor for diabetes and heart disease. Drug companies have received billion dollar fines for off-label marketing to kids, but these pale in comparison to the enormous revenues. Of note, the inappropriate use of antipsychotics is most pronounced among children who are economically disadvantaged.

He then accurately depicts the link between the rise in diagnoses of autism with the fact that a diagnosis is needed for a child to receive appropriate services:

The introduction of Asperger's by DSM-IV was expected to result in a 3- to 4-fold increase rates of autism. Severe classic autism had an unmistakable presentation with rates lower than 1 per 2000. Asperger's blends imperceptibly into normal eccentricity, and the rates of autism are now reported at 1 per 88 in the United States and 1 in 38 in Korea. Theories connecting the increase in prevalence to vaccination have been discredited. Instead, the rates have grown so rapidly because a diagnosis of autism is required to allow a child access to greatly enhanced school services. About half the youngsters who now receive the diagnosis do not really meet the DSM-IV criteria when these are carefully applied. And follow-up studies finding that half the kids no longer meet criteria also confirm that diagnostic inflation is rampant. Eligibility for school services should be decoupled from an unreliable clinical diagnosis and instead be based on educational need. 

The challenge, and Frances does acknowledge this fact, is to avoid over-diagnosis while at the same time not undertreating those who need help. Most of the children who receive these labels, and their families, are struggling in significant ways. They do need help,  and sometimes lots of it. The issue is inextricably linked with the need to "name" the problem, a need comes in part from both clinicians and parents, who may feel more of a sense of control if what they are struggling with has a name, and also insurance companies who require a diagnosis for reimbursement of services.

Psychiatric diagnoses in children, by definition, place the problem squarely in the child, when in fact it is almost always more complex than this. Genetic vulnerability and environment both have an important role to play. A recent article in the Archives of Diseases of Childhood; Poverty, Maltreatment and Attention Deficit Hyperactivity Disorder offers insight in to this complexity:

This paper hypothesises that the population of children receiving a clinical diagnosis of ADHD is aetiologically heterogeneous: that within this population, there is a group for whom the development of ADHD is largely genetically driven, and another who have a 'phenocopy' of ADHD as a result of very adverse early childhood experiences, with the prevalence of this phenocopy being heavily skewed towards populations living with poverty and violence. A third group will have a high genetic risk and have been exposed to violence.

The key phrase here is "aetiologically heterogeneous." Psychiatric labels, be it "ADHD" "bipolar disorder" or "autism," are artificial constructs that provide a false sense of simplicity.  When I see a child and family in consultation, the aim of the work is to take the time to listen to the story and understand where, and it may be in several places, the "problem" actually lies. In order to help these children and families in a meaningful way, we need to be able to, in the words of one of my mentors Ed Tronick, "embrace complexity."

The Harvard Center on the Developing Child has produced a new video: Building Adult Capabilities to Improve Child Outcomes: A Theory of Change. The video wisely identifies the need to support the adults in a child's life in order to promote long-term health, both physical and emotional. It points to the abundance of scientific evidence showing the need for providing safe and secure relationships in early childhood to reach these goals. Exposure to stress in the absence of such safe, secure relationships is termed "toxic stress."

As pediatricians have regular contact with young children and their families, the need to translate this research in to the clinical setting of pediatric practice is clear. The American Academy of Pediatrics (AAP) has embraced this task. The 2013 AAP national conference titled Early Brain and Child Development: Building Brains, Building Futures, will present the science of early childhood.

In addition, concurrent with the release of the above video are a number of publications addressing the need to integrate the research in to practice. One article, Listening to the Baby's Brain to Reduce Toxic Stress: Changing the Pediatric Check Up to Reduce Toxic Stress  describes new interventions.

Purposeful Parenting materials, for example, emphasize “face time” with infants, a type of “serve and return” interaction fundamental to the wiring of the brain: When an infant smiles, the caregiver should smile back—and should do so repeatedly throughout the day. When infants learn early on that smiling, then cooing, then words, are the best way to get attention, they keep using those strategies. But if face time fails to occur frequently enough, infants may learn less healthy ways—such as crying or whining—to get the attention or support they crave. The lack of something as simple as face time can lead to more infant stress and less healthy ways to cope with stress in the future.

This recommendation appears to draw on the powerful research of Ed Tronick showing the distress caused to an infant when a caregiver presents an unresponsive "still-face." His research has shown that when a caregiver is attuned with an infant in 30% of interactions, and if the remaining misattunements are recognized and repaired, the child develops a positive affective core-  an ability to experience joy and connection.

Given these findings, the AAP recommendation is a good one. But most caregivers intuitively provide this attunement without needing anyone to tell them what to do. They naturally experience what D. W. Winnicot termed "primary maternal preoccupation," acting as what he called the "ordinary devoted mother." When they do not, simply telling them to smile at their baby will likely be ineffective. This is where the link to the video comes in. To "build adult capacities" in this situation, there needs to be an opportunity to listen to that parent, who may be struggling with postpartum depression, may be socially isolated, or may herself have been abused.

Fortunately the AAP model also looks at the larger context. The director of Developmental and Behavioral Pediatrics at Yale University is quoted:

We live in a culture of advice and quick fixes. Increasingly, understanding of human experience is reduced to lists of symptoms, diagnosis and medication. There is less curiosity, less careful listening to one another.

Talk therapy, which perhaps should be called “listening therapy,” offers space and time to create a meaningful narrative, including an opportunity to experience feelings of grief and loss.

This is particularly important in work with children. When symptoms are medicated away, the opportunity to tell stories that give meaning to behavior may be lost. Research has shown that a child’s knowledge of family narrative, both the ups and downs, is highly correlated with self- esteem, resilience and mental health. Giving a parents an opportunity to tell their story to a nonjudgmental listener, to integrate their own narrative,  is critical to treatment of childhood “behavior problems.”

I am not advocating for talk therapy for children. Rather, in order to help children who are struggling with a range of "behavior problems," it is essential to listen to their parents, to give them an opportunity to reflect on the meaning of behavior. The behavior is a symptom, perhaps even an adaptive response, to the underlying problem. There is extensive evidence, that I describe in my book Keeping Your Child in Mind, that when parents reflect on the meaning of behavior in this way, they have the opportunity to promote healthy development at the level of gene expression and structure and biochemistry of the brain.

In my practice, where I see children under the age of five, parents typically present with concerns like, "he never listens" or "she is defiant." But as we take the time to think about how the problem developed, meaningful shifts in understanding occur. For example, parents may recognize the way a child's behavior pushes their buttons because of their own history of abuse. Or serious marital conflict, that often has zeroed in on the child's behavior, comes to the fore.  Or the impact of an easygoing sibling may be recognized. Tantrums and meltdowns at birthday parties may be understood in the context of a child's longstanding difficulty with processing sensory input.

Creating this narrative, this story that makes sense of the problem, may only be the beginning of the treatment. Intensive work with parent and child together, to address the way the child's behavior provokes the parent, is often indicated. Marital counselling, or even working with a couple who are not together, to help them work together to support their child may be necessary. Quality occupational therapy can be invaluable to help a child to feel calm in his body. Parents may benefit from things such as yoga to help them to calm their own reactions.

Here is where the trouble really starts. Quality clinicians who offer these services are in short supply. Insurance is often a huge obstacle. But, creating perhaps an even bigger obstacle, is the cultural norm of the "quick fix" approach of medicating symptoms, even in children as young as 5.  Not only must parents overcome these obstacles of finding a provider, making the time, allocating funds, as well as doing the important but often challenging emotional work of addressing these issues. They must go against pressure from teachers, relatives, friends and  health care providers.

I will continue to offer parents space and time to be heard, to create meaningful narrative, because I am confident that telling stories, and working through the feelings of grief and loss that often accompany them, is the path to meaningful connection and healthy emotional development.  It causes me great heartache when these efforts are thwarted by a system that works in opposition to this approach.

More comprehensive surveillance is needed to develop a public health approach that will both help prevent mental disorders and promote mental health among children.

More comprehensive surveillance is needed to develop a public health approach that will both help prevent mental disorders and promote mental health among children.

It seems that the National Institute of Mental Health (NIMH) may have dealt a death blow to the recently published Diagnostic and Statistical Manual of Mental Disorders (DSM 5) when the organization declared they would no longer fund research based on the DSM system of diagnosis. The views of NIMH director Thomas Insel were referenced in the recent New York Times article on the subject.

His goal was to reshape the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.

I am no fan of the DSM system, which reduces complex experience to lists of symptoms; focusing on the "what" rather than the "why."  However, the NIMH model has limits as well. There seems to be a wish to study mental illness in the same way we study cancer or diabetes. While I certainly have great respect for the complexity of the pancreas, or the process of malignant transformation of cells, trying to understand the brain/mind in an analogous way seems to be an unnecessary and even undesirable reduction of  human experience.

What is missing from both paradigms is recognition of the relational and historical context of being human. Fortunately there seems to be awareness that neither paradigm is complete. The Times article goes on to say:

Dr. Insel is one of a growing number of scientists who think that the field needs an entirely new paradigm for understanding mental disorders, though neither he nor anyone else knows exactly what it will look like.

The growing discipline of Infant Mental Health offers just such a paradigm. This discipline is characterized by four key components. First and foremost, it is relational, recognizing that humans (and that includes their genes and brains) develop in the context of caregiving relationships. Second, it is multidisciplinary. Experts in infant mental health offer different perspectives.  They come from many fields, including, among many others, developmental psychology, pediatrics, nursing, and occupational therapy.  Third, it encompasses research, clinical work and public policy.  The field looks at mental health within the context of culture and society. And last, it is reflective, looking at the meaning of behavior, not simply the behavior itself. The ability to attribute motivations and intentions to behavior is uniquely human, and research has shown that this capacity is closely linked with mental health.

Unfortunately when people hear the term infant mental health, they imagine babies lying on the couch.  In reality, the field offers a way of understanding all of human experience, well beyond infancy.  I recently taught a course on infant mental health to clinicians at the Austen Riggs Center, a hospital that offers intensive inpatient treatment for severely disturbed patients. None of them are infants- the youngest are in their late teens and most are well into adulthood.  My students found the insights from infant mental health very valuable for understanding and treating their patients.

The Center for Disease Control (CDC) Adverse Childhood Experience (ACES) study provides extensive evidence of the long-term effects of early exposure to a range of negative experience, including parental mental illness, divorce, abuse, and neglect, on mental health. The more severe the mental illness, the earlier in life disruptions to development probably occurred. Knowledge of infant mental health (that spans age 0-5) offers a textured understanding of this early experience.

Looking at an individual brain and/or genes, or listing the behavioral symptoms of an individual person, out of relational and historical context, how can one possibly understand the complexity of human experience? This complexity is represented by such things growing up in the home of a Holocaust survivor, a depressed parent,  in the setting of ongoing war trauma, with a physically and emotionally abusive parent, or some combination of all of these. A recent article on the blog ACES Too High,  "What motivated the Boston bombing suspects?" offers a fascinating look at the Tsarnaev brothers from an ACES perspective. The use of the word"motivation" in the title represents a curiosity about the meaning of behavior that is representative of an infant mental health perspective.

I had the privilege this week to participate in the 95th birthday celebration of pediatrician T. Berry Brazelton on the occasion of  the  annual Touchpoints National Forum.    I even got to sit at the table with Dr. Brazelton for the birthday lunch!  We watched a wonderful animated video about his life, created by Exceptional Minds, an animation studio for young adults on the autism spectrum. We listened to songs written about and for Dr. Brazelton, sang "Happy Birthday" and shared birthday cake.

I had been invited by Kevin Nugent, director of the Brazelton Institute, to present at a workshop entitled "Can we Use Media to Support Parents?"Much to my delight, Dr. Brazelton attended our workshop. One of my co-presenters was Lisa McElaney, president of Vida Health Communications. I learned from her about a brilliant evidence-based program called All Babies Cry, a collection of DVD's produced with the aim of preventing child abuse in infancy.  Dr. Brazelton was fully engaged and enthusiastic, asking probing questions.

Recently Dr. Brazelton was presented with the  Presidential Citizen's Medal by President Obama.  The essence of Dr. Brazelton's gift is his tremendous respect for children, parents and the people he works with. His Neonatal Behavior Assessment Scale brought to light a newborn baby's  extraordinary capacity for communication. In his work with parents he brings a nonjudgmental strength-based approach to his interactions.  Respectful listening among colleagues is central.

At first I wasn't sure what direction to take with my presentation. Unlike my fellow presenters, I am not a media professional. But then I realized that it gave me a wonderful opportunity to think about why I write for the media.  Just five years ago, I was simply a small town doc in Western Massachusetts.

As I reviewed the events of these five years, I saw that an overarching goal of all of my writing is perfectly aligned with the work of Dr. Brazelton. My aim is to promote a stance of listening with nonjudgmental curiosity. That includes listening to children and to parents, as well listening as among professionals who may approach work with children and families from different paradigms.

As part of my presentation, I told stories about pieces I have written that aim to crossing paradigms and  promote new ways of thinking. It all started with my first op-ed piece for the Globe in 2008, provocatively titled Mind Altering Drugs and the Problem Child, in the wake of the explosion of diagnosis of bipolar disorder in young children.  Continuing as a blogger for Boston.com, I had a similar aim with posts such as Diagnosing ADHD under Age 6: A Mistaken Idea, Could Sensory Processing Disorder be the Primary Problem?, and even The Poop Wars: Why Miralax is Just a Bandaid.

It was a thrill of a lifetime to share this celebration with Dr. Brazelton and then to be able to present my work to him. He is a great model and a true inspiration.

It was a heartbreakingly beautiful day.  I work at Newton-Wellesley Hospital, and as I live in Western Massachusetts, I had not yet had reason to come in to Boston.

Though I grew up in New York City, I have felt a strong attachment to Boston since I first lived here over 20 years ago, on what my husband fondly refers to as "far out" (Farrar) Street, that I never felt for New York.

I sat at the Starbucks on the corner of Charles and Beacon, working on my new book before heading to the State House for a  meeting of Representative Ellen Story's Postpartum Depression Commission. I had a bit of extra time, so I set out for a walk on the Common.

"Can I cry, walking alone in the middle all this life?" "Can I not?" My brain conversed in this way with my heart as I fought back tears. They did not come. I continued my walk, drawn to Boylston Street. I stopped to photograph some tulips. I saw a runner sitting on a bench tying her shoes. "Are you OK? "I wanted to ask.

I walked down Boylston to the memorial that has appeared, taking time to look at a huge card filled with signatures and words of gratitude addressed to Massachusetts General Hospital. It was getting late, so I headed back towards the State House.

Once again at the corner of Beacon and Charles, I stopped. I looked out across the Common at the magnificent burst of color against the perfect blue sky. I thought of a trip in April, 16 years earlier, with my then 2-year-old daughter.  My husband and I sat among the flowers in this same spot in the brilliant sunshine. A complex mix of feelings were brewing- anger at the loss of innocence, love for this beautiful city, and deep sadness for the people whose lives were directly impacted, and for the city as a whole. Then I let the tears come- enough to allow myself to know that this was not just an ordinary day of work.

I went to my meeting, fully engaged in the task at hand. Walking down the stone steps into the light of dusk, I was joined by a young man who had been at the meeting who I did not know. As I again looked out over the Common, I wanted to say, "This is my first time here since the bombing." Instead we simply smiled at each other. "Have a nice evening," he said as he walked the other way. "You too," I replied.

It is this intergenerational self and the strength and guidance that seem to derive from it that are associated with increased resilience, better adjustment, and improved chances of good clinical outcomes.

I had been working on a post on the subject of mourning and music. But with the trauma of the Boston Marathon bombing still so fresh, it did not seem appropriate to write about any other subject. I wondered, what could I add to the discussion? Then this morning, with the idea of music as a means to connect with feelings on my mind,  I heard on the radio the song Learn Me Right by Mumford and Sons. The lyrics, specifically the chorus (not the verses), are perfectly fitting to the moment, though the "scream" with hope will be one of joy,  not terror. And the music, particularly the version performed by Birdy for the movie Brave, captures the spirit of resilience. It can represent hope for the triumph of the people of Boston and of the Marathon itself. It may not be everyone's cup of tea, but for me, and perhaps for others, the music can help connect with the feelings of the day.

In the wake of the Newtown tragedy, many people, myself included, wrote about the need to address both gun control and mental health care. So it was rather jarring, on the same day that Connecticut's governor signed comprehensive new gun control legislation, to read that Cambridge Health Alliance was planning to cut 11 of 27 child inpatient psychiatry beds, including all inpatient service for children age 3-7.

But on closer consideration, I wonder if this loss in fact presents an opportunity. With no inpatient care for young children, it now behooves us as a society to make sure they never need such care. As a pediatrician with 25 years experience working with troubled children, I can be sure that when a child needs hospitalization at age 4, 5 or 6, his problems started way before that. The Globe article suggests that plans are headed in this direction.

Burke [chief of psychiatry] said the hospital is focusing more on efforts that can keep children out of the hospital, including services in schools and placing psychiatrists in pediatricians’ offices.

This is an excellent idea. But what does it look like in practice? Number one, we need a workforce experienced in early child development. There is an explosion of knowledge and research, coming out of the discipline known as infant mental health, that informs us of how to work with parents and children together to help set young children on a path of healthy development.

Such training programs are erupting all over the country. One superb program is right here in Boston- the UMass Infant-Parent Mental Health Post-Graduate Certificate Program under the direction of renowned researcher Ed Tronick.

Fellows in that program learn from leaders in the field, including child psychiatrist Bruce Perry, whose neurosequential model of therapeutics informs us of how to use knowledge of neurodevelopment to guide treatment.

We need these programs because most child psychiatrists have minimal to no education in early child development, and pediatricians, who live and breathe child development and have long-term relationships with families, are under pressure to see 6 patients an hour, and so have no time to help. In the ideal world, training in infant mental health would also be incorporated in to pediatric and child psychiatry training.

We cannot let the bottom fall out for these children. By taking away these beds, a preventive model is no longer optional. A person trained in early childhood mental health should be in every primary care office, and every childcare center should have easy access to early childhood mental health care professional for on-site consultation. I wonder if this might even cost less than maintaining inpatient beds.

Of course this does not help the children today who need inpatient care. Ideally we would be able to offer both forms of help. Perry's model is relevant for treatment of older children as well. I do not know the answer to this problem. However, I can be sure that parents, who are suffering terribly waiting with their severely troubled young child for an inpatient bed to become available, would have much preferred to get meaningful help years before.

A friend and colleague recently asked if I thought joy was an emotion or a state. Without pause, I responded that it was a way of being fully present.

Early the next morning I was at Starbucks writing to another colleague about a case from my pediatrics practice for a book we are writing about parenting. I was describing a scene with a mother and 4-month-old son.  He had been a very challenging newborn who cried all the time, and she had struggled with postpartum depression. In my office they gazed adoringly at each other with huge smiles of delight.  I wrote, "There was pure joy in their relationship."

I glanced up from my writing to see yet another scene. A father was calmly telling his two-year-old daughter that she needed to hold his hand when they crossed the street. He was negotiating his coffee and her juice while she repeatedly wriggled away. "I can carry you or you can hold my hand, " he said. No go. She reached out to him for an instant, but again dodged his reaching hand. "Big girls hold hands crossing the street." It seemed this would work as she again reached out, but again changed her mind. Then somehow very gracefully he switched his beverages and offered his other hand. "Do you want to hold this one?" This was the magic needed. It seemed as if she had to have some say before she would temporarily relinquish her growing independence.  I watched this big tall daddy and his little girl walk across the street hand-in-hand. Another moment of joy, both for them and for me.

Interestingly, the day before another colleague had invited me to speak at a conference for early childhood professionals about the "magic of the moment" in our work supporting early parent-child relationships.

A reader of my previous post asked how I "connect the dots" from supporting newborns and parents to "ADHD" treatment. He states that, "trying to figure out the cause will not help any kid today." This comment motivated me to clarify what I mean by cause, as I think finding out the cause will help every kid today.

What I mean by "finding out the cause" is to give parents the space and time to tell their story, to make sense of their child's symptoms.  The aim is not to determine if the child has enough symptoms to meet diagnositic criteria for a DSM defined disorder, but rather to support  parents' efforts to find a coherent narrative. It involves starting with at least 1-2 full hour visits with both parents.  I put "ADHD" in quotes because by giving the symptoms a name, as in "ADHD evaluation" we narrow our thinking before we even start. Ideally we listen to the family's story with an open minded curiosity.  

The story often starts with a fussy or colicky baby. Even before this, there may have been stress in pregnancy which is known to be associated with advanced motor development and behavioral dysregulation in the newborn. Postpartum depression and/or anxiety may have been present. Supporting a dysregulated baby is particularly challenging when a parent is affected by depression and/or anxiety. These babies often continue to have symptoms of dysregulation into the toddler and preschool years, with frequent tantrums, "not listening" or "explosive behavior." There is often a strong family history of "ADHD," substance abuse or other mental illnesses. This history is closely linked with current relationships. For example, if one parent has "ADHD," the child's behavior may be especially dysregulating for that parent. One parent who does not have ADHD may blame the other parent, resulting in marital discord. The child may have significant sensory processing challenges. The child may be developmentally immature and the youngest in a structured preschool program. Sleep disurbance on the part of both parent and child has a significant role to play in development of symptoms.  There are as many variations to this narrative as there are families. Clinicians also need to be attentive to the fact that child maltreatment is a rare cause of "ADHD"  that we do not want to miss, and must be considered.

 Once parents have the opportunity to make sense of their child's symptoms,  "what to do" follows naturally. Medication may, in a few cases, be indicated, particularly if a child's self esteem is suffering due to academic demands. But more often than not, the "what to do" is elsewhere. For example, a parent may need to do his own therapy to address troubled past relationships. A parent may take up yoga to manage the dysregulation her child's symptoms precipitate, so that she can remain calm in the face of his difficulties. Sleep disruptions are often part of the story and must be addressed. Marital counselling may be necessary. A good occupational therapist, who helps the family to manage the child's unique challenges in the context of relationships, can be invaluable.

Time, space and a nonjudgmental listener are an essential first step in evaluation of any child with behavioral symptoms. The "why" must come before the "what." Then the "what to do" will follow naturally.

An NIH funded study published last week in the Lancet revealed that five major mental health disorders- ADHD, autism, bipolar disorder, depression and schizophrenia- share genetic roots. The authors state that their findings blur diagnostic categories. They write:

These results provide evidence relevant to the goal of moving beyond descriptive syndromes in psychiatry, and towards a nosology informed by disease cause.

Epigenetics, or the environmental influence on gene expression, must immediately be brought in to any discussion of these important findings. "Cause" is related to a complex interplay between genetic risk and environmental effects.

Another study on ADHD published this week points to the problems inherent using this oversimplified diagnostic category. The study, published in Pediatrics, showed that not only do symptoms of ADHD persist into adulthood in 30% of cases, but there is also a significant amount of "co-morbidity," including these alarming statistics:

The study also found the risk for suicide was nearly five times higher among those diagnosed with ADHD than in the comparison group, and nearly 3% of study participants were in jail when recruited for the adult portion of the study.

A review of the study published in USA today includes this telling line:

Symptoms[of ADHD] can be controlled by a combination of behavioral therapy and medication. 

Maybe the reason that so many people have such poor outcomes is that we are neglecting to understand the underlying cause of the problem and instead simply labeling and "managing" symptoms. These dismal long-term results, along with the similarly dismal results reported in the preschool ADHD study showing that 90 percent of children had signficant symptoms at 6 year follow up, state loud and clear that the way we approach what we are now calling "ADHD"  is not working. We need to do something dramatically different from the current standard of care.

What we are calling "ADHD" is a constellation of symptoms that represent problems with regulation of attention, behavior, and emotion. The term itself gives the illusion that we know the specific biological mechanism in the way that we know how lack of insulin causes diabetes. This is however, far from true.

As the first study I refer to indicates, we are just beginning to learn about the underlying biology of mental illness, and those findings suggest that "ADHD" may be an artificial construct.

My clinical experience tells me that these genes they have described may be functionally related to sensory processing.  Problems with sensory processing seem to be common to many diagnostic categories for mental illness that we currently use. However, children develop the capacity for self-regulation in the context of relationships. Identifying the problematic gene is only part of the answer. Understanding and addressing the environmental risk is the other.

If we consider the interplay of genetics and environment, then a third study published last week, this one also in Pediatrics, will point us in the direction of meaningful preventive intervention. This study identified the problem of postpartum anxiety, concluding that:

Postpartum state anxiety is a common, acute phenomenon during the maternity hospitalization that is associated with increased maternal health care utilization after discharge and reduced breastfeeding duration. 

Given what we already know about the risk of psychiatric disorders in children of parents struggling with depression,  these findings only increase the urgency of focusing our resources on supporting parent-infant pairs. We need to help set development in a healthy direction from the start.  Genetic vulnerabilities are present at birth, and if we devote maximum resources to supporting the environment, then we may significantly decrease the risk of those vulnerabilities manifesting as psychiatric illness.

Research by psychologist Ed Tronick and his colleagues provides evidence that supports Winnicott’s idea that the good- enough mother, the mother who fails at times to be attuned to her child, facilitates her child’s healthy development. Tronick refers to moments of disruption, similar to Winnicott’s “failures of attunement.” Tronick and his colleagues videotaped minute-by-minute interactions between infants and their mothers. His research has demonstrated that these moments of disruption can actually enhance development of emotional regulation. Mismatches, when they are recognized and repaired, increase a child’s sense of mastery and confidence in his ability to cope with difficult feelings. The accumulated experience gained from dealing with and repairing multiple mismatches, or disruptions, become part of the infant’s way of relating to other people.

There are two important studies published in the latest issue of the Journal of the American Academy of Child and Adolescent Psychiatry. First, the PATS (preschool attention deficit/hyperactivity disorder treatment study) showed that at 6 year follow-up the treatment, consisting of medication and/or behavior management, was not working. Ninety percent of children continued to experience symptoms 6 years after diagnosis and ongoing treatment. This is because the current standard of care does not look at the cause of the symptoms, as I have written about repeatedly on this blog and in my book Keeping Your Child in Mind. Here is an example of  a story from a previous post.

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.

As I elaborate in more detail in that post, this prescribing of medication to young children represents a prejudice against children. A colleague described it as a massive exercise in societal repression.   Hidden abuse is an extreme example. It may be simply that the classroom environment is not suited to the child's particular vulnerabilites. There are countless different stories in between. It is not surprising that without an opportunity for these stories to be heard, medication and behavior management would fail to alleviate symptoms.

Second, less well-noticed but perhaps more important, is a study showing the link between late preterm birth, maternal depression and preschool psychiatric disorders. It showed that late preterm babies (34-36 weeks) were at increased risk for anxiety disorders at preschool age if their mothers had postpartum depression.

How fitting that T. Berry Brazelton is receiving the Presidential Citizen's Medal in coincidence with these studies. It is Brazelton who taught us to look at each baby's unique qualities and capacities for complex communication. In settings such as the ones described in that study, where both mother and baby are vulnerable, his  Neonatal Behavioral Assessment Scale, as modified to the NBO, has great relevance. Brazelton, in all his wealth of contributions, shows tremendous respect for both parents and children.

These two studies show that we need to invest resources in supporting mother-baby pairs from birth, and in listening to families with young children so that their stories can be heard.

Maybe Brazelton will tell this story to President Obama!!!

Now that the letters to the editor in response to the New York Times article Drowned in a Stream of Prescriptions have been published, I am going to take advantage of this blog to publish mine.

There is one glaring error in the generally well-researched and deeply disturbing article Drowned in a Stream of Prescriptions. In a record review of Richard’s treatment the reporters found none of  “the more conventional talk-based therapies that experts generally consider an important component of A.D.H.D. treatment.” If only this were true. Just last week, AAP Smartbriefs, a review of newsworthy events in pediatrics, offered this headline Non-Drug ADHD Treatments Don't Pan Out in Study. The “psychological treatments” the study refers to are cognitive and behavioral training and neurofeedback. Talk-based therapy isn't even mentioned.

What is noticeably absent in Richard’s treatment is not talking, but listening. In the age of the 10-minute med check, there is no room for listening. If Richard was truly a well functioning person until mid-college, was his primary diagnosis schizophrenia? Was there some kind of trauma? In a world where ADHD is so quickly diagnosed, there was no time given to fully hear his story. That time that might have saved his life. 

A number of people commented that my previous post seemed unfinished in that I did not offer an alternative approach. This is a valid point, and in part due to the fact that my household has been under siege by the flu. I decided to republish a post from two years ago (before I wrote for the Globe.) It offers an example of my approach, which I describe in detail, along with the research to support it, in my book Keeping Your Child in Mind: Overcoming Defiance, Tantrums, and other Everyday Behavior Problems by Seeing the World Through Your Child's Eyes. 

Holding A Child in Mind

Sam burst into the office, a two-year-old wild bundle of energy. Squealing with delight--or was it distress; it was hard to tell--he ran from toy to toy not looking at me or his mother, Jane. He was unable to engage with anything. Jane had brought him to see me in my pediatric practice because, “he hits me, has explosive tantrums, and I can’t take him anywhere.” She sank into the couch. I sat on the floor, wanting to listen to Jane, but also to include Sam in the visit. At first, I focused my attention on her story, while Sam continued his frantic exploration of the room. 

Jane described a scene at the playground. The other mothers had been engaged in easy conversation, but she was on edge. She knew Sam was “inflexible” and at any moment could go from happy play to a full-blown tantrum. Sure enough, as she tried to join in the group, she saw him getting upset because his toy car was stuck. She rushed over to calm him, but his crying escalated. As the other kids and moms turned to look, she quickly went from embarrassment to rage. She yelled at Sam to cut it out. This only made him scream more. Finally, she grabbed him, her bag and his toys and ran to her car, where she collapsed in tears of helplessness.

Things had not been easy for Jane. Sam’s father had abused her and was in prison. She was afraid when she felt Sam’s anger that he would turn out like his father. Of her own mother she said, “She was never there for me.” Jane was frustrated and bewildered by the fact that Sam could relate to other people, yet reserved all his difficult behavior for her.

At the beginning of the visit, Jane made several awkward attempts to interact with Sam, but without success. She was anxious and her body language felt intrusive, which seemed to cause Sam to withdraw. As she opened up and shared more of her painful feelings with me, however, an interesting transformation occurred. Sam began to engage in more focused play. Mom and I talked about what Sam was doing, observing together how he was calming down. At first he talked to me, bringing me toys and naming them and describing what he was doing. But then he spontaneously ran over and gave his mother a hug. Her whole body relaxed, she leaned forward on the couch toward him, her pleasure and relief palpable in the room. Sam began to engage her in his play, and to communicate with her. Jane told me that she had been reluctant to come for the appointment, but was glad she had.

Being a parent of such a child is a hard job. Raising a child alone, without support from extended family or a spouse, is even harder. In our culture of advice and quick fixes, in seeking help for her problems with him, Sam’s mother would find many who would offer “expert” advice about how to manage her child’s behavior. An increasing number would recommend some type of medication to control his “hyperactivity.” Helping her to be fully emotionally present with her child--supporting her in the challenges she faced as a mother--is not a common approach. 

Yet current research at the interface of developmental psychology, neuroscience and behavioral genetics is showing that it is just this type of intervention that will help children like Sam to manage strong emotions and relate to other people. A child’s mind grows and develops when the people who are most important to the child are able to think about and understand a child’s experience from the child’s perspective, without being overwhelmed or shutting down. A parent’s capacity to “hold the child in mind” leads to a child’s increased cognitive resourcefulness, greater social skills, and better capacity to regulate emotions. If we -pediatricians, teachers, therapists, grandparents, neighbors--can help a mother like Sam’s to join her child, to accept his “low frustration tolerance” as part of him, not a reflection of her own failure as a parent, then she can help him regulate his frustration. He can then learn to manage his feelings on his own. Most important, if she can do this, she may actually change the way his brain handles stress and strong emotions.

I have deliberately given this post a provocative title to offer a counter weight to the outpouring of news covering the California study demonstrating a close to 25% increase in ADHD diagnosis from 2001 to 2010.  I will say at the outset that I am not against medication, and recognize that a small percentage of children who have the diagnosis of ADHD may have a well-defined neurologically based difficulty with focusing and attention.  If such  a child is already school-age and falling behind academically, treatment with stimulants may protect that child from the damaging effects of low self esteem.

However, for the vast majority of children who have this label, things are much more complex. ADHD is diagnosed by DSM criteria that define the disorder by symptoms alone. In clinical setting in which these diagnoses are made, usually with one 50-minute visit for diagnostic evaluation and  subsequent medication checks in 15-30 minutes at 3 month intervals, the child's story is usually not heard.

This story may be of  an active, curious boy too restricted by the highly structured setting of today's kindergarten classrooms (a November 2012 study showed that the youngest in the class was 50% more likely to be treated with stimulants for ADHD), or of a child with sensory hypersensitivity who is unable to manage the barrage of sensory stimuli in a lunchroom or hallway.

The story may be one of a child who witnesses domestic violence or a parent who actively abuses alcohol, or both. A child may herself have been abused. In my behavioral pediatrics practice I have listened to countless stories of children, some as young as 2, who has been suspected to have ADHD. I find almost without exception a mulilayered story, sometimes involving multiple generations, that represents a complex interplay of biology and environment. The dignosis of ADHD as defined by DSM in these cases represents an artificial construct.

This past week I attended the National Meeting of the American Psychoanalytic Association in New York. Multiple excellent presentations offered a refreshing change from the oversimplified approach that is now the standard of care in both pediatrics and child psychiatry.  Dr. David Mintz, a psychiatrist who has written extensively about what is termed psychodynamic psychopharmacology, in his presentation, entitled "Recovery from Childhood Psychiatric Treatment," addressed the complex developmental meaning of medication. The presentation was filled with rich insights from his research and clinical experience, including, for example, his observation that a pill is often used to localize family pathology in a concrete way in one child.

Another highly instructive presentation came from Jack Novick, co-author with Kerry Kelly Novick of the book Emotional Muscle:Strong Parents, Strong Children, on the out-of control child. I was particularly struck by the opening paragraphs to this presentation, which offered an alternative model, similar to what they describe in their book. The paper is not yet published, but the authors gave me permission to use it. I have included the quote in its entirety, as it is an apt response to the current ADHD study.

There seems to be an exponential increase in the number of children who are described by parents, teachers and therapists as out of control. How are we to understand this kind of behavior, and how as therapists are we able to intervene and help restore these children to the path of progressive development? Currently the tendency is to diagnose these children as having neurological difficulties characterized as ADHD, OCD, executive function disorder (EFD), pervasive developmental disorder (PDD), or, increasingly, bipolar disorders.            

These children now seldom come for psychotherapy, but instead are treated by their desperate parents and teachers with reactive, repressive models of external behavioral controls, almost a reversion to 19^th-century modes of authoritarian domination. More perniciously, there is an explosive increase in the prescription of stimulant, anti-anxiety and antidepressant medications, as well as widespread off-label use of antipsychotic drugs. The assumption seems to be that there is a one-to-one relationship between atypical behavior and some specific brain disorder. This of course is the age-old dream of finding a single cause in the body or the mind.

            Recent neuroscience investigations, utilizing advances in the development of computer algorithms for classifying MRI images, have made possible large scale studies of normal and atypical brain development. These are able to capture any changes associated with these diagnoses. In an overview of such studies the authors conclude, "There is no identified 'lesion' common to all, or even most, children with the most frequently studied (psychiatric) disorders"             

            Ignoring such findings, pediatricians, psychiatrists and other clinicians continue to prescribe at ever-growing rates. ADHD and bi-polar diagnoses and their accompanying prescriptions have increased drastically in the past twenty years. 2.5 million American children are medicated for ADHD (10% of all 10-year-old boys); between 1994 and 2003 the number of children diagnosed with bi-polar disorder increased 40-fold. The proportion of underprivileged and minority children sedated for life is a blot on our health system, a social/political disgrace, and a permanent drain on our economy. Despite all the millions spent by pharmaceutical companies in marketing these drugs, the number of children struggling with such troubles continues to rise. If this rate of treatment failure occurred with a strictly medical treatment, the drugs would be withdrawn. 

Attending a meeting of Representative Ellen Story's Postpartum Depression Commission is always an uplifting experience. Talented, motivated, creative and hardworking people from a wide range of disciplines gather to figure out how to best address this significant public health problem. There are social workers, psychiatrists, pediatricians, obstetricians, health insurance industry representatives, and a range of others. There was a doula at the meeting this past week.

Representative Story told us about a pilot project based in two health centers. The project grew out of the recognition that mothers and babies are frequently at the office of a health care provider in the first weeks and months.  This model would capture a large number of families.   A person trained in working with mothers and babies together would be available for hour-long sessions for mothers in the postpartum period who are particularly stressed and overwhelmed.

Certainly if postpartum depression is identified, it is important to have a system in place to refer the mother for treatment. But the fact is that a mother who is struggling in the postpartum period is usually overwhelmed by the baby.  It is essential to bring the baby in to the work from the start. A person experienced working with both mothers and babies can listen to the mother while supporting her efforts to read the baby's signals and manage the normal challenges of sleep disruption, fussiness and feeding difficulties that come up in early infancy.

In my office at Newton-Wellesley Hospital's Early Childhood Social Emotional Health Program I have a special room for mothers and babies that has pastel rugs and soft chairs. It is quiet, private, and filled with light from a large window. One of my young clients called it a "feel better room." I think of it as what pediatrician/psychoanalyst D.W. Winnicott referred to as a "holding environment," where both mother and baby can feel safe, contained and understood.

It occurred to me at this meeting that perhaps we should aim to have a "feel better room" in every primary care office. True preventive mental health care starts in the newborn period. I am not saying that if things go wrong in the newborn period a child is destined for trouble. However, it is a time of rapid brain growth, and it is well known that the baby's brain grows in relationships with primary caregivers. With this model, we have the opportunity to set things right from the beginning.

A child psychiatrist at the meeting pointed out that "co-location" of mental health care in the primary care setting has run into trouble because of problems of economic viability. A pediatrician then brought in to the discussion the ACO (accountable care organization) model, whose intention is to promote preventive health care. He expressed concern that the needs of adults with chronic illness would overshadow the needs of children.

We know from a large body of research, particularly the ACE (Adverse Childhood Experiences) study, that true preventive care starts with promoting healthy secure relationships in the early years. This includes prevention not only in the realm of mental illness but also chronic physical illness such as asthma, diabetes, obesity and heart disease.

This model of investing in early relationships has been endorsed by nobel prize winning economist James J. Heckman. In a recent working paper, The Economics of Child Well-Being, he writes:

There is a growing interest in the well-being of children. Such interest is supported by recent evidence from both the biological and the social sciences, which points to the importance of the early years in shaping the capabilities that promote well-being across the lifecourse. It is now recognized that human development is a dynamic process that starts in the womb. Capabilities interact synergistically to create who we are and what we become. The foundations for adult success and failure are laid down early in life... 

Prevention is more cost effective than remediation. As implemented, most adolescent and adult remediation programs are ineffective and have much lower returns than early childhood programs that prevent problems before they occur... High quality early interventions that alter early life conditions are effective ways to promote well-being and human flourishing across the life cycle.

If the ACO model is really going to fulfil its aim of preventive care, then we would do well to find a way to make it "economically viable" to have "feel better room," staffed with professionals trained in work with mothers and babies, in every primary care office in the country.

I hope that the pilot program Representative Story referred to will serve to provide evidence for what the abundance of research already shows us will likely be a very good idea.

I am fortunate that my father is my greatest fan, although, perhaps because his original language was German, it has taken me years of patient listening and translation to recognize this fact. Recently, after receiving a biography of Charles Darwin for his 89th birthday, he has taken to comparing me to Darwin.

 I would certainly be more modest, recognizing that the ideas I write about draw on the work of great thinkers and researchers, together with my own clinical experience.   One of these great minds is Sigmund Freud. His discovery of the unconscious, his greatest contribution, is so much a part of the way we think and behave that is difficult to appreciate the revolutionary nature of this idea.  Even before he used the term unconscious, in his work as a neurologist, his original discovery was that symptoms have meaning.

Freud did not write very much about development under age three, perhaps because there was only so much he could do. However we do know that when he was a toddler his younger brother died. I wonder how much this early experience, and his mother's concurrent grief over the loss of her child, influenced the development of Freud's theories, though perhaps in a way that he himself was not conscious of.

Fortunately the next wave of researchers, including such great minds as John Bowlby, Peter Fonagy and Ed Tronick, and many others in the growing discipline of infant mental health, have focused on early development, showing that not only does behavior have meaning, but also how that meaning is co-created in relationships.

Here is an example. I have written on this blog about my growing recognition of the significance of sensory processing challenges in development.  While such a trait may originate in the child, it immediately takes on meaning within relationships. A newborn that is not cuddly and does not like to be held may evoke feelings of shame and even depression in a mother. A father who himself had sensory processing challenges but was physically abused because of his difficulties may be overwhelmed with anxiety in the face of his child's similar problems. The child's behavior takes on meaning in the context of the parent-child relationship. When a child is a newborn, it may be relatively easy to identify the relational nature of these problems. But when a child is older, there are layers of complexities, such as learning difficulties and concurrent self esteem issues that may accompany sensory processing challenges, or marital conflict that may occur in the face of a child who is struggling.  These complexities are usually out of a parent's awareness, or, returning to Freud's term, unconscious.

 As a society we have come far from this idea of looking for the meaning of behavior. Instead we treat only the symptom. Thus a child who has sensory processing challenges, unless he is working with an occupational therapist trained in infant mental health, may be treated by brushing, or listening to tapes designed to "re-program" his brain. Many parents have told me that they are actively discouraged from participating in the therapy. Yet if parent and child are separated in this way, the meaning of a symptom within the context of relationships is never discovered.

In mental health care, this shift away from the search for meaning is due at least in part to the birth of "biological psychiatry" and the hope that complex emotional struggles have a simple chemical explanation that can be solved with a drug.

On the list serve of the American Psychoanalytic Association there is currently an active discussion about the issue of CPT codes. In order for a service to be covered by insurance, a clinician must provide both a diagnostic code and a code for the type of service. An underlying problem is that our system of diagnosis, largely based on the DSM (Diagnostic and Statistical Manual)  is organized by symptoms, not by meaning. Clinicians who are used to helping people to discover meaning are restricted by a system that reduces these complex meanings to a number that corresponds to a list of behaviors. It is a deeply entrenched issue related to the whole structure of the health insurance industry and of our health care system. It is further complicated by the rise of electronic medical records and concurrent implications for confidentiality. Helping people to discover meaning that may be unconscious often involves intimate and private conversations.

This brings me full circle to my father's flattering comparison. It is indeed true that I am motivated not only to help the individual children and families I work with, but also to promote a paradigm shift in how we as a society understand human development, and, in turn, support newborns, young children and families.

Though my father is a magazine publisher, he is not a big fan of social media. He told me that Darwin kept his discoveries to himself, partly in fear of upsetting the mainstream thinking, until he had it all written down in the Origin of Species. My father suggested that I concentrate my efforts on producing my own analogous work.

He has a point. However, I choose to embrace the age of social media, and so aim to move our thinking one blog post at a time (although another book will also be forthcoming.)

For the families who lost children, their world as they knew it has effectively ended. Yet somehow the sun rises again and the next day is here. For the rest of us grieving along with these families, the only way to move forward is to take what President Obama called "meaningful action." I interpret this to be action that is radical and significant enough that it will somehow give meaning to this unimaginable loss.

The first and most obvious front is gun control. Without access to guns, apparently the same rifles used by troops in Afghanistan and Iraq, one individual could not have done this degree of harm. The politics of gun control is not my area of expertise, but certainly the politicians must now be motivated to, as Obama said, "put aside differences" and honor these children with dramatic changes to gun control laws.

The second front is preventive mental health care. This event is the result of a deeply disturbed individual with access to guns. My inbox this morning was full of emails from mental health colleagues referring to pieces they had written for other massacres such as Virginia Tech. I hope that this unspeakable horror will be  the one that will finally lead to real change in access to preventive mental health care.

One of these colleagues wrote of how these events are often perpetrated by young adults who have not been "acting out," but rather have been quietly bullied for years and seriously neglected at home. Their symptoms may be more subtle. Yet it is difficult to imagine that there were not people in this family's life who did not recognize that this boy/young man was mentally ill.

The emerging information speaks to  a deeply troubled relationship between the shooter and his mother as being at the root of the event. Apparently he first shot his mother and then went to the school to deliberately kill the children at the school where she worked. I wonder, was the hurt he experienced in his relationship with her magnified by his witnessing of the care she gave her young charges at her job?  Of course I don't know, and this is only theory as I struggle to make sense of something that doesn't make sense.

As I said to my editor when she asked for our thoughts on this event, the trauma is perhaps too fresh for an in-depth discussion of theory and policy change. However, I am hopeful that the coming weeks and months will be filled with meaningfully dialogue of how we as a society can honor the dead children, both through gun control and improved access to quality preventive mental health care.