Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary developmental science can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Friday, September 8, 2017

When Parents Fear "It's All My Fault"

Many of my colleagues in the field of early childhood mental health work with what are termed "high risk" populations. Children of drug addicted parents, victims of child abuse, and families in abject poverty. While the challenges these families face are daunting, I find myself feeling some envy for my colleagues whose clients are in such obvious distress that the need for intensive treatment of parent and infant is not in question.

In my rural, small-town population things are not so clear. Many families struggle under the radar for years. Recently in my behavioral pediatrics practice (details are changed to protect privacy) I saw a 3-year-old boy, who, in taking a detailed history, I could see barreling 100 miles an hour towards trouble from the moment he was born, or even before.  But the story unfolded before our eyes without intervention. Did the parents resist help? Did the many professionals in with contact with the family not recognize the problems? Probably some combination of both.

 We know from the CDC sponsored Adverse Childhood Experiences (ACEs) study that neglect and abuse, as well as more ubiquitous experiences of such things as marital conflict, parental mental illness, domestic violence, and substance abuse lead to a wide range of negative health outcomes both physical and mental. Yet babies come and go to pediatric practices and we don't discover or address until years later that in the early weeks and months, when their brains were most rapidly growing, parents-many themselves with a history of ACEs-struggled significantly. 

We need to find a way to engage these families with intensive support from the very beginning without making parents feel that they are somehow not "good-enough." Engagement means not only behavior management for children and/or medication for parents. It means listening to parents and infants together from the start. We need to listen to the vulnerabilities the child brings into the world as well as the often-complex relational issues between partners, among siblings, and with extended family.

The mother of my 3-year-old patient struggled with severe postpartum anxiety and profound social isolation. She described her son as "inconsolable" from birth. The marriage faltered. He developed severe separation anxiety, frequent explosive tantrums, and sleep disturbance among a range of other behavioral and developmental disturbances.

We know from infant research that a core sense of self develops in the moment-to-moment interactions between infants and their caregivers. Babies arrive in state of complete helplessness, relying 100% on their caregivers to make sense of the world and of themselves. This does not mean parents need to be perfect. In fact, perfection as well as absence can inhibit self-development and lead to fearful and rigid states. It is the very imperfections in relationships that help infants to develop resilience and a positive sense of themselves in the world.

But when parents are fighting constantly, when a mother or father is preoccupied with anxiety and/or depression, when a parent is in an altered mental state intermittently from substance abuse, this core sense of self may be distorted as infants struggles to make meaning of their experience. The "symptoms" of my 3-year-old patient can be understood as difficulties managing both his body and developing mind in a complex social world.

The transition to parenthood is challenging under the best of circumstances. Alicia Lieberman, one of the giants of the field of infant mental health, speaks in a kind of paradoxical way of how "trauma" is "normal." ACEs are extremely common. I recently heard a leader in the trauma field say in a presentation, "ACEs are normal."

If we engage families at or even before birth, presenting the challenges of the transition to parenthood as normal, when a parent struggles we will be right there to work more intensively to support these early relationships when bigger disruptions arise, rather than waiting until families are in crisis. Universal home visiting, relationship-based Early Intervention services and community support groups for parents and infants offer opportunities for a population based, non-stigmatizing approach to supporting new families.

Pediatricians present an ideal opportunity to engage families in this way. Currently Jack Shonkoff at the Center on theDeveloping Child is partnering with pediatric practices to develop a preventive model on the front lines where parents and babies regularly go. My colleague Ed Tronick has said on multiple occasions that parent-infant mental health should be the core of pediatrics, not a subspecialty. The abundant evidence from the ACE study certainly supports this claim.

At the tender of of 3 there is plenty of opportunity to help my patient and his family, who are invested in doing the work to set relationships and development on a better path. But I hope for shifts in culture, health care, and public health that will allow all families to set out on a healthy path from the start.

Tuesday, July 25, 2017

When Birth Plans Go Awry: Wisdom from Dr. Spock

Self- efficacy, or the belief in one's ability to be a good parent, plays a central role in healthy child development.  Many things can come along and derail that sense of confidence. Often the first of these is a delivery that does not go as planned.

In a recent conversation a colleague wondered if the abundance of books about the importance of the first months of life might serve to heighten parents' anxiety. I slept on her wise words and woke thinking of the famous opening line of Dr. Spock's Baby and Child Care, "Trust yourself: You know more than you think you do."

I went straight to my bookshelf that morning, and was surprised and pleased to find that he addresses what is today referred to as "birth trauma" in the opening pages:
If your labor and delivery experience is not what you expected, its normal to feel bad, even guilty. If you go in hoping for a natural birth and end up with a cesarean, its natural that you might feel that you were somehow to blame (you weren't) or that your baby will be somehow permanently harmed by the experience (almost never the case.) Many parents fear that if they are away from their baby in the first hours or days bonding will be permanently undermined. This is also not true. Bonding-the process of parent and baby falling in love with each other- develops over months, not hours.
The equating of bonding, a word that itself creates anxiety in parents, with falling in love, along with acknowledgment that this process is different for every family, holds great value. He brilliantly goes on, in words that echo pediatrician turned psychoanalyst D.W. Winnicott and anticipate research of psychologist Ed Tronick on the value of mismatch and repair, to dispel anxiety around a birth plan that goes awry:
Parenthood is an ideal guilt-generating business, and labor often delivers the first volley. I think this situation has come about in part because of the fantasy that everything has to be perfect in order for the child to do well. Of course nothing could be further from the truth. First off, the "perfect" parent has yet to see the light of day. Secondly there is no need to be perfect or to follow any one script. The process of human development is powerful. There is plenty of room for variation and even for making mistakes. Infants are incredibly resilient. As long as the infant is healthy, the type of childbirth is unlikely to have long-term consequences, unless there is so much guilt attached to the memory that it has a negative impact on parental self-confidence or starts the process with a strong but misguided sense of guilt. So my advice is to have your baby however seems right for you and your family. Then don't worry if what happens doesn't follow the script. Being a parent is tough enough without creating problems where there really aren't any.
Parents today are more likely to think of Spock as a Vulcan than a pediatrician.  With anxiety, stress, and uncertainty on the rise in our day-to-day lives, a healthy dose of Dr. Spock may be just what the doctor ordered.

Monday, June 26, 2017

The Decline of Empathy: A Hopeful Solution

Pediatrician T. Berry Brazelton was among the first to recognize the tremendous capacity of the newborn for complex connection and communication. Developmental psychologist Ed Tronick, drawing on this observation, designed the famous Still-Face Experiment to show the devastation, for both parent and baby, when they struggle to connect. Extensive research at the interface of developmental psychology, neuroscience, and genetics, as I document in my first book, shows the long-term benefit of investing in early parent-child relationships.

"Once you know it, you can't un-know it." My wise colleague Kyle Pruett, MD child psychiatrist, said this of the power of working with parents together with very young children to a move a family in a healthy direction.

After having recently written The Silenced Child, an admittedly dark account of how our society fails to listen to parents and children, and the potentially disastrous effects of this course of action, I am overjoyed to now be writing about a hopeful solution to this problem.  The following piece, published in our local paper on Sunday, offers a view into the work unfolding in this small rural town in Western Massachusetts. My hope is to bring this model to other communities. The aim is to offer this listening stance to all babies and families without potentially stigmatizing parents by identifying them as "at-risk."

Giving Every Newborn Baby A Voice
On a stormy November evening in 2016, I led a meeting in the small patient lounge of the maternity unit of Fairview, our local community hospital in rural Western Massachusetts. As the meeting was scheduled at change of shift, all 10 nurses who attend to the approximately 150 deliveries per year squeezed into the warm room. They eagerly shared their troubling feelings of helplessness when they see families who are clearly struggling, and have no choice but to send them home “on a wing and a prayer.”   They listened in rapt attention, and seemed empowered by the idea of learning new ways to support parents and newborns.

As a pediatrician specializing in parent-infant mental health, I attended the meeting under the auspices of the new Human Development Strategic Initiative at the Austen Riggs Center, led by Donna Elmendorf, PhD. a child clinical psychologist and director of the Center's Therapeutic Community Program.  The initiative seeks to bring Riggs’ relational view of early development to a community-based preventive model of care.
About six months later, on a spring weekend when from Friday to Sunday the weather shifted dramatically from snow to warm sunshine, half of these nurses, together with pediatricians, family and nurse practitioners, early intervention specialists, home visitors, and lactation consultants, many of whom are participants in the Berkshire United Way sponsored South County Community Coalition, gathered at Austen Riggs for a training in the Newborn Behavioral Observations system (NBO) to focus on giving babies in our community a healthy start.. The nurses who covered the maternity unit that April weekend traveled to Harvard Medical School in June for the same training.
We now have the opportunity to offer this intervention to every new baby and family, and an extended network of caregivers throughout our community who can support families in a similar way beyond the newborn period.
Early in his work as a general pediatrician in the 1950s, T. Berry Brazelton, recipient of Obama’s Presidential Citizen’s medal in 2012, observed the tremendous capacity of the newborn infant for complex communication. Research based on these observations led to development of the Neonatal Behavioral Assessment Scale (NBAS.) The scale changed the way both child development experts and pediatricians understood babies. The NBO, a clinical application of the NBAS developed by psychologist J. Kevin Nugent and colleagues, is a relationship-building tool that is as its core an opportunity for listening to parents and babies without judgment. Ongoing research around the world demonstrates the role of the NBO in supporting parent-infant relationships.
While the medical model of care often puts the professional in the role of expert, this intervention seeks to shift that mindset, mobilizing parents’ unique capacity to tune into and respond to their newborn. The 18 neurobehavioral observations of the NBO are not an assessment or evaluation. Rather, they offer a frame in which to support parents’ earliest efforts to get to know their baby.Participants in the training learn together about how to engage parents’ natural expertise and ability to listen to their baby’s earliest communications as they navigate this dramatic transition in their lives.

The Discovering Your Baby Project, the first community project of the Human Development Initiative, grew from a wish to have every family on our community feel heard and valued. We feel so fortunate to
have received local and national grant support for this burgeoning effort. Research at the interface of developmental psychology, neuroscience, and genetics offers evidence for  investing resources in these earliest relationships.
Families who deliver at Fairview Hospital may have relocated from the Upper West Side of Manhattan, lived for generations as local workers, or recently emigrated from Ecuador. Families from the full range of socioeconomic backgrounds may have struggled with generations of mental illness, substance abuse, or other adverse childhood experiences.
At the NBO training one of the nurses who has worked for decades on the same unit shared how she sees troubled family relationships passed from one generation to the next. “Now,” she said, “I feel hopeful that the next generation may have a different path.” 
Our population-based intervention for all families who deliver at Fairview aims to instill confidence and de-stigmatize the struggles of the transition to parenthood, with the larger community of caregivers available to engage families in this way as development progresses. We hope the Discovering your Baby Project can serve as a model for communities large and small, urban and rural, throughout our country.
We learn to listen by being listened to. We see our work as a “baby step” toward giving every person a voice from the moment of birth.  Perhaps it will also be a first step toward restoring empathy in our society.

Tuesday, May 23, 2017

What Do Parents Want? Parsing Contradictions in The Zero to Three National Parent Survey

Zero to Three, the Washington, DC based organization whose mission is to advocate for infants and toddlers to have a strong start in life, just released results of their ambitious project to answer this question. The data from the current report, a collaborative effort with the Bezos Family Foundation, comes from a 50-question Internet survey in Spanish and English distributed to a national sample of 2,200 parents of children age birth to 5. The survey was developed out of 10 in-depth discussion groups with parents from a wide range of backgrounds. 

The Zero to Three report contains some striking, and in some places contradictory, data. Starting out with results suggesting that most parents think that parenting can be taught, they offer this statistic:
69% of parents say that if they knew more positive parenting strategies they would use them.
One might conclude that giving more parenting advice would be the solution, but another statistic suggests a different interpretation might be indicated:
63% of parents overall say "I am skeptical of people who give parenting advice and recommendations if they don't know my child and my situation specifically."
This finding suggests that while parents feel the need for something, and name that "something" as a wish for "strategies" they, at least in part, recognize themselves as the expert with regard to their child and so balk at advice that comes without full understanding of their particular circumstance.

Adding to that contradiction is this disturbing, though not surprising, finding that:"90% of moms and 85% of dads feel judged. 46% of moms and 45% of dads say they feel judged all the time or nearly all the time." These statistics suggests that the abundance of "expert" advice may in fact cause more harm than good.

A whole section of results titled "There is a Missing First Year" captures the fact that parents consistently underestimate the importance of the early months of life.
Parents also don’t realize how deeply [infants] can be affected by the way parents interact with them in the first months of life. A notable portion of parents miss the mark by months, or even years. 
One might conclude from this finding that parents need more information. However, a majority of parents say that knowing the importance of the early years is both motivating and terrifying, with 35% equally or more terrified than motivated. This finding suggests that offering information alone could be counterproductive. It is possible that parents do in fact know how important they are.  The fact that they cannot, due to a wide range of stresses, be available to their babies in ways they want to be, may make this knowledge intolerable.

The survey shows that parents perceive support to be lacking when they feel stressed or overwhelmed, with almost half saying they do not get the support they need and 8% say they get no support at all. 

So what is the nature of "support?" 

This survey brought to mind a lecture I attended a number of years ago by the late esteemed psychoanalyst Daniel Stern entitled, "What do Mothers Want?" While the significance of fathers is notably absent from his work∗, his insights on mothers, gleaned from in-depth clinical work with mother-infant dyads, add an important dimension to the Zero To Three findings and might help parse some of the contradictions and answer this question. 

In his talk he presented what he terms The Motherhood Constellation, or the themes that emerge in a woman's life when she navigates the transition to motherhood.

1. Can she maintain the life and growth of the baby?
2. Can she emotionally engage with the baby in her own authentic manner, and will that engagement assure the baby's psychic development towards the baby she wants?
3. Will she know how to create and permit the necessary support system to fulfill these functions?
4. Will she be able to transform her self-identity to permit and facilitate these functions?

Stern is calling attention to the enormity of the transition to parenthood, beginning with the basic question of being able to sustain the life of this new human being. Being fully present emotionally to facilitate the baby's development is tied to both having the necessary support and validation of how a woman's self-identity is transformed in a normal and healthy way.

So it could be that "support" equals "listening." Support means a different thing for every individual. For one it might mean playing with an older sibling while mom and baby nap. For another it might mean grocery shopping. For another engaging a withdrawn and perhaps depressed partner might be needed. For yet another it might mean finally addressing her own experience of abuse so that she does not repeat the pattern with her child. 

A growing body of evidence suggests a central role of parental self-efficacy in healthy child development. Each parent needs to have his or her experience validated with the aim of helping achieve a sense of self-efficacy and expertise with respect to his or her child. Advice, strategies, and information may have a role to play, but only within the context of time for listening.

∗A striking finding of the Zero to Three survey concerns fathers, 73% of whom say their lives began when they became a dad, with 63% feeling unrecognized and 40% feeling shut out. 

Saturday, March 25, 2017

Did Mothers Save the Affordable Care Act?

In striking contrast to the happenings in the US congress on Thursday afternoon, Kate Middleton, future queen of England, spoke these words at London's Royal College of Obstetricians and Gynecologists on the occasion of a launch of educational films dealing with maternal mental health:
Nothing can really prepare you for you the sheer overwhelming experience of what it means to become a mother, It is full of complex emotions of joy, exhaustion, love and worry all mixed together. Your fundamental identity changes overnight. You go from thinking of yourself as primarily an individual, to suddenly being a mother, first and foremost.
Her normalization of the struggles of this transition, heightened by absence of the kind of support she acknowledges she, unlike many mothers, has in abundance, provided exactly what is needed to decrease stigma and shame. 

When after a tense day on Friday the House had to admit defeat and pull legislation to repeal the Affordable Care Act, it occurred to me that perhaps the late removal of 10 essential health benefits, including maternity and mental health care, done to appease the conservative Freedom Caucus, in fact contributed to the final demise of the American Health Care Act. 

Both maternity care and mental health care are exactly what we need in abundance to turn our country around. In his highly acclaimed book Hillbilly Elegy J.D. Vance comes to the conclusion that the problems afflicting the communities who feel unheard and unrecognized, and so voted in large numbers for President Trump, have their roots in Adverse Childhood Experiences

When parents feel heard and supported, they are available to be present with their children in a way that promotes healthy development, both physical and emotional. In contrast, when parents struggle- with things such as mental illness, substance abuse, marital conflict and domestic violence-it impacts upon their children's growing bodies and brains in ways that have long-term negative consequences. 

In my rural community in Western Massachusetts, we are bringing together clinicians who work with newborns and parents-including pediatricians, maternity nurses, early intervention specialists and home visitors- to insure that all babies and parents feel heard and supported from the moment of birth. An abundance of scientific evidence shows us that investment in the earliest days and weeks of life offers the greatest opportunity to promote development and prevent transmission of trauma to the next generation. 

I recognize that the politics are complicated. However, the idea that perhaps members of Congress, all of whom have mothers, could not bring themselves to vote against mothers in such an explicit way gives me hope. 

Perhaps we needed to come face-to-face with the importance of maternal and mental health care in a dramatic, high profile, and potentially dangerous way. Now that we are here, I am hopeful that momentum will move us forward to address this issue in ways that are broad and far-reaching. Kate Middleton, and her program Heads Together, serves as an excellent model.

Sunday, March 5, 2017

Rethinking Sensory Sensitivities: Why Music is Therapy

Towards the end of  our 2 day visit with neuroscientist Stephen Porges at the University of Massachusetts Boston Infant-Parent Mental Health program,  I asked about a young girl I treated a number of years ago with selective mutism.  Her parents described how during a large family gathering  she would shut down. But if they listened to classical music, she would join the gathering and begin to speak. This story, he replied, represents his theory in action.

In my 30 years practicing general and behavioral pediatrics and now specializing in early childhood mental health, I have increasingly come to recognize the central role of sensory processing in healthy emotional development. When I listen carefully to stories of parents, whether the child is 18 months, 5 years or even 17 years, with concerns ranging from a fussy baby, attention problems, behaviors associate with autism, anxiety, and explosive behavior, I invariably discover behaviors  suggestive of sensory processing sensitivities. A child could not ride in the car without screaming unless the same song was played over and over again. A visit to a butterfly museum ended in a meltdown as a child longed to have a butterfly land on his shirt but yet fell apart when it did. A newborn became completely disorganized and unable to feed when his father sneezed. These details I have collected over the years could fill several books.

Many have wondered about the central role of sensory processing in behaviors or "symptoms" we name as psychiatric disorders. Occupational therapy as a discipline has called for recognition of "Sensory Integration Disorder." Child psychiatrist Stanley Greenspan called attention to the way sensory  and affective experience are intimately intertwined.

In those two days, however, Stephen Porges fundamentally transformed my understanding of sensory processing and its role in emotional and behavioral disturbances.

The bones of the middle ear, it turns out, are a direct entry point, via the autonomic nervous system, to our social engagement system. He described how mammals are different from reptiles because two of these tiny bones are detached, allowing us to hear the low amplitude, high frequency sounds of the human voice.

Proper functioning of the middle ear muscles, along with the muscles of the face, particularly around the eyes, as well as the larynx that control intonation and prosody of voice, is essential for social engagement. When the way we take in sound is distorted, it disrupts the entire autonomic nervous system, interfering with this social engagement system.

Underlying this conceptualization is the Polyvagal Theory, founded on decades of detailed neurophysiology research. (The theory is very complex: I attempt to explain it more fully in my recently released book The Developmental Science of Early Childhood.)

Essentially Porges discovered that rather than the simple either-or of social engagement or fight flight, there is a third way that our body responds to the environment when we experience overwhelming threat. This response is under the influence of what he terms the "primitive vagus" and is closer in function to the reptilian brain.

When my patient with selective mutism listens to classical music, the sense of threat she is experiencing in the environment, that is paralyzing her social engagement system, subsides.

Porges has developed a model of treatment called The Safe and Sound Protocol, with body of evidence to support its efficacy in treating a range of difficulties. It is described as a "non-invasive intervention involves listening to music that has been processed specifically to retune the nervous system (regulating state) to introduce a sense of safety and the ability to socially engage."

Porges is calling on us to rethink static categories of "disorders" and rather to recognize the wide range of disturbances of emotion and behavior as distortions of the social engagement system via distortions in function of the autonomic nervous system. With this conceptualization, listening to music could be the primary treatment.

While Porges' theory and research resonate deeply with my clinical work, my profound understanding of his ideas actually comes from my son, who has given me permission to write about him. Sitting in a car in the parking lot with the windows closed while the rest of the family enjoyed fireworks, running in circles and not engaging with other children in preschool, gagging on foods other than the narrow range he could tolerate- these typical examples represent his early years. 

Unaware of Porges' theory, my son found his own treatment. In toy stores only the musical instruments interested him. At the age of 8 he took up the saxophone. His beautiful voice transformed to a deep bass in his adolescent years. Now in college, he performs regularly in two singing groups who are like second families.  Thriving academically,  his social engagement system is working. 

It is not often that someone comes along and profoundly alters the way we understand the world. In my view, Stephen Porges is one such person.