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.
Friday, September 8, 2017
Tuesday, July 25, 2017
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
"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
Tuesday, May 23, 2017
69% of parents say that if they knew more positive parenting strategies they would use them.
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."
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.
So what is the nature of "support?"
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
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
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.