Senin, 26 Desember 2011
Minggu, 25 Desember 2011
Jumat, 23 Desember 2011
Early Relationships and Brain Development
The research and knowledge about how early relationships shape brain development has been exploding in recent years. Three new studies caught my attention. The more we know about this area, the more we recognize how important it is to support parents and young children in the early years when the brain is most rapidly developing and so most "plastic," or able to change.
The first study, using neuroimaging techniques, showed that children exposed to severe maternal depression since birth had larger amygdalas at age 10. Much research has shown that postpartum depression can have long term impact on child development. In addition we know that the amygdala plays a critical role in emotional regulation. Trauma researcher Bessel van der Kolk has referred to it as "the smoke alarm of the brain." It makes sense that when mothers, because of their own emotional distress, are not able to be attuned with their babies as the would wish, the centers of the baby's brain responsible for emotional regulation may not develop as well. So the amygdala is, in a sense, unchecked.
The take home message is not that mothers should feel guilty if they are depressed, but that they should get help. I have written in a previous post about the dearth of services for women with PPD and new initiatives to address this problem. I have added my efforts to the cause by starting the Early Childhood Social Emotional Health Program at Newton Wellesley Hospital where mothers struggling with a range of perinatal emotional complications can be seen with their baby.
The second study, is also about the amygdala: Amygdalar Activation and Connectivity in Adolescents With Attention-Deficit/Hyperactivity Disorder. Also using neuroimaging, these researchers showed that the amygdala was overactive in a group of teenagers with the diagnosis of ADHD. I have written previously about ADHD as a problem of regulation of emotion, attention and behavior. The authors of the study link this finding to the difficulties with emotional reactivity seen in teenagers with ADHD. If we combine these findings with the previous study, it seems that treating mother-baby pairs in the setting of postpartum depression might in fact prevent ADHD! Such a study, known as an intervention study, is yet to be done, but certainly it seems to make sense to place our efforts in that direction.
The last study comes out of the Minnesota Longitudinal Study of Risk and Adaptation, which has followed a group of children from birth into adulthood. They showed a link between secure early attachment relationships and satisfying romantic relationships in young adults. The results were affected by quality of social skills in preschool and having a best friend in adolescence. The authors conclude that early relationships are very important, but other relationships along the way to adulthood can influence the effects.
While this study is not about neuroimaging, if we think about how being in a successful romantic relationship as an adult requires a good degree of emotional regulation, we can make a connection. Secure early attachment relationships are characterized by attunement between mother and infant. When something is amiss, as in the case of postpartum depression, these relationships may develop a quality of insecurity. This may show itself in the brain as an overactive amygdala, perhaps with relative underdevelopment of the centers of the brain responsible for regulating the amygdala. These studies together offer insight into how brain development may affect later adult relationships.
These studies span the developmental spectrum, from childhood to adolesence and on to adulthood. With such far reaching implications, it certainly makes sense to put our efforts into helping these young brains to grow in a healthy way from the start.
The first study, using neuroimaging techniques, showed that children exposed to severe maternal depression since birth had larger amygdalas at age 10. Much research has shown that postpartum depression can have long term impact on child development. In addition we know that the amygdala plays a critical role in emotional regulation. Trauma researcher Bessel van der Kolk has referred to it as "the smoke alarm of the brain." It makes sense that when mothers, because of their own emotional distress, are not able to be attuned with their babies as the would wish, the centers of the baby's brain responsible for emotional regulation may not develop as well. So the amygdala is, in a sense, unchecked.
The take home message is not that mothers should feel guilty if they are depressed, but that they should get help. I have written in a previous post about the dearth of services for women with PPD and new initiatives to address this problem. I have added my efforts to the cause by starting the Early Childhood Social Emotional Health Program at Newton Wellesley Hospital where mothers struggling with a range of perinatal emotional complications can be seen with their baby.
The second study, is also about the amygdala: Amygdalar Activation and Connectivity in Adolescents With Attention-Deficit/Hyperactivity Disorder. Also using neuroimaging, these researchers showed that the amygdala was overactive in a group of teenagers with the diagnosis of ADHD. I have written previously about ADHD as a problem of regulation of emotion, attention and behavior. The authors of the study link this finding to the difficulties with emotional reactivity seen in teenagers with ADHD. If we combine these findings with the previous study, it seems that treating mother-baby pairs in the setting of postpartum depression might in fact prevent ADHD! Such a study, known as an intervention study, is yet to be done, but certainly it seems to make sense to place our efforts in that direction.
The last study comes out of the Minnesota Longitudinal Study of Risk and Adaptation, which has followed a group of children from birth into adulthood. They showed a link between secure early attachment relationships and satisfying romantic relationships in young adults. The results were affected by quality of social skills in preschool and having a best friend in adolescence. The authors conclude that early relationships are very important, but other relationships along the way to adulthood can influence the effects.
While this study is not about neuroimaging, if we think about how being in a successful romantic relationship as an adult requires a good degree of emotional regulation, we can make a connection. Secure early attachment relationships are characterized by attunement between mother and infant. When something is amiss, as in the case of postpartum depression, these relationships may develop a quality of insecurity. This may show itself in the brain as an overactive amygdala, perhaps with relative underdevelopment of the centers of the brain responsible for regulating the amygdala. These studies together offer insight into how brain development may affect later adult relationships.
These studies span the developmental spectrum, from childhood to adolesence and on to adulthood. With such far reaching implications, it certainly makes sense to put our efforts into helping these young brains to grow in a healthy way from the start.
Minggu, 18 Desember 2011
A Troubling Parenting Moment at the Airport
The little boy, who looked to be about two, darted away in a fit of giggles. His young mother, who seemed thoroughly worn out and exasperated, ran after him, grabbed him by the arm and said in a harsh whisper, "You must stand here!"
We were on line waiting to board a Southwest Airlines flight. For those of you not familiar with the Southwest system, there are no assigned seats. Rather, when a passenger obtains a boarding pass, a number indicates a place in line. Then before boarding, passengers line up according to the number they have been given. It is a very well organized system, but doesn't necessarily work for a two-year-old.
I've been thinking a lot about what happened next. While I do not know anything about this mother-child pair, I have imagined many reasons why the situation unraveled as it did.
The above scene repeated itself two or three times. The mother had a companion, another young woman about her age, maybe a friend or her sister, who was fully absorbed with her phone for a few rounds of chasing before she looked up and said to the boy, "Do you want to watch a movie?" Immediately he stopped his darting and stood quietly looking at the phone, but the woman said, "You have to wait til we get on the plane." He screamed and ran off again. This time he threw himself on the ground in the middle of the two lines of people (interestingly right at my feet-perhaps he sensed a sympathetic observer.) At which point his mother said in a loud voice, "If you don't listen, all of these people are going to tell Santa you've been a bad boy!"
I was horrified, and might have even been tempted to intervene (probably not a good idea in the absence of frank abuse) but fortunately at that moment they began to board the plane.
So what went wrong? I start with the mother's perspective. Likely she was experiencing a flood of shame and humiliation, as parents of young children do when they "act out" in public. On every radio interview I've had, I am asked about the dreaded "supermarket scene," another place where a child must conform to the rules under the watchful eye of the general public.
The fact is that the "public eye" is generally either sympathetic or too involved in their own life to even notice. Yet shame pervades. In this situation it must have been particularly intense, as the mother passed this shame on to her son. She put the experience of humiliation directly in to him with her comment about Santa.
Next, I go on to the four aspects of holding a child in mind, as I describe 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
The first is to be curious about the meaning of behavior. I wonder if this boy had some difficulties processing sensory input. As I mention in a previous post, a recent study showed that sensory over-responsiveness occurs in 25% of cases of problem behavior. An airport is a very difficult place for a child with sensory processing problems. Or perhaps he had just had a difficult separation- an event that may precede a trip on a plane. Or he may simply have been tired or hungry.
The second component is empathy. His mother, likely because of her own distress(see step four) was particularly unempathic, not recognizing how even in the absence of the above possible stressors, standing still can be a challenge for a two-year-old.
The third component is regulating and containing behavior. The little boy likely felt very stressed by this out of control situation. He needed help containing his experience. The mother's companion was on the right track in offering the phone. He needed something that would help him to regulate himself. Reading a book, offering a movie or game, or even a snack, might have helped him to feel less out of control.
The last, and most difficult, is to manage your own distress. This mother might have been tired herself, might have been angry with her companion for being so unhelpful, or any countless number of feelings, in addition to the shame I describe above, that can get in the way of seeing things from your child's perspective. When a person is flooded with stress, the higher centers of the brain responsible for rational thought do not work well. Had she been thinking more clearly, it might have occurred to her that her companion could hold the place in line. She could have let her son run around before being confined to the plane. Likely the other passengers would have been fine with that.
It's a lot to think about for such a tiny moment. But it deserves this kind of attention, because repeated experiences of shaming are not good for a young child. Who says being a parent isn't the hardest job there is?
We were on line waiting to board a Southwest Airlines flight. For those of you not familiar with the Southwest system, there are no assigned seats. Rather, when a passenger obtains a boarding pass, a number indicates a place in line. Then before boarding, passengers line up according to the number they have been given. It is a very well organized system, but doesn't necessarily work for a two-year-old.
I've been thinking a lot about what happened next. While I do not know anything about this mother-child pair, I have imagined many reasons why the situation unraveled as it did.
The above scene repeated itself two or three times. The mother had a companion, another young woman about her age, maybe a friend or her sister, who was fully absorbed with her phone for a few rounds of chasing before she looked up and said to the boy, "Do you want to watch a movie?" Immediately he stopped his darting and stood quietly looking at the phone, but the woman said, "You have to wait til we get on the plane." He screamed and ran off again. This time he threw himself on the ground in the middle of the two lines of people (interestingly right at my feet-perhaps he sensed a sympathetic observer.) At which point his mother said in a loud voice, "If you don't listen, all of these people are going to tell Santa you've been a bad boy!"
I was horrified, and might have even been tempted to intervene (probably not a good idea in the absence of frank abuse) but fortunately at that moment they began to board the plane.
So what went wrong? I start with the mother's perspective. Likely she was experiencing a flood of shame and humiliation, as parents of young children do when they "act out" in public. On every radio interview I've had, I am asked about the dreaded "supermarket scene," another place where a child must conform to the rules under the watchful eye of the general public.
The fact is that the "public eye" is generally either sympathetic or too involved in their own life to even notice. Yet shame pervades. In this situation it must have been particularly intense, as the mother passed this shame on to her son. She put the experience of humiliation directly in to him with her comment about Santa.
Next, I go on to the four aspects of holding a child in mind, as I describe 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
The first is to be curious about the meaning of behavior. I wonder if this boy had some difficulties processing sensory input. As I mention in a previous post, a recent study showed that sensory over-responsiveness occurs in 25% of cases of problem behavior. An airport is a very difficult place for a child with sensory processing problems. Or perhaps he had just had a difficult separation- an event that may precede a trip on a plane. Or he may simply have been tired or hungry.
The second component is empathy. His mother, likely because of her own distress(see step four) was particularly unempathic, not recognizing how even in the absence of the above possible stressors, standing still can be a challenge for a two-year-old.
The third component is regulating and containing behavior. The little boy likely felt very stressed by this out of control situation. He needed help containing his experience. The mother's companion was on the right track in offering the phone. He needed something that would help him to regulate himself. Reading a book, offering a movie or game, or even a snack, might have helped him to feel less out of control.
The last, and most difficult, is to manage your own distress. This mother might have been tired herself, might have been angry with her companion for being so unhelpful, or any countless number of feelings, in addition to the shame I describe above, that can get in the way of seeing things from your child's perspective. When a person is flooded with stress, the higher centers of the brain responsible for rational thought do not work well. Had she been thinking more clearly, it might have occurred to her that her companion could hold the place in line. She could have let her son run around before being confined to the plane. Likely the other passengers would have been fine with that.
It's a lot to think about for such a tiny moment. But it deserves this kind of attention, because repeated experiences of shaming are not good for a young child. Who says being a parent isn't the hardest job there is?
Senin, 12 Desember 2011
Limit Setting as Containment of Feelings
Two recent experiences have gotten me thinking about the concept of "containment." It is the third component of keeping your child in mind, an approach to supporting healthy emotional development that I describe in my book, Keeping Your Child in Mind. In its most concrete form it refers to the importance of setting limits on your child's behavior. For example, by giving a "time out" every time your child hits, you show him that this behavior will not be tolerated. In doing so, you protect him from the intensity of his feelings by making sure that things do not get out of control. When young children are so consumed with anger and frustration that they hit, they feel out of control, and clear limits help them learn to regulate and manage these difficult emotions. (Combining limits with empathy, as I describe in my previous post, is essential.)
The first experience was a radio interview I had last week on the program Radio 2 Women on WBCR in the Berkshires. My interviewer, Serene Mastrianni, was among the best I've encountered. She had read the book twice, the first time going right to the section corresponding to her own child's age, and then again from the beginning. She had given it some careful thought. She had begun to actively use the book, not only in her own family, but to support friends. She told me the following story.
One such friend, the mother of a 12-year-old boy, had called her in tears. Her son had just had an explosive tantrum and at its height, he screamed at her, " I know you hate me, but I didn't know Dad hates me too!" Her friend was devastated. Serene's response to her hysterical friend was (after, "you've go to to read this book") "sit with him find out what this is all about." So her friend, rather than reacting in anger or hurt, did just that. And with time, the story unfolded that he had been bullied at school. He was a very successful student, president of his class, and he had never had this experience. He was furious with his parents for having failed to protect him, even though in reality they knew nothing about it.
This story combined with the second experience, attending the Zero to Three conference,"the premier conference for professionals dedicated to promoting the health and well-being of infants and toddlers," this past week in Washinton, DC, led me to consider the deeper meaning of the term 'containment." At a lecture I attending on teaching therapists to work with parent-infant pairs, the speaker described containment as "tolerating and sitting with feelings until the meaning unfolds." This is exactly what Serene's friend had done.
Tolerating your child's feelings in this way can be very difficult for a parent, as your child's behavior, particularly when it involves either physical or verbal assault, may provoke intense reactions. But the rewards, as this story shows, are great. Containment requires that, for the moment, you put your own distress aside (the fourth component of keeping a child in mind.) The beauty of Serene's story is that she was able to help her friend with this challenging task. It points out that for parents to be able to keep their child in mind in this way, there must be someone keeping them in mind. That person could be a friend, spouse, family member, pediatrician, or therapist.
"What about positive feelings?" Serene asked. I love this question. Much attention is given in the parenting literature to negative feelings, such as anger, frustration and sadness. But meeting a child’s experience of excitement and joy is in many ways equally important in promoting healthy development. Failure recognize and contain joy may slip under parents' radar as the behavior that follows may not be disruptive. But a child brimming with excitement over an experience with a friend or teacher who is met by a distracted parent may feel unrecognized, as the above child would have been if rather than being listened to he were sent to his room for "talking back." A parent who is depressed may have particular difficulty meeting a child's joy. This is one of many reasons why it is critical for parents who are struggling with depression to get help.
Serene told of a time when her daughter came home in just such an excited state, and she busy with something and did not respond. Later that day, however, Serene recognized what had happened and said to her daughter, "you were really happy when you came home and I wasn't listening. I'm sorry. Come here now and tell me all about it."
In the everyday stress of life, there are many times when a parent will not be available to contain a child's feelings, whether positive or negative, in the way I have described. But this very process of recognizing such a moment of disruption, and subsequently repairing it, is, in itself, essential for promoting healthy emotional development.
The first experience was a radio interview I had last week on the program Radio 2 Women on WBCR in the Berkshires. My interviewer, Serene Mastrianni, was among the best I've encountered. She had read the book twice, the first time going right to the section corresponding to her own child's age, and then again from the beginning. She had given it some careful thought. She had begun to actively use the book, not only in her own family, but to support friends. She told me the following story.
One such friend, the mother of a 12-year-old boy, had called her in tears. Her son had just had an explosive tantrum and at its height, he screamed at her, " I know you hate me, but I didn't know Dad hates me too!" Her friend was devastated. Serene's response to her hysterical friend was (after, "you've go to to read this book") "sit with him find out what this is all about." So her friend, rather than reacting in anger or hurt, did just that. And with time, the story unfolded that he had been bullied at school. He was a very successful student, president of his class, and he had never had this experience. He was furious with his parents for having failed to protect him, even though in reality they knew nothing about it.
This story combined with the second experience, attending the Zero to Three conference,"the premier conference for professionals dedicated to promoting the health and well-being of infants and toddlers," this past week in Washinton, DC, led me to consider the deeper meaning of the term 'containment." At a lecture I attending on teaching therapists to work with parent-infant pairs, the speaker described containment as "tolerating and sitting with feelings until the meaning unfolds." This is exactly what Serene's friend had done.
Tolerating your child's feelings in this way can be very difficult for a parent, as your child's behavior, particularly when it involves either physical or verbal assault, may provoke intense reactions. But the rewards, as this story shows, are great. Containment requires that, for the moment, you put your own distress aside (the fourth component of keeping a child in mind.) The beauty of Serene's story is that she was able to help her friend with this challenging task. It points out that for parents to be able to keep their child in mind in this way, there must be someone keeping them in mind. That person could be a friend, spouse, family member, pediatrician, or therapist.
"What about positive feelings?" Serene asked. I love this question. Much attention is given in the parenting literature to negative feelings, such as anger, frustration and sadness. But meeting a child’s experience of excitement and joy is in many ways equally important in promoting healthy development. Failure recognize and contain joy may slip under parents' radar as the behavior that follows may not be disruptive. But a child brimming with excitement over an experience with a friend or teacher who is met by a distracted parent may feel unrecognized, as the above child would have been if rather than being listened to he were sent to his room for "talking back." A parent who is depressed may have particular difficulty meeting a child's joy. This is one of many reasons why it is critical for parents who are struggling with depression to get help.
Serene told of a time when her daughter came home in just such an excited state, and she busy with something and did not respond. Later that day, however, Serene recognized what had happened and said to her daughter, "you were really happy when you came home and I wasn't listening. I'm sorry. Come here now and tell me all about it."
In the everyday stress of life, there are many times when a parent will not be available to contain a child's feelings, whether positive or negative, in the way I have described. But this very process of recognizing such a moment of disruption, and subsequently repairing it, is, in itself, essential for promoting healthy emotional development.
Selasa, 06 Desember 2011
Why "Defiant" Behavior Pushes Parents' Buttons
Recently NPR had a story about temper tantrums, describing a new study showing that the sounds children make during a tantrum indicate that they are primarily sad rather than angry. The written version of the story opens with description of tantrums as " the cause of profound helplessness among parents."
I thought this was an interesting choice of words, as I have always thought of tantrums as representing a sense of helplessness in children. In fact, in my over 20 years of practicing pediatrics I have told parents that, for the most part, tantrums are a normal healthy phenomenon. They occur when young children emerge for a stage of omnipotence in the first year to recognize that they are relatively powerless. An excerpt from my book describes the phenomenon.
The word"defiant" is a perfect example of this negative language. That word(as well as "tantrums") is actually in the title of my book Keeping Your Child in Mind: Overcoming Defiance, Tantrums and other Everyday Behavior Problems by Seeing the World Through Your Child's Eyes. The first part of the title was my doing, as it comes from an important concept in contemporary developmental science. The subtitle was my publisher's doing, but I understand why it was chosen, as this is a common language. Perhaps, however, it is time to rethink that language.
Recently I was asked to do an email interview for a parenting blog about defiance. The interviewer also used the word "impudence," another highly negative word. I suggested that this word projects intentions onto the child that are likely not there. In fact, "defiant" behavior almost always has its origins in a feeling of being out of control. From the child's perspective, his experience is not being recognized or understood. In a way he is not "seen."
Herein lies the explanation of why defiance pushes our buttons. In a sense a parent is having exactly the same experience as the child. He or she is not being "seen" or recognized as an adult deserving of respect. A parent might have had other experiences of not being "seen,” perhaps by a spouse, co-worker or by her own parents, that makes her particularly vulnerable to getting upset about not being “seen” by her child.
In almost every instance of “defiant" behavior, if one digs a bit below the surface, there is a way the child is also not being seen, or a way in which her experience is not recognized. For a particularly dramatic example, a six-year-old was brought to my practice with a chief complaint of “defiant behavior”. Further history revealed significant trauma in the child’s life. An alcoholic father who had abandoned the child as a toddler had recently been making visits, at which time he was often drunk and very loud. Yet her feelings about visits had not been discussed until they came to see me for “defiant” behavior,” which was worse around bedtime.
This child began sleeping all night in her bed after a couple of visits with me. We discussed this experience, recognizing her need for her mother's company at bedtime for stories, comfort and reassurance. Once a child feels that he is being seen, that his experience is recognized and understood, the "difficult" behavior often evaporates.
In general, if there is increasing “defiance” it is important to take a step back and try to understand what feels out of control for the child. It might be that he is very sensitive to loud noises or taste, and battles around "making a scene” at a family outing or being “picky eater” are related to these sensory sensitivities. It might be that there is a new baby and everyone is chronically sleep deprived. Or there may be financial stress or marital conflict. Simply recognizing that these things are difficult for a child and acknowledging his experience, even if the stressors are still there, goes a long way in having a child feel understood, and in turn decreasing “defiant” behavior.
Limits on behavior are essential, and my book goes on to say that the above toddler must be taught that hitting is never OK. But understanding, empathy and managing our own distress are all equally important. Reframing "difficult" behavior as "stressed" behavior is an important first step.
I thought this was an interesting choice of words, as I have always thought of tantrums as representing a sense of helplessness in children. In fact, in my over 20 years of practicing pediatrics I have told parents that, for the most part, tantrums are a normal healthy phenomenon. They occur when young children emerge for a stage of omnipotence in the first year to recognize that they are relatively powerless. An excerpt from my book describes the phenomenon.
Imagine that your toddler sets his sight on your glasses and declares proudly, “mine.” In an appropriate way, you might calmly say, “No, those are Mommy’s. I need them to see.” Suddenly he is confronted with the fact of his relative smallness and powerlessness. If he happens to be in a particularly vulnerable state, such as before lunch or naptime, he might become enraged that you, his beloved mother, have burst the bubble of his omnipotence. Unable to contain his intense feelings, he might lash out and hit you.The NPR piece got me thinking that we often describe children's behavior in negative terms, which immediately sets up a relationship of antagonism and confrontation. A colleague of mine, Suzanne Zeedyk, wisely has suggested that we reframe "challenging" behavior as "stressed" behavior. Then the language itself puts us in a position to empathize with the child's perspective.
The word"defiant" is a perfect example of this negative language. That word(as well as "tantrums") is actually in the title of my book Keeping Your Child in Mind: Overcoming Defiance, Tantrums and other Everyday Behavior Problems by Seeing the World Through Your Child's Eyes. The first part of the title was my doing, as it comes from an important concept in contemporary developmental science. The subtitle was my publisher's doing, but I understand why it was chosen, as this is a common language. Perhaps, however, it is time to rethink that language.
Recently I was asked to do an email interview for a parenting blog about defiance. The interviewer also used the word "impudence," another highly negative word. I suggested that this word projects intentions onto the child that are likely not there. In fact, "defiant" behavior almost always has its origins in a feeling of being out of control. From the child's perspective, his experience is not being recognized or understood. In a way he is not "seen."
Herein lies the explanation of why defiance pushes our buttons. In a sense a parent is having exactly the same experience as the child. He or she is not being "seen" or recognized as an adult deserving of respect. A parent might have had other experiences of not being "seen,” perhaps by a spouse, co-worker or by her own parents, that makes her particularly vulnerable to getting upset about not being “seen” by her child.
In almost every instance of “defiant" behavior, if one digs a bit below the surface, there is a way the child is also not being seen, or a way in which her experience is not recognized. For a particularly dramatic example, a six-year-old was brought to my practice with a chief complaint of “defiant behavior”. Further history revealed significant trauma in the child’s life. An alcoholic father who had abandoned the child as a toddler had recently been making visits, at which time he was often drunk and very loud. Yet her feelings about visits had not been discussed until they came to see me for “defiant” behavior,” which was worse around bedtime.
This child began sleeping all night in her bed after a couple of visits with me. We discussed this experience, recognizing her need for her mother's company at bedtime for stories, comfort and reassurance. Once a child feels that he is being seen, that his experience is recognized and understood, the "difficult" behavior often evaporates.
In general, if there is increasing “defiance” it is important to take a step back and try to understand what feels out of control for the child. It might be that he is very sensitive to loud noises or taste, and battles around "making a scene” at a family outing or being “picky eater” are related to these sensory sensitivities. It might be that there is a new baby and everyone is chronically sleep deprived. Or there may be financial stress or marital conflict. Simply recognizing that these things are difficult for a child and acknowledging his experience, even if the stressors are still there, goes a long way in having a child feel understood, and in turn decreasing “defiant” behavior.
Limits on behavior are essential, and my book goes on to say that the above toddler must be taught that hitting is never OK. But understanding, empathy and managing our own distress are all equally important. Reframing "difficult" behavior as "stressed" behavior is an important first step.
Jumat, 02 Desember 2011
When Time and Space is the Treatment
In my pediatric practice, it is not uncommon for a parent, given the space and time, to reveal a critical and unexpected piece of information. Consider these two stories, with details changed to protect privacy. Jennifer’s Mom was desperate for a change in her ADHD medication. A previous doctor had diagnosed her and now she was increasingly distracted in school. In telling me Jennifer’s story, Mom focused on all the different medications she had been on and how they had controlled her symptoms. Towards the very end of the 50 minute visit Mom almost casually dropped this information. “She’s wary of therapists because of what happened with DCF (Department of Children and Families.)” I asked why. Recently, Jennifer had told a therapist about her stepfather’s behavior and it had been reported as possible abuse.
Five year old Kevin’s Mom was distraught about his constant fighting with his younger sister. He always had to have everything first, his demands were escalating. They were having increasing difficulty getting out of the house in the morning. I saw them for 2 fifty minute visits. The first involved the whole family and we talked about some common approaches to managing behavior. I was struck by Mom’s level of distress, which seemed out of proportion to this fairly typical sibling rivalry. Towards the end of the second visit, when Mom was alone with Kevin, she quietly began to cry. I looked puzzled. She told me of the horrible accident that had taken the life of her older brother when she was a child. Her family had never mourned this loss. That trauma came flooding back now that she had two children of her own.
“If you ask questions you get answers-and hardly anything else.” This well know aphorism in medicine comes from a book, The Doctor, HIs Patient and the Illness by Hungarian psychiatrist Michael Balint. In this book he documents his experience running groups for primary care doctors. He writes of the “doctor as drug,” describing how doctors use themselves and their relationship with their patients as an important part of the care they offer.
Time and space, then, is the treatment. It gives patients a chance to say what is really important, the things that won’t come out if doctors just ask questions. For parents who feel stressed and alone, an opportunity to sit in a quiet room with respected and attentive listener for 50 minutes is invaluable. It gives them an opportunity to think about their child, rather than simply get advice about what to do. In both of these cases, telling their story was essential for effective treatment. For Jennifer, she needed an acknowledgement of the trauma of that experience with DCF, which now got in the way of her asking for help. Kevin’s mother recognized how her own unresolved loss interfered with her ability to respond effectively to her children. In a brief visit structured by questions, parents are unlikely to develop the comfort required to open up.
The world of business has its own saying: “Time is money.” For the private health insurance industry it is more profitable to cover a brief "medication check" than a 50 minute visit. Put this together with huge marketing efforts from the pharmaceutical industry and you have a big problem. Prescribing medication takes much less time than sitting with someone until they trust you enough to talk about what is important.
Primary care practices must have a large staff to manage the complexities of multiple different insurance plans. Office managers spend hours making calls and filling out forms to get insurance companies to give prior authorization for such things as MRIs and neuropsychological testing. In order for the practice to be viable and support this staff, the doctors are forced to see more patients in less time.
The interests of the private health insurance industry and the interests of children can stand in direct opposition to one another. As health care reform (I hope!) proceeds, the perspective of this non-voting population must be taken into account.
Five year old Kevin’s Mom was distraught about his constant fighting with his younger sister. He always had to have everything first, his demands were escalating. They were having increasing difficulty getting out of the house in the morning. I saw them for 2 fifty minute visits. The first involved the whole family and we talked about some common approaches to managing behavior. I was struck by Mom’s level of distress, which seemed out of proportion to this fairly typical sibling rivalry. Towards the end of the second visit, when Mom was alone with Kevin, she quietly began to cry. I looked puzzled. She told me of the horrible accident that had taken the life of her older brother when she was a child. Her family had never mourned this loss. That trauma came flooding back now that she had two children of her own.
“If you ask questions you get answers-and hardly anything else.” This well know aphorism in medicine comes from a book, The Doctor, HIs Patient and the Illness by Hungarian psychiatrist Michael Balint. In this book he documents his experience running groups for primary care doctors. He writes of the “doctor as drug,” describing how doctors use themselves and their relationship with their patients as an important part of the care they offer.
Time and space, then, is the treatment. It gives patients a chance to say what is really important, the things that won’t come out if doctors just ask questions. For parents who feel stressed and alone, an opportunity to sit in a quiet room with respected and attentive listener for 50 minutes is invaluable. It gives them an opportunity to think about their child, rather than simply get advice about what to do. In both of these cases, telling their story was essential for effective treatment. For Jennifer, she needed an acknowledgement of the trauma of that experience with DCF, which now got in the way of her asking for help. Kevin’s mother recognized how her own unresolved loss interfered with her ability to respond effectively to her children. In a brief visit structured by questions, parents are unlikely to develop the comfort required to open up.
The world of business has its own saying: “Time is money.” For the private health insurance industry it is more profitable to cover a brief "medication check" than a 50 minute visit. Put this together with huge marketing efforts from the pharmaceutical industry and you have a big problem. Prescribing medication takes much less time than sitting with someone until they trust you enough to talk about what is important.
Primary care practices must have a large staff to manage the complexities of multiple different insurance plans. Office managers spend hours making calls and filling out forms to get insurance companies to give prior authorization for such things as MRIs and neuropsychological testing. In order for the practice to be viable and support this staff, the doctors are forced to see more patients in less time.
The interests of the private health insurance industry and the interests of children can stand in direct opposition to one another. As health care reform (I hope!) proceeds, the perspective of this non-voting population must be taken into account.
Jumat, 25 November 2011
Modern Christmas Decorating
Sock Bump Anxiety Disorder? Understanding Children with Sensory Over-responsiveness
In the December issue of the Journal of the American Academy of Child and Adolescent Psychiatry there is an article, with an accompanying commentary, that encourages me to think that perhaps the discipline of psychiatry is making moves from the "what" to the "why" of mental illness. Alice Carter, a brilliant researcher at UMass Boston, has an article entitled Sensory Over-Responsivity, Psychopathology, and Family Impairment in School-Aged Children.
In their editorial in the same issue Cynthia Rogers and Joan Luby write:
I have wondered what it is that makes one child with sensory over-responsiveness and concurrent problems of self-regulation develop depressive symptoms, other autistic symptoms and yet another hyperactivity and attention problems. I suspect we will find that the gene(s) responsible for sensory processing are associated with different genetic vulnerabilities, and so the symptom takes a different path.
Occupational therapists have long recognized the significance of these problems, and many have advocated for adding a diagnosis of "sensory integration disorder" to the DSM list. Rather than debate whether sensory over-responsiveness is a disorder in and of itself, it is in my opinion, enough to recognize, as Dr. Carter has done, that it can be a significant problem for a child and family. Then primary care clinicians, mental health care providers as well as friends and family can offer the validation and support these families need. Waiting for a DSM defined diagnosis to emerge may narrow thinking and cloud our view of the complexity of the family's experience (Such a label maybe necessary, unfortunately, to bill insurance for services.) As I have said before on this blog, these "problems" of sensory over-responsiveness may be transformed into adaptive assets when children, validated and understood by their caregivers, develop the language skills and capacity for self-regulation that come with growing up.
In their editorial in the same issue Cynthia Rogers and Joan Luby write:
This work suggests that developmental scientists and mental health clinicians should recognize sensorimotor processing as an important independent developmental domain and key area of challenge in early childhood that has tangible implications for behavioral and emotional functioning.Interestingly Joan Luby has written about the validity of diagnosing major depressive disorder in preschool children, an idea about which I have grave concerns. I wrote, in a response in the Boston Globe when her work on this subject was first published:
My sense is that these children process the world differently. One mother described carrying her screaming son for hours until she realized that he didn't want to be held. Another mother said her daughter was "not cuddly" and difficult to feed. As they become toddlers, the issues change. I hear about what I call "sock bump anxiety," where many changes of socks are required to find the one with the right seam in the toes. "Fun" family outings to a county fair can end in disaster as kids become overwhelmed by all of the sights and sounds. Intense tantrums and meltdowns are frequent.Now I wonder if Luby an I are more on the same page than I had thought. The question, in my opinion, should be not "what is the disorder" but rather "what is the expereince of this particular child and family?" Unfortunately, as Dan Carlat states in his book Unhinged: the Trouble with Psychiatry
The tradition of psychological curiosity has been dying a gradual death, and the DSM is part cause, part consequence of this transformation of our profession. These days psychiatrists are less interested in ‘why’ and more interested in ‘what’.My clinical experience is consistent with Dr. Carter's findings. I see young children with a wide range of behavioral concerns. Sometimes they have symptoms of anxiety. Others are "explosive" or "hyperactive and impulsive" Still others have rigid rituals, and teachers have raised concern about autism spectrum disorder. In almost every story, there are symptoms of sensory over-responsiveness. These symptoms are inevitably accomapied by problems of self-regulation and in fact have been called "regulatory disorders" in the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood–Revised(DC:0-3R). And as Dr. Carter describes, these symptoms are very disruptive to family functioning. Often siblings are the most dramatically affected when their needs are relegated to the back burner, as families struggle to avoid and then manage the frequent meltdowns that inevitably accompany these sensory difficulties.
I have wondered what it is that makes one child with sensory over-responsiveness and concurrent problems of self-regulation develop depressive symptoms, other autistic symptoms and yet another hyperactivity and attention problems. I suspect we will find that the gene(s) responsible for sensory processing are associated with different genetic vulnerabilities, and so the symptom takes a different path.
Occupational therapists have long recognized the significance of these problems, and many have advocated for adding a diagnosis of "sensory integration disorder" to the DSM list. Rather than debate whether sensory over-responsiveness is a disorder in and of itself, it is in my opinion, enough to recognize, as Dr. Carter has done, that it can be a significant problem for a child and family. Then primary care clinicians, mental health care providers as well as friends and family can offer the validation and support these families need. Waiting for a DSM defined diagnosis to emerge may narrow thinking and cloud our view of the complexity of the family's experience (Such a label maybe necessary, unfortunately, to bill insurance for services.) As I have said before on this blog, these "problems" of sensory over-responsiveness may be transformed into adaptive assets when children, validated and understood by their caregivers, develop the language skills and capacity for self-regulation that come with growing up.
Selasa, 22 November 2011
A Small Town, A Little Boy, and a Terrible Disease
(This post was written for a former patient from my days of doing general pediatrics, who turned 11 on 11/11/11)
Charley was with his mother in my office for his three-year-old check-up. Having taken care of Charley since he was born, I knew his family well. They had relocated from New York to our small New England town. As often happens in a small town, we shared many other connections. Tracy, Charley’s mother, taught at the school my children attended. We had many friends in common. Shortly before this visit, I ran into her outside the community center after dropping my kids at camp. Tracy was 5 months pregnant with a girl. “How’s your summer going?” I asked. Her smile was huge. “Great!” she replied. “Sam (her older son) is in camp so I get to spend all this special time with Charley.” She looked over at him as he ran around on the grass. “I fall more in love with him every day.”
Charley sat quietly on the exam table as our conversation flowed easily from social events to sleep habits. He was generally healthy, but was in early intervention for low muscle tone and mild language delay. His language was progressing, and the physical therapist, Tracy told me, was not concerned. “But he’s having some trouble climbing stairs,” she said. This struck me as odd, as Charley was a very active boy in an athletic family, and I made a mental note. Later that afternoon, I called our local pediatric neurologist. “I should see him,” he said. “And send him to the lab for a CPK (an enzyme made by muscles).” I called Tracy. She and her husband Benjy decided that they preferred to go to a neurologist in New York, and would schedule their own appointment, but agreed to pick up the lab slip for the blood test.
One evening several months later I was on call, the only doctor in the office with a sick child. I was on the phone with the ICU doctor at the hospital when my nurse handed me a slip of paper.
Charley S.
Critical Value
CPK 21,000
An hour later I was home, having somehow managed to transfer the little girl. I held the message in my hand. I had never seen a CPK this high, the normal number being under 100. After anxiously pacing around for a few minutes, I paged the neurologist I had originally spoken with. “He has muscular dystrophy,” he said without pause. I hung up the phone, trembling. I would have to tell a family that their son was going to die.
I needed to speak with the neurologist who had seen Charley. But I didn’t know who it was. So I had to call Tracy. I tried to be calm, explaining that the test results weren’t quite normal and that I wanted the name of the neurologist they had seen in New York. She gave me his number and asked, “How abnormal are they?” “They are high”, I replied. “I’ll speak with the neurologist tonight and meet you in the office first thing in the morning.” “OK”, she said. I hung up the phone and said to myself, “She knows.”
I spent the next hour on the phone with the New York neurologist. He said it was most likely Duchene’s muscular dystrophy (DMD). He described the current prognosis as “wheelchair by 10, death by 20”. But he suggested that I share with Charley’s parents that current research in gene therapy might offer a cure in the next 10-20 years. He wished me luck. During the few minutes that I slept that night, I had tormented dreams about telling them.
Tracy came alone. Years later she told me, “I purposefully kept quiet that morning as Benjy kissed the kids goodbye and went off to work just to give him one more morning of a normal life. ”
The nurse led her to an exam room and reported to me, “She’s a little shaky.” “That makes two of us,” I replied. I took a deep breath and walked in the room. I sat next to Tracy and held her, both of us sobbing. However, I was sure to reinforce that there was hope- that current research offered the possibility of a cure.
After a few weeks of living in shock, Tracy and Benjy took action. They started Charley’s Fund, whose sole aim is to raise money for research to find a cure for DMD. In seven years they have raised over $17 million. In the Fund’s most recent brochure, they write, ”All that “plugging away” has led to a very exciting moment in DMD history: first-ever human clinical trials for DMD boys.”
Tracy told me of a recent visit to the neurologist. “The doc examined Charley and just blurted out "Wow...this is epic!" He could barely believe that Charley can hold his head off a pillow when lying on his back for 60 seconds. The fact that he can even jump off the floor, let alone a considerable distance, is amazing and I know that is due to the fact that we received his diagnosis early and started steroids, supplements, night braces, and a nightly physical therapy routine. I know many, many parents of DMD kids who were not diagnosed until 6 years old or even later because teachers, physical therapists, friends, even pediatricians tell them that all kids develop at their own pace and your son will catch up in time.”
I think often of that moment I stood looking at the lab slip. It was a last moment of calm before a collision between the small town doc and the family whose life would be forever changed. I sometimes wonder if it was the intimacy of the small town life that in some way led to the early diagnosis, and to the explosion of energy now propelling Charley’s family, and all the other boys with this devastating diagnosis, forward toward a cure.
Charley was with his mother in my office for his three-year-old check-up. Having taken care of Charley since he was born, I knew his family well. They had relocated from New York to our small New England town. As often happens in a small town, we shared many other connections. Tracy, Charley’s mother, taught at the school my children attended. We had many friends in common. Shortly before this visit, I ran into her outside the community center after dropping my kids at camp. Tracy was 5 months pregnant with a girl. “How’s your summer going?” I asked. Her smile was huge. “Great!” she replied. “Sam (her older son) is in camp so I get to spend all this special time with Charley.” She looked over at him as he ran around on the grass. “I fall more in love with him every day.”
Charley sat quietly on the exam table as our conversation flowed easily from social events to sleep habits. He was generally healthy, but was in early intervention for low muscle tone and mild language delay. His language was progressing, and the physical therapist, Tracy told me, was not concerned. “But he’s having some trouble climbing stairs,” she said. This struck me as odd, as Charley was a very active boy in an athletic family, and I made a mental note. Later that afternoon, I called our local pediatric neurologist. “I should see him,” he said. “And send him to the lab for a CPK (an enzyme made by muscles).” I called Tracy. She and her husband Benjy decided that they preferred to go to a neurologist in New York, and would schedule their own appointment, but agreed to pick up the lab slip for the blood test.
One evening several months later I was on call, the only doctor in the office with a sick child. I was on the phone with the ICU doctor at the hospital when my nurse handed me a slip of paper.
Charley S.
Critical Value
CPK 21,000
An hour later I was home, having somehow managed to transfer the little girl. I held the message in my hand. I had never seen a CPK this high, the normal number being under 100. After anxiously pacing around for a few minutes, I paged the neurologist I had originally spoken with. “He has muscular dystrophy,” he said without pause. I hung up the phone, trembling. I would have to tell a family that their son was going to die.
I needed to speak with the neurologist who had seen Charley. But I didn’t know who it was. So I had to call Tracy. I tried to be calm, explaining that the test results weren’t quite normal and that I wanted the name of the neurologist they had seen in New York. She gave me his number and asked, “How abnormal are they?” “They are high”, I replied. “I’ll speak with the neurologist tonight and meet you in the office first thing in the morning.” “OK”, she said. I hung up the phone and said to myself, “She knows.”
I spent the next hour on the phone with the New York neurologist. He said it was most likely Duchene’s muscular dystrophy (DMD). He described the current prognosis as “wheelchair by 10, death by 20”. But he suggested that I share with Charley’s parents that current research in gene therapy might offer a cure in the next 10-20 years. He wished me luck. During the few minutes that I slept that night, I had tormented dreams about telling them.
Tracy came alone. Years later she told me, “I purposefully kept quiet that morning as Benjy kissed the kids goodbye and went off to work just to give him one more morning of a normal life. ”
The nurse led her to an exam room and reported to me, “She’s a little shaky.” “That makes two of us,” I replied. I took a deep breath and walked in the room. I sat next to Tracy and held her, both of us sobbing. However, I was sure to reinforce that there was hope- that current research offered the possibility of a cure.
After a few weeks of living in shock, Tracy and Benjy took action. They started Charley’s Fund, whose sole aim is to raise money for research to find a cure for DMD. In seven years they have raised over $17 million. In the Fund’s most recent brochure, they write, ”All that “plugging away” has led to a very exciting moment in DMD history: first-ever human clinical trials for DMD boys.”
Tracy told me of a recent visit to the neurologist. “The doc examined Charley and just blurted out "Wow...this is epic!" He could barely believe that Charley can hold his head off a pillow when lying on his back for 60 seconds. The fact that he can even jump off the floor, let alone a considerable distance, is amazing and I know that is due to the fact that we received his diagnosis early and started steroids, supplements, night braces, and a nightly physical therapy routine. I know many, many parents of DMD kids who were not diagnosed until 6 years old or even later because teachers, physical therapists, friends, even pediatricians tell them that all kids develop at their own pace and your son will catch up in time.”
I think often of that moment I stood looking at the lab slip. It was a last moment of calm before a collision between the small town doc and the family whose life would be forever changed. I sometimes wonder if it was the intimacy of the small town life that in some way led to the early diagnosis, and to the explosion of energy now propelling Charley’s family, and all the other boys with this devastating diagnosis, forward toward a cure.
Jumat, 18 November 2011
Parenting in China: Academic Achievement or Empathy and Resourcefulness?
Recently I learned that a publishing company in China with the delightful name of "Good Morning Press" has purchased the rights to publish my book Keeping Your Child in Mind. I admit that China was the last country I expected to publish my book, which is in many ways the antithesis to the controversial book Battle Hymn of the Tiger Mother that received so much attention earlier this year. It made me wonder if, just as many Americans question the need to replicate the very rigid parenting methods espoused in the book in order to "compete with China," the Chinese (or at least some segment of the population) have recognized the value of instilling not high level skill, but rather empathy, flexibility, cognitive resourcefulness and social adaptation. The approach I describe in my book, based on over 40 years of developmental science research, points the way towards these qualities.
When Chua's book came out, I wrote the following post (I repeat it here, as it predated my Boston.com presence):
"All this talk about Amy Chua’s parenting techniques has me thinking about Brandon Fisher, the manufacturer of drilling equipment who President Obama recognized in the State of the Union Address for his critical role in the rescue of the Chilean miners. While I cannot claim to know anything about Fisher's upbringing, I do know a great deal about what qualities in a parent-child relationship lead to the characteristics he exhibited, namely empathy, flexibility and resourcefulness.
I wonder if the anxiety being experienced on a grand scale by American parents in the wake of Chua’s book is due to the fact that that while severe parenting techniques designed to achieve academic success may not be palatable, parents feel a void when it comes to finding an acceptable alternative model, as exemplified by the Boston globe op ed, The tiger mother roars, and slacker parents shudder.
John Bowlby, the father of attachment theory (no relation to “attachment parenting” as described by William Sears) describes the importance of a secure early relationships in raising a child who, in Bowlby’s words, is “self-reliant and bold in his explorations of the world, co-operative with others, and also-a very important point-sympathetic and helpful to others in distress.”
Contemporary research offers a close up view of a secure parent-child relationship that can instill these qualities. It involves a balance of empathy and limit setting. There are four key elements. The first is wondering about the meaning of a child’s behavior rather than responding to the behavior itself. The second is empathy. This is more than saying “I know how you feel.” It means actually feeling what your child is feeling, but reflecting it back to him in a way that says, “I know you’re upset, but we’ll manage.” The third is containing difficult emotions, often in the form of setting limits. Limit setting is about teaching the essential life skills of frustration tolerance, impulse control and emotional regulation. And forth, and perhaps most challenging, is doing all this without letting your own distress get in the way.
Lest this list cause a parent to feel overwhelmed by the enormity of the task, research of Ed Tronick, child development expert, offers hope. If parents are attuned with their child only 30% of the time, if 70% of the time you don’t connect with your child in the way I describe, as long as most disruptions are recognized and repaired, development moves forward in a healthy direction. In fact, disruptions and their subsequent repair are essential in instilling resilience, an important fourth attribute to add to Bowlby’s list. D.W.Winnicott, pediatrician turned psychoanalyst coined the phrase the “good-enough mother” to describe a mother who is not perfect, and in her very imperfection helps her child to manage life’s challenges in direct proportion to what he is capable of.
Chua’s book, in addition to creating mass unease in American parents, has raised fear regarding our ability to compete with China. Towards that end, raising a generation of Brandon Fishers, citizens with the qualities of empathy, flexibility, resourcefulness, and resilience, is essential. In order to accomplish this task, we must support parent-child relationships from the beginning. There is extensive evidence that children learn these skills in infancy, when the brain is making as many as 1.8 million neural connections per second.
Unfortunately our country does not value parents in this way. Our lack of support of early parent-child relationships is exemplified by our maternity leave policy that lags far behind other countries, as well as the rapid increase of prescribing of psychoactive medication to very young children. This second phenomenon is in turn inextricably linked with the very powerful health insurance industry and the lack of value placed on primary care and mental health care services.
Public policy to support early parent-child relationships is essential. For example, postpartum depression can negatively impact a mother's ability to be present with her child in a way that promotes healthy emotional development. Recently a new law was passed in Massachusetts that calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.
Contemporary research in child development offers an answer to the questions raised by Chua, both on a small scale: a model of parenting to follow, and on a large scale: a model of social policy to support parents in this task. I thank her for providing the motivation to address issues that are critical for the future of our children and of our country."
Perhaps this interest in my book implies that China (at least in some small way) has caught on to the importance of valuing parent-child relationships. If so, now more than ever is the time for our country to recognize the need to nurture these, in a sense, American qualities of empathy, flexibility, resourcefulness and resilience.
When Chua's book came out, I wrote the following post (I repeat it here, as it predated my Boston.com presence):
"All this talk about Amy Chua’s parenting techniques has me thinking about Brandon Fisher, the manufacturer of drilling equipment who President Obama recognized in the State of the Union Address for his critical role in the rescue of the Chilean miners. While I cannot claim to know anything about Fisher's upbringing, I do know a great deal about what qualities in a parent-child relationship lead to the characteristics he exhibited, namely empathy, flexibility and resourcefulness.
I wonder if the anxiety being experienced on a grand scale by American parents in the wake of Chua’s book is due to the fact that that while severe parenting techniques designed to achieve academic success may not be palatable, parents feel a void when it comes to finding an acceptable alternative model, as exemplified by the Boston globe op ed, The tiger mother roars, and slacker parents shudder.
John Bowlby, the father of attachment theory (no relation to “attachment parenting” as described by William Sears) describes the importance of a secure early relationships in raising a child who, in Bowlby’s words, is “self-reliant and bold in his explorations of the world, co-operative with others, and also-a very important point-sympathetic and helpful to others in distress.”
Contemporary research offers a close up view of a secure parent-child relationship that can instill these qualities. It involves a balance of empathy and limit setting. There are four key elements. The first is wondering about the meaning of a child’s behavior rather than responding to the behavior itself. The second is empathy. This is more than saying “I know how you feel.” It means actually feeling what your child is feeling, but reflecting it back to him in a way that says, “I know you’re upset, but we’ll manage.” The third is containing difficult emotions, often in the form of setting limits. Limit setting is about teaching the essential life skills of frustration tolerance, impulse control and emotional regulation. And forth, and perhaps most challenging, is doing all this without letting your own distress get in the way.
Lest this list cause a parent to feel overwhelmed by the enormity of the task, research of Ed Tronick, child development expert, offers hope. If parents are attuned with their child only 30% of the time, if 70% of the time you don’t connect with your child in the way I describe, as long as most disruptions are recognized and repaired, development moves forward in a healthy direction. In fact, disruptions and their subsequent repair are essential in instilling resilience, an important fourth attribute to add to Bowlby’s list. D.W.Winnicott, pediatrician turned psychoanalyst coined the phrase the “good-enough mother” to describe a mother who is not perfect, and in her very imperfection helps her child to manage life’s challenges in direct proportion to what he is capable of.
Chua’s book, in addition to creating mass unease in American parents, has raised fear regarding our ability to compete with China. Towards that end, raising a generation of Brandon Fishers, citizens with the qualities of empathy, flexibility, resourcefulness, and resilience, is essential. In order to accomplish this task, we must support parent-child relationships from the beginning. There is extensive evidence that children learn these skills in infancy, when the brain is making as many as 1.8 million neural connections per second.
Unfortunately our country does not value parents in this way. Our lack of support of early parent-child relationships is exemplified by our maternity leave policy that lags far behind other countries, as well as the rapid increase of prescribing of psychoactive medication to very young children. This second phenomenon is in turn inextricably linked with the very powerful health insurance industry and the lack of value placed on primary care and mental health care services.
Public policy to support early parent-child relationships is essential. For example, postpartum depression can negatively impact a mother's ability to be present with her child in a way that promotes healthy emotional development. Recently a new law was passed in Massachusetts that calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.
Contemporary research in child development offers an answer to the questions raised by Chua, both on a small scale: a model of parenting to follow, and on a large scale: a model of social policy to support parents in this task. I thank her for providing the motivation to address issues that are critical for the future of our children and of our country."
Perhaps this interest in my book implies that China (at least in some small way) has caught on to the importance of valuing parent-child relationships. If so, now more than ever is the time for our country to recognize the need to nurture these, in a sense, American qualities of empathy, flexibility, resourcefulness and resilience.
Minggu, 13 November 2011
Antidepressants in Pregnancy and Autism: A Possible Link
Studies abound that aim to answer both the question "What causes autism?" and "What is the reason for the increase in incidence and prevalence of autism?" A study published in the November issue of the Archives of General Psychiatry, Antidepressant Use During Pregnancy and Childhood Autism Spectrum Disorders caught my attention. As both the prevalence of autism and the use of SSRI's (selective serotonin reuptake inhibitors) have increased dramatically in recent years, and SSRI's are powerful medications that act on the brain, the findings do seem plausible.
Writing about research for a general audience, I want to say at the start that this is a preliminary investigation, one that simply raises a question. Pregnant women or those planning to conceive who are on these medications should not rush to go off them. The authors of the study are careful to say that, "The potential risk associated with exposure must be balanced with the risk to the mother or fetus of untreated mental health disorders." Untreated mental health disorders do pose a risk to mother and fetus. Women who are pregnant or of childbearing age and contemplating getting pregnant who have been on SSRI's may have a great difficulty getting off of them even if there is a question of risk to a fetus.
In this population based study done at the Kaiser Permanente Medical Care Program in Northern California, the researchers found
The authors conclude:
Recently I had the privilege to read an advance review copy of a book due to come out this April with the compelling title Dosed: The Medication Generation Grows Up. A well-researched book written by a journalist who has herself been on SSRI's since her teenage years, it shows how these drugs are often not a quick fix, but rather may be followed by a decades-long relationship with psychiatric medication. One particularly striking story is of a woman started on a SSRI at age 11 who, now pregnant in her thirties, is unable to get off them despite her strong desire to protect her unborn child from the potential risks of the drug.
Because these medications can cause such dramatic symptom relief, it is understandable how parents, physicians and teenagers themselves are drawn to them. Seeing your child in emotional pain is one of the greatest challenges of being a parent. However, in the absence of suicidality, holding them through these crises, with a combination of careful listening and quality psychotherapy, may in fact give them the tools to manage future crises they may encounter as they venture out into the world on their own. In my book, Keeping Your Child in Mind, the chapter on adolescence shows how these interventions can promote healthy emotional development.
Shortage of quality mental health care services, as well as lack of support for parents of teenagers, may make this kind of help difficult to attain. But now that this risk of SSRI's to a fetus is out there as a possibility, I believe it is more important than ever that we as a society make an effort to provide treatment for children and adolescents with mild to moderate depression that does not include prescribing psychiatric medication.
Writing about research for a general audience, I want to say at the start that this is a preliminary investigation, one that simply raises a question. Pregnant women or those planning to conceive who are on these medications should not rush to go off them. The authors of the study are careful to say that, "The potential risk associated with exposure must be balanced with the risk to the mother or fetus of untreated mental health disorders." Untreated mental health disorders do pose a risk to mother and fetus. Women who are pregnant or of childbearing age and contemplating getting pregnant who have been on SSRI's may have a great difficulty getting off of them even if there is a question of risk to a fetus.
In this population based study done at the Kaiser Permanente Medical Care Program in Northern California, the researchers found
a 2-fold increased risk of ASD(autism spectrum disorder) associated with treatment with selective serotonin reuptake inhibitors by the mother during the year before delivery, with the strongest effect associated with treatment during the first trimester.They found that there was no increase in risk for ASD if a mother had been treated for mental health problems but did not receive SSRI's. This finding attempts to answer the question of whether it is the depression or the drug that is associated with ASD. Their findings suggest that it is the drug.
The authors conclude:
Although the number of children exposed prenatally to selective serotonin reuptake inhibitors in this population was low, results suggest that exposure, especially during the first trimester, may modestly increase the risk of ASD. Further studies are needed to replicate and extend these findings.My reaction to the study is not its implication for women who are pregnant now, but for young girls and adolescents who are being placed on these medications, often by pediatricians, for relatively mild symptoms. SSRI's have been shown to be effective for severe depression, and certainly in the setting of suicidal behavior, the urgent need for treatment may outweigh the potential long-term risk.
Recently I had the privilege to read an advance review copy of a book due to come out this April with the compelling title Dosed: The Medication Generation Grows Up. A well-researched book written by a journalist who has herself been on SSRI's since her teenage years, it shows how these drugs are often not a quick fix, but rather may be followed by a decades-long relationship with psychiatric medication. One particularly striking story is of a woman started on a SSRI at age 11 who, now pregnant in her thirties, is unable to get off them despite her strong desire to protect her unborn child from the potential risks of the drug.
Because these medications can cause such dramatic symptom relief, it is understandable how parents, physicians and teenagers themselves are drawn to them. Seeing your child in emotional pain is one of the greatest challenges of being a parent. However, in the absence of suicidality, holding them through these crises, with a combination of careful listening and quality psychotherapy, may in fact give them the tools to manage future crises they may encounter as they venture out into the world on their own. In my book, Keeping Your Child in Mind, the chapter on adolescence shows how these interventions can promote healthy emotional development.
Shortage of quality mental health care services, as well as lack of support for parents of teenagers, may make this kind of help difficult to attain. But now that this risk of SSRI's to a fetus is out there as a possibility, I believe it is more important than ever that we as a society make an effort to provide treatment for children and adolescents with mild to moderate depression that does not include prescribing psychiatric medication.
Kamis, 10 November 2011
Star Sculptures By John Kostick
These delightful Star Sculptures are the work of John Kostick. "The abstract lines that define geometric forms are indicated by actual physical parts that interact synergetically," says the designer. "Thus symmetry and structural integrity are the results of the assemblage of simple linear components, tension and compression, push and pull." See link above or Design Within Reach
Rabu, 09 November 2011
Handmade Home at Gilt Group
Global Views
Arterior Homes
Tina Frey
Arterior Homes
Alice Goldsmith
Cyan
Selasa, 08 November 2011
Superstar Tree, Modern Christmas and Hanukkah
Tcherassi Hotel and Spa, Cartagena
Set in a restored 250 year old mansion, Tcherassi Hotel and Spa is the creation of fashion designer Silvia Tcherassi. Boasting seven unique rooms and suites, four pools, an Italian restaurant and a spa, the space is a mix of glitz and simplicity, colonial charm and contemporary design. Photos: Tcherassi Hotel & Spa.
Senin, 07 November 2011
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