Carolyn Riley’s act of giving her daughter Rebecca an overdose of prescribed medication may have been the immediate cause of Rebecca’s death, the conclusion reached by the jury that convicted her of murder. Even if, as the prosecutor argued, Carolyn and her husband concocted symptoms of mental illness and the psychiatrist, who diagnosed bipolar disorder, was a gullible enabler, the real guilty party in this story is, in my opinion, our health care system. With our over-reliance on psychoactive medication to fix complex problems, we condone the actions of the psychiatrist. We have failed to create a system that values prevention and meaningful, relationship based intervention. If she didn't have the drugs, Rebecca would not have died.
A recent announcement by The American Psychiatric Association that it intends to include a new diagnosis in its upcoming fifth edition of the Diagnostic and Statistical Manual(DSM-V) has me feeling optimistic. The new condition will be called temper dysregulation with dysphoria(TDD). The hope is that new label will be used instead of the bipolar label, allowing clinicians to describe a serious behavior problem without committing children to a chronic lifelong disorder.
Gabrielle Carson, a child psychiatrist at Stony Brook University offers this perspective on the issue in an NPR piece.. Many of the behaviors associated with what is currently referred to as “bipolar disorder” were previously described as “conduct disorder”, She says, “If you’ve got something that is not a medical problem, insurance is not going to pay for it. Conduct disorder is bad parenting, lousy environment, poor supervision, you’re a bad seed. It ain’t a medical problem. Bipolar they’ll pay for.”
Concerned about the large numbers of children being placed on powerful medications with serious side effects, David Schaffer, a psychiatrist on the DSM-V committee, proposed to create a new diagnosis. The hope is that this new disorder TDD, will be understood as a biologically based disorder that does not necessarily need to be treated with medication.
What if, instead of being prescribed medication to control her young children’s behavior (all three were on psychoactive medication by age 3), Carolyn had received a different type of intervention, one that aimed to repair relationships? For example at the Yale based Minding the Baby program, Carolyn would have been given the opportunity, in the presence of a caring and non judgmental person, to consider experiences from her own troubled past that contributed to her difficult handling her daughter’s challenging behavior. That person would have worked with Carolyn and Rebecca together over time to support Carolyn in her efforts to think about her daughter’s inner world. Such interventions have been demonstrated to have a significant positive impact on a child’s mental health.
There is convincing evidence that psychoactive medication reduces problem behavior. But just as an Escher print offers two completely different ways to look at the same picture, research at the interface of neuroscience, developmental psychology and behavioral genetics offers a different paradigm from that offered by the pharmaceutical industry.
Problem behavior is a symptom. Children with behavior characteristic of bipolar disorder have difficulty with emotional regulation. Young children learn to regulate emotions in relationships. When people who care for a child can think about his experience of the world, when they can help him to contain intense emotions without becoming overwhelmed themselves, that child learns to manage himself in a complex social environment. A child may be born with a genetic vulnerability for difficulty regulating emotions. Responsive parenting, however, may alter the actual expression of these genes, and even change the chemistry and structure of the brain.
As a pediatrician, I understand why we are so quick to turn to drugs. Parents feel overwhelmed. The combination of a temperamentally difficult infant and a parent with few supports who may herself have been abused is particularly challenging. Mental health resources are severely limited. Parents are pressured by teachers, whose classrooms are disrupted by these children. Pediatricians, psychiatrists, parents and teachers are bombarded by intense marketing efforts of the pharmaceutical industry.
Just because a problem is biologically based does not mean drugs are the answer. Relationships, too, can change the brain. I hope we can get health care reform moving again and build a system that values prevention and early intervention. It is too late for Carolyn and Rebecca Riley. But let’s not make the same mistake twice.
Jumat, 12 Februari 2010
Selasa, 09 Februari 2010
Who Listens to the Doctor?
A recent editorial in the Boston Globe addressed the dearth of primary care physicians. The piece concluded: “Federal funding for new residency slots should follow reforms that address the underlying reasons - principally money - that lead doctors to choose to specialize.”Money is certainly important. But there is another obstacle to attracting primary care doctors that is more subtle, though perhaps equally important. Consider the following story.
Recently I had the opportunity to teach a group of pediatric interns and residents about contemporary child development research. As they filtered into the room, I overheard one young doctor wearing scrubs say to another, “I was up in the NICU (neonatal intensive care unit) all night - I’m going to sleep through this one.”
About halfway through the talk, I asked the group if they had ever been surprised by the things parents tell them in continuity clinic -the primary care experience doctors in training have where they follow children over a three year period.
I admit to having felt pleased when this doctor's hand shot up. She told the story of frustration trying to teach a mother how to control her three year old son’s increasingly explosive behavior. This young doctor explained how she felt like she was “beating her head against the wall” as the mother of the little boy seemed unable to follow through with anything she said. Then one day, what seemed to her “out of the blue,” the boy’s mother began to cry. She told the intern about the death of her own mother shortly after her son was born. She admitted to debilitating feelings of depression that made it hard for her to even be with her son, much less set limits as the doctor had been prescribing.
This mother’s unresolved grief was in the way of her ability to take in this young doctor’s “advice.” Her trust in the doctor, a result both of the relationship they had developed, and the implicit trust people often feel for their pediatrician, had enabled her finally to share these feelings of grief. If this problem had not been uncovered, it is likely that the intern’s continued efforts at “giving advice” would have failed.
I asked the doctor to tell us what she had been experiencing while this mother shared her story. She described feeling panicked and inadequate. Not only was she worried about the waiting room full of families who might have to wait longer if she got “stuck” with this grieving mother, but she didn’t know “what to do.” The idea that listening to this mother was actually exactly what she needed to do had not occurred to her.
This intern had conveyed to this mother that it was OK to talk about these difficult feelings. If doctors do not communicate this interest, it is not because they are not interested. It is because they fear that they will be inadequate to the task of “solving the problem.”
In addition, just as the mother needed to have her experience heard in order to be available for her child, this intern needed the support of her colleagues to help her manage her feelings. She was fortunate to have an opportunity to share with us her feelings about this upsetting experience.
To hold someone’s pain in the way that this intern had to do is not easy. Imagine hearing 10 stories of trauma and loss over the course of a week. It is very hard to hear these stories without having a place to share the burden. As a matter of self protection, doctors in training may not let on that they want to hear.
This dilemma occurs not only in training programs. Primary care clinicians are struggling under many pressures, including decreasing reimbursement necessitating more visits in less time to cover the administrative costs of accepting many different insurance plans. Doctors know the importance of listening to their patients, but don’t have the time or the emotional support to open up in this way.
Financial reward is critical for attracting doctors to primary care. In addition, our culture, including our medical education system, needs to value the role of doctor as listener, or these young clinicians will burn out before they even start.
Recently I had the opportunity to teach a group of pediatric interns and residents about contemporary child development research. As they filtered into the room, I overheard one young doctor wearing scrubs say to another, “I was up in the NICU (neonatal intensive care unit) all night - I’m going to sleep through this one.”
About halfway through the talk, I asked the group if they had ever been surprised by the things parents tell them in continuity clinic -the primary care experience doctors in training have where they follow children over a three year period.
I admit to having felt pleased when this doctor's hand shot up. She told the story of frustration trying to teach a mother how to control her three year old son’s increasingly explosive behavior. This young doctor explained how she felt like she was “beating her head against the wall” as the mother of the little boy seemed unable to follow through with anything she said. Then one day, what seemed to her “out of the blue,” the boy’s mother began to cry. She told the intern about the death of her own mother shortly after her son was born. She admitted to debilitating feelings of depression that made it hard for her to even be with her son, much less set limits as the doctor had been prescribing.
This mother’s unresolved grief was in the way of her ability to take in this young doctor’s “advice.” Her trust in the doctor, a result both of the relationship they had developed, and the implicit trust people often feel for their pediatrician, had enabled her finally to share these feelings of grief. If this problem had not been uncovered, it is likely that the intern’s continued efforts at “giving advice” would have failed.
I asked the doctor to tell us what she had been experiencing while this mother shared her story. She described feeling panicked and inadequate. Not only was she worried about the waiting room full of families who might have to wait longer if she got “stuck” with this grieving mother, but she didn’t know “what to do.” The idea that listening to this mother was actually exactly what she needed to do had not occurred to her.
This intern had conveyed to this mother that it was OK to talk about these difficult feelings. If doctors do not communicate this interest, it is not because they are not interested. It is because they fear that they will be inadequate to the task of “solving the problem.”
In addition, just as the mother needed to have her experience heard in order to be available for her child, this intern needed the support of her colleagues to help her manage her feelings. She was fortunate to have an opportunity to share with us her feelings about this upsetting experience.
To hold someone’s pain in the way that this intern had to do is not easy. Imagine hearing 10 stories of trauma and loss over the course of a week. It is very hard to hear these stories without having a place to share the burden. As a matter of self protection, doctors in training may not let on that they want to hear.
This dilemma occurs not only in training programs. Primary care clinicians are struggling under many pressures, including decreasing reimbursement necessitating more visits in less time to cover the administrative costs of accepting many different insurance plans. Doctors know the importance of listening to their patients, but don’t have the time or the emotional support to open up in this way.
Financial reward is critical for attracting doctors to primary care. In addition, our culture, including our medical education system, needs to value the role of doctor as listener, or these young clinicians will burn out before they even start.
Kamis, 04 Februari 2010
On Not Giving Advice
"Parenting behaviors impact young children's development'" says an interesting study by Frances Glascoe, PhD and Shirley Leew, PhD in the February issue of the journal Pediatrics. Using well validated measurement tools, they demonstrate that the way a parent interacts with her child has an impact on language development as early as six months of age. In addition, specific risk factors, including multiple moves, more than 3 siblings and parental depression are associated with interactions less likely to promote language development. In the discussion, the authors suggest that "future research in parenting behaviors that affect child development is crucial," and that "in the interim, clinicians should advise parents routinely on the value of talking frequently with their children... and describing what they are doing."
This is an important study, supporting extensive existing research demonstrating the critical role of early parent-child relationships on brain development. But I wonder, if in the discussion, pediatricians might do well to borrow some ideas from our psychoanalyst colleagues.
Pediatricians are trained with a model of "giving advice." We are the experts and people look to us to be told what to do. Psychoanalysts, on the other hand, are trained to listen.
Being understood and having your feelings recognized by a person who is important to you is one of the most powerful experiences there is. When our feelings are validated, we know that we are not alone. I wonder if these parents in the study whose children were not on a healthy developmental path, parents who are clearly stressed, might benefit more from time spent sharing their feelings with an attentive and non-judgemental person, than they would from being given advice about talking more to their child.
As a scholar of psychoanalytic thought, I have applied a psychoanalytic model in my pediatric practice. Recently I sat with Ashley, the mother of 4 month old Brian, while her husband Tom held the baby and walked around the office. Ashely cried as she spoke of her debilitating depression. She shared her feelings of inadequacy as a mother when she was too overwhelmed to respond to Brian's crying. She did not want to increase her medication because she was breastfeeding, but she longed for some relief. She spoke of a strained relationship with her own mother, who she found to be cold and unhelpful. Two weeks later I again met with Ashley and Brian. Ashley described a complete transformation in their relationship. I watched the two of them exchange joyful smiles. I asked her what had changed. She explained that at our last visit, she had felt understood, both by me and by her husband. This understanding gave her the strength to be more responsive to Brian. In turn, she said, he seemed to be more calm.
Pediatricians, who are on the front lines with growing children and families, may understand child behavior and development better than any profession. Psychoanalysts understand how to use relationships to help people make meaningful changes in their lives.
I have been to several conferences with such titles as "Pediatrics and Psychiatry: An Essential Partnership" many of which end up being primarily discussions of how to work together around prescribing medication. My wish is for a collaboration entitled "Pediatrics and Psychoanalysis: An Essential Partnership." We have a tremendous amount to teach each other.
This is an important study, supporting extensive existing research demonstrating the critical role of early parent-child relationships on brain development. But I wonder, if in the discussion, pediatricians might do well to borrow some ideas from our psychoanalyst colleagues.
Pediatricians are trained with a model of "giving advice." We are the experts and people look to us to be told what to do. Psychoanalysts, on the other hand, are trained to listen.
Being understood and having your feelings recognized by a person who is important to you is one of the most powerful experiences there is. When our feelings are validated, we know that we are not alone. I wonder if these parents in the study whose children were not on a healthy developmental path, parents who are clearly stressed, might benefit more from time spent sharing their feelings with an attentive and non-judgemental person, than they would from being given advice about talking more to their child.
As a scholar of psychoanalytic thought, I have applied a psychoanalytic model in my pediatric practice. Recently I sat with Ashley, the mother of 4 month old Brian, while her husband Tom held the baby and walked around the office. Ashely cried as she spoke of her debilitating depression. She shared her feelings of inadequacy as a mother when she was too overwhelmed to respond to Brian's crying. She did not want to increase her medication because she was breastfeeding, but she longed for some relief. She spoke of a strained relationship with her own mother, who she found to be cold and unhelpful. Two weeks later I again met with Ashley and Brian. Ashley described a complete transformation in their relationship. I watched the two of them exchange joyful smiles. I asked her what had changed. She explained that at our last visit, she had felt understood, both by me and by her husband. This understanding gave her the strength to be more responsive to Brian. In turn, she said, he seemed to be more calm.
Pediatricians, who are on the front lines with growing children and families, may understand child behavior and development better than any profession. Psychoanalysts understand how to use relationships to help people make meaningful changes in their lives.
I have been to several conferences with such titles as "Pediatrics and Psychiatry: An Essential Partnership" many of which end up being primarily discussions of how to work together around prescribing medication. My wish is for a collaboration entitled "Pediatrics and Psychoanalysis: An Essential Partnership." We have a tremendous amount to teach each other.
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