The trauma for Artyom continues. After having been given up to an orphanage by his alcoholic mother who lost her parental rights, being adopted by a US family, sent back to Russia alone when his adoptive mother allegedly was unable to cope with his psychological problems, he has now become the object of a tug-of war between Russia and the US over his citizenship. His future seems to hold unimaginable uncertainty for a vulnerable seven year old boy.
As this battle plays out over the coming weeks to months, I hope we can learn from this tragic tale. As a behavioral pediatrician I often see families who have adopted children out of situations similar to Artyom’s. Among the most hopeful of these is the story of Rachel and Sam.
I vividly remember Rachel’s “aha” moment. She had brought her six year old son Sam to see me because he was aggressive and defiant. Sam was adopted from an orphanage in another country when he was four. Prior to the orphanage he had lived on the streets with his abusive mentally ill mother.
When Sam first came home, he was a terrified child with little language. He immediately began to thrive. But now at six, he was wearing the whole family down. Sam would argue about everything, and frequently these arguments turned into physical battles. Rachel was exhausted and discouraged. She wanted my advice about what to do to control his behavior.
Over 20 years of longitudinal child development research has demonstrated what can happen to children who have been hurt by the very person who was supposed to protect them. This paradoxical situation leads to confused and confusing behavior in relationships with people close to them. When children fear the same person they look to for safety at a time when their brains are rapidly growing, this experience affects the biochemistry of the brain. It creates what is referred to as a state of “hyper-arousal.” This means that a child has great difficulty regulating emotions and may have an overabundance of stress hormones released in response to what seems like a minor event. They do not know how to feel calm and safe.
The adoption agency gave Sam's new family none of this information. Thus his parents were bewildered by the fact that the discipline techniques that had been so effective with their biological children failed completely. I wanted to help Rachel to understand the magnitude of the challenge she and her husband faced, while at the same time not discouraging her.
My thinking was guided by an important research study termed “The Attachment Representations and Adoption Outcome Study.” Miriam Steele and her colleagues found that an adoptive parent’s ability to understand the meaning of a child’s behavior led to a positive relationship between parent and child.
On that magical day of the “aha” moment, Rachel was feeling resigned, deflated. We were focusing on some strategies to manage difficult mornings when she began to talk about her biological children. She suddenly recalled a term from the home schooling philosophy on which they had been raised. The term was “tomato staking” It referred to the way parents stand firm while their developing children twist and turn as they grow up. A parent is always present to guide them in the right direction, and does not ever abandon them.
The image was a vivid one: these plump juicy red tomatoes, healthy because of the strong and steady stake which did little more than stand there. But, Rachel realized, Sam did not have this experience in his early years of development.
Following this visit, Rachel’s approach to Sam changed. She sought out intensive help for Sam. She realized that the whole family needed support in coming to terms with the enormous challenges they faced. Though the work was very hard, the self blame and guilt from which she had been suffering all but disappeared.
I cannot claim to understand what went so terribly wrong for Artyom and his adoptive family. But if we can learn anything from this tragedy, it is that when adopting a child who has been traumatized, it is essential for a family to have both hearts and eyes wide open. And as a country we must offer access to the help they need.
Jumat, 16 April 2010
Kamis, 08 April 2010
Psychotropic Meds for Preschoolers? Think Again.
The most recent issue of Child and Adolescent Psychopharmacology News is devoted to this controversial subject. The author, Joan Luby, MD, provides a fair and thorough overview of the complexities of the issue. For example, she writes:
But then she goes on to say, in the section of her piece entitled, " Balancing Risk and Urgency to Help: Clinicians on the Front Line,":
As one of those clinicians "on the front lines" I find this suggestion unacceptable. Certainly there may be cases of severe mental illness in very young children which warrant treatment with psychopharmacological agents. But if such a young child had a brain tumor, parents and clinicians would find the means to get the child appropriate comprehensive treatment by a specialist. Such an illness would not be treated by clinicians "on the front lines." Last year in the Boston Globe I published a column entitled Backed into a Treatment Corner which speaks to just this dilemma.
After just having addressed the problem of use of psychopharmacological agents as sedatives, Dr. Luby has gone on to advocate for just that, essentially saying "if their is no other option, give drugs." As long as we continue to accept this second class citizen status of childhood mental illness, it is unlikely that significant progress will be made towards, in her words, "high quality and appropriate mental health care for children."
The article does address alternatives to psychopharmacology, but states, "the availability of empirically proven psychosocial therapies is insufficient to meet the need." This is where our efforts should be going. Here is one potentially fruitful route of investigation.
Longitudinal studies that follow children from infancy through adulthood have demonstrated a clear connection between a parent’s capacity to reflect on her child’s experience and secure attachment. Secure attachment relationships facilitate the capacity for emotional regulation. Emotional regulation in turn leads to resourceful thinking, social adaptation and overall mental health.
Selma Fraiberg was among the first to describe an intervention that aims to support a parent’s efforts to understand her child’s experience in her classic paper Ghosts in the Nursery. Subsequently, the fields of parent- infant and parent-child psychotherapy have expanded upon these ideas. Minding the Baby at Yale is one example of a reflective parenting program. Short Term Mentalization and Relational Therapy is a form of family therapy that specifically aims to facilitate a parent’s capacity to reflect on her child’s experience.
These interventions are currently used mostly by specialized infant mental health clinicians. I have been able to use this type of intervention in the setting of primary care pediatrics with significant results. In fact, by virtue of the longstanding relationship of trust that many parents have with their pediatrician, the primary care setting is ideally suited to make use of this model of intervention. Perhaps if we put as much energy into investigating these therapeutic techniques, and teaching them to clinicians on the front lines, as we do in discussing and promoting use of psychotropic medication, we would make a safer and more lasting impact on children's mental health.
Several factors in the current health care system, including structures now in place that provide reimbursement for medication treatment at far higher rates than for psychotherapy, lack of sufficient age-appropriate psychotherapeutic resources in many communities, and impediments and burdens to families that prevent them from obtaining more intensive psychotherapeutic care are all important factors in contributing to inappropriate use of psychotropic agents. Further, over use of pharmacological agents as sedatives should not be used as rationale for thwarting needed research, but should rather be addressed in the pursuit of high quality and appropriate mental health care for children.
But then she goes on to say, in the section of her piece entitled, " Balancing Risk and Urgency to Help: Clinicians on the Front Line,":
In circumstances where no other services are available(lack of transportation, lack of a caregiver with capacity to pursue therapy, no clinicians available with appropriate expertise) and symptoms are severe and impairing, pharmacological agents may be necessary as a first line agent in a young child.
As one of those clinicians "on the front lines" I find this suggestion unacceptable. Certainly there may be cases of severe mental illness in very young children which warrant treatment with psychopharmacological agents. But if such a young child had a brain tumor, parents and clinicians would find the means to get the child appropriate comprehensive treatment by a specialist. Such an illness would not be treated by clinicians "on the front lines." Last year in the Boston Globe I published a column entitled Backed into a Treatment Corner which speaks to just this dilemma.
After just having addressed the problem of use of psychopharmacological agents as sedatives, Dr. Luby has gone on to advocate for just that, essentially saying "if their is no other option, give drugs." As long as we continue to accept this second class citizen status of childhood mental illness, it is unlikely that significant progress will be made towards, in her words, "high quality and appropriate mental health care for children."
The article does address alternatives to psychopharmacology, but states, "the availability of empirically proven psychosocial therapies is insufficient to meet the need." This is where our efforts should be going. Here is one potentially fruitful route of investigation.
Longitudinal studies that follow children from infancy through adulthood have demonstrated a clear connection between a parent’s capacity to reflect on her child’s experience and secure attachment. Secure attachment relationships facilitate the capacity for emotional regulation. Emotional regulation in turn leads to resourceful thinking, social adaptation and overall mental health.
Selma Fraiberg was among the first to describe an intervention that aims to support a parent’s efforts to understand her child’s experience in her classic paper Ghosts in the Nursery. Subsequently, the fields of parent- infant and parent-child psychotherapy have expanded upon these ideas. Minding the Baby at Yale is one example of a reflective parenting program. Short Term Mentalization and Relational Therapy is a form of family therapy that specifically aims to facilitate a parent’s capacity to reflect on her child’s experience.
These interventions are currently used mostly by specialized infant mental health clinicians. I have been able to use this type of intervention in the setting of primary care pediatrics with significant results. In fact, by virtue of the longstanding relationship of trust that many parents have with their pediatrician, the primary care setting is ideally suited to make use of this model of intervention. Perhaps if we put as much energy into investigating these therapeutic techniques, and teaching them to clinicians on the front lines, as we do in discussing and promoting use of psychotropic medication, we would make a safer and more lasting impact on children's mental health.
Sabtu, 03 April 2010
Teaching Young Pediatricians to Wonder
Last week, I again had the privilege of teaching pediatricians in training. These students were very bright, challenging and asked excellent questions. They all agreed about the limit of the pediatric model of "giving advice." One resident, who had young children of her own, spoke of new mothers using blogs for emotional support. Many of these mothers speak less than kindly about their pediatricians, who they perceive as "not getting it" and telling them "what to do." We agreed that being given advice could be disempowering and that many parenting books, full of advice, actually make parents feel worse.
My seminar's aim was to teach them about the application of contemporary ideas about child development into their practice of pediatrics. This research shows that when parents can think about the meaning of their child's behavior, rather than respond just to the behavior itself, they facilitate their child's healthy emotional development. I shared with them an example from my practice to show how they could support parents in this task.
3 year old Mary had prolonged tantrums at bedtime and was up several times a night. Her parents told me that they would hold the door shut while Mary screamed and threw herself at the door in increasing agitation. Finally after an hour or so of this, one parent would go in to lie down with Mary because she was so agitated, and then she would fall asleep.
My students found the story disturbing, as it was obvious to them that this experience would be frightening for Mary. But I asked them to resist the impulse to give advice about how to manage bedtime and instead asked them to wonder, why were her parents, bright loving people, doing this?
I showed them a slide from a recent lecture by leading researchers in developmental psychology, Peter Fonagy and Mary Target. The slide showed how when people are stressed, their ability to reflect on another person's experience significantly decreased.
Rather than give these parents advice about how to manage this sleep problem, my task was to listen to their story, support them and even perhaps uncover the source of this stress. In doing so I might be able to help them think about what was happening from Mary's perspective.
Because we had a full 50 minute visit, and they began to feel comfortable with me, they did eventually share what was going on. They spoke of a terrible upheaval in Dad's family business and significant financial stress. They realized that Mary was likely responding to the huge amount of tension in the household. she was struggling to engage her increasingly emotionally distant parents. They understood that Mary was experiencing a kind of separation anxiety,and was looking for reassurance. Her anxiety came out most intensely at bedtime, which naturally precedes a long period of separation.
I gave these parents minimal advice about what to do. Instead, I helped them to understand a different way to be with Mary at bedtime. Within a few weeks her sleep problem resolved. My wondering about the meaning of their behavior led them to wonder about the meaning of Mary's behavior.
One of the residents asked me "what do I say?" Residents are taught "what to do" and then tell their patients "what to do." I hope that I conveyed to them that is not about what to say. Its about being present, open and emotionally available. Its about wondering. If they begin to wonder why parents behave the way they do with their children, they will be able to support parent's efforts to wonder about the meaning of a child's behavior.
I realize it's a big leap. One resident in the group was doing a rotation in the neonatal intensive care unit . When treating a critically ill newborn, knowing "what to do" is appropriate. I am asking him to use his brain in a completely different way.
Practicing primary care can be a deeply rewarding experience if we use our relationship with families in the way I have described. But it is not easy. One must be able to switch from a "what to do" mode when dealing with a sick child, to a wondering mode when working with behavior problems, which can make up as much as 40% of primary care visits.
However, if we can do this, we are in an ideal position to promote the healthy emotional development of the next generation. When seen from this perspective, primary care clinicians should be the highest, not the lowest, both paid and valued providers in our health care system.
My seminar's aim was to teach them about the application of contemporary ideas about child development into their practice of pediatrics. This research shows that when parents can think about the meaning of their child's behavior, rather than respond just to the behavior itself, they facilitate their child's healthy emotional development. I shared with them an example from my practice to show how they could support parents in this task.
3 year old Mary had prolonged tantrums at bedtime and was up several times a night. Her parents told me that they would hold the door shut while Mary screamed and threw herself at the door in increasing agitation. Finally after an hour or so of this, one parent would go in to lie down with Mary because she was so agitated, and then she would fall asleep.
My students found the story disturbing, as it was obvious to them that this experience would be frightening for Mary. But I asked them to resist the impulse to give advice about how to manage bedtime and instead asked them to wonder, why were her parents, bright loving people, doing this?
I showed them a slide from a recent lecture by leading researchers in developmental psychology, Peter Fonagy and Mary Target. The slide showed how when people are stressed, their ability to reflect on another person's experience significantly decreased.
Rather than give these parents advice about how to manage this sleep problem, my task was to listen to their story, support them and even perhaps uncover the source of this stress. In doing so I might be able to help them think about what was happening from Mary's perspective.
Because we had a full 50 minute visit, and they began to feel comfortable with me, they did eventually share what was going on. They spoke of a terrible upheaval in Dad's family business and significant financial stress. They realized that Mary was likely responding to the huge amount of tension in the household. she was struggling to engage her increasingly emotionally distant parents. They understood that Mary was experiencing a kind of separation anxiety,and was looking for reassurance. Her anxiety came out most intensely at bedtime, which naturally precedes a long period of separation.
I gave these parents minimal advice about what to do. Instead, I helped them to understand a different way to be with Mary at bedtime. Within a few weeks her sleep problem resolved. My wondering about the meaning of their behavior led them to wonder about the meaning of Mary's behavior.
One of the residents asked me "what do I say?" Residents are taught "what to do" and then tell their patients "what to do." I hope that I conveyed to them that is not about what to say. Its about being present, open and emotionally available. Its about wondering. If they begin to wonder why parents behave the way they do with their children, they will be able to support parent's efforts to wonder about the meaning of a child's behavior.
I realize it's a big leap. One resident in the group was doing a rotation in the neonatal intensive care unit . When treating a critically ill newborn, knowing "what to do" is appropriate. I am asking him to use his brain in a completely different way.
Practicing primary care can be a deeply rewarding experience if we use our relationship with families in the way I have described. But it is not easy. One must be able to switch from a "what to do" mode when dealing with a sick child, to a wondering mode when working with behavior problems, which can make up as much as 40% of primary care visits.
However, if we can do this, we are in an ideal position to promote the healthy emotional development of the next generation. When seen from this perspective, primary care clinicians should be the highest, not the lowest, both paid and valued providers in our health care system.
Langganan:
Postingan (Atom)
