When I see children in my pediatric practice for behavior problems, I often hear stories from mothers who struggled terribly when their children were very young infants. A most dramatic example of this was a mother with severe postpartum depression whose father died suddenly when her baby was four months old. Much to my astonishment, she described being relieved by this event. It wasn't because she didn’t love her father. Rather, in sharing the grief with her siblings, mother and extended family, she no longer felt so completely alone.
A Massachusetts law passed this summer calls attention to the public health problem of postpartum depression (PPD). The most common complication of pregnancy, extensive research has demonstrated its significant long term effects on a child’s development, with increased risk for behavior problems in childhood and depression in adolescence.
The new law requires Massachusetts health insurers to submit annual reports on their efforts to screen for postpartum depression. The department of Public Health will develop regulations and policies to address postpartum depression. In addition the law calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.
The Boston Globe editorial board endorsed this legislation with the following statement: "Early detection could stave off far more serious problems for mothers and their babies, whose well-being is deeply linked to the first few months of care. And universal screening would ensure that no woman falls through the cracks. The sooner new mothers can be diagnosed, the sooner they will recover."
The critical step in bringing this last statement from a wish to a reality is to find effective treatment for PPD. Ideally an intervention would both improve a mother’s depression and positively impact on her child’s development. Unfortunately is it far from clear exactly how to accomplish this goal.
Last weekend, I learned all about the latest research on the subject of postpartum depression as part of the Infant-Parent Mental Health Post-Graduate Certificate Program that I have described in previous posts. I was eager to learn from these world experts about effective treatment. These researchers, however, described difficulty defining, in a way that would be feasible for a well designed research study, what an effective intervention for PPD would look like.
Perhaps the mother I described above offers a clue. Being understood by a person you love is one of our most powerful yearnings. The need for understanding is part of what makes us human. When our feelings are validated, we know that we’re not alone. The truth of this statement is reflected by such sources as literature, philosophy and religion.
The necessary intervention, therefore, is perhaps more of a societal intervention. The most important component of an effective treatment for PPD may be that a new mother have an opportunity to be understood. She needs to feel supported over time in relationships that are of value to her. When partner, family members and friends are not sufficient for this role, or when there are enormous strains on these other relationships, the disciplines are available to support a mother include social workers, educators and primary care clinicians. These are among the lowest paid professionals in our society.
The law promoting PPD screening is a small step in the right direction. But in addition to focusing on the specifics of treatment interventions, it is critical to maintain a larger focus on the value we as a society place on the role of mother.
Selasa, 19 Oktober 2010
Kamis, 14 Oktober 2010
An Exquisite Parenting Moment at the General Store
As I stood at the counter of our little general store waiting to buy my newspaper, I turned suddenly, along with all the other customers, to find the source of a loud, insistent voice coming from below the counter. "I want candy now!" We looked down to see a little boy who was about three years old. He tugged at his father's arm. His father calmly replied."Lunch first. Then you can have your candy." "NO! CANDY NOW!" said the not so little voice. The other people in the store, including myself, shared knowing smiles. After several exchanges like this, his father, seemingly unperturbed by his fellow town members listening in, said firmly "OK, then you can't have the candy." "Noooo! I want candy!!!" he cried. His mother, who had been quietly standing behind them chimed in. "Now you're really mad," she observed in a respectful tone. With this he began to stomp around the store, wearing an intense scowl on his face. His father, a rather large man, began to stomp around after him. After passing by the grocery aisle a couple of times, the little boy dissolved in a fit of giggles. I paid for my paper and went home, thankful for the inspiration for a blog post.
It was such a small moment. One of millions that make up the day to day challenges of being a parent. Yet such grace under pressure!! His parents were calm and sure of themselves. They were willing to face the consequences of setting a limit with their son, even if it precipitated this public display of three-year-old outrage. His mother conveyed, simply with the tone of her voice, that she accepted his reaction and understood his feelings, but she and his father were not going to change their minds. His father playfully showed him that they both could survive this disruption and move on.
This interaction has all the elements of holding a child in mind, the central theme of my book, which is due to be published in the fall of 2011. These are: 1) understanding a child's behavior from the perspective of his stage of development, 2) empathizing with a child's feelings, 3) containing and regulating both the feeling and behavior, and 4) and perhaps most difficult, staying present with a child without letting one's own distress get in the way. When parents do this repeatedly a child learns to understand his own mind. He develops the ability to regulate intense emotions, think clearly and manage himself in a complex social world.
Those parents in the general store likely thought they were simply saving their son's appetite for a good lunch. They were actually taking one more small but important step in the direction of promoting their son's healthy emotional development.
It was such a small moment. One of millions that make up the day to day challenges of being a parent. Yet such grace under pressure!! His parents were calm and sure of themselves. They were willing to face the consequences of setting a limit with their son, even if it precipitated this public display of three-year-old outrage. His mother conveyed, simply with the tone of her voice, that she accepted his reaction and understood his feelings, but she and his father were not going to change their minds. His father playfully showed him that they both could survive this disruption and move on.
This interaction has all the elements of holding a child in mind, the central theme of my book, which is due to be published in the fall of 2011. These are: 1) understanding a child's behavior from the perspective of his stage of development, 2) empathizing with a child's feelings, 3) containing and regulating both the feeling and behavior, and 4) and perhaps most difficult, staying present with a child without letting one's own distress get in the way. When parents do this repeatedly a child learns to understand his own mind. He develops the ability to regulate intense emotions, think clearly and manage himself in a complex social world.
Those parents in the general store likely thought they were simply saving their son's appetite for a good lunch. They were actually taking one more small but important step in the direction of promoting their son's healthy emotional development.
Sabtu, 09 Oktober 2010
Supporting Infant-Parent Relationships: The Right Choice
Though not the major aim of this blog, it turns out that it is also serving to document the trajectory of my professional life. I am certain now that where I have landed is the right place.
My earlier posts documented my sense of frustration seeing many patients for "ADHD evaluation." I listened to story after story of mothers alone and depressed with their fussy, "difficult" infant. This infant then became an "explosive" toddler. Child and parents continued to struggle until now at the age of seven, ten or even fifteen, they came to see me in search of a diagnosis and medication. More often than not their symptoms did meet DSM criteria for some diagnosis, usually ADHD. Between imminent failure in school, intense pressure from teachers and a severe shortage of quality mental health services, medication often seemed to be the only option.
It caused me great pain to see a child's life experience reduced in this way, and, as is also documented on this blog, I decided that I needed to focus my efforts on prevention.
Next weekend is my second installment of the Infant-Parent Mental Health Post Graduate Certificate Program I have referred to in the two previous blog posts. As I review the material in advance, I am learning about research providing evidence that postpartum depression, particularly if the depression is chronic, affects a child's cognitive development, and is associated with behavior regulation problems and depression.
Last week, I saw a mother and her 3 month old daughter. A single mother struggling with depression and anxiety, she hadn't slept in a long time. Her baby fussed and squirmed on her lap. I held the baby, walking her around the room to quiet her while her mother talked of feelings of helplessness and frustration. The other doctors in my practice, who had been called almost daily by this mother with problems of feeding, sleep and crying, didn't know what to do for her. Pediatricians, who are seeing these mother-baby pairs on a regular basis, are mostly unaware of this important field of study.
I am well aware that there are many other professionals who have been doing this work for a long time. One social worker in my program does home visits with high risk pregnant women and then together with their newborns for a year after delivery. Sadly, they are paid practically nothing for this critical work.
John Bowlby, the father of attachment theory, in a 1980 lecture said:
My earlier posts documented my sense of frustration seeing many patients for "ADHD evaluation." I listened to story after story of mothers alone and depressed with their fussy, "difficult" infant. This infant then became an "explosive" toddler. Child and parents continued to struggle until now at the age of seven, ten or even fifteen, they came to see me in search of a diagnosis and medication. More often than not their symptoms did meet DSM criteria for some diagnosis, usually ADHD. Between imminent failure in school, intense pressure from teachers and a severe shortage of quality mental health services, medication often seemed to be the only option.
It caused me great pain to see a child's life experience reduced in this way, and, as is also documented on this blog, I decided that I needed to focus my efforts on prevention.
Next weekend is my second installment of the Infant-Parent Mental Health Post Graduate Certificate Program I have referred to in the two previous blog posts. As I review the material in advance, I am learning about research providing evidence that postpartum depression, particularly if the depression is chronic, affects a child's cognitive development, and is associated with behavior regulation problems and depression.
Last week, I saw a mother and her 3 month old daughter. A single mother struggling with depression and anxiety, she hadn't slept in a long time. Her baby fussed and squirmed on her lap. I held the baby, walking her around the room to quiet her while her mother talked of feelings of helplessness and frustration. The other doctors in my practice, who had been called almost daily by this mother with problems of feeding, sleep and crying, didn't know what to do for her. Pediatricians, who are seeing these mother-baby pairs on a regular basis, are mostly unaware of this important field of study.
I am well aware that there are many other professionals who have been doing this work for a long time. One social worker in my program does home visits with high risk pregnant women and then together with their newborns for a year after delivery. Sadly, they are paid practically nothing for this critical work.
John Bowlby, the father of attachment theory, in a 1980 lecture said:
Successful parenting is a principal key to the mental health of the next generation. In most societies throughout the world these facts have been and still are, taken for granted and the societies organized accordingly. Paradoxically it has taken the world’s richest societies to ignore these basic facts. Man and woman power devoted to production of material goods counts as a plus in all our economic indices. Man and woman power devoted to the production of happy, healthy, and self-reliant children in their own homes does not count at all. We have created a topsy turvy world.Next weekend I will learn more about effective interventions for these mother-baby pairs. I am very much looking forward to it. For now, sitting in a room with this mother and her young infant, at least I know I am in the right place to start.
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