Ode to Grandmothers

Last week, a friend told me a story that motivated me to recognize the important role of grandmothers, not specifically for their grandchildren, but for their adult daughters who are now mothers.

My friend, mother to a fifteen year old boy in the throes of adolescent turmoil, did not have a close relationship with her mother when her children were young. Her mother preferred "not to meddle," despite her daughter's clear requests for her involvement. My friend struggled with this for years, seeking help and support from others, particularly her husband and close friends. Still she very much longed to connect with her mother. So she continued into her forties to put a lot of effort into this relationship. The other day, she told me, the effort seemed to have paid off.

She was having a particularly bad moment with her son, who chose an afternoon when she was feeling tired and stressed by her own work, to regale her with all of her faults and accuse her of being the cause of all his misery. The more she tried to talk to him, the more the conversation degenerated, to the point where she couldn't stand it anymore and got in her car and drove off. Much to her surprise, she found herself driving to her parents house, something she never spontaneously did, despite the fact that they lived close by.

Both her mother and father were overjoyed at her unexpected appearance. They made her tea and listened while she unloaded her distress. Then her mother, in a most uncharacteristic way said to her, "I know I might not have done all the right things when you were a kid, but I do remember that sometimes the only option was to keep a sense of humor."

My friend, who had been so caught up in her conflict with her son, suddenly saw that she had been fighting with him like she herself was a teenager. In the heat of the moment she forgot, though at saner moments certainly knew well, that teenagers are at times incapable of rational discussion. But until her mother heard her and reflected back what was happening, she had been unable to see it herself.

Dan Stern, in his book The Motherhood Constellation that outlines the basic principles of parent-infant psychotherapy, refers to the “good grandmother transference” to describe the kind of relationship a parent develops with the therapist who is working with a parent and child together. Transference is a psychoanalytic term that refers to the way people tend to transfer feelings from one relationship, often from childhood, to another current relationship. He writes:

The transference that evolves in this situation involves a desire to be valued, supported, aided,taught, and appreciated by a maternal figure.This desire for such a maternal figure is evidenced in many situations outside of the therapeutic one. Beginning in the hospital with the birth of the baby, mothers frequently find someone to fill this role or part of it. It is often a nurse, a nurses aide, the cleaning lady, or someone else who takes a moment to share personal experience and give heartfelt encouragement. It is amazing how important these short encounters can be. They are overwhelmingly with other mothers more experienced in motherhood...Later other mothers met in the park may fill this role, to say nothing of the mother's actual mother, grandmother, older sisters, and experienced friends.

Berry Brazelton, in his book Touchpoints: Birth to Three, in the section devoted to grandparents writes:

The best thing that has happened to me as a grandparent has been the chance for my children and me to have a whole new relationship...Each grandchild is a miracle, but a new relationship with your own children is an even greater one.

My forthcoming book, now in the final editing stages, speaks to the importance of supporting parents' efforts to be fully emotionally available for their children. Many of the mothers I describe in the book, mothers who have come to see me in my pediatric practice because of struggles with their children, have strained relationships with their own mothers. In effect they develop a kind of "good grandmother transference" with me. This is often very helpful to them in the task of raising their children. Though perhaps not within the scope of my role as pediatrician, I certainly wish for these mothers, and support them in any way I can, that they find peace, as my friend seems to have achieved, with their own mothers.

American Academy of Pediatrics Endorses Management of Postpartum Depression in Pediatric Practice

Its nice to know I'm on the cutting edge. After no fewer than four recent posts about the importance of identification and management of postpartum depression, I learned yesterday that in the November issue of Pediatrics, the official Journal of the American Academy of Pediatrics, there is an article entitled: Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice It is an excellent, thorough article that speaks to the many issues I have raised. A couple of sample quotes are:

Maternal postpartum depression threatens the mother-child (dyad) relationship(attachment and bonding)and, as such, creates an environment for the infant that adversely affects the infant’s development. The processes for early brain development—neuronal migration, synapse formation,and pruning—are responsive to and directed by environment as well as genetics. For example, it is known that an infant living in a neglectful environment,which is common with depressed mothers, can have adverse changes visible on MRI of the brain.

and

The primary care pediatrician, by virtue of having a longitudinal relationship with families, has a unique opportunity to identify maternal depression and help prevent untoward developmental and mental health outcomes for the infant and family.

The article addresses the associated problems of, among many others, marital discord, breast feeding issues and difficulty managing chronic health conditions.

In addressing what pediatricians have to offer, the article speaks to the roles of screening and referral as well as support of the parent-child relationship within the context of a pediatric practice.

It is in this last role that I think pediatricians may have more to offer than is generally recognized, even by pediatricians themselves. This morning I was thinking about a successful intervention for PPD Peter Cooper described at the course I recently attended(see previous posts). The intervention was done in a South African peri-urban settlement with marked adverse socioeconomic circumstances. In this study:

Women were visited in their homes by previously untrained lay
community workers who provided support and guidance in parenting. The purpose of the intervention was to promote sensitive and responsive parenting and secure infant attachment to the mother.

The intervention was successful in that it:

had a significant positive impact on the quality of the mother-infant relationship and on security of infant attachment, factors known to predict favourable child development.

I was wondering to myself if the therapeutic action in this intervention was actually the relationship between these workers and the mothers. The mothers became very attached to these women, viewing them as a kind of grandmother figure. I think it likely that this relationship in turn fortified them in their efforts to be more fully emotionally available for their infants.

If this is in fact correct, then a pediatrician, by virtue of a long standing relationship with parents that is usually one of trust and respect, is in an ideal position to promote the mother-infant relationship.

I hope that with the AAP endorsement of this important issue will also come a recognition, cultivation and valuing of this role. This would involve changes not only in how pediatricians think about themselves, but also in more global changes in such areas as reimbursement and medical education. But that's for another blog post!!

Research and stories: both have a role to play in advancing knowledge

Last weekend, as I listened to leading researchers grapple with the question of how to design a feasible study of intervention for postpartum depression, I held in my mind an image of a particular moment in my office.

I was sitting on the floor with 10 month old Madison and her mother Nancy, who was struggling with postpartum depression. Nancy spoke of the strain Madison's refusal to take a bottle and her frequent night wakings were placing on her marriage. Madison contentedly played with the toy her mother had brought and then began to expand her exploration to the other toys in the office. We proceeded through the history, beginning with Nancy telling me about her pregnancy. Then I asked about her family. “My mother was severely depressed and frequently suicidal,” she said. Tears welled up in her eyes. “I don’t want Madison to go through what I did.” As she spoke, Nancy was freely crying.

Madison stopped her exploration of the toys. At first she sat completely still, observing her mother. This only made Nancy cry harder, as she saw the effect of her tears on Madison. Then Madison crawled up on to her mother and help on tight. They were both quiet for a bit. Madison began to fuss and reach for Nancy’s breast. Nancy got her settled to nurse, and very soon Madison fell fast asleep.

I understand the need for what is known as "evidence based medicine" to advance our knowledge of effective treatment. But given the constraints of research design, I could not help but wonder how to capture the complexity of this tiny moment. The researchers who spoke that weekend were trying to design interventions that would affect not only the mother's depression, but also the mother-child relationship.

In that moment I was literally inside in the mother-child relationship and witness to its enormous richness. I saw how Nancy was using the nursing to protect Madison from her depression. I understood that if I were to help Nancy her find time for herself and her marriage, I would need to help her find an alternative way to comfort Madison when her depression threatened to overwhelm her. I could only understand this by actually being in the moment of interaction between Nancy and Madison. By listening to Nancy and recognizing her experience as a mother, I could support her efforts to think about Madison's experience and how she could help Madison manage these difficult moments.

I struggled that weekend with the question of the relative role of research and clinical experience in advancing knowledge and promoting the healthy emotional development of children and parents. Upon my return home, my sixteen year old daughter handed me a paper she had written. The assignment was to write a daily theme on a subject of her choosing. That day she chose to write about the power of books. In her conclusion, she said:

Reading has power. A good author has the ability to craft words from his thoughts and change lives without even leaving his desk. A book is timeless, and can be read over and over by generation after generation and never lose its charm. A book is timely, and can erupt a change in the thoughts and opinions of people in the time period.

I believe she is right-that a book, or stories, have the power to change the way people think. Interestingly the Infant-Parent Mental Health Post Graduate Certificate Program, that I have written about in previous blog posts, brings together leading researchers with a group of fellows who are primarily clinicians immersed on a daily basis in the complexities of struggling families. I hope together we can join forces to make the world a better place for children.