Prevent Bullying and Violence by Nurturing Parents and Supporting Families

“Momma, have you ever felt like there’s a puzzle and there’s a piece missing and you find the piece and it fits? When I’m with the Maasai all the pieces fit.” This is a quote from my friend Roland, a seven year old boy, on a trip to Tanzania with his mother. He was on a safari and, using a stick, he was learning how the Maasai use spears to protect them from lions. His mother told me how at home in the United States, she always feels like she is apologizing for his aggression.

Her story made me think of many 2 year olds who I see in my pediatric practice. They come because they hit and are “too aggressive.” Their parents want help controlling the behavior. Once they feel comfortable talking with me, these parents frequently confess that when they see their child hit another child or throw a toy they have “visions of Colombine.”

We as a culture seem to be on a road to outlaw aggression. The fact is, however, that aggression is a normal, healthy feeling. Assertiveness, a quality generally considered to be a positive one, actually has a similar meaning, but looks different in a two year old than in an adult. Lacking the verbal skills to express intense emotion, Johnny, wanting the red truck another child just took out of his hands, may not have a calm discussion, but rather might grab the truck and whack the other child on the head.

Parents clearly have the responsibility to teach a child that such behavior is unacceptable. But, in order to avoid having a child grow up like Roland, with a sense that a piece of him is missing, it is essential that not only parents, but our culture, is accepting of the feeling behind the behavior.

In fact, the latest research at the intersection of neuroscience, behavioral genetics and developmental psychology is demonstrating that a parents’ ability to reflect and contain a child’s feelings will help that child learn to manage these feelings, and may change the way his brain handles strong emotions. He may be less likely to behave aggressively in the future. If, on the other hand, a child gets the idea that his feelings are “bad” and “wrong”, these feelings don’t go away. They just become disconnected from the child’s sense of who he is, like Roland’s missing puzzle piece.

If a child does not have a way to think about his feelings, he is likely to simply act them out. Children who continue, as they grow up, to behave in aggressive ways that are inappropriate for their age are often describes as “impulsive.” Impulsive literally means to act without thinking. A child needs to learn from the adults around him how to think about his feelings.

So where does this difficulty thinking about aggression come from? Many mothers and fathers reveal that they have experienced violence somewhere in their past. When Johnny whacks another kid with a truck, or hits them, it brings back a surge of feelings of intense stress and even rage. These feelings are completely unrelated to Johnny, but make it very difficult to think about Johnny’s experience from his two year old perspective. Other parents, like Roland’s mom, tell of having a sense from extended family and/or their social environment that aggressive feelings are bad.

Just as it is important for parents reflect and contain their toddler’s aggressive feelings, when children go to school and are behaving in unacceptably aggressive way it is essential to recognize the meaning of the behavior. Simply enforcing “bully –free zones” will not work. Often bullying reflects children’s experience of stress and violence at home. It may be more intense if as young children they did not learn to contain their aggressive feelings.

All of which points to two very specific needs. Our society must support parents in the challenging task of being fully present emotionally with their young children. We must provide a high quality and accessible mental healthcare system to support families in their efforts to help children who are struggling to contain and manage their aggression in the school setting. An acceptance of and respect for healthy aggression may in the long run decrease the risk of another Columbine.

Cell Phones and "Primary Maternal Preoccupation"

Recently I was on vacation at a pool with my kids. I noticed a father with his infant daughter who looked to be about 3 months old. Perched on a table in her car seat, she sat kicking and smiling. Her father faced her, but was talking on his cell phone. He distractedly shook the rattle hanging in front of her as he spoke in an animated way with the person on the other end of the line. His daughter continued to smile and kick for a while. Gradually, however, she slowed down. She became quiet. Then she began to fuss. Still on the phone, he made more intense efforts to engage her with the rattle. But he was not successful. Her crying escalated. Finally he had to abandon the cell phone as he needed two hands to take her out of the car seat. Then he picked her up and held her, walking around the pool in an effort to quiet her, which eventually he did.

I was thinking about this scene when re-reading about D.W. Winnicott's notion of what he called "Primary Maternal Preoccupation'(One shortcoming of Winnicott is that he essentially ignored fathers, so when referring to his work I only refer to mothers. To compensate for this inequality I refer to babies as "he"). This idea captures the way in which parents in a healthy way are completely absorbed with their young infant and attentive to his every nuance of expression. It is through this kind of mirror role that an infant begins to make sense of who he is.

Linda Mayes and colleagues, in fascinating research at the Yale Child Study Center, are examining the neurobiology of this maternal behavior and its effect on the developing infant brain. For example they have shown that oxytocin, which is present in high levels in a new mother, is connected to what under other circumstances might be called obsessive compulsive behavior, but in the setting of having a new baby is not only normal but highly adaptive both for mother and baby.

So what does this have to do with cell phones, which are now ubiquitous in our culture? Adam Phillips , in his biography of Winnicott writes:

When the infant looks at the mother's face, he can see himself, how he feels reflected back in her expression. If she is preoccupied by something else, when he looks at her he will only see how she feels. He will not be able to get 'something of himself back from the environment.' He can only discover what he feels by seeing it reflected back. If the infant is seen in a way that makes him feel that he exists, in a way that confirms him, he is free to go on looking.

When a parent is on a cell phone, he or she is "preoccupied with something else." It is certainly understandable that a person, who may have previously been absorbed with a successful career and is suddenly in the role of spending most of her time with a being that does not talk and requires enormous amounts of care 24 hours a day, would be drawn to the possibility of adult conversation. But I wonder if new parents are aware of the importance to a baby's development of that 'primary maternal preoccupation.' Perhaps if they were, they would consider spending a little less time on the phone.

DSM, Drugs and Labeling the "Troubled Child"

In this past week's New England Journal of Medicine there is an article with the captivating title Pediatric Mental Health Care Dysfunction. Gabrielle Carlson and her colleagues address the controversy over the new DSM V diagnosis Temper Dysregulation Disorder with dysphoria(TDD). They write: "No existing DSM diagnosis conveys the appropriate severity and complexity of these children's moods and behaviors: the "bipolar disorder" label was meant to provide a home for children who were "diagnostically homeless."

But why, I wonder, do young children need to have any label at all? What is the purpose of such a label? Dan Carlat in his new book Unhinged: The Trouble with Psychiatry has a wonderful chapter about the history of DSM, source of these labels, offering a balanced portrayal of the benefits and limitations of this so called "Bible of Psychiatry."

He writes, "DSM assigns each slice of craziness with a name and a number." When parents are struggling with a troubled child, there may be great comfort in having an answer. They may also have the idea that a label points to the correct treatment. But there are serious downsides to this approach.

Since the mid-1990's when a "small but influential group of child psychiatrists" proposed to label children with severe mood dysregulation as "bipolar" the number of children receiving this diagnosis increased 40 fold. Carlson writes: "These children, some preschoolers, were primarily treated with mood stabilizers and a new generation of antipsychotic drugs. But, as Carlson acknowledges in her article, the evidence for efficacy of the medications used to treat bipolar disorder in childhood, medications with very serious side effects, is "sparse at best." The argument that labelling leads to appropriate treatment falls flat.

Moreover, she offers the alarming research finding that "a recent study of large data bases of privately insured individuals showed that most young children prescribed antipsychotic medications did not receive adjunctive psychosocial treatment."

This past March I had an oped in the Boston Globe addressing the TDD diagnosis entitled Warning Label on a new Diagnosis. I describe what a child with severe explosive behavior looks like, and what "psychosocial treatment" might involve.

I saw 5-year-old Alex with his parents in my pediatric practice (details have been changed to protect privacy) for “explosive behavior and irritability.’’

One morning Alex’s father, Ben, called to Alex upstairs and asked if his younger sister could have some of his pancakes. There was a misunderstanding; Ben thought he said “yes’’ but Alex insisted he had said “maybe.’’ Alex came into the kitchen and found his sister eating his pancakes. He immediately began to scream, and threw her plate on the floor.

He hit his mother, Carla, who, overwhelmed with rage herself, grabbed him and carried him up the stairs to his room. There he attempted to kick the door down. After about 45 minutes, both Alex and Carla collapsed in tears of exhaustion and frustration. This type of scene occurred in their home several times a day.

I met with Ben and Carla alone, and they described Alex as a challenging baby from the start. Carla cried as she spoke of her own abusive father and her difficulty managing her anger. She decided to address these issues in her own therapy. Ben told of stresses in their marriage that they felt had resulted from having such a difficult child. Over time, as these issues were brought to light, Ben and Carla felt better equipped to help Alex contain and manage his frustration. Though the problems are far from resolved, a more positive pattern of interaction was set in place, and Alex’s development is on a healthier track.

In Carlat's discussion of DSM he writes, "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."

When young children are labeled with any diagnosis, the "why" is often not explored. Yet it is the "why" that offers the path to effective treatment. As I wrote in my op ed:

I hope that this new diagnosis will open up discussion about the meaning of these children’s behavior. Use of the word “dysregulation’’ is an important first step. Extensive research at the interface of developmental psychology and neuroscience has demonstrated that young children learn to regulate emotions in the setting of relationships with their caregivers.

A child may be born with a genetic vulnerability for emotional dysregulation. Responsive parenting, however, may alter the actual expression of these genes, and even change the chemistry and structure of the brain.

Emotional “dysregulation’’ is an accurate description of Alex’s behavior. DSM-V is primarily a descriptive document that does not address cause. However, if clinicians treating this new disorder think about emotional regulation as a quality that is learned in relationships, it may open up a path to considering meaningful alternative interventions.

Use of psychiatric drugs and not answering the "why" are two significant downsides to labelling to young children with a psychiatric disorder. I propose a third downside, in my opinion perhaps the most compelling reason not to label a young child.

In my blog, I have been writing about the ideas of D.W.Winnicott, pediatrician turned psychoanalyst. Another brilliant contribution was his notion of the "true self." A complex idea beyond the scope of a blog post, I will simplify it by saying that a child develops a healthy sense of self when the people who care for him recognize the meaning of his behavior, rather than substituting their own adult meaning. Parent's who receive a diagnostic label for their child inevitably go through a period of mourning. The child they had is gone and replaced by the child with a "disorder." For a very young child whose development is unfolding, his "true self" might be lost. Given that we know so little about either the diagnosis of bipolar disorder or the new temper dysregulation disorder, I would argue that the comfort of a label is never a valid reason to risk such a loss.