Many parents are understandably reluctant to begin their children on psychiatric medication, and indeed, in many cases this is inappropriate as a first step. An intervention modeled on the early work of Selma Fraiberg, the Minding the Baby program at Yale Child Study Center, and the practice of parent-infant psychotherapy as described by Daniel Stern, among many others, can be an effective nonmedication strategy for some young children (Fraiberg SH et al., J Am Acad Child Adoles Psychiatry 1975;14:387–422; Slade A, Sadler LS, et al., Psychoanalytic Study of the Child 2005;60:74–100; Stern DN The Motherhood Constellation 1995; New York: Basic Books). Unlike psycho-educational interventions such as parent training, which focus on what to do, these intervention aim to give parents a new way to “be” with their child.
Marlie, a 3 ½ year old girl, was brought in to my behavioral pediatrics practice by her parents, Mark and Eileen, for “explosive behavior.” (Names and other identifying characteristics have been altered.) They described rapidly fluctuating moods, saying, “She goes from zero to 60 in seconds flat.” They described her as having “personal space” and “sensory” issues. Sleep was also a problem. For the past year and a half, she had been resisting going to bed. She would wake during the night, calling out for her mother. It could take over an hour to get her back to sleep again.
The mother, Eileen, had severe postpartum depression for the first six months of Marlie’s life, and had suffered a relapse when the child was two. This corresponded with Marlie’s sleep disruption, which only aggravated Eileen’s depression.
Although Marlie could be described as having “broad phenotype bipolar disorder” (Brotman MA et al., Biol Psychiatry 2006;60 (9):991–997), contemporary research in developmental psychology offers an alternative explanation for Marlie’s problematic behavior. In this paradigm, explosive behavior is understood as “affect dysregulation.” Children learn to regulate emotions in the setting of primary attachment relationships. 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 (Fonagy P et al., Infant Mental Health J 1991;12:201–218; Steele H and Steele M, “Understanding and Resolving Emotional Conflict: The London Parent Child Project.” In: Grossman K, Grossman K, and Waters, E. eds. Attachment from Infancy to Adulthood: The Major Longitudinal Studies. New York: Guilford Press; 2005).
Here is a clinical example: During one visit with Marlie and Eileen, Marlie had set up some train tracks, and played briefly in a calm contented way. Then when she pulled the trains along, one got hung up on the connection between two pieces of track, and she made a small sound of frustration. Eileen and I were sitting on the floor and talking while Marlie played beside us. But at the first utterance, Eileen leapt to her side. She began trying to divert her from the trains to play with something else. But Marlie resisted and her crying intensified.
Rather than helping Marlie to contain her feeling, Eileen desperately tried to make it go away. This gave Marlie the sense that her feeling was in some way “wrong.” So Eileen’s intervention had the opposite effect as Marlie protested her interference. She got more and more frustrated and finally angry, throwing the train across the room.
“What’s happening?” I asked. Eileen discussed her painful feelings of inadequacy, and her body began to relax. Meanwhile, Marlie’s frenetic movements decreased, and she came over to us and sat on her mother’s lap. Eileen held her for a minute or two. They both seemed to calm down together. Then Marlie got up, and like a recharged battery, began again to play with the toys in the calm manner in which she had started the visit.
I reinterpreted Marlie’s behavior, not as a sign of Eileen’s failure, but as a reflection of Marlie’s low frustration tolerance. Eileen realized that she needed to help Marlie manage these feelings, not to make them go away. She saw how her agitation increased Marlie’s agitation and that when she was calm, Marlie could be calm.
At another visit, Mark and Eileen described the typical scene at bedtime, which was becoming increasingly chaotic. Eileen would hold the door shut while Marlie screamed and kicked. Eileen spoke of being horrified by what she was doing, but feeling desperate for sleep. Mark felt helpless in the face of his wife’s distress. He reminded Eileen of her experience with her own mother when she was two. I asked her if she would feel comfortable telling me about this.
Eileen recalled how she had felt abandoned when she was two years old and her mother moved to another city to go to school. Eileen’s memory of her was that she was extremely unpredictable in her emotional availability. As Eileen spoke about these painful memories, she had an insight about Marlie. She said, “It just occurred to me that Marlie needs me and not just anyone.”
Marlie’s story is a complex one. Other interventions such as developmental testing and occupational therapy were also indicated. Addressing Marlie’s difficulties will take persistence and hard work over the long run. The aim of the intervention I have described is to get the rapidly moving train of development back on track. Supporting Mark and Eileen’s efforts to think about the meaning of Marlie’s behavior had the effect of calming everyone down. Marlie’s behavior quickly became less explosive. Within several weeks, the sleep problem had improved. Mark and Eileen felt a powerful sense of competence in their newfound ability to help Marlie.