Motherhood, war, and attachment: what does it all mean?


The antebellum tales
Scene 1: Two fathers encounter each other at a Boy Scout meeting. After a little conversation, one reveals that his son won’t be playing football because of concerns about head injuries. The other father reveals that he and his son love football, that they spoke with their pediatrician about it, and that their son will continue with football at least into middle school. There’s a bit of wary nodding, and then, back to the Pinewood Derby.

Scene 2: Two mothers meet on a playground. After a little conversation about their toddlers, one mother mentions that she still breastfeeds and practices “attachment parenting,” which is why she has a sling sitting next to her. The other mother mentions that she practiced “cry it out” with her children but that they seem to be doing well and are good sleepers. Then one of the toddlers begins to cry, obviously hurt in some way, and both mothers rush over together to offer assistance.

Scene 3: In the evening, one of these parents might say to a partner, “Can you believe that they’re going to let him play football?” or “I can’t believe they’re still breastfeeding when she’s three!” Sure. They might “judge” or think that’s something that they, as parents, would never do.

But which ones are actually involved in a war?

War. What is it good for?

I can’t answer that question, but I can tell you the definition of ‘war’: “a state of armed conflict between different nations or states or different groups within a nation or state.” Based on this definition and persistent headlines about “Mommy Wars,” you might conclude that a visit to your local playground or a mom’s group outing might require decking yourself out cap-á-pie in Kevlar. But the reality on the ground is different. There is no war. Calling disputes and criticisms and judgments about how other people live “war” is like calling a rowboat on a pond the Titanic. One involves lots of energy release just to navigate relatively placid waters while the other involved a tremendous loss of life in a rough and frigid sea. Big difference.

I’m sure many mothers can attest to the following: You have friends who also are mothers. I bet that for most of us, those friends represent a spectrum of attitudes about parenting, education, religion, Fifty Shades of Grey, recycling, diet, discipline, Oprah, and more. They also probably don’t all dress just like you, talk just like you, have the same level of education as you, same employment, same ambitions, same hair, or same toothpaste. And I bet that for many of us, in our interactions with our friends, we have found ourselves judging everything from why she insists on wearing those shoes to why she lets little Timmy eat Pop Tarts. Yet, despite all of this mental observation and, yes, judging, we still manage to get along, go out to dinner together, meet at one another’s homes, and gab our heads off during play dates.

That’s not a war. That’s life. It’s using our brains as shaped by our cultural understanding and education and rejection or acceptance of things from our own upbringing and talks with medical practitioners and books we’ve read and television shows we’ve watched and, for some of us, Oprah. Not one single friend I have is a cookie cutter representation of me or how I parent. Yet, we are not at war. We are friends. Just because people go online and lay out in black and white the critiques that are in their heads doesn’t mean “war” is afoot. It means expressing the natural human instinct to criticize others in a way that we think argues for Our Way of Doing Things. Online fighting is keeping up with the virtual Joneses. In real life, we are friends with the Joneses, and everyone tacitly understands what’s off limits within the boundaries of that friendship. That’s not war. It’s friendly détente.

The reality doesn’t stop the news media from trying to foment wars, rebellions, and full-on revolutions with provocative online “debates” and, lately, magazine covers. The most recent, from Time, features a slender mother, hand on cocked hip, challenging you with her eyes as she nurses her almost-four-year-old son while he stands on a chair. As Time likely intended, the cover caused an uproar. We’ve lampooned it ourselves (see above).

But the question the cover asks in all caps, “Are you mom enough?” is even more manipulative than the cover because it strikes at the heart of all those unspoken criticisms we think–we know–other women have in their heads about our parenting. What we may not consider is that we, too, are doing the same, and still… we are not actually at war. We’re just women, judging ourselves and other women, just like we’ve done since the dawn of time. It’s called “using your brain.” Inflating our interactions and fairly easily achieved parental philosophy détentes to “war” caricatures us all as shrieking harpies, incapable of backing off and being reasonable.

The real question to ask isn’t “Are you mom enough?” In fact, it’s an empty question because there is no answer. Your parenting may be the most perfect replica of motherhood since the Madonna (the first one), yet you have no idea how that will manifest down the road in terms of who your child is or what your child does. Whether you’re a Grizzly or a Tiger or a Kangaroo or a Panda mother, there is no “enough.”

So, instead of asking you “Are you mom enough?”, in keeping with our goal of bringing women evidence-based science, we’ve looked at some of the research describing what might make a successful parent–child relationship. Yes, the answer is about attachment, but not necessarily of the physical kind. So drop your guilt. Read this when you have time. Meanwhile, do your best to connect with your child, understand your child, and respond appropriately to your child.  

Why? Because that is what attachment is–the basic biological response to a child’s needs. If you’re not a nomad or someone constantly on the move, research suggests that the whole “physically attached to me” thing isn’t really a necessary manifestation of attachment. If you harken to it and your child enjoys it (mine did not) and it works for you without seeming like, well, an albatross around your neck, go for it.

What is attachment?

While attachment as a biological norm among primates has been around as long as primates themselves, humans are more complicated than most primates. We have theories. Attachment theory arose from the observations of a couple of human behaviorists or psychologists (depending on whom you ask), John Bowlby and Mary Ainsworth. Bowlby derived the concept of attachment theory, in which an infant homes in on an attachment figure as a “safe place.” The attachment figure, usually a parent, is the person who responds and is sensitive to the infant’s needs and social overtures. That parent is typically the mother, and disruption of this relationship can have, as most of us probably instinctively know, negative effects.

Bowlby’s early approach involved the mother’s having an understanding of the formational experiences of her own childhood and then translating that to an understanding of her child. He even found that when he talked with parents about their own childhoods in front of their children, the result would be clinical breakthroughs for his patients. As he wrote,

Having once been helped to recognize and recapture the feelings which she herself had as a child and to find that they are accepted tolerantly and understandingly, a mother will become increasingly sympathetic and tolerant toward the same things in her child.

Later studies seem to bear out this observation of a connection to one’s childhood experiences and more connected parenting. For example, mothers who are “insightful” about their children, who seek to understand the motivations of their children’s behavior, positively influence both their own sensitivity and the security of their infant’s attachment to them.  

While Bowlby’s research focused initially on the effects of absolute separation between mother and child, Mary Ainsworth, an eventual colleague of Bowlby, took these ideas of the need for maternal input a step further. Her work suggested to her that young children live in a world of dual and competing urges: to feel safe and to be independent. An attachment figure, a safe person, is for children an anchor that keeps them from become unmoored even as they explore the unknown waters of life. Without that security backing them up, a child can feel always unmoored and directionless, with no one to trust for security.

Although he was considered an anti-Freudian rebel, Bowlby had a penchant for Freudian language like “superego” and referred to the mother as the “psychic organizer.” Yet his conclusions about the mother–child bond resonate with their plain language:

The infant and young child should experience a warm, intimate, and continuous relationship with his mother (or permanent mother substitute) in which both find satisfaction and enjoyment.

You know, normal biological stuff. As a side note, he was intrigued by the fact that social bonds between mother and offspring in some species weren’t necessarily tied to feeding, an observation worth keeping in mind if you have concerns about not being able to breastfeed.

The big shift here in talking about the mother–child relationship was that Bowlby was proposing that this connection wasn’t some Freudian libidinous communion between mother and child but instead a healthy foundation of a trust relationship that could healthily continue into the child’s adulthood.

Ainsworth carried these ideas to specifics, noting in the course of her observations of various groups how valuable a mother’s sensitivity to her child’s behaviors were in establishing attachment. In her most famous study, the “Baltimore study” [PDF], she monitored 26 families with new babies. She found that “maternal responsiveness” in the context of crying, feeding, playing, and reciprocating seemed to have a powerful influence on how much a baby cried in later months, although some later studies dispute specific influences on crying frequencies.

Ainsworth also introduced the “Strange Situation” lab test, which seems to have freaked people out when it first entered the research scene. In this test, over the course of 20 minutes, a one-year-old baby is in a room full toys, first with its mother, then with mother and a strange woman, then with the stranger only (briefly), then with the mother, and then alone before the stranger and then the mother return. The most interesting findings of the study came from when the mother returned after her first absence, having left the baby alone in the room with a stranger. Some babies seemed quite angry, wanting to be with their mothers but expressing unhappiness with her at the same time and physically rejecting her.

From her observations during the Strange Situation, Ainsworth identified three types of attachment. The first was “Secure,” which, as its name implies, suggested an infant secure and comfortable with an attachment figure, a person with whom the infant actively seeks to interact. Then there’s the insecure–avoidant attachment type, in which an infant clearly is not interested in being near or interacting with the attachment figure. Most complex seems to be the insecure–resistant type, and the ambivalence of the term reflects the disconnected behavior the infant shows, seeming to want to be near the attachment figure but also resisting, as some of the unhappy infants described above behaved in the Strange Situation.

Within these types are now embedded various subtypes, including a disorganized–disoriented type in which the infant shows “odd” and chaotic behavior that seems to have no distinct pattern related to the attachment figure.

As you read this, you may be wondering, “What kind of attachment do my child and I have?” If you’re sciencey, you may fleetingly even have pondered conducting your own Strange Situation en famille to see what your child does. I understand the impulse. But let’s read on.

What are the benefits of attachment?

Mothers who are sensitive to their children’s cues and respond in ways that are mutually satisfactory to both parties may be doing their children a lifetime of favors, in addition to the parental benefit of a possibly less-likely-to-cry child. For example, a study of almost 1300 families looked at levels of cortisol, the “stress” hormone, in six-month-old infants and its association with maternal sensitivity to cues and found lower levels in infants who had “more sensitive” mothers.

Our understanding of attachment and its importance to infant development can help in other contexts. We can apply this understanding to, for example, help adolescent mothers establish the “secure” level of attachment with their infants. It’s also possibly useful in helping women who are battling substance abuse to still establish a secure attachment with their children.

On a more individual level, it might help in other ways. For example, if you want your child to show less resistance during “clean-up” activities, establishing “secure attachment” may be your ticket to a better-looking playroom.

More seriously, another study has found that even the way a mother applies sensitivity can be relevant. Using the beautiful-if-technical term ‘dyads’ to refer to the mother–child pair, this study included maternal reports of infant temperament and observations of maternal sensitivity to both infant distress and “non-distress.” Further, the authors assessed the children behaviorally at ages 24 and 36 months for social competence, behavioral problems, and typicality of emotional expression. They found that a mother’s sensitivity to an infant’s distress behaviors was linked to fewer behavioral problems and greater social competence in toddlerhood. Even more intriguing, the child’s temperament played a role: for “temperamentally reactive” infants, a mother’s sensitivity to distress was linked to less dysregulation of the child’s emotional expression in toddlerhood. 


And that takes me to the child, the partner in the “dyad”

You’re not the only person involved in attachment. As these studies frequently note, you are involved in a “dyad.” The other member of that dyad is the child. As much as we’d like to think that we can lock down various aspects of temperament or expression simply by forcing it with our totally excellent attachment skills, the child in your dyad is a person, too, who arrived with a bit of baggage of her own.

And like the study described above, the child’s temperament is a key player in the outcome of the attachment tango. Another study noted that multiple factors influence “attachment quality.” Yes, maternal sensitivity is one, but a child’s native coping behaviors and temperament also seem to be involved. So, there you have it. If you’re feeling like a parental failure, science suggests you can quietly lay at least some of the blame on the Other in your dyad–your child. Or, you could acknowledge that we’re all human and this is just part of our learning experience together.

What does attachment look like, anyway?

Dr. William Sears took the concept of attachment and its association with maternal sensitivity to a child’s cues and security and… wrote a book that literally translated attachment as a physical as well as emotional connection. This extension of attachment–which Sears appends to every aspect of parenting, from pregnancy to feeding to sleeping–has become in the minds of some parents a prescriptive way of doing things with benefits that exclude all other parenting approaches or “philosophies.” It also involves the concept of “baby wearing,” which always brings up strange images in my mind and certainly takes outré fashion to a whole new level. In reality, it’s just a way people have carried babies for a long time in the absence of other easy modes of transport.

When I was pregnant with our first child and still blissfully ignorant about how little control parents have over anything, I read Sears’ book about attachment parenting. Some of it is common-sense, broadly applicable parenting advice: respond to your child’s needs. Some of it is simply downright impossible for some parent–child dyads, and much of it is based on the presumption that human infants in general will benefit from a one-size-fits-all sling of attachment parenting, although interpretations of the starry-eyed faithful emphasize that more than Sears does.

Because much of what Sears wrote resonated with me, we did some chimeric version of attachment parenting–or, we tried. The thing is, as I noted above, the infant has some say in these things as well. Our oldest child, who is autistic, was highly resistant to being physically attached much of the time. He didn’t want to sleep with us past age four months, and he showed little interest in aspects of attachment parenting like “nurturing touch,” which to him was seemingly more akin to “taser touch.” We ultimately had three sons, and in the end, they all preferred to sleep alone, each at an earlier and earlier age. The first two self-weaned before age one because apparently, the distractions of the sensory world around them were far more interesting than the same boring old boob they kept seeing immediately in front of their faces. Our third was unable to breastfeed at all.

So, like all parents do, we punted, in spite of our best laid plans and intentions. Our hybrid of “attachment parenting” could better be translated into “sensitivity parenting,” because our primary focus, as we punted and punted and punted our way through the years, was shifting our responses based on what our children seemed to need and what motivated their behaviors. Thus, while our oldest declined to sleep with us according to the attachment parenting commandment, he got to sleep with a boiled egg because that’s what he wanted. Try to beat that, folks, and sure, bring on the judging.

The Double X Science
Sensitivity Parenting (TM) cheat sheet.

What does “sensitive” mean?

And finally, the nitty-gritty bullet list you’ve been waiting for. If attachment doesn’t mean slinging your child to your body until you’re lumbar gives out or the child receives a high-school diploma, and parenting is, indeed, one compromise after another based on the exigencies of the moment, what consistent tenets can you practice that meet the now 60-year-old concept of “secure” attachment between mother and child, father and child, or mother or father figure and child? We are Double X Science, here to bring you evidence-based information, and that means lists. The below list is an aggregate of various research findings we’ve identified that seem reasonable and reasonably supported. We’ve also provided our usual handy quick guide for parents in a hurry.
  • Plan ahead. We know that life is what happens while you’re planning things, but… life does happen, and plans can at least serve as a loose guide to navigation. So, plan that you will be a parent who is sensitive to your child’s needs and will work to recognize them.
  • Practice emotion detection. Work on that. It doesn’t come easily to everyone because the past is prologue to what we’re capable of in the present. Ask yourself deliberately what your child’s emotion is communicating because behavior is communication. Be the grownup, even if sometimes, the wailing makes you want your mommy. As one study I found notes, “Crying is an aversive behavior.” Yes, maybe it makes you want to cover your ears and run away screaming. But you’re the grownup with the analytical tools at hand to ask “Why” and seek the answer.
  • Have infant-oriented goals. If you tend to orient your goals in your parent–child dyad toward a child-related benefit (relieve distress) rather than toward a parent-oriented goal (fitting your schedule in some way), research suggests that your dyad will be a much calmer and better mutually adapted dyad.
  • Trust yourself and keep trying. If your efforts to read your child’s feelings or respond to your child’s needs don’t work right away, don’t give up, don’t read Time magazine covers, and don’t listen to that little voice in your head saying you’re a bad parent or the voice in other people’s heads screaming that at you. Just keep trying. It’s all any of us can do, and we’re all going to screw this up here and there.
  • Practice behaviors that are supportive of an infant’s sensory needs. For example, positive inputs like a warm voice and smiling are considered more effective than a harsh voice or being physically intrusive. Put yourself in your child’s place and ask, How would that feel? That’s called empathy. 
  • Engage in reciprocation. Imitating back your infant’s voice or faces, or showing joint attention–all forms of joint engagement–are ways of telling an infant or young child that yes, you are the anchor here, the one to trust, and really good time, to boot. Allowing this type of attention to persist as long as the infant chooses rather than shifting away from it quickly is associated with making the child comfortable with independence and learning to regulate behaviors.  
  • Talk to your child. We are generally a chatty species, but we also need to learn to chat. “Rich language input” is important in early child development beginning with that early imitation of your infant’s vocalizations.
Lather, rinse, repeat, adjusting dosage as necessary based on age, weight, developmental status, nanosecond-rate changes in family dynamics and emotional conditions, the teen years, and whether or not you have access to chocolate. See? This stuff is easy.

                                                          

Finally

As you read these lists and about research on attachment, you’ll see words like “secure” and “warm” and “intimate” and “safe.” Are you doing this for your child or doing your best to do it? Then you are, indeed, mom enough, whether you wear your baby or those shoes or both. That doesn’t mean that when you tell other women the specifics of your parenting tactics, they won’t secretly be criticizing you. Sure, we’ll all do that. And then a toddler will cry, we’ll drop it, and move on to mutually compatible things.

Yes, if we’re being honest, it makes most of us feel better to think that somehow, in some way, we’re kicking someone else’s ass in the parenting department. Unfortunately for that lowly human instinct, we’re all parenting unique individuals, and while we may indeed kick ass uniquely for them, our techniques simply won’t extend to all other children. It’s not a war. It’s human… humans raising other humans. Not one thing we do, one philosophy we follow, will guarantee the outcome we intend. We don’t even need science, for once, to tell us that.


By Emily Willingham, DXS managing editor

These views are the opinion of the author and do not necessarily either reflect or disagree with those of the
DXS editorial team. 

Is it really healthier to be a few pounds overweight? That’s not what the study says.

Don’t start making plans to ignore those extra pounds just yet.

by Jennifer Gunter, MD, FRCS(C), FACOG, DABPM

This post first appeared at Dr. Gunter’s blog, where she wields the lasso of truth.

A new study published in the Journal of the American Medical Association (JAMA) indicates that a body mass index or BMI of 25-29.9 (overweight) is associated with the lowest risk of death and that class 1 obesity (BMI 30-34.9) is not associated with an increased risk of mortality. As this study hit the presses January 2nd (and I’m sure no editorial thought was given by JAMA to such a study coming out at the first of the year) when many people are thinking about weight loss resolutions, it was covered widely in the press and I read several op-eds claiming vindication for obesity. One op-ed on a major news site was indignant that CT scanners couldn’t accommodate a friend (some CT scanners have difficulty accommodating patients over 300 lbs). The author’s solution? Build bigger CT scanners because obesity isn’t bad at all. This new study proves it.

First of all the study doesn’t say that being overweight is good for you and that being an ideal weight is bad. What the study does tell us is that people who have a BMI of 35 or greater are more likely to die. This is not new information. A BMI of 35 is a lot of extra weight, depending on your height it could easily mean 70 extra pounds or more.15% of Americans have a BMI of 35 or greater.Only people with a BMI over 35, way over 35, need bigger CT scanners. I’m not saying that severely obese people shouldn’t have access to imaging studies, but the answer to the epidemic of severe obesity is not to claim vindication based on the inaccurate interpretation of one study and simply build bigger equipment.

What about the lower risk of death in the overweight and class 1 obesity groups compared with the normal BMI group? Well, this can be explained by a variety of factors:

  • The wrong control group. Many researchers question whether the control group should really be a BMI of 22-24.9, not the wider range of 18.5-24.9 used in this study. The reason, many people at the thinner end of the scale are thin because of illness and this obviously skews mortality statistics.
  • BMI is an imperfect tool with which to predict mortality when the result isn’t one extreme (< 18.5) or the other (>34.9). This is not a new finding. BMI just looks at weight, not the proportion of weight that is muscle mass vs. fatty tissue. Many people with a normal BMI have very little muscle mass and thus are carrying around excess fat and are less healthy than their BMI suggests. There are better metrics to look at mortality risk for people who have a BMI in the 18.5-34.9 range, such as waist circumference, resting heart rate, fasting glucose, leptin levels, and even DXA scans (just to name a few). The problem is that not all these measurement tools are practical on a large-scale.
  • A small amount of fat may provide an extra energy reserve for someone who becomes chronically ill, thus skewing the survival stats. For example, consider the dramatic weight loss associated with chemo…if you can’t eat due to extreme nausea and you have a little extra fat then you burn fat, but if you have no fat and can’t eat then you start breaking down muscle. This is a phenomenon has popped up in a few studies and definitely requires more research, because obesity is definitely associated with worse outcomes in many cancers.
  • Not all fat is created equal. Belly fat, the metabolically active muffin top, is what contributes to diabetes and other inflammatory conditions. Having a few extra pounds around the middle is far worse than having a few extra pounds on the hips. Again, not new information. BMI doesn’t distinguish between belly fat and thigh fat.

What is very important is that we don’t take erroneous messages from this study (hello, health reporters for major news outlets looking for attention-grabbing headlines). This study says nothing more than we need better tools than BMI to assess mortality risk for people who have a body mass index between 18.5 and 34.9 and that BMI doesn’t predict “ideal weight,” it only tells us that extremes are bad. This study also confirms that the 15% of Americans with a BMI of 35 are at increased risk of dying prematurely, a point sadly missed by many.

Body mass index simply doesn’t convey enough information to assess mortality risk for 85% of the population, but that fact (which isn’t new) shouldn’t stop each and every one of us from striving everyday to be the healthiest that we can be.

Dr. Jennifer Gunter is an OB/GYN and a pain medicine physician who has authored the book, The Preemie Primer a guide for parents of premature babies. In addition to her academic publications, her writing has appeared in USA Today, the A Cup of Comfort series, KevinMD.com, EmpowHer.com, Exceptional Parent, Parents Press, Sacramento Parent, and the Marin Independent Journal. Continue reading

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Is the bar high enough for screening breast ultrasounds for breast cancer?

The stormy landscape of the breast, as seen
on ultrasound. At top center (dark circle) is
a small cyst. Source: Wikimedia Commons.
Credit: Nevit Dilmen.
By Laura Newman, contributor

In a unanimous decision, FDA has approved the first breast ultrasound imaging system for dense breast tissue “for use in combination with a standard mammography in women with dense breast tissue who have a negative mammogram and no symptoms of breast cancer.” Patients should not interpret FDA’s approval of the somo-v Automated Breast Ultrasound System as an endorsement of the device as necessarily beneficial for this indication and this will be a thorny concept for many patients to appreciate.

If the approval did not take place in the setting of intense pressure to both inform women that they have dense breasts and lobbying to roll out all sorts of imaging studies quickly, no matter how well they have been studied, it would not be worth posting.

Dense breasts are worrisome to women, especially young women (in their 40s particularly) because they have proved a risk factor for developing breast cancer. Doing ultrasound on every woman with dense breasts, though, who has no symptoms, and a normal mammogram potentially encompasses as many as 40% of women undergoing screening mammography who also have dense breasts, according to the FDA’s press release. Dense breast tissue is most common in young women, specifically women in their forties, and breast density declines with age.

The limitations of mammography in seeing through dense breast tissue have been well known for decades and the search has been on for better imaging studies. Government appointed panels have reviewed the issue and mammography for women in their forties has been controversial. What’s new is the “Are You Dense?” patient movement and legislation to inform women that they have dense breasts.

Merits and pitfalls of device approval
The approval of breast ultrasound hinges on a study of 200 women with dense breast evaluated retrospectively at 13 sites across the United States with mammography and ultrasound. The study showed a statistically significant increase in breast cancer detection when ultrasound was used with mammography.

Approval of a device of this nature (noninvasive, already approved in general, but not for this indication) does not require the company to demonstrate that use of the device reduces morbidity or mortality, or that health benefits outweigh risks.

Eitan Amir, MD, PhD, medical oncologist at Princess Margaret Hospital, Toronto, Canada, said: “It’s really not a policy decision. All this is, is notice that if you want to buy the technology, you can.”

That’s clearly an important point, but not one that patients in the US understand. Patients hear “FDA approval” and assume that means a technology most certainly is for them and a necessary add-on. This disconnect in the FDA medical device approval process and in what patients think it means warrants an overhaul or at the minimum, a clarification for the public.

Materials for FDA submission are available on the FDA website, including the study filed with FDA and a PowerPoint presentation, but lots of luck, finding them quickly. “In the submission by Sunnyvale CA uSystems to FDA, the company stated that screening reduces lymph node positive breast cancer,” noted Amir. “There are few data to support this comment.”

Is cancer detection a sufficient goal?
In the FDA study, more cancers were identified with ultrasound. However, one has to question whether breast cancer detection alone is meaningful in driving use of a technology. In the past year, prostate cancer detection through PSA screening has been attacked because several studies and epidemiologists have found that screening is a poor predictor of who will die from prostate cancer or be bothered by it during their lifetime. We seem to be picking up findings that don’t lead to much to worry about, according to some researchers. Could new imaging studies for breast cancer suffer the same limitation? It is possible.

Another question is whether or not the detected cancers on ultrasound in the FDA study would have been identified shortly thereafter on a routine mammogram. It’s a question that is unclear from the FDA submission, according to Amir.

One of the problems that arises from excess screening is overdiagnosis, overtreatment, and high-cost, unaffordable care. An outcomes analysis of 9,232 women in the US Breast Cancer Surveillance Consortium led by Gretchen L. Gierach, PhD, MPH, at the National Institutes of Health MD, and published online in the August 21 Journal of the National Cancer Institute, revealed: “High mammographic breast density was not associated with risk of death from breast cancer or death from any cause after accounting for other patient and tumor characteristics.” –Gierach et al., 2012

Proposed breast cancer screening tests
Meanwhile, numerous imaging modalities have been proposed as an adjunct to mammography and as potential replacements for mammography. In 2002, proponents of positron emission tomography (PET) asked Medicare to approve pet scans for imaging dense breast tissue, especially in Asian women. The Medicare Coverage Advisory Commission heard testimony, but in the end, Medicare did not approve it for the dense-breast indication.

PET scans are far less popular today, while magnetic resonance imaging (AKA MR, MRI) and imaging have emerged as as adjuncts to mammography for women with certain risk factors. Like ultrasound, the outcomes data is not in the bag for screening with it.

In an interview with Monica Morrow, MD, Chief of Breast Surgery at Memorial Sloan-Kettering Cancer Center, New York, several months ago concerning the rise in legislation to inform women about dense breasts, which frequently leads to additional imaging studies, she said: “There is no good data that women with dense breasts benefit from additional MR screening.” She is not the only investigator to question potentially deleterious use of MR ahead of data collection and analysis. Many breast researchers have expressed fear that women will opt for double mastectomies, based on MR, that in the end, may have been absolutely unnecessary.

“There is one clear indication for MR screening,” stressed Morrow, explaining that women with BRCA mutations should be screened with MRI. “Outside of that group, there was no evidence that screening women with MR was beneficial.”

At just about every breast cancer meeting in the past two years, the benefits and harms of MR and other proposed screening modalities come up, and there is no consensus in the field.  It  should be noted, though, that plenty of breast physicians are skeptical about broad use of MR– not just generalists outside of the field. In other words, it is not breast and radiology specialists versus the US Preventive Services Task Force – a very important message for patients to understand.

One thing is clear: as these new technologies gain FDA approval, it will be a windfall for industry. If industry is successful and doctors are biased to promoting these tests, many may offer them on the estimated 40% of women with dense breasts who undergo routine mammograms, as well as other women evaluated as having a high lifetime risk.  The tests will be offered in a setting of unclear value and uncertain harms. Even though FDA has not approved breast MRI for screening dense breasts, breast MR is being used off label and it is far more costly than mammography.

When patients raise concerns about the unaffordability of medical care, they should be counseled about the uncertain benefit and potential harms of such a test. That may be a tall bill for most Americans to consider: it’s clear that the more is better philosophy is alive and well. Early detection of something, anything, even something dormant, going nowhere, is preferable to skipping a test, and risking who-knows-what, and that is something, most of us cannot imagine at the outset.

[Today's post is from Patient POVthe blog of Laura Newman, a science writer who has worked in health care for most of her adult life, first as a health policy analyst, and as a medical journalist for the last two decades. She was a proud member of the women’s health movement. She has a longstanding interest in what matters to patients and thinks that patients should play a major role in planning and operational discussions about healthcare. Laura’s news stories have appeared in Scientific American blogs, WebMD Medical News, Medscape, Drug Topics, Applied Neurology, Neurology Today, the Journal of the National Cancer Institute, The Lancet, and BMJ, and numerous other outlets. You can find her on Twitter @lauranewmanny.]

Ed note: The original version of this post contains a posted correction that is incorporated into the version you’ve read here.

The opinions in this article do not necessarily conflict with or reflect those of the DXS editorial team. 

Anorexia nervosa, neurobiology, and family-based treatment

Via Wikimedia Commons
Photo credit: Sandra Mann
By Harriet Brown, DXS contributor

Back in 1978, psychoanalyst Hilde Bruch published the first popular book on anorexia nervosa. In The Golden Cage, she described anorexia as a psychological illness caused by environmental factors: sexual abuse, over-controlling parents, fears about growing up, and/or other psychodynamic factors. Bruch believed young patients needed to be separated from their families (a concept that became known as a “parentectomy”) so therapists could help them work through the root issues underlying the illness. Then, and only then, patients would choose to resume eating. If they were still alive.

Bruch’s observations dictated eating-disorders treatments for decades, treatments that led to spectacularly ineffective results. Only about 35% of people with anorexia recovered; another 20% died, of starvation or suicide; and the rest lived with some level of chronic illness for the rest of their lives.

Not a great track record, overall, and especially devastating for women, who suffer from anorexia at a rate of 10 times that of men. Luckily, we know a lot more about anorexia and other eating disorders now than we did in 1978.

“It’s Not About the Food”

In Bruch’s day, anorexia wasn’t the only illness attributed to faulty parenting and/or trauma. Therapists saw depression, anxiety, schizophrenia, eating disorders, and homosexuality (long considered a psychiatric “illness”) as ailments of the mind alone. Thanks to the rising field of behavioral neuroscience, we’ve begun to untangle the ways brain circuitry, neural architecture, and other biological processes contribute to these disorders. Most experts now agree that depression and anxiety can be caused by, say, neurotransmitter imbalances as much as unresolved emotional conflicts, and treat them accordingly. But the field of eating-disorders treatment has been slow to jump on the neurobiology bandwagon. When my daughter was diagnosed with anorexia in 2005, for instance, we were told to find her a therapist and try to get our daughter to eat “without being the food police,” because, as one therapist informed us, “It’s not about the food.”

Actually, it is about the food. Especially when you’re starving.

Ancel Keys’ 1950 Semi-Starvation Study tracked the effects of starvation and subsequent re-feeding on 36 healthy young men, all conscientious objectors who volunteered for the experiment. Keys was drawn to the subject during World War II, when millions in war-torn Europe – especially those in concentration camps – starved for years. One of Keys’ most interesting findings was that starvation itself, followed by re-feeding after a period of prolonged starvation, produced both physical and psychological symptoms, including depression, preoccupation with weight and body image, anxiety, and obsessions with food, eating, and cooking—all symptoms we now associate with anorexia. Re-feeding the volunteers eventuallyreversed most of the symptoms. However, this approach proved to be difficult on a psychological level, and in some ways more difficult than the starvation period. These results were a clear illustration of just how profound the effects of months of starvation were on the body and mind.

Alas, Keys’ findings were pretty much ignored by the field of eating-disorders treatment for 40-some years, until new technologies like functional magnetic resonance imaging (fMRI) and research gave new context to his work. We now know there is no single root cause for eating disorders. They’re what researchers call multi-factorial, triggered by a perfect storm of factors that probably differs for each person who develops an eating disorder. “Personality characteristics, the environment you live in, your genetic makeup—it’s like a cake recipe,” says Daniel le Grange, Ph.D., director of the Eating Disorders Program at the University of Chicago. “All the ingredients have to be there for that person to develop anorexia.”

One of those ingredients is genetics. Twenty years ago, the Price Foundation sponsored a project that collected DNA samples from thousands of people with eating disorders, their families, and control participants. That data, along with information from the 2006 Swedish Twin Study, suggests that anorexia is highly heritable. “Genes play a substantial role in liability to this illness,” says Cindy Bulik, Ph.D., a professor of psychiatry and director of the University of North Carolina’s Eating Disorders Program. And while no one has yet found a specific anorexia gene, researchers are focusing on an area of chromosome 1 that shows important gene linkages.

Certain personality traits associated with anorexia are probably heritable as well. “Anxiety, inhibition, obsessionality, and perfectionism seem to be present in families of people with an eating disorder,” explains Walter Kaye, M.D., who directs the Eating Disorders Treatment and Research Program at the University of California-San Diego. Another ingredient is neurobiology—literally, the way your brain is structured and how it works. Dr. Kaye’s team at UCSD uses fMRI technology to map blood flow in people’s brains as they think of or perform a task. In one study, Kaye and his colleagues looked at the brains of people with anorexia, people recovered from anorexia, and people who’d never had an eating disorder as they played a gambling game. Participants were asked to guess a number and were rewarded for correct guesses with money or “punished” for incorrect or no guesses by losing money.

Participants in the control group responded to wins and losses by “living in the moment,” wrote researchers: “That is, they made a guess and then moved on to the next task.” But people with anorexia, as well as people who’d recovered from anorexia, showed greater blood flow to the dorsal caudate, an area of the brain that helps link actions and their outcomes, as well as differences in their brains’ dopamine pathways. “People with anorexia nervosa do not live in the moment,” concluded Kaye. “They tend to have exaggerated and obsessive worry about the consequences of their behaviors, looking for rules when there are none, and they are overly concerned about making mistakes.” This study was the first to show altered pathways in the brain even in those recovered from anorexia, suggesting that inherent differences in the brain’s architecture and signaling systems help trigger the illness in the first place.

Food Is Medicine

Some of the best news to come out of research on anorexia is a new therapy aimed at kids and teens. Family-based treatment (FBT), also known as the Maudsley approach, was developed at the Maudsley Hospital in London by Ivan Eisler and Christopher Dare, family therapists who watched nurses on the inpatient eating-disorders unit get patients to eat by sitting with them, talking to them, rubbing their backs, and supporting them. Eisler and Dare wondered how that kind of effective encouragement could be used outside the hospital.

Their observations led them to develop family-based treatment, or FBT, a three-phase treatment for teens and young adults that sidesteps the debate on etiology and focuses instead on recovery. “FBT is agnostic on cause,” says Dr. Le Grange. During phase one, families (usually parents) take charge of a child’s eating, with a goal of fully restoring weight (rather than get to the “90 percent of ideal body weight” many programs use as a benchmark). In phase two, families gradually transfer responsibility for eating back to the teen. Phase three addresses other problems or issues related to normal adolescent development, if there are any.

FBT is a pragmatic approach that recognizes that while people with anorexia are in the throes of acute malnourishment, they can’t choose to eat. And that represents one of the biggest shifts in thinking about eating disorders. The DSM-IV, the most recent “bible” of psychiatric treatment, lists as the first symptom of anorexia “a refusal to maintain body weight at or above a minimally normal weight for age and height.” That notion of refusal is key to how anorexia has been seen, and treated, in the past: as a refusal to eat or gain weight. An acting out. A choice. Which makes sense within the psychodynamic model of cause.

But it doesn’t jibe with the research, which suggests that anorexia is more of an inability to eat than a refusal. Forty-five years ago, Aryeh Routtenberg, then (and still) a professor of psychology at Northwestern University, discovered that when he gave rats only brief daily access to food but let them run as much as they wanted on wheels, they would gradually eat less and less, and run more and more. In fact, they would run without eating until they died, a paradigm Routtenberg called activity-based anorexia (ABA). Rats with ABA seemed to be in the grip of a profound physiological imbalance, one that overrode the normal biological imperatives of hunger and self-preservation. ABA in rats suggests that however it starts, once the cycle of restricting and/or compulsive exercising passes a certain threshold, it takes on a life of its own. Self-starvation is no longer (if it ever was) a choice, but a compulsion to the death.

That’s part of the thinking in FBT. Food is the best medicine for people with anorexia, but they can’t choose to eat. They need someone else to make that choice for them. Therapists don’t sit at the table with patients, but parents do. And parents love and know their children. Like the nurses at the Maudsley Hospital, they find ways to get kids to eat. In a sense, what parents do is outshout the anorexia “voice” many sufferers report hearing, a voice in their heads that tells them not to eat and berates them when they do. Parents take the responsibility for making the choice to eat away from the sufferer, who may insist she’s choosing not to eat but who, underneath the illness, is terrified and hungry.

The best aspect of FBT is that it works. Not for everyone, but for the majority of kids and teens. Several randomized controlled studies of FBT and “treatment as usual” (talk therapy without pressure to eat) show recovery rates of 80 to 90 percent with FBT—a huge improvement over previous recovery rates. A study at the University of Chicago is looking at adapting the treatment for young adults; early results are promising.

The most challenging aspect of FBT is that it’s hard to find. Relatively few therapists in the U.S. are trained in the approach. When our daughter got sick, my husband and I couldn’t find a local FBT therapist. So we cobbled together a team that included our pediatrician, a therapist, and lots of friends who supported our family through the grueling work of re-feeding our daughter. Today she’s a healthy college student with friends, a boyfriend, career goals, and a good relationship with us.

A few years ago, Dr. Le Grange and his research partner, Dr. James Lock of Stanford, created a training institute that certifies a handful of FBT therapists each year. (For a list of FBT providers, visit the Maudsley Parents website.) It’s a start. But therapists are notoriously slow to adopt new treatments, and FBT is no exception. Some therapists find FBT controversial because it upends the conventional view of eating disorders and treatments. Some cling to the psychodynamic view of eating disorders despite the lack of evidence. Still, many in the field have at least heard of FBT and Kaye’s neurobiological findings, even if they don’t believe in them yet.

Change comes slowly. But it comes.

* * *

Harriet Brown teaches magazine journalism at the S.I. Newhouse School of Public Communications in Syracuse, New York. Her latest book is Brave Girl Eating: A Family’s Struggle with Anorexia (William Morrow, 2010).

be there for that person to develop anorexia.”

One of those ingredients is genetics. Twenty years ago, the Price Foundation sponsored a project that collected DNA samples from thousands of people with eating disorders, their families, and control participants. That data, along with information from the 2006 Swedish Twin Study, suggests that anorexia is highly heritable. “Genes play a substantial role in liability to this illness,” says Cindy Bulik, Ph.D., a professor of psychiatry and director of the University of North Carolina’s Eating Disorders Program. And while no one has yet found a specific anorexia gene, researchers are focusing on an area of chromosome 1 that shows important gene linkages.
Certain personality traits associated with anorexia are probably heritable as well. “Anxiety, inhibition, obsessionality, and perfectionism seem to be present in families of people with an eating disorder,” explains Walter Kaye, M.D., who directs the Eating Disorders Treatment and Research Program at the University of California-San Diego. Another ingredient is neurobiology—literally, the way your brain is structured and how it works. Dr. Kaye’s team at UCSD uses fMRI technology to map blood flow in people’s brains as they think of or perform a task. In one study, Kaye and his colleagues looked at the brains of people with anorexia, people recovered from anorexia, and people who’d never had an eating disorder as they played a gambling game. Participants were asked to guess a number and were rewarded for correct guesses with money or “punished” for incorrect or no guesses by losing money.
Participants in the control group responded to wins and losses by “living in the moment,” wrote researchers: “That is, they made a guess and then moved on to the next task.” But people with anorexia, as well as people who’d recovered from anorexia, showed greater blood flow to the dorsal caudate, an area of the brain that helps link actions and their outcomes, as well as differences in their brains’ dopamine pathways. “People with anorexia nervosa do not live in the moment,” concluded Kaye. “They tend to have exaggerated and obsessive worry about the consequences of their behaviors, looking for rules when there are none, and they are overly concerned about making mistakes.” This study was the first to show altered pathways in the brain even in those recovered from anorexia, suggesting that inherent differences in the brain’s architecture and signaling systems help trigger the illness in the first place.
Food Is Medicine
Some of the best news to come out of research on anorexia is a new therapy aimed at kids and teens. Family-based treatment (FBT), also known as the Maudsley approach, was developed at the Maudsley Hospital in London by Ivan Eisler and Christopher Dare, family therapists who watched nurses on the inpatient eating-disorders unit get patients to eat by sitting with them, talking to them, rubbing their backs, and supporting them. Eisler and Dare wondered how that kind of effective encouragement could be used outside the hospital.
Their observations led them to develop family-based treatment, or FBT, a three-phase treatment for teens and young adults that sidesteps the debate on etiology and focuses instead on recovery. “FBT is agnostic on cause,” says Dr. Le Grange. During phase one, families (usually parents) take charge of a child’s eating, with a goal of fully restoring weight (rather than get to the “90 percent of ideal body weight” many programs use as a benchmark). In phase two, families gradually transfer responsibility for eating back to the teen. Phase three addresses other problems or issues related to normal adolescent development, if there are any.
FBT is a pragmatic approach that recognizes that while people with anorexia are in the throes of acute malnourishment, they can’t choose to eat. And that represents one of the biggest shifts in thinking about eating disorders. The DSM-IV, the most recent “bible” of psychiatric treatment, lists as the first symptom of anorexia “a refusal to maintain body weight at or above a minimally normal weight for age and height.” That notion of refusal is key to how anorexia has been seen, and treated, in the past: as a refusal to eat or gain weight. An acting out. A choice. Which makes sense within the psychodynamic model of cause.
But it doesn’t jibe with the research, which suggests that anorexia is more of an inability to eat than a refusal. Forty-five years ago, Aryeh Routtenberg, then (and still) a professor of psychology at Northwestern University, discovered that when he gave rats only brief daily access to food but let them run as much as they wanted on wheels, they would gradually eat less and less, and run more and more. In fact, they would run without eating until they died, a paradigm Routtenberg called activity-based anorexia (ABA). Rats with ABA seemed to be in the grip of a profound physiological imbalance, one that overrode the normal biological imperatives of hunger and self-preservation. ABA in rats suggests that however it starts, once the cycle of restricting and/or compulsive exercising passes a certain threshold, it takes on a life of its own. Self-starvation is no longer (if it ever was) a choice, but a compulsion to the death.
That’s part of the thinking in FBT. Food is the best medicine for people with anorexia, but they can’t choose to eat. They need someone else to make that choice for them. Therapists don’t sit at the table with patients, but parents do. And parents love and know their children. Like the nurses at the Maudsley Hospital, they find ways to get kids to eat. In a sense, what parents do is outshout the anorexia “voice” many sufferers report hearing, a voice in their heads that tells them not to eat and berates them when they do. Parents take the responsibility for making the choice to eat away from the sufferer, who may insist she’s choosing not to eat but who, underneath the illness, is terrified and hungry.
The best aspect of FBT is that it works. Not for everyone, but for the majority of kids and teens. Several randomized controlled studies of FBT and “treatment as usual” (talk therapy without pressure to eat) show recovery rates of 80 to 90 percent with FBT—a huge improvement over previous recovery rates. A study at the University of Chicago is looking at adapting the treatment for young adults; early results are promising.
The most challenging aspect of FBT is that it’s hard to find. Relatively few therapists in the U.S. are trained in the approach. When our daughter got sick, my husband and I couldn’t find a local FBT therapist. So we cobbled together a team that included our pediatrician, a therapist, and lots of friends who supported our family through the grueling work of re-feeding our daughter. Today she’s a healthy college student with friends, a boyfriend, career goals, and a good relationship with us.
A few years ago, Dr. Le Grange and his research partner, Dr. James Lock of Stanford, created a training institute that certifies a handful of FBT therapists each year. (For a list of FBT providers, visit the Maudsley Parents website.) It’s a start. But therapists are notoriously slow to adopt new treatments, and FBT is no exception. Some therapists find FBT controversial because it upends the conventional view of eating disorders and treatments. Some cling to the psychodynamic view of eating disorders despite the lack of evidence. Still, many in the field have at least heard of FBT and Kaye’s neurobiological findings, even if they don’t believe in them yet.
Change comes slowly. But it comes.
* * *
Harriet Brown teaches magazine journalism at the S.I. Newhouse School of Public Communications in Syracuse, New York. Her latest book is Brave Girl Eating: A Family’s Struggle with Anorexia (William Morrow, 2010).