Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. I aim to show how contemporary developmental science points us on a path to effective prevention, intervention, and treatment, with the aim of promoting healthy development and wellbeing of all children and families.

Thursday, July 12, 2018

Parent-Child Separation as Existential Trauma

The face of a 2-year-old Honduran girl, dwarfed by the adults who only appear as legs in the photo, communicates undeniable anguish. Used to represent the horror of children separated from their parents at the US Mexican border, the photo became a lightning rod for controversy when it turned out that this particular child was not actually separated from her mother. In an interview for CBS News the border patrol officer involved in the incident explained that they asked the mother to put her daughter down so she could be searched. He explained, "It took less than two minutes. As soon as the search was finished, she immediately picked the girl up, and the girl immediately stopped crying."  

The fact that the girl recovered immediately shows that she has had accumulated a reservoir of experience with her mother coming back. Rather than falling apart, she was immediately comforted. The very presence of her mother appears to have given her the skills to manage her distress. In an instant she is OK.

But when separations are beyond a young child’s ability to manage, the capacity to recover in the face of disruption is compromised. Time is of the essence.   With too much time, “stress” is transformed into “trauma.”

Pediatrician turned psychoanalyst D.W. Winnicott captures the role of time in child development in a way that seems particularly poignant in light of current events. In his book Playing and Reality he describes how a young child comes to have a sense of himself in relation to the world around him:

“It is perhaps worth while trying to formulate this in a way that gives the time factor due weight. The feeling of the mother’s existence lasts x minutes. If the mother is away more than x minutes, then the imago fades, and along with this the baby’s capacity to use the symbol of the union ceases. The baby is distressed, but this distress is soon mended because the mother returns in x+y minutes. In x+y minutes the baby has not become altered. But in x+y+z minutes the baby has become traumatized. Trauma implies that the baby has experienced a break in life’s continuity… [his behavior] now becomes organized to defend against a repetition of ‘unthinkable anxiety.’”

When the Honduran girl’s mother picked her up her rapid recovery reflects an experience Winnicott describes with the lovely phrase “going on being.” The countless experiences of the mother coming back, in typical day-to-day interactions, literally builds a child sense of self. The “unthinkable anxiety” he references is the profound unraveling that accompanies a loss of bearings, a loss of sense of self.

While unfortunate that the photograph was misrepresented, in fact it proves a point about the actual separations known to have occurred in large numbers. Young children rely completely on their parents to hold them together. Self-regulation, the ability to manage on one’s own, is a developmental process that occurs over countless moment to moment interactions in co-regulation with primary caregivers. Separation beyond a young child’s ability to manage represents, from a developmental perspective, a fundamental threat to existence.

Sunday, March 18, 2018

Can We Harness Pediatrician T. Berry Brazelton's Message of Hope?

As our nation mourns the passing of renowned pediatrician T. Berry Brazelton, hearing his voice through the outpouring of articles, video clips, and conversations on social media feels like a balm for the soul.  In these trying times, his simple shift from learning "what's wrong" to listening for "what's right" in a child and family seems very much needed.

In his 50 years practicing pediatrics, he saw up close the ways parents can struggle. With his profound observation that leaps in development are preceded by periods of disorganization, he helps us to see that the struggles are not to be avoided, but to be embraced and worked through. In collaboration with developmental researcher Ed Tronick, he showed how we learn and grow by repair of the countless inevitable disruptions in relationships. Together they offered "evidence" of pediatrician D.W. Winnicott's observations of the "good-enough mother" who facilitates her infant's growth and development by failing to meet his or her every need. Our very imperfections propel development forward in a healthy direction.

It seems somehow fitting that he died the same day as Stephen Hawking, who said, “Without imperfection, you or I would not exist.” One person on social media commented that Brazelton was to babies what Hawking was to the cosmos. 

 In a way that was revolutionary at the time, he called on us to protect time to listen to every new baby's unique voice. He was among the first to recognize the newborn infant's tremendous capacity for connection and communication. In a beautiful video clip shared on the Facebook page of Mind in the Making he describes his Newborn Assessment (NBAS) as "the most important thing I ever did for the field." He describes its origin in his observations of his own children that led him to recognize that "each child shaped the environment around them." He says, "My goal was to share the neonatal assessment with parents so they understood what kind of person they were getting." He describes parents asking,  "How am I going to know what kind of person this is?" and he observes that, "as soon as they play with the baby, they know." The idea the newborn infant is fully connected and available to play is one we need to hold front and center.

In collaboration with Dr. Kevin Nugent, Dr. Brazelton's newborn assessment was translated into a clinical tool termed the Newborn Behavioral Observations (NBO) system. By eliminating the word "assessment" the NBO emphasizes the non-judgmental aspect of our observations. Parenting inevitably comes with a hefty dose of guilt.  The NBO does not test the parent or the baby, but simply protects time to listen to both.

In our rural community in Western Massachusetts, we are taking steps to carry out Dr. Brazelton's dream that "every parent will have opportunity to give his or her child the best future they can dream of." By integrating the Newborn Behavioral Observation into routine care at our local hospital, and training a wide range of practitioners who interface with infants and parents in the NBO we aim to give every newborn baby a voice.

A line in the New York Times obituary gave me pause.
Nevertheless, Dr. Brazelton’s work never entered mainstream pediatrics and is not taught in most medical curriculums.
Sometimes a person's genius is not fully appreciated until after death. I am hopeful that the attention now focused on his brilliant observations, and his deep empathy for both parents and children, will have new life.

The impact of his work extends well beyond pediatrics. Not only is it relevant for all individuals on the front lines caring for young children and families. The idea that disorganization- or what Dr. Tronick refers to as the "messiness" -is not to be avoided, but rather embraced, worked through, and repaired, may have profound implications for the way we live our lives.

Saturday, January 27, 2018

A Conversation with Nadine Burke Harris: How Should Pediatricians Address Childhood Adversity?

Pediatrician Nadine Burke Harris is a masterful storyteller. I learned in a conversation with her at Wheelock College before her presentation for the Brookline, MA organization Steps to Success, that before she decided to become doctor, Dr. Burke Harris wanted to be an author. Only after the smashing success of her TED talk: How childhood trauma affects health across a lifetime, when she was approached by a literary agent, did she find her way to writing. Her newly released book The Deepest Well: Healing the Long-term Effects of Childhood Adversity is filled with engaging stories that intertwine personal experience and scientific discovery. Now on the road promoting the book, Burke Harris is able to put her storytelling skills to use in spreading the important messages of her work.

In the book, Dr. Burke Harris describes the convergence of two events. First, while working at a clinic that she founded in a high needs, low resourced community in San Francisco , she observed that children with ADHD, asthma, and other common childhood illnesses had experienced massive levels of adversity. Then fortuitously, a colleague showed her the CDC- Kaiser Permanente co-sponsored Adverse Childhood Experiences (ACE) study, that offers dramatic epidemiological evidence of the high correlation between 10 adverse childhood experiences and negative health outcomes both physical and emotional. As an example of her skill at vivid communication, in describing this moment of discovery Dr. Burke made a "whoosh" sound to accompany the visual depiction with movement of her hands that, "the top of my head blew off." 

Now Dr. Burke Harris is a woman on a mission to make ACEs screening an integral part of pediatric care. The launch of her book tour coincided with the website for this initiative NPPCACES (The National Pediatric Practice Community on Adverse Childhood Experiences) going live. The hope is for all pediatricians to give parents a "de-identified" screen. Those with a high score go on to another level of care.  

As a pediatrician specializing in the developmental science of early childhood, I was interested to learn from Dr. Burke Harris how the she sees the science of ACEs impacting on the way we care for parents and infants.

Toxic stress, defined as stress in the absence of safe, secure caregiving relationships, is a mechanism by which adverse experiences get under our skin and wreak their long-term havoc on our health.  I wondered if the clinicians whose main task is to support these relationships might be the front line of care, with the pediatrician as the specialist. 

While Dr. Burke agreed in theory she said, “we’re not there yet." She went on to explain, "The medical specialist is the authority," She see the entry point for integrating ACES as firmly embedded in the medical model. She does not want to force pediatricians to take on the role of promoting relationships, which is not what many have signed on for. As an example, she said that pediatricians will more likely embrace screening for ACEs if they see that it will help in management of asthma, revealing which patients may benefit more from decreasing adversity than from treatment with bronchodilators. Once they see the high prevalence of ACEs, as was demonstrated in the original study and has been replicated in many, then they may come around to a focus on supporting relationships.

I was also curious about the poignant stories in the book where she comes up against resistance. At a meeting where she had to step out to pump breast milk for her infant son, she returned to find people describing her as “that doctor from San Francisco telling us that our kids are brain damaged.” While most people depicted in her book find learning their ACE score to be deeply empowering, a subset experience it as victimizing and blaming.

When I raised the question of what might lead a person to have a negative reaction, immediately Dr. Burke Harris gave an impassioned defense of screening to address what she describes as a public health emergency. She likened the problem of a negative reaction to a side effect of a life saving antibiotic. We agreed that identifying a subpopulation that might have a negative reaction to screening would mitigate this risk.

During the Q&A following her talk, an audience member described how when she tried explaining ADHD as symptoms associated with adversity, she got pushback from both parents and teachers. Dr. Burke Harris responded that we must dispel misinformation and “shout our message from the rooftops.”
At Montefiore Medical Center where ACEs screening has been implemented, pediatricians explain to parents that higher ACE scores are tied to long-term impact on their child’s health. But as Dr. Burke Harris herself described, when we feel threatened, the thinking parts of our brain do not function well. Perhaps some of the people who resist cannot hear this rational explanation.
As I listened to her presentation following our conversation, the work of neuroscientist Stephen Porges came to mind. His research shows that under situations of overwhelming threat, rather fight or flight a third response of our nervous system, under the influence of the primitive vagus nerve, takes over. Not only does our thinking brain go “offline” but also the muscles of the middle ear literally do not function normally. When people feel safe, the “smart” vagus of the parasympathetic system comes online and we are able to listen and connect.

As I'm sure Dr. Burke Harris would agree, screening and safety need to go hand in hand. As I contemplated our conversation, I thought about the possibility of substituting the word "listening" for the word "screening." At one point in the book she writes, "By being open about ACEs with family and friends, people are normalizing adversity as part of the human story." This phrase brought to mind the work of Buddhist Thich Nhat Hahn on the universal experience of suffering. He writes:
When we listen with our whole being, we can diffuse a lot of bombs. . . . If there is someone capable of sitting calmly and listening with his or her heart for one hour, the other person will feel great relief from his suffering. 
I wonder if ACE screening is a form of communicating to parents, "I recognize your suffering and I am here to listen." If so, then universal screening offers a clear path to healing.

Thursday, December 14, 2017

Adverse Childhood Experiences (ACE) Study: Beyond Screening in Pediatrics

The evidence is clear. When bad things happen to us as young children, we are at significantly increased risk for not only mental health problems, but also a wide range of physical health problems including asthma, heart disease, and even early death. These "bad things" all involve disruptions in caregiving relationships. A national movement directed at screening for ACEs in pediatric practices has emerged from this work.

My suggestion that the implication of the Adverse Childhood Experiences (ACE) study is orders of magnitude greater than screening was met by spontaneous applause at two presentations I gave at the recent Zero to Three annual conference in San Diego.

If poor health outcome is directly proportional to experiences that adversely impact relationships, the natural conclusion is that promoting healthy parent-child relationships from birth must be the core of children's health care. 

An entire new field, termed infant-parent mental health, infant mental health or early childhood mental health, has emerged out of the wealth of scientific knowledge at the interface of genetics, neuroscience, and developmental psychology to inform a model of prevention, early intervention and treatment. My most recent book, The Developmental Science of Early Childhood synthesizes this work into a practical guide to its application from infancy through adolescence.  Efforts at "co-location" point in the right direction. However, it is the pediatric specialist who should be co-located.  The clinician whose primary task is to promote healthy relationships should be the primary care provider.    

What would such a restructuring look like?  Clinician training that places this body of knowledge at the center, rather than as elective, would be a start. Structure reimbursement so that the clinicians on the front lines, in essence saving lives by spending time listening to parents and children, would be financially rewarded. We would draw the most talented clinicians from the more lucrative subspecialties to the work of primary prevention. 

The original ACE research grew out of the observed high association between adult obesity and childhood sexual abuse. The original ACE questionnaires address experiences specific to relationships. Recent adaptations have expanded to include external stressors such as poverty and racism. Looking to the research of Ed Tronick (credit image below,) we can understand the parent-infant relationship as being either a buffer against or a transducer of these stressors. 

Healthcare clinicians cannot solve problems of poverty and racism. But we are ideally situated to use our relationship with families to build buffering relationships. 

Decades ago John Bowlby, influenced by Charles Darwin, observed that safe, secure caregiving relationships are central to our evolutionary success. Now abundant scientific research supports this observation. We need an army of clinicians whose primary objective, drawing on contemporary developmental science, is to promote healthy relationships from birth. I hope the powerful driving force of the ACE study, exemplified by advance praise of Nadine Burke Harris' forthcoming book on the subject, will move us beyond screening to deeper long-term solutions.