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.

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. 


Sunday, November 26, 2017

Community Trauma Prevention Starts with Parent-Infant Relationships

I recently had the privilege of listening to Bessel van der Kolk, trauma researcher and author of The Body Keeps Score. He began his talk with a video clip of a mom and her baby, who looked to be about 3 months old, having a conversation. It started with an exchange of soft sounds, moving on to more complex communication, including shared facial expressions. Palpable delight characterized the moment of meeting.
As the conversation between mother and baby increased in complexity, a slight lapse appeared between the baby's signal and the mother's response. Herein lies the development of resilience. World-renowned child development researcher Ed Tronick, who van der Kolk referenced at the start of his talk, has demonstrated, with second-to-second videotape analyses, that in typical relationships parent and infant are mismatched in 70 percent of interactions. What he terms "quotidian resilience" develops in the repair of these countless moments.
Ways of being together are laid down in our minds and bodies the early weeks, months, and years of life. They become part of us; part of our DNA. Our earliest relationships sculpt our nervous system and the way our body responds to stress. The moment-to-moment mismatch and repair of early infancy is the material of which our self, with our own skin—our own border—is made. Survival of disruption, together with the joy of repair, creates trust, an essential ingredient of intimacy. We develop a confidence that when we feel bad, we won’t always feel bad. This early experience builds a foundation of hope. 
The talk was sponsored by Berkshire United Way, which is taking a lead in making our community "trauma-informed." Driving the movement to create "trauma-informed communities" is the powerful longitudinal Adverse Childhood Experiences Study showing the poor long-term outcomes of a range of experiences including not only abuse and neglect, but the more ubiquitous experiences of parental mental illness, marital conflict, and divorce. The greater the number of ACEs, the greater the likelihood of a wide range of negative physical, emotional, and social consequences.  
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. Again 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. 

 An extensive body of research shows us how these early experiences get into the body and the brain.  But perhaps we need look no further than van der Kolk's opening video. My colleague in Scotland, Suzanne Zeedyk, who is taking extraordinary strides to make an entire country "trauma-informed" in large part through showings of the film Resilience  about the ACEs study, began her work in the arena of public policy with a beautiful film, the connected baby. Both she and van der Kolk recognize that babies have an extraordinary capacity for connection and communication from the moment of birth. "ACEs" are experiences that violate that connection. 
Adverse Childhood Experiences can be understood as developmental derailment of the healthy process of mismatch and repair. Prolonged lapse between mismatch and repair occurs when a parent is preoccupied with depression, substance use, marital conflict, or domestic violence. Absent mismatch occurs with an anxious intrusive parent. Unrepaired mismatch occurs in the setting of abuse and neglect. 
Van der Kolk went on to demonstrate, using research evidence and clinical examples, how when bad things happen to us early in our lives, the experiences live in the body. Offering a message of hope, he encouraged his audience—a broad range of individuals from our local community—to recognize that healing begins with the body. Theater, martial arts, drawing, drumming, yoga, and dance are among the many ways in which, in the setting of relationships, parts of the brain damaged by the experience of trauma can begin to heal. 
In conclusion, van der Kolk returned to babies. He advised us to look to paid parental leave, high-quality daycare for all, and other measures to support new parents as the path to a trauma-informed community. In keeping with his recommendations, our local Berkshire United Way chapter is supporting a project designed to give every newborn baby and parent a voice.
Using the Newborn Behavioral Observations (NBO) system, founded in the work of pediatrician T. Berry Brazelton, as a model of care for all new families, we aim to offer opportunities for nonjudgmental listening to parent and baby together. One mother had an unexpected emergency cesarean section and feared that the disruption in her birth plan would damage her connection with her baby. When we used the NBO to take time to demonstrate how well she did, in fact, understand her baby, she was flooded with relief and joy. 
A recent Time magazine article, The Goddess Myth, identifies the unrealistic expectations of the transition to motherhood as potentially damaging to mothers. The article cites the statistic that close to 50 percent of mothers have deliveries that do not go according to plan. Sometimes referred to as "birth trauma,"  the lack of ability to repair the disruption in a holding environment characterized by connected relationships can enhance the traumatic nature of the experience. 
The word "trauma" can itself be traumatizing. As we move forward with this work, I wonder if we might aim to build not "trauma-informed" communities, but, taking the lead from van der Kolk's presentation of mother and baby, simply "connected communities."  Parents and babies are an excellent place to start.


Friday, September 8, 2017

When Parents Fear "It's All My Fault"

Many of my colleagues in the field of early childhood mental health work with what are termed "high risk" populations. Children of drug addicted parents, victims of child abuse, and families in abject poverty. While the challenges these families face are daunting, I find myself feeling some envy for my colleagues whose clients are in such obvious distress that the need for intensive treatment of parent and infant is not in question.

In my rural, small-town population things are not so clear. Many families struggle under the radar for years. Recently in my behavioral pediatrics practice (details are changed to protect privacy) I saw a 3-year-old boy, who, in taking a detailed history, I could see barreling 100 miles an hour towards trouble from the moment he was born, or even before.  But the story unfolded before our eyes without intervention. Did the parents resist help? Did the many professionals in with contact with the family not recognize the problems? Probably some combination of both.

 We know from the CDC sponsored Adverse Childhood Experiences (ACEs) study that neglect and abuse, as well as more ubiquitous experiences of such things as marital conflict, parental mental illness, domestic violence, and substance abuse lead to a wide range of negative health outcomes both physical and mental. Yet babies come and go to pediatric practices and we don't discover or address until years later that in the early weeks and months, when their brains were most rapidly growing, parents-many themselves with a history of ACEs-struggled significantly. 

We need to find a way to engage these families with intensive support from the very beginning without making parents feel that they are somehow not "good-enough." Engagement means not only behavior management for children and/or medication for parents. It means listening to parents and infants together from the start. We need to listen to the vulnerabilities the child brings into the world as well as the often-complex relational issues between partners, among siblings, and with extended family.

The mother of my 3-year-old patient struggled with severe postpartum anxiety and profound social isolation. She described her son as "inconsolable" from birth. The marriage faltered. He developed severe separation anxiety, frequent explosive tantrums, and sleep disturbance among a range of other behavioral and developmental disturbances.

We know from infant research that a core sense of self develops in the moment-to-moment interactions between infants and their caregivers. Babies arrive in state of complete helplessness, relying 100% on their caregivers to make sense of the world and of themselves. This does not mean parents need to be perfect. In fact, perfection as well as absence can inhibit self-development and lead to fearful and rigid states. It is the very imperfections in relationships that help infants to develop resilience and a positive sense of themselves in the world.

But when parents are fighting constantly, when a mother or father is preoccupied with anxiety and/or depression, when a parent is in an altered mental state intermittently from substance abuse, this core sense of self may be distorted as infants struggles to make meaning of their experience. The "symptoms" of my 3-year-old patient can be understood as difficulties managing both his body and developing mind in a complex social world.

The transition to parenthood is challenging under the best of circumstances. Alicia Lieberman, one of the giants of the field of infant mental health, speaks in a kind of paradoxical way of how "trauma" is "normal." ACEs are extremely common. I recently heard a leader in the trauma field say in a presentation, "ACEs are normal."

If we engage families at or even before birth, presenting the challenges of the transition to parenthood as normal, when a parent struggles we will be right there to work more intensively to support these early relationships when bigger disruptions arise, rather than waiting until families are in crisis. Universal home visiting, relationship-based Early Intervention services and community support groups for parents and infants offer opportunities for a population based, non-stigmatizing approach to supporting new families.

Pediatricians present an ideal opportunity to engage families in this way. Currently Jack Shonkoff at the Center on theDeveloping Child is partnering with pediatric practices to develop a preventive model on the front lines where parents and babies regularly go. My colleague Ed Tronick has said on multiple occasions that parent-infant mental health should be the core of pediatrics, not a subspecialty. The abundant evidence from the ACE study certainly supports this claim.

At the tender of of 3 there is plenty of opportunity to help my patient and his family, who are invested in doing the work to set relationships and development on a better path. But I hope for shifts in culture, health care, and public health that will allow all families to set out on a healthy path from the start.