Early Relationships and Brain Development as the Core of Medical Practice

Given the current explosion of knowledge about the effects of early relationships on brain development, I believe that research at the interface of developmental psychology, neuroscience and genetics will soon need to be at the center of our medical education system. Thus I was excited and heartened to read about the Bayview Child Health Center and its medical director Nadine Burke in this week's New Yorker. An article entitled The Poverty Clinic describes a practice in a poor inner city neighborhood that applies this research to their daily care of patients.

Burke was most heavily influences by what is referred to as the ACE study, a retrospective review that showed a strong connection between adverse childhood experiences(including such parental divorce, abuse and neglect, being raised by a family member with mental illness) and many long term health outcomes. These include chronic medical conditions as emphysema and heart disease illness, substance abuse and other mental illness. She is also influenced by research in neuroendocrinology and behavioral genetics, including work of Michael Meaney and Bruce McEwen.

Burke's idea, drawing on the evidence that adverse experiences affect the brain and body on a molecular level, is to treat early childhood trauma as a medical problem. She describes "multidisciplinary rounds" modeled on treatment of cancer where care is coordinated among surgeons and other specialists. The article states:

At Bayview clinic, having the patient's ACE data, and a theoretical framework for discussion the effects of trauma, has inspired Burke and her colleagues to be more vigilant about abuse and neglect. It also makes them more likely to help children get the social services they need, and better prepared to talk to parents early about the importance of secure attachment.

Treatment interventions may include one or more psychological interventions and alternative therapies including yoga and medication. Alicia Lieberman, a leader in the field of infant parent mental health, is collaborating with Burke.

I wonder if Dr. Burke's medical model is successful in part because it allows clinicians to put the emotional component of this very difficult work at a distance. Bruce Perry, a brilliant psychiatrist at the Child Trauma Academy who has written extensively about working with traumatized children, describes very similar interventions. It may be that for clinicians who have not chosen a mental health profession, such as internists and pediatricians, viewing early trauma as a biological problem may be adaptive. It may allow them to do the work without being overwhelmed by feelings that the emotional suffering of their patients may bring up. This form of defense may be particularly important for clinicians who themselves have experienced some kind of early trauma, and for whom their patient's experiences are a bit too close to home. In the mental health professions, there are opportunities to discuss these types of reactions to the work. However, training in medicine and pediatrics rarely offers such opportunities.

In a sense analogous to testing for iron deficiency because of our knowledge about its importance in brain development, primary care clinicians on the front lines with young children and families will need to know about and apply our knowledge of the importance of early relationships on brain development. Dr Burke's clinic is an important step in the right direction. As this model makes its way into medical practice, however, it will be important to find a place for recognizing the emotional piece of the work. Not only will this avoid clinician "burn out" but it will give value to the relationship between clinician and patient. It can be the clinician him or herself who is the most important part of the treatment.