Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary research in child development can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Wednesday, March 23, 2011

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.


  1. Dear Dr. Gold,

    Thank you for your thoughtful comments about the article. Your question about whether using a medical framework allows us to keep the emotional suffering of our patients at a distance is a good one. In fact, it is exactly the opposite. I believe that the mental health community understands and is responding to the longterm impacts of child trauma on emotional health. What breaks my heart is that the kids I see are more likely to suffer and die of heart disease, chronic lung disease, hepatitis and cancer and there has been very little response or intervention from the medical community. It seems that many believe that poor health is simply a condition of poverty, rather than the result of a lifetime of neurologic, endocrine and immune insults. I treat children, but anyone who does this work understands that a pediatrician, particularly in a low-income urban setting, must treat the whole family. There is no way to do this work without feeling the pain of children who are abused, neglected and abandoned . . . or of their parents who almost uniformly had the same experience in their childhoods and yet repeat the behavior with agonizing reliability. My multidisciplinary team gives me tools to manage the challenges that come along with that. I focus on the medical sequelae because that is my training and because I see a huge void in this field.

    I believe that the success of this work comes from our multidisciplinary model. I work extremely closely with mental health and social work professionals on my team to provide comprehensive care to our kids. During rounds we discuss how the emotional health of the family can create barriers to adequate health care. A depressed or psychotic parent is much less likely to give daily asthma controller medicines. If we are serious about eliminating health disparities then we must deal with the medical sequelae of child trauma. This begins with adequate training of physicians to recognize the symptoms, understand the mechanism of pathology and utilize the appropriate treatments which may include psychologic, behavioral and medical interventions.

    This is certainly a complex problem and Paul Tough does an amazing job in his research and explanation of issue. I hope that it helps to move us closer to effective solutions.


  2. I am assuming this is the Nadine Burke of the New Yorker Article. I am thrilled to read your response. I think that you are doing an amazing kind of work. I am also happy to read about the interdisciplinary rounds in more detail-perhaps this aspect of the work did not come through in the article as clearly as you describe it here. I agree that the science is an important point of entry, though do feel that in the training of primary care clinicians more attention could be paid to the emotional impact of the work on the clinician and to the therapeutic value of the relationship with the patient. What does come thorough in the New Yorker article is that you have such a relationship with your patients.
    In my forthcoming book(August 30) I describe a treatment intervention that I have been using in my pediatric practice for a number of years that draws upon contemporary research at the interface of developmental psychology, neuroscience and genetics.