Relationships: The Fourth Vital Sign

Respiratory rate, heart rate, blood pressure- these are the three vital signs that those on the front lines of health care are well trained to measure as initial assessment of a patient. Given the explosion of knowledge emerging at the intersection of neuroscience, genetics and developmental psychology about the essential role of early caregiver-child relationships on lifelong health, it is time to add a fourth vital sign- relationships. I first learned of this idea from a colleague, David Willis who is Chair of the American Academy of Pediatrics (AAP) Early Brain and Child Development Initiative. He in turn learned it from Colleen Kraft. Adding this fourth vital sign puts assessment and support of early relationships front and center.

The AAP policy statement Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health captures the critical role of relationships in healthy development.

In contrast to positive or tolerable stress, toxic stress is defined as the excessive or prolonged activation of the physiologic stress response systems in the absence of the buffering protection afforded by stable, responsive relationships..toxic stress early in life plays a critical role by disrupting brain circuitry and other important regulatory systems in ways that continue to influence physiology, behavior, and health decades later.

A remarkable study coming out of the Yale Child Study Center and described in the New York Times  shows the wisdom of this focus on relationships. It was a randomized control study of the Child and Family Traumatic Stress Intervention(CFTSI). Children who received the intervention were 65 percent less likely than those in the comparison group to have developed full-blown post-traumatic stress disorder and 73 percent less likely to experience partial post-traumatic stress disorder. These are the kind of numbers that make one stand up and take notice.

What makes this intervention different is that it specifically works with caregiver and child together to support the caregiver's efforts to understand the meaning of the child's behavior.

Unlike traditional counseling, which is often unstructured and prolonged and may not involve both child and caregiver, this program follows a proven pattern: first a session with the caregiver, then one with the child, then two sessions with them together.

Steve Marans, lead author on the study, explains the results.

When children are alone with and don’t have words to describe their traumatic reactions, symptoms and symptomatic behaviors are their only means of expression. And caregivers are often unable to understand the connection between the traumatic event and their children’s symptoms and behaviors. To heal, children need recognition and understanding from their caregivers.

These remarkable results make perfect sense to me. Children want to be understood by their parents, not their therapist. This is the model I have been using for years in my pediatric practice to address any behavioral symptom, not only those associated with trauma, and I too have had remarkable results. It is wonderful to see this approach validated by a high quality randomized control study. As I write in my book Keeping Your Child in Mind

Being understood by a person we love is one of our most powerful yearnings, for adults and children alike. The need for understanding is part of what makes us human. When our feelings are validated, we know that we’re not alone. For a young child, this understanding helps develop his mind and sense of himself. When the people who care for him can reflect back his experience, he learns to recognize and manage his emotions, think more clearly, and adapt to his complex social world

This concept of supporting parent's efforts to reflect on the meaning of a child's behavior comes out of decades of research showing how this kind of understanding promotes health development at the level of gene expression and biochemistry of the brain.

When baby is born, if heart rate, respiratory rate and blood pressure are OK, our next priority is to support the primary relationships by carefully listening to both caregiver and baby. One way to accomplish this is to use a wonderful tool the Newborn Behavioral Observation system, developed by J.Kevin Nugent, colleague of T. Berry Brazelton. If problems are identified, such as a biologically vulnerable child whose cues are hard to read, or postpartum depression, or lack of social support for mother, we can address them. We will then be setting this new life out on a course of healthy development from the start.