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 developmental science 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.

Saturday, August 13, 2016

The Allure (and Danger) of Certainty: A Developmental View

“You don’t know who you can trust, but to survive you need to be connected to the social world. So you align yourself with the worst possible people.” Peter Fonagy, researcher, psychoanalyst, and Chief Executive of the Anna Freud Centre in London, spoke these words at the conclusion of a masterful presentation of the developmental origins of our ability to function in a complex social environment.

Rather than focus on the cause of disease, he led his audience, a range of professionals working to support early parent-child relationships, through decades of research at the interface of neuroscience, genetics and developmental psychology to an understanding of what defines emotional health.

Connection to others is central to our humanity. It regulates our physiology and protects against the harmful effects of stress. Its absence, the profound aloneness that accompanies difficulty in communicating with others, is the common factor underlying all forms of mental distress.

The foundations of connection are laid in early childhood, when caregivers respond to us as individuals with motivations and desires. Rather than simply controlling our behavior, they listen to us and reflect on the meaning of our communication. This process, referred as mentalization, or in more common language, being held in mind, exploded into the world of developmental psychology and neuroscience research after Fonagy and colleagues identified its significance in the early 1990’s.

But how does this early childhood experience of being held in mind help us to be connected in a social world? The next wave of research has demonstrated that the answer lies in what he terms “epistemic trust.” Epistemic means “of or relating to knowledge.” He defines the concept as “an individual’s willingness to consider new knowledge from another person as trustworthy, generalizable, and relevant.”

In other words, the way we acquire new knowledge about others and our social world is intimately intertwined with how we are listened to as a developing child. Children learn, from the cues a trusted caregiver offers, to whom they should listen, and what is important for them to learn.

An elegant series of experiments by Elizabeth Meins and colleagues demonstrates that the quality of early relationships is intimately tied with the development of epistemic trust.  A secure early relationship makes us more discerning about whom to trust, while instilling confidence to reject others’ views when these are inconsistent with the facts.

Stress and adversity are ubiquitous. Adversity becomes “trauma” when it is compounded by a sense that one’s mind is alone.

In an environment characterized by paucity of mentalization, epistemic mistrust, or hypervigilence, along with a sense of social isolation, develops. An individual then faces what Fonagy terms an “epistemic dilemma, “ characterized by cycling between hypervigilence and excessive credulity.

For a person facing this dilemma, a leader who speaks with absolute certainty, leaving no doubt that he or she is the one to whom we should listen, has power to protect against the emotionally intolerable experience of being alone. In this state, feelings can override facts.

 This developmental model helps to make sense of our current political situation.  In a democracy, when a large population feels fundamentally disconnected and unheard, filled with mistrust yet also vulnerable to emotionally driven messages, it makes all of us vulnerable. 

Fonagy, who aims to use his research to inform of social policy, is making broad inroads across the ocean in England. Kate Middleton, the Duchess of Cambridge, is now Royal Patron of the Anna 
Freud Centre which, with a handful of other mental health charities is joining with Princes William and Harry to change the discourse on mental health with their campaign Heads Together.

An article on her first foray into the public eye following the birth of Charlotte when she visited the Centre states:
 “Mental health experts hope the integrated approach with joint lessons for children and their parents will be replicated around Britain, as the Government prepares to invest £1.25 billion over five years to tackle the problems affecting around one million young people, often as a result of family breakdown, abuse, illness, and bereavement.”

In the United States we have been failing terribly in this respect. We are one of two developed countries without government supported parental leave. Childcare workers are among the lowest paid, with little support or training in child development. We have an epidemic of expulsion from preschool. Primary care clinicians are more likely to diagnose psychiatric disorders in young children than to take time to listen, as I describe in my new book The Silenced Child.

Fonagy’s brilliant body of research, together with all the best science of our time, tells us that we must invest in childhood, when the brain is making as many as 700 new connections per second. By supporting listening and connection between young children and their caregivers, we promote healthy development of the next generation. With the leadership that recognizes the value of this new science, we will have an opportunity to apply contemporary research and knowledge, setting our children and our country on a healthy path.