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.

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.

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