The Opioid Crisis and the Next Generation

Joy and love mix with disorganization, sometimes verging on chaos, when a new life enters the world. As renowned pediatrician T. Berry Brazelton and developmental psychologist Ed Tronick have wisely observed, that disorganization itself facilitates healthy growth and development as parents and baby engage in the messy process of getting to know each other. 

The level of chaos and need when a new life enters a family in the grips of opioid use can feel overwhelming.  In a new statewide program in Massachusetts, brave and heroic individuals who have themselves navigated the treacherous waters of addiction, generously draw on their own struggles to help others find a better path. 

The Massachusetts Department of Public Health’s FIRST (Families In Recovery SupporT) Steps Together is a new home visiting program in the Bureau of Family Health and Nutrition’s Division of Pregnancy, Infancy, and Early Childhood. Funding for this project is provided through SAMHSA’s State Opioid Response grant to Massachusetts, administered through the Bureau of Substance Addictions Services.

Clinicians work alongside Family Recovery Support Specialists. As one of the infant-parent mental Health specialists, I aim to promote parent confidence and support healthy parent-infant relationships. 

A recent Sunday issue of the Berkshire Eagle, our local paper in Pittsfield, MA, one of the program's 5 locations, featured an article with the headline "Set them on  healthy path from the beginning," featuring this quote. "If you want to change unhealthy patterns that have been going on for generations, this is the time to do it."

Six months after entering the program with her newborn infant, one mother said of her relationship with her son, "We have a bond that you cannot break."

The first months of life, when parent and infant meet and get to know each other, offer an opportune moment of healing. As a paper from the Alliance for the Advancement of Infant Mental Health wisely explains: "The parent-infant/young child relationship is the vehicle for repair that can break the cycle of substance use-substance abuse-rehabilitation and relapse."

The body of research offering evidence for this dyadic work is captured in a review article titled The opioid dependent mother and newborn dyad: non:pharmacological care, which summarizes the concept:

"By examining the newborn in the presence of the mother, the provider can demonstrate the range of the infant’s physiological and behavioral competencies and weaknesses, as well as adaptive or maladaptive responses to external stimulation. At the same time the maternal responses to each displayed newborn sign can be observed. Attention to maternal reactions and behaviors can direct the intervention with the dyad to diminish emotional overload and provide external organization until the infant can develop higher sensory limits and consistent behavioral self-regulation."

Extensive scientific evidence supports investing in these tender new relationships. The Newborn Behavioral Observations System is one tool we can use. A clinical application of the original observations of Dr. Brazelton that each new baby comes into the world with a unique capacity for connection and communication, the NBO provides a structure for organizing our observations. It brings us into the moment of connection, highlighting the value of listening to parent and infant together.  A new program in Western Massachusetts, The Hello It's Me Project, provides trainings in the NBO to a wide range of practitioners who work with these vulnerable parent-infant pairs. Another tool, the FAN (Facilitating Attuned Interactions) offers a model that can be applied in setting where practitioners work with parents and infants.  It is organized around a core idea of "being with" without attempt to change what another the person is doing or believing. Rather than imposing well-meaning efforts to "fix" a problem, we offer our listening presence to empower parents and build a sense of confidence. In doing so we promote healthy development of both parent and infant. 

The newborn brain makes over one million new connections per second. In the early days, weeks, and months of life, these connections develop in interaction with primary caregivers. Developmental specialists refer to these caregivers as "neuroarchitects." When we acknowledge their expertise in this role, and devote sufficient resources to keep the normal disorganization of this developmental stage at a manageable level, we can get things going right from the start for the whole family. 

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Helping New Parents Make Room for Uncertainty

A new program for parents and infants is coming to Pittsfield, Massachusetts. The Hello It’s Me Project shines a spotlight on these tender new relationships, investing resources around the birth of a baby with the long-term goal of building a healthy community from the bottom up. 

When world-renowned child development researcher Dr. Ed Tronick spoke in the spring of 2018 for an audience of a wide variety of practitioners in Berkshire County who work with children and families, he began with a quote from Steven Hawking, “One of the basic rules of the universe is that nothing is perfect. . . .Without imperfection, neither you nor I would exist.”

Perhaps best known for developing the Still Face Paradigm, an experimental manipulation designed to demonstrate the young infant’s tremendous capacity for connection and communication, Dr. Tronick shared his decades of research, revealing not only the inevitability, but also the necessity of imperfection in human interaction.

In contrast to the expectation of a kind of mythical idealized attunement, he found, through detailed microanalysis of interactions in our primary love relationship, that healthy, typical parent-infant interactions are in fact mismatched 70% of the time. Through the repair of these moment-to-moment mismatches we develop sense of agency and hope, a sense that “I can act on my world to make it better.”

Psychologist Dr. Jayne Singer continued the afternoon presentation for the community, sharing the Touchpoints model, developed by Dr. Tronick together with pediatrician T. Berry Brazelton, who passed away in March 2018 at the age of 99.  Touchpoints offers a way to apply the core concept of mismatch and repair beyond infancy in a range of clinical settings.

Pediatricians, early intervention specialists, educators, child protection workers, home visitors, literacy advocates from Berkshire United Way, and others from across Berkshire County engaged in lively discussion. Bringing home the importance of investing in early relationships, Dr. Singer showed a picture of a newborn infant, saying, “This is early literacy.” She encouraged audience members to suspend certainty inherent in being the “expert” and to instead create a space for listening with curiosity.

On the Saturday and Sunday that followed this event, another group gathered for a Newborn Behavioral Observations (NBO) training. While the medical model of care often puts the professional in the role of expert, this intervention seeks to shift that mindset, mobilizing parents’ unique capacity to tune into and respond to their newborn. The 18 neurobehavioral observations of the NBO are not an assessment or evaluation. Rather, they offer a frame in which to support parents’ earliest efforts to get to know their baby.

Community practitioners from a wide variety of disciplines learned from Dr. Claudia Gold and Dr. Kevin Nugent, who developed the NBO, about listening to a baby’s earliest communications. On the second day the group devoted time to thinking together about how to collaborate to provide a holding environment for vulnerable families such as those struggling with opiate addiction. We acknowledged the need to support all families, recognizing the “normative crisis” of the transition to parenthood and the need to destigmatize asking for help.

Dr Gold is collaborating with the Family Birth Center at Fairview Hospital, supporting the efforts of the maternity nurses, who have all been trained, to incorporate the tool into routine care. As Doreen Hutchison, RN, vice president of operations and patient care wisely observed, “We want parents to go home with their baby feeling confident that they know their baby best.”

The Hello It’s Me Project will offer NBO training to all nurses on the Mother-Baby Unit of Berkshire Medical Center with the aim of integrating the NBO into routine care of newborns and their family. Partners in the project include Berkshire Obstetrics and Gynecology where the program will be introduced in the prenatal period. Recognizing critical role of home visiting in promoting health parent-infant relationships the trainings will be offered to Healthy Families, Pediatric Development Center, and Parents as Teachers, and Berkshire Nursing Families with the aim of integrating the NBO into their respective programs. Recovery coaches in FIRST (Families In Recovery SupporT) Steps Together, a peer recovery and parenting support program for pregnant and parenting women with current or past opioid use disorder, will attend the trainings. The first two of three annual trainings are scheduled for September 2019 and March 2020.

The NBO bring the idea of “play,” with its inherent imperfections, into parent-infant and sibling relationships right from birth. Many parents today are burdened by an expectation of perfection. When we can protect time to listen to parent and baby together, we convey the idea that, in contrast to a “right” way, they will figure things out together. Growth happens through repair of inevitable mistakes we make along the way.