Quotidian Trauma, Quotidian Resilience: Boston Conference on Contemporary Developmental Neuroscience

When Frank was a young boy, and he committed some typical toddler transgression such as having a meltdown when it was time to leave the playground, his father would slap him across the face, hurting and humiliating him in a very public way.

When I spoke with Frank over 20 years later, in the context of helping him with his own son Leo's frequent tantrums in my behavioral pediatrics practice, he did not describe this experience as "trauma." Rather, he described it in a very matter-of-fact tone.

But when we explored in detail his response to his son's tantrums, we discovered that, flooded by the stress of his own memories, Frank in a sense would shut down. Normally a thoughtful and empathic person, he simply told Leo to "cut it out." As we spoke he recognized how he was emotionally absent during these moments, which were increasing in frequency. It seemed as if Leo was testing Frank, perhaps looking for a more appropriate response that would help him manage this normal behavior. Once this process was brought in to awareness, Frank was able to be present with Leo- to tolerate his tantrums and understand them from his 2-year-old perspective. Soon the frequency and intensity of the tantrums returned to a level typical for Leo's developmental stage. Frank, greatly relieved, once again found himself enjoying his son.

The upcoming Boston conference; Psychological Trauma: Neuroscience, Attachment, and Therapeutic Interventions, promises to offer insight in to the developmental neuroscience behind this story.

What Frank experienced as a young child might be termed "quotidian" or "everyday" trauma. It was not watching a relative get shot, or having his house washed away in an avalanche. It was a daily mismatch with his father- he was looking for reassurance and containment and instead got a slap across the face. It was what leading researcher Ed Tronick would term "unrepaired mismatch." Frank, in a way that is extremely common- termed "intergenerational transmission of trauma" was then repeating this cycle with his own child. When this dynamic was brought in to awareness, was able to "repair the mismatch," setting his relationship with his own son on a healthier path.

Tronick, who runs the Infant Parent Mental Health Postgraduate Certificate Program at UMass Boston, and will be presenting at next week's conference, describes this process in a paper entitled Quotidian resilience: Exploring mechanisms that drive resilience from a perspective of everyday stress and coping. Resilience is a capacity that develops over time through the typical misattunments that inevitably occur between parent and child. D. W. Winnicott, pediatrician turned psychoanalyst, coined the phrase "the good-enough mother" to describe this phenomenon.

Quotidian trauma, on the other hand, occurs when these mismatches are not repaired. Tronick's research as shown that even if they are only repaired 30% of the time, development still proceeds in a healthy direction.

Steven Porges, a professor of psychiatry at University of North Carolina Chapel Hill, another speaker at the conference, has developed through his research, a fascinating theory to explain this process on a neurobiological basis. Tronick dramatically demonstrates the effects on an infant of these misatunement, or mismatches, in his Still Face experiment. In it we see how a young infant becomes highly distressed and disorganized when his mother does not respond to him in the typical way.

Many are familiar with the term "fight-flight" response to describe how when the body is faced with extreme stress, the sympathetic nervous system kicks in. What Porges brilliantly identifies is that in the setting of parenting, the drive to protect one's child may override this response. So what happens when a parent, like Frank, is flooded with stress, but cannot fight or take flight? A more primitive stress response, mediated not by the sympathetic, but by the parasympathetic nervous system, takes over. This is the "freeze response" that leads an animal to play dead in the face of overwhelming threat.

The parasympathetic nervous system innervates the muscles of the face and voice, controlling on a neurobiological basis that attunement that is so important to healthy development. Putting this together with Tronick's research, we can understand what happened to Frank. In a way that was unconscious and so out of his control, flooded with stress but with his fight-flight reaction unavailable, his parasympathetic system took over. The result is a literal still face. Leo's increasing tantrums match the increasing distress seen in the infant in Tronick's experiment.

At this week's conference, organized by Bessel van der Kolk, whose work with psychological trauma is featured in the New York Times Magazine this weekend, there will be much more to learn. This exploding field of study, while often identified with "Trauma" with a capital "T," has much to teach us about prevention. From the research that will be presented, we are able to understand not only how to treat trauma, but also how to intervene in the earliest months and years to break the cycle of transmission of trauma and set development on a healthy path.

Roz Chast on Parent-Child Relationships

Roz Chast's new book Can't we talk about something more pleasant?, a touching, funny, sad, and thought provoking graphic memoir, is primarily about her caregiving role as her elderly parents approach death. She makes her painful subject tolerable with humor. For example, at a point when Chast thinks her mother's death is imminent, she arrives at the "the Place" where her mother is under the care of a new nurse. She finds her sitting up, dressed, and eating lunch. Chast writes, "Where in the five Stages of Death, is EAT TUNA SANDWICH?!?!?"

Chast has a troubled, fraught relationship with both parents, though more so with her mother, right up to the end. Though the focus of the book is the final years, Chast gives some insights in to the origins of these difficulties.  Reading the memoir with an eye to understanding parent-child relationships, I found an interesting example of the way parent and child can dysregulate each other. Of how when things go wrong, the problem is not either exclusively in the parent or the child, but in the relationship.

Chast was born one month premature, delivered by cesarean section as a precaution because her mother's first baby, a girl, had died at 7 and 1/2 months. A family narrative suggested that the death was related to standing on a stool to change a lightbulb, something Chast's meek and fearful father refused to do. But the actual cause was placenta previa. An obstetrician had told Chast's mother that her "uterus would rupture" if she carried to term.

Chast describes herself as "probably not a fun baby." She had low tone, cried a lot, didn't like to eat or sleep. Likely some of these traits were related to her prematurity. Chast writes, "I had one cold after another, and from the time I could speak, one anxiety after another." Temperamentally she was much more like her father than her mother. While as an adult she writes of her mother, "I can sympathize with her desire to leave me in the care of someone else for a while," she follows with," who knows what I thought back then."

Chast's mother came from a history of trauma. Her father, Chast's maternal grandfather, was an engineer in Russia but came to the US, presumably following persecution of the Jews, to a life of extreme poverty that left him "bitter and angry."  It is possible that her mother's experience as a parent was colored not only by this history, but also her history of loss. Even today pregnancy loss may not be recognized as an experience with its own significant grieving process. Certainly in 1940 it is likely that one was expected to just carry on.

The aim of the book, I believe, is to call attention to the inherent challenges of caring for aging parents. But it is a rich and beautiful story, with other lessons as well. Chast, with her sparse details, offers us a picture of a parent-child relationship that got off on the wrong foot. I wonder if Chast's brilliant creativity is in part a result of having to cope with this difficult and painful family story. If so, her struggles become our gift.

Keep Mothers in Mind for Mother's Day and Mental Health Month

In recognition of May as National Mental Health Awareness Month, President Obama made a proclamation that included this statement

My Administration is also investing in programs that promote mental health among young people. 

While he went on to speak of working with teachers and students, my hope is that Obama will recognize that prevention starts with parents and babies. A social and cultural valuing of parents, as occurs in countries like Australia and Finland, is the path to a truly preventive model.

A recent issue of the journal Current Problems in Pediatric and Adolescent Health Care identifies the following:

The presence of parental psychological problems, such as depression or anxiety, can lead to prolonged periods of disorganized parent-infant social interaction, compromising long-term infant outcomes. A wealth of studies has shown that maternal depression is a strong predictor of infants' social, emotional, and cognitive problems throughout the lifespan.

Representative Ellen Story and her Postpartum Depression Commission have recognized this fact. While the initial focus of the group had been on screening for postpartum depression, it has expanded to focus on the emotional well being of parents during pregnancy and in the postpartum period. This includes supporting of strong, healthy parent-child relationships.

One of the initiatives is a new program MCPAP for Moms. The aim of the program is to provide statewide support for pediatricians, obstetricians and other clinicians who have the opportunity to identify and treat new parents who may be struggling with a range of perinatal emotional complications. MCPAP for Moms is partnering with the wonderful organization, MotherWoman, to integrate the community based perinatal support model, as well as the important and valuable program at the Massachusetts School of Professional Psychology,  the MSPP Interface Referral Service, that connects people in need of help with appropriate care.

D.W.Winnicott observed in his work as a pediatrician and psychoanalyst what he termed the "ordinary devoted mother." In the early weeks and months, when the infant is completely helpless, he relies on this devotion. When his caregivers are present in this way, development proceeds in a healthy direction. But when a parent is, in the words of Winnicott's biographer Adam Phillips, "preoccupied by something else," in the face of such things as social isolation, depression, anxiety or even PTSD, containing the helpless baby can be very difficult. Add a fussy baby to the mix, and this is where development can first get off track.

I am happy to be part of the MCPAP for Moms initiative because its leaders recognize the need to the focus is on the relationship. It is not only about treating the mother, but also bringing in the baby- identifying stressed early relationships and finding ways to support those relationships.

The baby is an active participant from the start. Crying, sleep and feeding problems often affect the emotional well being of new parents. The baby's mood can affect the parents, and the parents' mood can affect the baby. Parent and baby can interact in a way that causes worsening of each other's distress. This is the point at which help is needed- for the parent, for the baby, for the relationship.

By valuing the role of parents, and investing resources in the early weeks, months, and years when the baby's brain is most rapidly developing, we will be engaging in promotion of mental health and primary prevention of mental illness.

Accepting Gratitude

How often, when someone thanks us for something, do we respond with some variation of, "don't worry about it," or, "it's nothing?"  My yoga teacher, a beautiful and inspirational person who starts every class with thoughts to guide our practice for the day, first brought this issue to my attention. She confessed to having difficulty accepting gratitude. She was making an effort to pause, check her natural reaction, and instead respond with a simple, "you're welcome." To remind herself, she would accompany the words with a gesture of hand to heart.

The subject again came up at a medical conference and really got me thinking. In the health care setting, thanking can have particularly great significance. For the person who is doing the thanking, it isn't "nothing."  Our natural inclination to be dismissive in the face of gratitude may feel, to the person expressing it, like a form of pushing away, a kind of rejection. Of course it isn't meant that way, and is more likely to come from an honest place of being humble or perhaps even self-effacing.

The person giving the conference suggested a response of thanks in return. But this didn't feel right to me. It may be away of getting the last word, and also may communicate rejection. Some form of "I'm glad I could help,"  seems closer to the mark. But perhaps the exact words don't matter as much as the feeling behind them.

There is much evidence that expressing gratitude is good for our mental health.  It can be a form of meaningful connection, a kind of expression of love. Perhaps we need to be more mindful of the benefits, on both sides, of graciously receiving it.

Alex's Wake: trauma, creativity, and healing

Martin Goldsmith's new book, Alex's Wake: A Voyage of Betrayal and a Journey of Remembrance is at one level a history lesson as memoir. It offers a view of the horrors of the Holocaust from a deeply personal perspective. Goldsmith describes a six week journey with his wife in 2011 to follow the path of his grandfather Alex and uncle Helmut. Revisiting the locations where they lived, he describes the transformation from a life of prosperity and success, through the early years of Hitler's regime, to their ill-fated voyage aboard the SS St Louis where the promise of freedom in Cuba ended in return to France, and eventually to a final demise at Auschwitz.

The book also reads as demonstration of the healing power of story telling, and of the transformation of terrible loss in to great beauty. The book has its origin in tragedy, as the death of the author's father is followed less that a year later by the sudden death of his brother. Goldsmith writes:

Exactly eleven months later, on March 30, 2010, I received the shocking inexplicable news that my brother had died. A once brilliant student at Stanford University...Peter had in recent years been struck low by physical ailments and a profound depression that, I am sure, was exacerbated by the long-standing family guilt and shame. Now he was gone, quickly felled by a heart attack. He was 60.

The guilt and shame to which he refers is connected to his own father's untold history; the story of how his father and brother, Goldsmith's grandfather and uncle, were left behind to experience a brutal and gruesome end. In the wake of the loss of his own father and brother, Goldsmith finds himself driven to tell that story before his own 60th birthday.

Both Goldsmith's parents escaped Nazi Germany, a story he tells in his previous book, The Indistinguishable Symphony. But his grandfather and uncle were left behind, despite desperate letters of appeal.

There were reasons aplenty why every effort under the sun might have failed to win his family's freedom, but the inescapable fact remains that Alex begged his son to save his life and my father failed to do so.

Goldsmith's parents never spoke of this early history, a fact he understands as an effort to protect him and his brother from the truth. He describes the experience of growing up in that silence:

The guilt that my father carried he passed on to my brother, Peter, and me as our emotional inheritance...How little they suspected that, even without words, we could feel and absorb the unspoken pain that circulated like dust in the air of our home, and how much we were aware of the darkness, the enormous unknown yet deeply felt secret that obscured the light of truth. 

Goldsmith is motivated by his own loss to follow a different path from his father and brother. He sets off on this journey of discovery. As such loss is transformed in to creativity.

Many reviews focus on the fascinating history revealed in the book, particularly the terrible, but less well recognized, maltreatment of Jews in France during World War II. I found myself drawn to the story of the two Goldsmith brothers. One lost his way, eventually succumbing to depression and ill health. The other, I hope, found his way to health, in part through the very book I am writing about.

I well understand how those who directly experienced the horror of the Holocaust may be too close to speak about, much less mourn their loss. It may be for them, in a sense, unmournable.  It is left to the next generation, inheriting not only their loss, but also their strength, to tell their story.

Goldsmith's father denied his Jewish heritage. Goldsmith writes:

 And there was no acknowledgement that we were Jews, despite that being the singular reason for our family's violent dismemberment. When I, as a teenager, discovered our religious roots, my father dismissed it all by declaring that we were, at most, "so-called Jews," He did not choose to regard himself as a Jew despite the unavoidable fact that he'd been bar mitzvahed, that his parents were both Jews..."Adolf Hitler thought I was a Jew, so I had no choice. I choose to exercise that choice now. I am not a Jew," he said.

Yet Goldsmith finds his way to his Jewish identity, resonating on a profound level with the Kol Nidre prayer of Yom Kippur and eventually being Bar Mitzvah'd himself at the age of 55.

At one point in his journey Goldsmith discovers a memorial etched with the words of the Talmud, "Who Saves One Life Saves the Entire Universe." Knowing how this untold story may have been instrumental in Goldsmith's brother's death, one can view this book as an effort to save his own life. This brings to mind yet another Jewish concept, Tikkun Olam, which refers to humanity's shared responsibility to "heal the world." With the writing of Alex's Wake, Goldsmith has done his part.

Antipsychotics for foster care kids with ADHD?

A recent study, one that received relatively scant media attention (compared with a concurrent New York Times piece about a new psychiatric diagnosis termed "sluggish cognitive tempo" that may be the "new ADHD") showed that antipsychotics are being prescribed to nearly one third of kids (age 2-17) in foster care who are diagnosed with attention deficit hyperactivity disorder (ADHD.)

This disturbing statistic brought to mind a common complaint I hear from parents about putting on shoes to go out of the house. A child will dawdle, ignoring multiple requests. The situation will escalate to the point where the parent becomes increasingly angry and frustrated, and the child descends in to an all out tantrum.

This kind of scene likely plays out in some form in every household with a young child. It can be useful to keep in mind as we aim to understand why a child who is in foster care might exhibit behavior that calls for bringing out these pharmaceutical big guns.

While there is a range of reasons for a child to be in foster care, one can assume that there has at minimum been some experience of trauma and loss. This might include physical and/or emotional abuse.

Research in the field of developmental psychology and attachment offers a way to understand this situation. Young children inevitably have tantrums. It is a normal healthy part of development. But if a caregiver herself has a history of trauma, her child's behavior may, as they say, "push her buttons." She may become flooded with stress in the face of her child's acting out. Unable to think clearly, she may respond with behavior that is either frightened or frightening. She may either become overwhelmed with rage, or shut down emotionally. In the language of psychology this is termed "dissociation." For the child, it is as if his caregiver suddenly isn't there. In this situation, the child learns to recognize his own emotional distress as a signal for abandonment.

Now put this same child in foster care and ask him to put his shoes on to go outside. What starts out as a "typical" parent-child interaction can quickly descend in to wildly uncontrollable behavior. I've heard parents who have adopted kids out of trauma say, "its like he's not even there." When the child was in this kind of situation with an abusing caregiver, he might, in a way that is in fact adaptive, responded to her dissociation with his own form of dissociation. Now he has learned that behavior. But out of context, in foster care with a non-abusing caregiver, it may look "crazy."

When this kind of "not listening" extends to other arenas, it may be reframed as "not paying attention."  This behavior often occurs together with the impulsivity. Impulsivity literally means to act without thinking. An inability to think in the face of strong emotions, as I describe in my book Keeping Your Child in Mind, can also be understood as part of the trauma, of not having been held in mind by caregivers early in development.  With problems of both inattention and impulsitivity the child may, according checklists commonly used to make the diagnosis, earn the ADHD label.

Perhaps this is how kids in foster care end up on antipsychotic medication for ADHD.

But by taking this path, we are essentially putting a muzzle on the child. The child's behavior is a form of communication. It says, "I have never learned how to manage myself in the face of life's inevitable frustrations." Rather than silence him with a powerful drug, that is well known to have serious side effects, we need to listen to that communication.

The first step is to recognize the meaning of the behavior. Once caregivers understand the "why" of the behavior, they can better support the child's efforts to regulate himself in the face of frustration. At first this might be in a very physical way. For example he might need to be held in a firm and loving embrace. Or he might need to run around the room. Or hit a punching bag. He might need a soft and gentle voice rather than a harsh and angry one. As a child gets older, regulating activities like dance, theater and martial arts can have a significant role to play. Once a child has developed the capacity to regulate his body in the face of distress, he can begin, perhaps in the setting of psychotherapy, to give words to his experience.

But if we simply silence him with medication, all of this opportunity for growth and healthy development may be lost.

Autism: difference or disorder?

About 2 years ago, when the change in diagnostic criteria for Autism Spectrum Disorder proposed for DSM 5 was in the news, I wrote a blog post about the problem of giving children a diagnostic label in order to "get services covered" by insurance. An irate reader, himself a well know speaker and advocate for people with Autism and Asperger's, wrote a blog post in response, in which he said, "Dr.Gold simply does not understand that Autism is not a psychiatric disorder."

In the wake of the recent CDC statistics indicating that 1 in 68 children has autism, and the designation of April as autism awareness month, I have been thinking about this dilemma a great deal. For this young man and I were really exactly on the same page. Both of us were calling for a respect for and value of uniqueness and differentness.

This perspective was again beautifully articulated in a TED talk by Andrew Solomon, author of Far From the Tree. In an in-depth discussion of a range of entities including homosexuality, deafness, as well as autism, Solomon identifies the power of unconditional love in the context of complete acceptance of individual differences.

While I fundamentally agree with the perspective of these two men, my mind stumbles on these facts. The DSM 5 is the fifth version of the Diagnostic and Statistical Manual of Mental Disorders. The CDC is the Center for Disease Control. So much as we may want to think of autism as a celebration of individual differences, the prevailing view is that it is a disorder.

Solomon suggests that by hoping a child does not have autism, a parent is saying that she wishes this child did not exist and that she had a different child. I see the exact opposite. The parents I see who are in this position unconditionally love their child for who he is. They are motivated to make sense of his experience and give him space to grow in to himself.

While there is emerging evidence of the role genetic and neurobiological mechanisms in the behaviors collectively referred to as autism, it is not a know biological entity in the way, for example, diabetes is.

One little girl I worked with ran around in circles at preschool and repeated letters in nonsensical patterns. There was a strong family history of both anxiety and "quirky" behavior. She was easily overwhelmed by a range of sensory inputs.  Her mother would herself become overwhelmed in the face of her child's struggles as she recalled her own difficult childhood. Another little boy endlessly repeated whole scenes of dialogue from Disney movies. He ate only 3 different foods for the first 7 years of his life. His parents fought frequently about his challenging behavior, which usually caused it to escalate.

For both these children the diagnosis of autism was raised. But both sets of parents resisted. When they addressed the child's unique qualities as well as the environmental stresses that contributed to the problematic behavior, dramatic changes occurred. Both are now teenagers. The first is a talented actress, singer and musician. The second is a chef. Both have active and successful social lives. One view is that they "outgrew" autism. Another is that they were they given space and time to grow into themselves.

It the first five years of life there are major changes in the brain, changes that occur in the context of relationships.  We are now recognizing that changes occur not only in brain structure, but in genes and gene expression as well. It is a work in progress.

These children and families do benefit significantly from help. This may be in the form of a special preschool placement, occupational therapy, family therapy or other interventions that can set these children on a healthy path of development. In order to get these services, a diagnosis is often necessary. This is an example of the tail wagging the dog.

The massive rise in diagnosis of autism indicates that something is amiss. I wonder if that "something" is that in our fast-paced society we rarely take the time to listen to the story, to let meaning unfold. There is a need for an "answer." There is a lack of tolerance for uncertainty.

When a child is young, when his "true self" is emerging, supporting parents efforts to "hang in there" without the need to name, to label, to diagnose, may give these young children the best opportunity to transform what in early childhood may be challenges and vulnerabilities in to adaptive assets and strengths.