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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When Parents Fear "It's All My Fault"

Many of my colleagues in the field of early childhood mental health work with what are termed "high risk" populations. Children of drug addicted parents, victims of child abuse, and families in abject poverty. While the challenges these families face are daunting, I find myself feeling some envy for my colleagues whose clients are in such obvious distress that the need for intensive treatment of parent and infant is not in question.

In my rural, small-town population things are not so clear. Many families struggle under the radar for years. Recently in my behavioral pediatrics practice (details are changed to protect privacy) I saw a 3-year-old boy, who, in taking a detailed history, I could see barreling 100 miles an hour towards trouble from the moment he was born, or even before.  But the story unfolded before our eyes without intervention. Did the parents resist help? Did the many professionals in with contact with the family not recognize the problems? Probably some combination of both.

 We know from the CDC sponsored Adverse Childhood Experiences (ACEs) study that neglect and abuse, as well as more ubiquitous experiences of such things as marital conflict, parental mental illness, domestic violence, and substance abuse lead to a wide range of negative health outcomes both physical and mental. Yet babies come and go to pediatric practices and we don't discover or address until years later that in the early weeks and months, when their brains were most rapidly growing, parents-many themselves with a history of ACEs-struggled significantly. 

We need to find a way to engage these families with intensive support from the very beginning without making parents feel that they are somehow not "good-enough." Engagement means not only behavior management for children and/or medication for parents. It means listening to parents and infants together from the start. We need to listen to the vulnerabilities the child brings into the world as well as the often-complex relational issues between partners, among siblings, and with extended family.

The mother of my 3-year-old patient struggled with severe postpartum anxiety and profound social isolation. She described her son as "inconsolable" from birth. The marriage faltered. He developed severe separation anxiety, frequent explosive tantrums, and sleep disturbance among a range of other behavioral and developmental disturbances.

We know from infant research that a core sense of self develops in the moment-to-moment interactions between infants and their caregivers. Babies arrive in state of complete helplessness, relying 100% on their caregivers to make sense of the world and of themselves. This does not mean parents need to be perfect. In fact, perfection as well as absence can inhibit self-development and lead to fearful and rigid states. It is the very imperfections in relationships that help infants to develop resilience and a positive sense of themselves in the world.

But when parents are fighting constantly, when a mother or father is preoccupied with anxiety and/or depression, when a parent is in an altered mental state intermittently from substance abuse, this core sense of self may be distorted as infants struggles to make meaning of their experience. The "symptoms" of my 3-year-old patient can be understood as difficulties managing both his body and developing mind in a complex social world.

The transition to parenthood is challenging under the best of circumstances. Alicia Lieberman, one of the giants of the field of infant mental health, speaks in a kind of paradoxical way of how "trauma" is "normal." ACEs are extremely common. I recently heard a leader in the trauma field say in a presentation, "ACEs are normal."

If we engage families at or even before birth, presenting the challenges of the transition to parenthood as normal, when a parent struggles we will be right there to work more intensively to support these early relationships when bigger disruptions arise, rather than waiting until families are in crisis. Universal home visiting, relationship-based Early Intervention services and community support groups for parents and infants offer opportunities for a population based, non-stigmatizing approach to supporting new families.

Pediatricians present an ideal opportunity to engage families in this way. Currently Jack Shonkoff at the Center on theDeveloping Child is partnering with pediatric practices to develop a preventive model on the front lines where parents and babies regularly go. My colleague Ed Tronick has said on multiple occasions that parent-infant mental health should be the core of pediatrics, not a subspecialty. The abundant evidence from the ACE study certainly supports this claim.

At the tender of of 3 there is plenty of opportunity to help my patient and his family, who are invested in doing the work to set relationships and development on a better path. But I hope for shifts in culture, health care, and public health that will allow all families to set out on a healthy path from the start.

When Birth Plans Go Awry: Wisdom from Dr. Spock

Self- efficacy, or the belief in one's ability to be a good parent, plays a central role in healthy child development.  Many things can come along and derail that sense of confidence. Often the first of these is a delivery that does not go as planned.

In a recent conversation a colleague wondered if the abundance of books about the importance of the first months of life might serve to heighten parents' anxiety. I slept on her wise words and woke thinking of the famous opening line of Dr. Spock's Baby and Child Care, "Trust yourself: You know more than you think you do."

I went straight to my bookshelf that morning, and was surprised and pleased to find that he addresses what is today referred to as "birth trauma" in the opening pages:

If your labor and delivery experience is not what you expected, its normal to feel bad, even guilty. If you go in hoping for a natural birth and end up with a cesarean, its natural that you might feel that you were somehow to blame (you weren't) or that your baby will be somehow permanently harmed by the experience (almost never the case.) Many parents fear that if they are away from their baby in the first hours or days bonding will be permanently undermined. This is also not true. Bonding-the process of parent and baby falling in love with each other- develops over months, not hours.

The equating of bonding, a word that itself creates anxiety in parents, with falling in love, along with acknowledgment that this process is different for every family, holds great value. He brilliantly goes on, in words that echo pediatrician turned psychoanalyst D.W. Winnicott and anticipate research of psychologist Ed Tronick on the value of mismatch and repair, to dispel anxiety around a birth plan that goes awry:

Parenthood is an ideal guilt-generating business, and labor often delivers the first volley. I think this situation has come about in part because of the fantasy that everything has to be perfect in order for the child to do well. Of course nothing could be further from the truth. First off, the "perfect" parent has yet to see the light of day. Secondly there is no need to be perfect or to follow any one script. The process of human development is powerful. There is plenty of room for variation and even for making mistakes. Infants are incredibly resilient. As long as the infant is healthy, the type of childbirth is unlikely to have long-term consequences, unless there is so much guilt attached to the memory that it has a negative impact on parental self-confidence or starts the process with a strong but misguided sense of guilt. So my advice is to have your baby however seems right for you and your family. Then don't worry if what happens doesn't follow the script. Being a parent is tough enough without creating problems where there really aren't any.

Parents today are more likely to think of Spock as a Vulcan than a pediatrician.  With anxiety, stress, and uncertainty on the rise in our day-to-day lives, a healthy dose of Dr. Spock may be just what the doctor ordered.

The Decline of Empathy: A Hopeful Solution

Pediatrician T. Berry Brazelton was among the first to recognize the tremendous capacity of the newborn for complex connection and communication. Developmental psychologist Ed Tronick, drawing on this observation, designed the famous Still-Face Experiment to show the devastation, for both parent and baby, when they struggle to connect. Extensive research at the interface of developmental psychology, neuroscience, and genetics, as I document in my first book, shows the long-term benefit of investing in early parent-child relationships.

"Once you know it, you can't un-know it." My wise colleague Kyle Pruett, MD child psychiatrist, said this of the power of working with parents together with very young children to a move a family in a healthy direction.

After having recently written The Silenced Child, an admittedly dark account of how our society fails to listen to parents and children, and the potentially disastrous effects of this course of action, I am overjoyed to now be writing about a hopeful solution to this problem.  The following piece, published in our local paper on Sunday, offers a view into the work unfolding in this small rural town in Western Massachusetts. My hope is to bring this model to other communities. The aim is to offer this listening stance to all babies and families without potentially stigmatizing parents by identifying them as "at-risk."

Giving Every Newborn Baby A Voice

On a stormy November evening in 2016, I led a meeting in the small patient lounge of the maternity unit of Fairview, our local community hospital in rural Western Massachusetts. As the meeting was scheduled at change of shift, all 10 nurses who attend to the approximately 150 deliveries per year squeezed into the warm room. They eagerly shared their troubling feelings of helplessness when they see families who are clearly struggling, and have no choice but to send them home “on a wing and a prayer.”   They listened in rapt attention, and seemed empowered by the idea of learning new ways to support parents and newborns.

As a pediatrician specializing in parent-infant mental health, I attended the meeting under the auspices of the new Human Development Strategic Initiative at the Austen Riggs Center, led by Donna Elmendorf, PhD. a child clinical psychologist and director of the Center's Therapeutic Community Program.  The initiative seeks to bring Riggs’ relational view of early development to a community-based preventive model of care.

About six months later, on a spring weekend when from Friday to Sunday the weather shifted dramatically from snow to warm sunshine, half of these nurses, together with pediatricians, family and nurse practitioners, early intervention specialists, home visitors, and lactation consultants, many of whom are participants in the Berkshire United Way sponsored South County Community Coalition, gathered at Austen Riggs for a training in the Newborn Behavioral Observations system (NBO) to focus on giving babies in our community a healthy start.. The nurses who covered the maternity unit that April weekend traveled to Harvard Medical School in June for the same training.

We now have the opportunity to offer this intervention to every new baby and family, and an extended network of caregivers throughout our community who can support families in a similar way beyond the newborn period.

Early in his work as a general pediatrician in the 1950s, T. Berry Brazelton, recipient of Obama’s Presidential Citizen’s medal in 2012, observed the tremendous capacity of the newborn infant for complex communication. Research based on these observations led to development of the Neonatal Behavioral Assessment Scale (NBAS.) The scale changed the way both child development experts and pediatricians understood babies. The NBO, a clinical application of the NBAS developed by psychologist J. Kevin Nugent and colleagues, is a relationship-building tool that is as its core an opportunity for listening to parents and babies without judgment. Ongoing research around the world demonstrates the role of the NBO in supporting parent-infant relationships.

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.Participants in the training learn together about how to engage parents’ natural expertise and ability to listen to their baby’s earliest communications as they navigate this dramatic transition in their lives.

The Discovering Your Baby Project, the first community project of the Human Development Initiative, grew from a wish to have every family on our community feel heard and valued. We feel so fortunate to

have received local and national grant support for this burgeoning effort. . Research at the interface of developmental psychology, neuroscience, and genetics offers evidence for  investing resources in these earliest relationships.

Families who deliver at Fairview Hospital may have relocated from the Upper West Side of Manhattan, lived for generations as local workers, or recently emigrated from Ecuador. Families from the full range of socioeconomic backgrounds may have struggled with generations of mental illness, substance abuse, or other adverse childhood experiences.

At the NBO training one of the nurses who has worked for decades on the same unit shared how she sees troubled family relationships passed from one generation to the next. “Now,” she said, “I feel hopeful that the next generation may have a different path.” 

Our population-based intervention for all families who deliver at Fairview aims to instill confidence and de-stigmatize the struggles of the transition to parenthood, with the larger community of caregivers available to engage families in this way as development progresses. We hope the Discovering your Baby Project can serve as a model for communities large and small, urban and rural, throughout our country.

We learn to listen by being listened to. We see our work as a “baby step” toward giving every person a voice from the moment of birth.  Perhaps it will also be a first step toward restoring empathy in our society.

What Do Parents Want? Parsing Contradictions in The Zero to Three National Parent Survey

Zero to Three, the Washington, DC based organization whose mission is to advocate for infants and toddlers to have a strong start in life, just released results of their ambitious project to answer this question. The data from the current report, a collaborative effort with the Bezos Family Foundation, comes from a 50-question Internet survey in Spanish and English distributed to a national sample of 2,200 parents of children age birth to 5. The survey was developed out of 10 in-depth discussion groups with parents from a wide range of backgrounds. 

The Zero to Three report contains some striking, and in some places contradictory, data. Starting out with results suggesting that most parents think that parenting can be taught, they offer this statistic:

69% of parents say that if they knew more positive parenting strategies they would use them.

One might conclude that giving more parenting advice would be the solution, but another statistic suggests a different interpretation might be indicated:

63% of parents overall say "I am skeptical of people who give parenting advice and recommendations if they don't know my child and my situation specifically."

This finding suggests that while parents feel the need for something, and name that "something" as a wish for "strategies" they, at least in part, recognize themselves as the expert with regard to their child and so balk at advice that comes without full understanding of their particular circumstance.

Adding to that contradiction is this disturbing, though not surprising, finding that:"90% of moms and 85% of dads feel judged. 46% of moms and 45% of dads say they feel judged all the time or nearly all the time." These statistics suggests that the abundance of "expert" advice may in fact cause more harm than good.

A whole section of results titled "There is a Missing First Year" captures the fact that parents consistently underestimate the importance of the early months of life.

Parents also don’t realize how deeply [infants] can be affected by the way parents interact with them in the first months of life. A notable portion of parents miss the mark by months, or even years. 

One might conclude from this finding that parents need more information. However, a majority of parents say that knowing the importance of the early years is both motivating and terrifying, with 35% equally or more terrified than motivated. This finding suggests that offering information alone could be counterproductive. It is possible that parents do in fact know how important they are.  The fact that they cannot, due to a wide range of stresses, be available to their babies in ways they want to be, may make this knowledge intolerable.

The survey shows that parents perceive support to be lacking when they feel stressed or overwhelmed, with almost half saying they do not get the support they need and 8% say they get no support at all. 

So what is the nature of "support?" 

This survey brought to mind a lecture I attended a number of years ago by the late esteemed psychoanalyst Daniel Stern entitled, "What do Mothers Want?" While the significance of fathers is notably absent from his work∗, his insights on mothers, gleaned from in-depth clinical work with mother-infant dyads, add an important dimension to the Zero To Three findings and might help parse some of the contradictions and answer this question. 

In his talk he presented what he terms The Motherhood Constellation, or the themes that emerge in a woman's life when she navigates the transition to motherhood.

1. Can she maintain the life and growth of the baby?

2. Can she emotionally engage with the baby in her own authentic manner, and will that engagement assure the baby's psychic development towards the baby she wants?

3. Will she know how to create and permit the necessary support system to fulfill these functions?

4. Will she be able to transform her self-identity to permit and facilitate these functions?

Stern is calling attention to the enormity of the transition to parenthood, beginning with the basic question of being able to sustain the life of this new human being. Being fully present emotionally to facilitate the baby's development is tied to both having the necessary support and validation of how a woman's self-identity is transformed in a normal and healthy way.

So it could be that "support" equals "listening." Support means a different thing for every individual. For one it might mean playing with an older sibling while mom and baby nap. For another it might mean grocery shopping. For another engaging a withdrawn and perhaps depressed partner might be needed. For yet another it might mean finally addressing her own experience of abuse so that she does not repeat the pattern with her child. 

A growing body of evidence suggests a central role of parental self-efficacy in healthy child development. Each parent needs to have his or her experience validated with the aim of helping achieve a sense of self-efficacy and expertise with respect to his or her child. Advice, strategies, and information may have a role to play, but only within the context of time for listening.

∗A striking finding of the Zero to Three survey concerns fathers, 73% of whom say their lives began when they became a dad, with 63% feeling unrecognized and 40% feeling shut out.