Heartland: Poverty and Belonging in Rural America

Note to readers: With a new book being released June 2nd, 2020,  I have relocated Child in Mind to my updated website.  Please sign up to here receive new posts! 

Over the past two and a half years writing a book with psychologist Ed Tronick, who developed the still-face paradigm, I’ve immersed myself in contemplation of the sources of meaning in our lives. In our book, my experience as a pediatrician, mother, and daughter is added to the mix of insight that comes from Dr. Tronick’s decades of research observing intimate moments between mothers and infants to address basic questions we pose in our introduction, including: “How is our ability to feel a sense of belonging and  attachment to other people linked with the way we develop our individual sense of self?”

Just as we were finishing the book, the owner of a local bookstore recommended I read Heartland: A Memoir of Working Hard and Being Broke in the Richest Country on Earth. As the political scene heats up with the approaching new year, I was interested to learn more about economic inequality, an issue central to the upcoming election.

Thus, I was surprised to find that while certainly author Sarah Smarsh gives a compelling analysis of poverty and social class in rural America, the most powerful aspect of the book for me was the insights she gives into the intertwining of poverty and parent-child relationships.

In our book, we offer evidence that moment-to-moment interactions in our earliest relationships shape our core sense of self and our ability to be close with others. Drawing on Dr. Tronick’s buffer-transducer model, we describe poverty as a state that stresses our primary caregiving relationships. We write: “Poverty, for example, is an environmental risk factor. The experience of poverty draws energy from caregivers, making them less available to buffer a child from stress.”

It wasn’t until I read Smarsh’s book that I really understood what we were saying. She writes this striking line early in the book: “The poverty I felt most, then, was a scarcity of the heart, a near constant state of longing for the mother right in front of me yet out of reach”.

So while there is much to say about the lessons from her brilliant book, I am writing this post to highlight the insights she offers into the complex intertwining of poverty and parent-child relationships.

By narrating the book to her imagined unborn child, she addresses the issue of teen pregnancy in a powerful and deeply personal way. She tells the story of three generations of women conceived of teen pregnancies; her grandmother Betty, her mother Jeannie, and herself, beginning with the matriarch her great-grandmother Dorothy, who suffered from schizophrenia . She writes “When I was a little older I’d come to wonder whether my mom and grandma’s vagabond ways amounted to behavioral training from a mentally ill matriarch.”

Smarsh brings us inside her own experience to tackle the interplay of poverty with domestic violence, substance abuse, and mental illness. She takes care to describe the rarity of her own father’s peaceful nature, and her grandfather Arnie, another man unlike most of the men in the book who behave abusively towards the women in their lives. While she balks at the question of how she “got out” and became the first in her family to go to college and move away, I found myself wondering about the significant role played by these two men.

In this review, however, I wish to call attention to her extraordinary capturing of the exquisite pain and longing in the generations of mothers and daughters. She shows a steadfast determination to avoid becoming a teen mother against what feels like an overwhelming pull, writing: “I knew deep in my cells what it felt like to grow inside a girl who couldn’t afford or even love me because of some mix of financial and emotional poverties that I had no choice but to inherit.”

Smarsh communicates empathy for the mothers of these unwanted children, including her own. Of her mother’s childhood and her grandmother’s motherhood she writes:

“Jeannie had a pet monkey, a little stuffed toy. She hung on to that, ya, know, like some babies carry blankets and stuff,” Betty told me, holding back tears. “This was her security, this stuffed monkey. And it got lost. I guess we left it on the train.”

It wasn’t the lost stuffed animal that made Betty cry, of course, but knowing how miserable her daughter’s childhood had been-even her security blanket, of sorts, got lost in the chaos- and interpreting this as her having been a bad mother.”

Smarsh has a remarkable clarity of vision of what the next generation’s experience might have been had she followed the same path:

“The mother I would have been then was doing well on the outside but was in deep pain alone at night. Like it did for my own mother, I think, that pain would have taken over when you cried or tried my patience. I would have slapped you or screamed at you or shut up, or worst of all, beamed that same quiet hatred in your direction that I once felt.”

Smarsh tells us early on that she has named her unborn child “August.” While the name has a number of sources, towards the end of the book she writes, “An august thing is impressive and dignified, and beneath my mother’s pain she saw me and perhaps herself just that way.”

Smarsh addresses the subject of belonging, an experience known to be central to our core sense of emotional wellbeing. When describing the itinerant nature of her childhood and the impact of frequently changing schools she writes: “Belonging is, on a psychological level, a primal need, too. It is often denied to the poor.” Later she raises the issue of belonging in the painful choice she faced in taking a different path from that of her family: “We both knew I was leaving soon, not just from the farm but from the only way of life Grandpa had ever known. It was a separation born of class, that a child might lose a sense of belonging within her own family for going to college.”

I sense from Smarsh, and of course, I do not know for certain, that by holding on to deep love and empathy for a family that was frequently the source of pain, she succeeded in belonging to both worlds. I hope for her sake that she has.

Of her decision to follow a different path she writes: “My life’s work was to be heard, and the poor young mother will have a hard row at that.” I am thankful that her voice has been heard. She has much of importance to say.

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.