Promoting Health and Wellbeing of Children and Families Through Relationship Based Interventions.I aim to show how contemporary developmental science points us on a path to effective prevention, intervention, and treatment, with the aim of promoting healthy development and wellbeing of all children and families.
Soon we will we celebrate mothers for a day- bringing breakfast in bed, going out to dinner, buying flowers. In my personal experience, one of the greatest pleasures of Mother's Day is to take joy in my children as they grow and develop and make their way out into the world.
D. W. Winnicott, pediatrician turned psychoanalyst, famously said, "There is no such thing as a baby." He meant that one cannot fully understand a baby without considering the relationship with the mother. Equally true is that without a child, there is no such thing as a mother. In order to understand a mother's experience, it important to consider the child and what he or she brings to the relationship.
Winnicott coined the phrase 'the holding environment" to describe the way in which a mother, by being present both physically and emotionally with her baby, helps him to manage and contain intense feelings. He wrote:
"It will be observed that though at first we were talking about very simple things, we were also talking about matters that have vital importance, matters that concern the laying down of the foundations for mental health."
A number of years ago I had the privilege of participating in the important work of The Ellen Story Commission on Postpartum Depression. Now retired, Rep. Story (D-Amherst) originally filed a bill that mandated universal PPD screening in multiple settings (OB and pediatric), but it was amended to a law that calls on the Department of Public Health to issue regulations on best practices for PPD screening. The law also created the Commission, whose job is to help DPH in its work to develop plans for the state of Massachusetts to address PPD.
Rep Story will be speaking in Dalton,MA on the evening of June 19th at the first quarterly dinner/educational event of the Hello It's Me Project, whose primary aim is to build a community "holding environment" to promote healthy parent-infant relationships.
What makes postpartum depression different from other forms of depression is that it occurs in the setting of responsibility for a new life-with a person who is completely dependent- who brings his or her unique qualities to the relationship. To fully hold the mother's experience, it is important to recognize the baby's contribution.
For example, a baby who has difficulties settling to sleep, or is not naturally cuddly will have significant impact on a mother's emotional experience. For a mother, sleep deprivation and feelings of inadequacy may compound an existing depression. In turn, the mother's state of mind, particularly if she is preoccupied with her own distress, may impair her ability to help the baby to contain and manage his experience. Onestudy showed that mothers struggling with anxiety and depression often wake their babies at night, offering an example of how mother and baby interact to impact emotional development of one another.
How fitting that Mother's Day occurs in the middle of Mental Health Awareness Month. The work of Representative Story and the PPD commission is a tribute to both. When we as a society attend to the emotional needs of new mothers (and fathers- who get their own day in June) we help them to emerge from pain and suffering to take joy in their children. This not only promotes their children's healthy development, but it also makes for a really great Mother's Day!!
A new program for parents and infants, thanks to generous support from Mill Town Capital, 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.
Several years ago NPR had a story about temper tantrums, describing a study showing that the sounds children make during a tantrum indicate that they are primarily sad rather than angry. The written version of the story opens with description of tantrums as " the cause of profound helplessness among parents."
I thought this was an interesting choice of words, as I have always thought of tantrums as representing a sense of helplessness in children. In fact, in my over 20 years of practicing pediatrics I have told parents that, for the most part, tantrums are a normal healthy phenomenon. They occur when young children emerge for a stage of omnipotence in the first year to recognize that they are relatively powerless. An excerpt from my book describes the phenomenon.
Imagine that your toddler sets his sight on your glasses and declares proudly, “mine.” In an appropriate way, you might calmly say, “No, those are Mommy’s. I need them to see.” Suddenly he is confronted with the fact of his relative smallness and powerlessness. If he happens to be in a particularly vulnerable state, such as before lunch or naptime, he might become enraged that you, his beloved mother, have burst the bubble of his omnipotence. Unable to contain his intense feelings, he might lash out and hit you.
The NPR piece got me thinking that we often describe children's behavior in negative terms, which immediately sets up a relationship of antagonism and confrontation. A colleague of mine, Suzanne Zeedyk, wisely has suggested that we reframe "challenging" behavior as "stressed" behavior. Then the language itself puts us in a position to empathize with the child's perspective.
I was once asked to do an email interview for a parenting blog about defiance. The interviewer also used the word "impudence," another highly negative word. I suggested that this word projects intentions onto the child that are likely not there. In fact, "defiant" behavior almost always has its origins in a feeling of being out of control. From the child's perspective, his experience is not being recognized or understood. In a way he is not "seen."
Herein lies the explanation of why defiance pushes our buttons. In a sense a parent is having exactly the same experience as the child. He or she is not being "seen" or recognized as an adult deserving of respect. A parent might have had other experiences of not being "seen,” perhaps by a spouse, co-worker or by her own parents, that makes her particularly vulnerable to getting upset about not being “seen” by her child.
In almost every instance of “defiant" behavior, if one digs a bit below the surface, there is a way the child is also not being seen, or a way in which her experience is not recognized. For a particularly dramatic example, a six-year-old was brought to my practice with a chief complaint of “defiant behavior”. Further history revealed significant trauma in the child’s life. An alcoholic father who had abandoned the child as a toddler had recently been making visits, at which time he was often drunk and very loud. Yet her feelings about visits had not been discussed until they came to see me for “defiant” behavior,” which was worse around bedtime.
This child began sleeping all night in her bed after a couple of visits with me. We discussed this experience, recognizing her need for her mother's company at bedtime for stories, comfort and reassurance. Once a child feels that he is being seen, that his experience is recognized and understood, the "difficult" behavior often evaporates.
In general, if there is increasing “defiance” it is important to take a step back and try to understand what feels out of control for the child. It might be that he is very sensitive to loud noises or taste, and battles around "making a scene” at a family outing or being “picky eater” are related to these sensory sensitivities. It might be that there is a new baby and everyone is chronically sleep deprived. Or there may be financial stress or marital conflict. Simply recognizing that these things are difficult for a child and acknowledging his experience, even if the stressors are still there, goes a long way in having a child feel understood, and in turn decreasing “defiant” behavior.
Limits on behavior are essential, and my book goes on to say that the above toddler must be taught that hitting is never OK. But understanding, empathy and managing our own distress are all equally important. Reframing "difficult" behavior as "stressed" behavior is an important first step.
In the program notes of a recent concert at my son's university, the choral director wrote: "while the music in this concert is mainly secular in nature, each piece contains imagery which tells the story of our collective movement through the life cycles of order, disorder, and re-order."
The phrase brought to mind the groundbreaking research of developmental psychologist Ed Tronick, who in his moment-to-moment analysis of videotapes our earliest love relationships, offers evidence for the critical role of moving through mismatch to repair in healthy development. Tronick’s research, founded in dynamic systems theory, shows us how disorder followed by re-order is in fact the process by which we gain energy and grow.
If disorder, and the process of moving through disorder to re-order is a not only normal, but an essential part of human development, perhaps it calls for a rethinking of what we now name mental "illness?"
A recent controversy on Twitter exemplified the emotionally charged nature of this conversation. My colleague Suzanne Zeedyk referenced my blog post Big Pharma and the Question: Is ADHD Real? Below is an excerpt that speaks directly to this question.
The latest research by Peter Fonagy, psychoanalyst and director of the Anna Freud Centre in London, leads us to focus not on “what is the disorder” but rather “what makes us well?” In a brilliantly laid out argument, Fonagy and colleagues present the concept of a “p” factor that is common to all forms of mental suffering now categorized under the structure of mental health “disorders.”
An irate twitter follower responded with this provocative comment, "ADHD is not a mental illness, Suzanne. What a horrific insult." Suzanne responded with a comment that in my view is right on the mark. "There is no shame in any life struggle, whatever you call it. All struggles are real."
She makes an essential point, that may account for the intensity of reaction to any questioning of our current paradigm of mental illness. Questioning of the language may be heard as a denial of an individual's experience of suffering. Can we recognize that the suffering is real, without calling it an "illness" or a "disease?"
How is her twitter follower right? When we recognize that from the moment we are born, our behavior and emotions are a vehicle for communication and for making sense of our experience, we can understand behaviors associated with ADHD not as an illness, but as a form of communication.
As I describe in my book The Silenced Child, the problem comes when rather than listening to the meaning of that communication, we instead silence the communication either with behavior "management" or medication.
For if behaviors serve an adaptive function, are actually a way of coping or holding ourselves together, eliminating the symptoms might be a short-term solution. While medication can have a role to play in relief of profound emotional suffering, if we fail to offer ample time and space to listen for the meaning of behavior, we should not be surprised if "symptoms" reappear in different and sometimes more problematic forms.
“But its genetic” or “these are brain diseases,” are frequent response to this reframing of our concepts of mental wellness and illness. Once we recognize that our genes, brains, and bodies develop in relationships, the false duality of biology and experience, of nature and nurture collapses. Expression of our genes and wiring of our brains occurs in the interactive process of mismatch and repair in our closest relationships starting from birth. It used to be thought that brain wiring was pre-determined; that our brains had a fixed wiring plan. But now we know this is not true. Formation of new neural connections- the “wires” that make up the brain- is flexible not only in early development, but throughout our lifespan.
If we understand "disorder" as "normal" we need to re-think our system of mental health care that now equates "disorder" with "illness." Fonagy points us in the direction of a solution when he says writes:
“In that sense, many forms of mental disorder might be considered manifestations of failings in social communication.”
When we move through the experience of disconnection to moments of connection and healing, we grow and change. Relief of emotional suffering lies not in naming and eliminating problematic behavior, but in creating ample opportunity for a mosaic of social connection, with all its inherent messiness and disorder.
Fred Rogers, in his 1969 testimony before the Senate subcommittee on communications in defense of public television, transforms a clearly skeptical Senator Pastore from, "Alright Rogers you've got the floor" to, "You’ve earned yourself 20 million dollars."
How does he accomplish this transformation? One line from Senator Pastore gives us some insight. Several minutes into Mr. Rogers testimony he says, "This is the first time I've had goosebumps in the last two days," to which Rogers graciously responds, "I'm grateful, not only for your goosebumps, but for your interest in our kind of communication."
What are goosebumps in this context? They represent a form of activation not in the higher cortical or "thinking" centers of the brain but in the lower limbic, or "feeling" centers of the brain. The raising of the hairs on his body reflect Senator Pastore literally feeling his response to Mr. Rogers words.
Rogers opens by saying that rather than read his statement, he prefers to just talk. He tells Senator Pastore, "I trust you" [to read it.] For the next 5 minutes he describes how his television program helps young children to name and manage their big feelings. The significance of the interaction lies as much in his direct gaze, his gentle tone, and the lilting rhythm, or prosody, of his voice as in the content of the words themselves.
He shared with us that while he is gratified that the study has finally begun to inform current healthcare practices, he cautions against the oversimplified application in the form of universal ACE screening. In a recent tweet he wrote:
We need to keep reminding everyone of the complexities of development and the importance of acknowledging individuals as unique. Relational health is more influential on health outcomes than adversity. ACEs are not actionable (unless ongoing). Relational poverty is..
The story of Mr. Rogers and Senator Pastore demonstrates how we change the way we think and behave when we feel something in the context of a relationship. Simply giving information is usually insufficient to effect change.
We can also view this interaction in the context of the work of Dr.Ed Tronick, world-renowned developmental psychologist and chief faculty of the UMass Boston program. From his decades of research using the Still-Face paradigm, evidence emerged that growth and change happen through the process of mismatch and repair in everyday interactions.
At the outset, Mr. Rogers and Senator Pastore were clearly mismatched, with wildly different intentions and motivations. In that "moment of meeting" they moved through mismatch to repair. The result was significant growth- in the form of salvation of what at the time was a new concept of public television.
Dr. Perry's research has demonstrated that current relational health is the single best predictor of health outcomes. One of the fellows in the IPMH program described a group process for parents in her clinical work. They met together several times in a group setting, both before and after filling out their ACE questionnaire. At one of these meetings they focused on identifying positive, healthy relationships in their lives. They create what they term a map of resilience. Perhaps most importantly, the group itself becomes a current positive relational experience.
The ACE study has profound implications for a wide range of settings. But before we rush to implement universal ACE screening in healthcare, we need to recognize the limits of information in effecting change. When we connect in relationships at the level of feelings, not simply words, meaningful change occurs.
Jane’s story offers an example. A new mom, she had experienced intimate partner violence during her pregnancy and had troubled relationships with her own parents, both of whom were alcoholics. I learned this information not in a screening but in conversation with her.
At our first meeting she shared her worry that her baby would be a “stranger.” Haunted by the cultural image of perfect bonding at the moment of birth, she was able to express her fears in the 20 minutes we spent in the hospital getting to know her son Aaron.
When I saw Aaron with Jane in a visit a few weeks later, tears filled her eyes and her voice cracked as she said, “I can say to him ‘I love you’ and I know I really mean it.” With opportunity to tell her story in her relationship with me, she moved through mismatch to repair in her relationship with her infant son. Information about her ACE score took a back seat to moments of connection- between Jane and me and between Jane and her son.
For professionals, the ACE study provides a critical frame to "inform" the way we listen to the story. But this frame does not translate into giving patients information about the effects of trauma on long-term health. Without sufficient relational support, such information might be deeply destabilizing.
In a previous post I suggest we replace the word "screening" with the word "listening." Screening is something you give to someone while listening is something you do with someone. As Dr. Perry shows, current relational health buffers against adversity. Offering space and time for the kind of connection we observe between Mr. Rogers and Senator Pastore may be just the "action" that is needed.
The face of a 2-year-old Honduran girl, dwarfed by the adults who only appear as legs in the photo, communicates undeniable anguish. Used to represent the horror of children separated from their parents at the US Mexican border, the photo became a lightning rod for controversy when it turned out that this particular child was not actually separated from her mother. In an interview for CBS News the border patrol officer involved in the incident explained that they asked the mother to put her daughter down so she could be searched. He explained, "It took less than two minutes. As soon as the search was finished, she immediately picked the girl up, and the girl immediately stopped crying."
The fact that the girl recovered immediately shows that she has had accumulated a reservoir of experience with her mother coming back. Rather than falling apart, she was immediately comforted. The very presence of her mother appears to have given her the skills to manage her distress. In an instant she is OK.
But when separations are beyond a young child’s ability to manage, the capacity to recover in the face of disruption is compromised. Time is of the essence. With too much time, “stress” is transformed into “trauma.”
Pediatrician turned psychoanalyst D.W. Winnicott captures the role of time in child development in a way that seems particularly poignant in light of current events. In his book Playing and Reality he describes how a young child comes to have a sense of himself in relation to the world around him:
“It is perhaps worth while trying to formulate this in a way that gives the time factor due weight. The feeling of the mother’s existence lasts xminutes. If the mother is away more than xminutes, then the imago fades, and along with this the baby’s capacity to use the symbol of the union ceases. The baby is distressed, but this distress is soon mended because the mother returns in x+y minutes. In x+y minutes the baby has not become altered. But in x+y+zminutes the baby has become traumatized. Trauma implies that the baby has experienced a break in life’s continuity… [his behavior] now becomes organized to defend against a repetition of ‘unthinkable anxiety.’”
When the Honduran girl’s mother picked her up her rapid recovery reflects an experience Winnicott describes with the lovely phrase “going on being.” The countless experiences of the mother coming back, in typical day-to-day interactions, literally builds a child sense of self. The “unthinkable anxiety” he references is the profound unraveling that accompanies a loss of bearings, a loss of sense of self.
While unfortunate that the photograph was misrepresented, in fact it proves a point about the actual separations known to have occurred in large numbers. Young children rely completely on their parents to hold them together. Self-regulation, the ability to manage on one’s own, is a developmental process that occurs over countless moment to moment interactions in co-regulation with primary caregivers. Separation beyond a young child’s ability to manage represents, from a developmental perspective, a fundamental threat to existence.