Pediatric Leaders on Health and Resilience: Listen to Parents

"We need to actively engage parents before we jump to invest in pre-K for all," Jack Shonkoff, director of the Center on the Developing Child at Harvard University wisely proclaimed yesterday at the American Academy of Pediatrics (AAP) Symposium on Child Health, Resilience and Toxic Stress in Washington, DC. Promoting a "two generation approach,"  symposium speakers recognized that not only the child, but the parent-child relationship, is the concern of the pediatrician.

One of the speakers addressed the problem of "uncompensated time." This phrase hit the nail on the head. Time and space is the treatment. People need to feel safe to be able talk about what is important.  This includes both the clinician and the parent. When the pediatrician feels stressed by a waiting room full of patients that the current system of care demands he must see, he is not able to be present with a parent in the way that careful listening requires.

It  is like a set of Russian dolls. The society values the clinician's time, offering the opportunity to listen to the parent, who listens to the child. And as many at the symposium recognized, it is not just pediatricians, but also child care workers, teachers, home visitors and others who have the opportunity to support stressed parents. All policy needs to be focused on protecting space and time to listen. Listening is not high tech. But it is this space and time, where parents feel safe and valued, that we have the opportunity to grow healthy brains and minds.

Pediatrician and journalist Perri Klass gave a beautiful talk about Reach Out and Read, a national program that distributes books to parents in pediatrician's offices. She spoke honestly about the growing realization that benefits were not from larger vocabulary or "school readiness." Rather it was the act of reading, the gentle sound of the parent's voice, fully in the moment with the child, that was responsible for positive results.

One audience member asked a wise question about giving a book to a mother who has herself not been read to, and so does not have a model for this kind of intimate interaction. Klass responded that this is true of any advice or guidance we give to a parent. Her response leads back to the notion that rather than giving information, or teaching skills, first we need to listen, to be curious about the experience of the person we are with.

My first book, Keeping Your Child in Mind, whose second chapter is "Listening to Parents, Strengthening the Secure Base"  translates the explosion of contemporary research that Shonkoff referred to in his presentation. The book shows what this approach looks like for a range of everyday parenting concerns from newborn to teenage years.

While the symposium was occurring, a relevant headline,  A Case Study in Maternal Mental Illness, on New York Times front page, told the tragic story of a mother's struggles with her belief that she had caused her baby harm. This conviction eventually led to her jump from a building with her infant strapped to her chest. While one cannot fully understand the treatment she received by reading a newspaper article, it appears that there were multiple interventions along the way, all of which treated the mother and baby separately. Many pediatricians reassured the mother that there was "nothing wrong." Psychiatrists diagnosed depression and prescribed medication.

Knowing the research on the value of treating parent and child together, I can't help but wonder if time with an experienced clinician who could sit on the floor with both parent and baby, might have offered the opportunity to make sense of her suffering and so set the pair on a different path. In the abundance of advice, reassurance and diagnosing of illness, was there time and space for listening?

For when parents, who may be stressed and overwhelmed, feel heard, recognized and understood, they are better able to do the same for their child. When  parents listen to their child, are fully present with their child, they offer the opportunity build resilience and the capacity to manage adversity. It is not about giving information, or even about teaching skills. It is about supporting parents' efforts to connect with their most competent self.

Central to this view is the notion of the good-enough mother, a phrase coined by pediatrician turned psychoanalyst D.W. Winnicott, and demonstrated in the contemporary research of developmental psychologist Ed Tronick. The good-enough mother is not perfect. But it is her very imperfection that drives development forward in a healthy way. Parents make mistakes. It is through these mistakes, and their subsequent recognition and repair, that children learn to manage the inevitable challenges of life.

It was an inspiring symposium, but we may be making this more complicated than it needs to be. All the best science tells us that our single aim should be to protect time and space for listening to parents, and so to children. This is the road to health and resilience.

Take new smartphone use study with a hefty dose of empathy for parents

A new study documenting the ubiquitous use of smartphones by parents at fast food restaurants with their young children is getting a lot of media attention. From Time magazine there is this headline: " Don't Text While Parenting- It Will Make You Cranky." "Put Down that Cellphone" from NBC. "Parents on Smartphone Ignore Their Kids," from ABC News.

I doubt that anyone is surprised by the findings of this study. People everywhere are on their smartphones all the time. In the arena of parenting, it is important to call attention to the impact of this behavior. There is extensive evidence that face-to-face interaction is critical for healthy emotional development. Mealtime offers an important opportunity for this type of interaction, especially in today's fast-paced culture.

However, I worry about the parent blaming tone of these headlines. Rather than saying, "This is bad, don't do it," perhaps we should be curious about why parents are using smartphones in this way.

One answer lies the increasing recognition of the addictive nature of these devices. Everyone, not just parents in fast food restaurants, is using smartphones all the time. The other may lie in the fact that parents, especially parents of young children, often feel alone, stressed and overwhelmed. Putting these two together and the allure of the screen becomes understandable.

The American Academy of Pediatrics press release states:

The study raises several questions for future research, including ...what are the long-term effects on child development from caregivers who frequently become absorbed with a device while spending time with their children.

I think we already know the answer to this question. I wonder if another important question might read: "How do we support parents in being more fully present with their young children, given the combination of high stress and an easy available, socially acceptable addictive device?"

Social responsibility to support new parents must follow demise of Isis Parenting

"Where I live (Paris) women are very lonely when having a baby. Is it the same in the US?"

A French journalist posed this question to me in an email interview two days ago. My verbatim response:

"Social isolation and often along with that postpartum depression are problems here in the US for new mothers.
There are mother- baby groups to try to address this issue, but not nearly enough."

Now, in our Boston communities and other places in the US, there are a lot fewer.

The economics of the sudden demise of Isis Parenting, a private retail company,is described in the Globe article today. But as my colleague at the Freedman Center at MSPP (Massachusetts School For Professional Psychology) that also runs mother-baby groups, said in reaction to the announcement by Isis, "you cant make money running mother-baby groups." 

A harsh tweet derides the company for catering to the wealthy with high end products. But in the absence of a system of social support of new parents, what choice is there? 

Isis offered what D.W. Winnicott termed a "holding environment" for new parents. Not just a physical space, but a community of relationships. This fact is reflected in a collection of tweets about Nancy Holtzman, vice president of clinical content and e-learning, at #thingsnancytaughtme.

Another way to describe what Isis offered is a "secure base:" In my book Keeping Your Child in Mind ( that was just released in France, thus the interview with the French journalist) I describe the extensive research evidence for the role of this secure base, both for parent and child, in healthy emotional development. 

John Bowlby, describing the essential role of attachment relationships in survival, spoke of a child’s need for what he called a “secure base” from which to explore the world and grow into a separate person. He also recognized the need for a mother to have a secure base of her own in order to provide this security for her child

In our culture extended families, that in past times might have offered that "holding environment" or "secure base," are often fragmented by distance and/or divorce. If one parent, usually the father, works very long hours, a new mother may feel very much alone. Isis parenting helped these parents not to feel alone. 

The United States lags behind significantly in support of new parents, as represented by a highly restrictive parental leave policy. A recent BBC article described an alternative approach in Finland: 

For 75 years, Finland's expectant mothers have been given a box by the state. It's like a starter kit of clothes, sheets and toys that can even be used as a bed. And some say it helped Finland achieve one of the world's lowest infant mortality rates.

Not only does this gift offer material help, but also an official recognition by the government that new parents have an important role to play and deserve to be valued and supported.

President Obama has recognized the need to invest resources in early childhood, and developed an Early Childhood Initiative. This is an important step in the right direction. 

But this will not help the families in the Boston area, who are now on their own with the loss of Isis. What can we do on the local level? It is my hope that government agencies, foundations and others who are in a position to support the kind of services Isis offered, that almost by definition do not make money, will step up to the plate to help fill the void. It will be an important investment in children, families and our future.

Epigenetics, Psychoanalysis, and Listening to Parents

Psychoanalysts for over a hundred of years have recognized the significance of early relationships in health and development. Now the exploding science of early childhood offers evidence that early parental care regulates physiology, influences development of the stress response, and even affects the expression of genes and structure and function of the brain.

The latest issue of the journal Neuropsychoanalysis provides an integration of psychoanalytic thought and contemporary developmental and evolutionary science. The article by Myron Hofer, and the accompanying commentary contain an abundance of evidence for the significance of early relationships.

Michael Meaney, a father of the new and rapidly growing field of epigenetics, offers this comment.

As Hofer noted, “maternal- infant interactions ... regulate the basic physiology of developing infants (such as sleep states, body temperature, autonomic balance, level of general motoric activity, and adrenal and growth hormone levels)”. These studies also revealed that these same maternal regulators were a source of information that shaped long-term phenotypic adaptation [gene expression and individual charcteristics.]

But all the science in the world may fall on deaf ears if our culture does not support parents in being present with their infants in the way the research suggests is critically important. 

If we pass laws condoning 8-week maternity leave, how can we take in and apply this abundance of research pointing to the significance of the early weeks, months and years? If, rather than addressing the problem of parents feeling overwhelmed and alone, and offering meanignful support, we are quick to diagnose them (and their children) with ADHD and prescribe medication, opportunities to make use of this wealth of scientific evidence are lost.  

Beatrice Beebe, a leading researcher in infant development whose detailed videotapes of mothers and infants offer elegant evidence for the richness and complexity of early parent-child relationships, praises Hofer's integration of theory and research. But Beebe, in conversation with a colleague of mine who is a general pediatrician, suggested that video be used in every 4-month well child visit. This comment represents a kind of disconnect between science and reality. The science certainly supports this kind of investment in time and attention to parent-child relationships in infancy.  But in today's fast-paced world of primary care, where clinicians are under pressure to see more and more patients in less and less time, such a suggestion is almost laughable.

In his concluding remarks, Meaney points in the right direction:

Developmental psychobiology established the conceptual framework within which to better understand the biology of early experience. The challenge is to now translate the emerging scientific advances into psychiatry and clinical psychology.

It seems like a kind of chicken-egg phenomenon. If as a culture we can place value on parents caring for themselves in order to be present with their children; if we value time for listening to parents and children together in the setting of primary care as well as mental health care, we may be better able to hear what the science is (and has been) telling us. 

What might redefining "term pregnancy" mean for parents and babies?

So far the discussion on the policy change by the American College of Obstetrics and Gynecology (ACOG) has focused on the implication for timing of delivery. While previously babies had been considered "term" at 37- 42 weeks, the new policy defines term as 39-40 weeks. Babies born at 37-38 weeks are considered "early term" and those born at 41-42 weeks "late term."

The main consequence of this policy change is an official recognition that babies at 37-38 weeks are still not optimally mature for delivery.  The main objective of the policy is to "expand efforts to prevent nonmedically indicated deliveries before 39 weeks gestation*." In other words, doctors should not electively induce delivery or perform c-sections before 39 weeks. An article in Time magazine on the subject refers to a recent study showing an increased incidence of medical complications in what are now officially "early term" deliveries.

But given my interest in the parent-baby relationship and its impact on healthy development after birth, I had a different take on the significance of this change. Many babies born at 37-38 weeks are not induced or delivered by c-section. For a range of reasons, most of the time not an identifiable one, a mother may spontaneously go in to labor at 37 weeks. And, in contrast to the babies in the above study, the vast majority of these babies do not end up in the neonatal intensive care unit. They are in the regular nursery for the typical 48 hour stay.

My hope is that the policy change will focus more attention on the vulnerabilities of these babies.  The important question is,  "What is the implication for these babies who are not at optimal states of maturity, yet are cared for along side the now "term" babies and treated by professionals as if they are no different?" I put this question to a colleague of mine who is a hospitalist in a major teaching hospital in Boston. Her full time job is to care for newborns and parents following delivery and up to discharge in the regular nursery.

Personally I think this more nuanced classification of who the "full-term" baby is will be important for the parents and other professional who are supporting and teaching the family in the early weeks of life - eg. nurses in the well nursery, lactation consultants and medical providers.  Currently, unless a baby is under 37 weeks, they are all seen as fairly similar in their capabilities with differences being attributed to temperament or "personality" rather than gestation maturity.

There's a continuum to observed physiological parameters that may not be appreciated or fully noticed when babies are lumped together as full-term between 37-42wks; these include degree of sleepiness, subtlety of feeding cues, amount of energy reserves, ability to regulate state changes, muscular tone to name a few.  All of these impact the newborns' behaviors; especially feeding which is a primary focus for parents with their newborns.

Understanding that their infant's capabilities are related very often to his/her gestational age will reassure parents about their own capabilities as they learn to observe/make sense of their new infant's behaviors/cues with a more informed/understanding eye and less self-blame when trying (or struggling) to feed or to calm or to awaken their newborn.  

As my colleague wisely points out, what it looks like in real life when a baby is not "optimally mature," is that the baby may be difficult to arouse,  cry more or in general be more challenging to care for. Much of a new parent's sense of competence comes from successfully feeding her baby. If the baby's challenges with feeding are not identified and linked to his early gestational age, a parent may experience feelings of frustration and failure. She may abandon breast feeding or slide in to depression as she struggles to meet the needs of her baby.

In previous posts, I have referred to a wonderful tool, the Newborn Behavioral Observation System, that offers the opportunity to identify a baby's unique strengths and vulnerabilities.  This video of a brief excerpt of the NBO with a 3-day-old infant shows the newborn's tremendous capacities for communication. The NBO offers the opportunity to look at these qualities in a systematic way.

My hope is that now that the ACOG has officially identified these "early term " babies as vulnerable, professionals who interact with these families will offer parents the opportunity to identify possible challenges and develop strategies to manage these challenges, which with care and attention will resolve in a short time as the baby matures.

*Gestational age refers to the number of weeks since a mother's last normal menstrual period.

Stressed Doctors, Parents, and Children

This past weekend I had the privilege to present the ideas I have been describing in my blog and book to an audience of general pediatricians at the North Pacific Pediatric Society.  It was a wonderful, highly receptive audience. The essence of the problem, in my opinion, is that this cascade of stress impairs effective listening.  We have a basic human need to be heard and understood. This holds true for clinicians, parents and children.

 The American Academy of Pediatrics, in a recent policy statement, has charged pediatricians, along with a very long list of things to do in a 15-minute visit, with preventing "toxic stress" or stress in the absence of a secure, safe caregiving relationship. Extensive research has shown that these kind of relationships can protect against many negative health outcomes. We are ideally suited for this task, as primary care clinicians as a profession have by far the largest interface with young children and families, and usually have a relationship of implicit trust.

Time to listen to parents and an opportunity to share their own experiences with other clinicians are two essential components needed to enable primary care clinicians to take on this critical task of promoting healthy relationships. Currently a pediatrician is paid more for a 10-minute visit for an ear infection (that may very well get better on its own) than a 50-minute visit for an emotional or behavioral concern. On the policy level, changing this would be a good place to start.

As is usually the case after giving such a talk, I think of points that I would have liked to address but did not. Fortunately I have this blog, so can add them here.

 1) I spoke about the need to reframe a child's "difficult" behavior as "stressed" behavior. Over the course of the weekend, a number of references were made to the "difficult" parent. Equally important is to reframe this notion of the "difficult" parent" as the "stressed" parent. We cannot help the child if we do not have an empathic stance toward the caregiver.

 2) I talked about the significance of D.W. Winnicott's contributions, but neglected to mention his very important notion of the "good-enough mother."  The essence of this idea is that mistakes we make as parents, moments when we miss our children's cues, lose our cool or any number of things that inevitable go wrong in the daily life of families, if these "mistakes," or disruptions, are recognized and addressed, are not only OK but essential to move development forward in a healthy direction.

 3) A general pediatrician questioned why I, as a specialist in infant mental health, would ever be referred a patient with colic, a problem that is so common and so much considered the job of the primary care clinician. The point I wanted to make is that meaningful evaluation of this issue may involve more than a 15-minute visit. Colic is traditionally viewed as residing in the baby. But when we see it as a relationship problem, it makes sense to give it more time. For a new mother who imagined blissful hours of with her newborn, having a baby who is either crying or sleeping with little time available for gazing lovingly into each other's eyes, colic can be devastating. At the very least there is severe sleep deprivation, and there may be feelings of low self-esteem and even depresssion. Bringing these issues out in the open at the beginning, validating the mother's experience and helping her to find support, may prevent more long-term problems.

 The last talk of the weekend was about mindfulness. The speaker was a specialist in adolescence, and she was advocating for mindfulness both for parents of teenagers and for the clinicians in the audience. She offered Jon Kabat-Zinn's definition:

Mindfulness means paying attention in a particular way; On purpose, in the present moment, and nonjudgmentally.

This is one tool that can help us to slow down just enough to be able to carefully listen to each other. In doing so, we will go a long way in stopping this cascade of stress that has potential to wreak havoc on our society in the long run.

Engaging Our Right Brains to Support Parents and Children

"People have to feel something in order to change the way they think and behave." This is a quote from my book Keeping Your Child in Mind. The right brain is the seat of emotional regulation. Most, if not all, emotional and behavioral problems are intrinsically tied to the ability to regulate emotions. Changes in the brain can occur only if the right brain centers that regulate emotion are actually firing.

I was thinking about this idea when I attended an amazing conference at the Picower Institute for Learning and Memory at MIT, New Insights on Early Life Stress and Mental Health. Leaders from a range of disciplines presented the explosion of scientific evidence showing that early caregiving relationships have a significant long term impact on both mental and physical health.

MIT is a particularly left brain place, and there was a lot of hard core science at this talk. One speaker, Robert Anda, did inject a bit of right brain experience. Anda is one of the main authors of the ACES study, a powerful longitudinal research project that shows the cumulative effect of adverse childhood experiences, including parental mental illness, divorce, neglect and abuse, on many outcomes related to physical and emotional health. He used art to make our right brains fire. In a painting he showed, a little boy of about seven sat at the dinner table as his parents engaged in an argument, his father holding a knife and his mother's face distorted by rage. The terror on the boy's face was palpable.

The conference was very much framed around the concept of adversity. Anda kept apologizing for making us depressed. Consider the conference description:

Within the last two decades, scientists have begun to examine the biological repercussions of early childhood stress, and have uncovered clues as to how these early life experiences cause lasting changes in DNA and the brain that predispose individuals to disabling behavioral and psychiatric disorders in adolescence and adulthood.

The whole day I found myself thinking that what was missing was a right brain experience of what it feels like when things go well. We know it is bad for kids when they do not have a secure safe relationship. But what does it feel like when parents and children do connect in a way that makes a child feel safe and secure? Earlier in the day I had had the opportunity to share just such a right brain experience.

I had given Pediatric Grand Rounds at Newton-Wellesley Hospital, where I was introducing the scientific basis of my new Social Emotional Health program, where I see families of children under age six. When families come to see me, parents and children feel sad, angry, and out-of-control. By carefully listening to parents' own experience I help them to reflect on the meaning of their child's behavior, rather than responding to the behavior itself. This approach is founded in decades of longitudinal research at the intersection of developmental psychology, neuroscience and genetics that I describe in my book.

I told my audience the story of a visit with a mother who experienced her 3-year-old son's behavior as an assault. I had reframed the child's behavior in these out-of-control moments as helpless rather than defiant. She said, "I know what you mean." She described one moment when, rather than getting angry, she had held her son firmly on her lap and said gently "What's wrong?" She told me how her son "melted in my arms" and replied softly, "I don't know."

This mother felt this change not only in her brain, but in her body. It is not uncommon for parents to have themselves experienced trauma in early relationships. They react to their child's provocative behavior on a physical level that is related to their own history, not to the child. By carefully listening to parents, in a visit that is not fifteen minutes but an hour, I help them to make these connections. Once their own issues are in a sense moved out of the way, they are free to reflect on their child's experience in a way that is not encumbered by their own trauma history. When a child feels understood in this way, his behavior improves. A positive cycle of interaction is set in place.

When I told this story during Grand Rounds, I felt a tingling in my arms as I spoke of this mother's transformation in my office. The visit with that family had been a powerful experience for me. The fact that I felt something in the telling makes me hopeful that I was able to convey this to my audience. Maybe they understood how this kind of careful listening may actually change brains.

My book is full of stories like this one. If we are going to change this path that was described at MIT, of early childhood stress leading to terrible outcomes, these conferences need to include stories of what goes right; when clinician-parent-child connect in a meaningful way. Once we know what this feels like, we will be closer to understanding what we need to do to set children and families on a better path.