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.

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

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

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

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

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

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

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

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

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

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

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

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