Pediatricians and prevention of toxic stress

The Harvard Center on the Developing Child has produced a new video: Building Adult Capabilities to Improve Child Outcomes: A Theory of Change. The video wisely identifies the need to support the adults in a child's life in order to promote long-term health, both physical and emotional. It points to the abundance of scientific evidence showing the need for providing safe and secure relationships in early childhood to reach these goals. Exposure to stress in the absence of such safe, secure relationships is termed "toxic stress."

As pediatricians have regular contact with young children and their families, the need to translate this research in to the clinical setting of pediatric practice is clear. The American Academy of Pediatrics (AAP) has embraced this task. The 2013 AAP national conference titled Early Brain and Child Development: Building Brains, Building Futures, will present the science of early childhood.

In addition, concurrent with the release of the above video are a number of publications addressing the need to integrate the research in to practice. One article, Listening to the Baby's Brain to Reduce Toxic Stress: Changing the Pediatric Check Up to Reduce Toxic Stress  describes new interventions.

Purposeful Parenting materials, for example, emphasize “face time” with infants, a type of “serve and return” interaction fundamental to the wiring of the brain: When an infant smiles, the caregiver should smile back—and should do so repeatedly throughout the day. When infants learn early on that smiling, then cooing, then words, are the best way to get attention, they keep using those strategies. But if face time fails to occur frequently enough, infants may learn less healthy ways—such as crying or whining—to get the attention or support they crave. The lack of something as simple as face time can lead to more infant stress and less healthy ways to cope with stress in the future.

This recommendation appears to draw on the powerful research of Ed Tronick showing the distress caused to an infant when a caregiver presents an unresponsive "still-face." His research has shown that when a caregiver is attuned with an infant in 30% of interactions, and if the remaining misattunements are recognized and repaired, the child develops a positive affective core-  an ability to experience joy and connection.

Given these findings, the AAP recommendation is a good one. But most caregivers intuitively provide this attunement without needing anyone to tell them what to do. They naturally experience what D. W. Winnicot termed "primary maternal preoccupation," acting as what he called the "ordinary devoted mother." When they do not, simply telling them to smile at their baby will likely be ineffective. This is where the link to the video comes in. To "build adult capacities" in this situation, there needs to be an opportunity to listen to that parent, who may be struggling with postpartum depression, may be socially isolated, or may herself have been abused.

Fortunately the AAP model also looks at the larger context. The director of Developmental and Behavioral Pediatrics at Yale University is quoted:

In order to make these changes, Weitzman says, pediatricians will need broad systemic changes to support them, including better medical training, payment systems, treatment options, and help to coordinate care.

What is needed is space and time to listen. That includes listening to the pediatricians who are themselves under tremendous pressures. This need is addressed my book Keeping Your Child in Mind, whose  second chapter  is titled "Strengthening the Secure Base: Listening to Parents." The book demonstrates this idea of supporting adults with the aim of supporting children, showing what this approach looks like from infancy to adolescence, as seen from the front lines of pediatric practice. It concludes:

 If those who care for children and families on the front lines have the time to develop these relationships, if there is a strong system of mental health care to support families who are struggling and a medical education system that encourages clinicians to listen to parents’ stories, we will be well on our way. The image comes to mind of a set of Russian dolls. When the health care system allows the primary care clinician time to listen to the whole of parents’ experience and to support their inherent wisdom and intuition, parents are enabled to be fully present with their child. In other words, the system holds the clinician, who holds the parents, who hold the children. 

Toxic Stress and Survival of Our Species

Yesterday I listened to an important webinar from the Harvard School of Public health: Toxic Stress and Early Childhood Adversity: Rethinking Health and Education Policy. The forum centered on growing evidence that when young children experience a constant state of internal stress, it leads not only to mental health problems but long-term poor health outcomes in the form of asthma, obesity, diabetes and other chronic illnesses. Jack Shonkoff, a pediatrician and Director of the Center on the Developing Child at Harvard University, summed up the problem well when he said, in response to a question about growing and new external stresses like cyberbullying and the recent economic crisis, that "Toxic stress happens in the body." He went on to say that prevention of toxic stress is dependent on a child growing up in the company of a relationship with an adult/adults who offer a sense of safety in the face of external stress."

These words could have come straight from John Bowlby, considered to be the father of attachment theory. I summarize his work in my book Keeping Your Child in Mind as follows:

In England during World War II, as in most Western societies at that time, a mother was thought of mainly as a provider of the physical necessities of food and shelter. The mother–child relationship itself was accorded little value; children were routinely removed from their families to keep them safe, and hospitalized children were separated from their parents for long periods of time. D. W. Winnicott, a pediatrician turned psychoanalyst, was among the first to introduce a different way of thinking. He saw that children developed a strong, healthy sense of self when the people close to them accepted their feelings and helped to manage their emotional experiences. To describe this ideal situation, Winnicott coined the phrase “the holding environment.” The way in which a mother makes sense of her infant’s expression gives rise to what Winnicott referred to as the child’s “true self.”

John Bowlby, a British psychoanalyst and contemporary of Winnicott’s, observed the devastating effects of separating mother and child. He described the way a child keeps close to his mother in times of stress and fear as “attachment” behavior. Greatly influenced by Darwin, Bowlby postulated that this attachment relationship was essential to the survival of the species.

Shonkoff is saying the same thing, only now we have the scientific evidence, not available to Bowlby, of exactly how the species will become extinct if children do not have these secure, safe relationships. It will be through violence associated with mental illness, and death from chronic illness.

This is not a matter of shifting funding sources. This is a matter of survival of our species. As Shonkoff wisely said, "we find money to build prisons and cure cancer." Why then is it so hard to recognize the need to support young children? I believe it is linked to another phenomenon that I address in a previous post, namely prejudice against children. This phenomenon is described in the book by the late Elizabeth Young Breuhl, Childism: Confronting Prejudice Against Children. One particularly striking statement came from the moderator of the forum that could be seen as a reflection of this societal prejudice. Wondering about how pediatricians will be paid in keeping with the importance of their role in promoting early caregiver- child relationships, she said "the orthopedists aren't going to say "I'll get a paid less."" So now our survival is up to the orthopedists? Actually that is now in a sense true, as currently reimbursement is decided by the Specialty Society Relative Value Scale Update Committee, commonly called the RUC, which as was described in a recent New York times article, How One Group Sets Doctor's Pay. This committee has very few primary care clinicians. When it comes to policy changes, this might be a good place to start.

The policy statement upon which this forum was based comes from the American Academy of Pediatrics and calls upon pediatricians to take up this role as protectors of children from toxic stress. Over 40 years of attachment research that followed Bowlby's original observations offers solid evidence that secure attachment relationships develop when caregivers are able to listen carefully to their children, to reflect on the meaning of behavior, to, as I also describe in my book "hold their child's mind in mind." In order to support parent's efforts to be present with their child in this way, there must be a place for them to be heard, for their struggles to be recognized and understood. The primary care clinician's office can be such a place. As Dr. Block, president of the American Academy of Pediatrics, stated during the forum, a pediatrician should be able to spend 25-30 minutes instead of 10 listening to a parent. This is an excellent, very concrete plan (though 50 minutes would be better.) Next would come changes to our medical education system to value the role of taking time to listen as a form of healing. These would be small but important steps in the direction of insuring survival of our species.