Tag Archives: Tronick

Infant Parent Mental Health Weekend: Bruce Perry

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Bruce Perry came to speak to the Infant Parent Mental Health course last weekend. As usual, I was impressed by his discussion, and I agreed with him that his thinking has changed and grown more sophisticated and complex even from when I first met and was inspired by him a decade ago.

This time I was especially gripped by the notion of “dosing” the interventions that are aimed at growing the brain. I put that idea together with two other primary principles of Perry’s Neurosequential Model of Development – changing the environment to meet the developmental needs of the child, and repetitive, rhythmic patterned activity – to create the mnemonic, “RED”. Here is a summary of my thoughts after the weekend. These thoughts are directly relevant to the subjects of ADHD and Executive Function Disorder.

R: Perry frequently talks about the regulating function of repetitive rhythmic patterned behavior. This makes sense, since the body has many rhythms that are repeated over and over again mostly out of our awareness, creating micro patterns that then coordinate to create macro patterns, that help to organize and integrate our human body and mind. For example, we don’t usually pay attention to our heart rate or respiratory rate unless something is going wrong, such as the rapid heart rate associated with anxiety or panic. But our sense of well being emerges from among other things the signals these rhythms send us. An example of the coordination of these rhythms is the coordination of respiratory rate with walking. If walking at a comfortable pace, many people tend to take two strides for one inhalation and between two and three strides for one exhalation. Perry refers explicitly to walking as a regulatory activity, as well as dancing and drumming, and many other repetitive rhythmic patterned activities. In fact, music and dance often provide refined regulatory procedures that make one feel good – calm (“music soothes the savage beast”) or invigorated.

A child develops regulatory capacity through a process of mutual regulation with a caregiver (Cohn & Tronick, 1988, Tronick, 2005). This helps to explain why regulatory activities done with another person are often even more effective than done alone, for example, taking walk with another person. Even having a conversation with another person involves rich processes of turn taking that creates coordinated rhythms between the two people and also simultaneously within each individual (Beebe et al, 1992).

E: One of Perry’s key points is the importance of changing the environment to accommodate the child’s developmental needs for both regulation and for engagement.

From the point of view of regulation, that means more than adding regulatory activities to the child’s schedule. It also means evaluating the child’s capacity for processing sensory input to make sure that the noise, the visual stimulation, and the touch occurring in the child’s daily life is not overwhelming to the child. A crowded classroom or a disorganized routine can be modified to make life easier for a child with sensory sensitivities and that makes life easier for everyone in the family. Sometimes this is called a “sensory diet”.

From the point of view of engagement, this means that the child’s vulnerabilities must be engaged. As Perry says, “You can’t change any neural network unless you activate that neural network.” (Perry, 2015). Not surprisingly, children resist activities that require them to exercise functions that are hard for them, especially if their development is uneven and they do other things quite well. In that case they will tend to stick to what they do well and avoid what is hard. To help them grow, their caregivers must support them in attempting the difficult or uncomfortable task. For some children who are socially skilled but have a learning disability, this means practicing academic tasks that are difficult for them. For other children who have academic strengths but are stressed by interacting with other people, it means drawing them into social interactions, usually in play.

D: But how does one engage a child who is highly stressed by, for example, social interaction, such as very shy children or children on the autistic spectrum? Perry’s idea, which I find very useful, is that of dosing. By paying attention to the child’s cues, you can “read” the child’s intentions to “do something with you” or not. In the rather extreme case of an ASD child, you can’t just let him remain in a withdrawn position without attempting to make a connection; you often have to take the initiative yourself. I recommend small gestures that take place in short time intervals and are over quickly, and also that are of low to medium level of intensity (in noise, visual stimulation, affective tone, and arousal). After you have taken the initiative, you watch for the response. If the child seems not to respond you might try one more time. If the child pulls back further, you might wait. If the child looks a little interested, you might repeat the gesture.

The beauty of this notion of dosing is that it is coordinating intention with the child, and dosing is repetitive and has a rhythm to it. Together with the child you are creating patterns of ways of being together. So you are putting together regulation-enhancing activities with growth-stimulating activities. Another good thing about dosing is that it takes the emphasis off success or failure and places it on creating a balance. If the child indicates, “no”, then you don’t feel, “Oh, I lost him.” Instead, you think, “OK, that was a “no”; I will wait and try again. The “no” is part of what we are doing together. It is part of the back and forth.” And, of course, back and forth is a rhythm too.

How is this discussion related to ADHD and EFD? Both ADHD and EFD can be thought of as regulatory disorders (or difficulties on a dimension, if we use my preferred terminology). I will discuss this further in another blog posting.

References:

Beebe, B., Jaffe, J. & Lachmann, F. (1992). A dyadic systems view of communication. In N. Skolnick & S. Warshaw (Eds.), Relational perspectives in psychoanalysis (pp. 61-81). Hillsdale, NJ: Analytic Press.
Cohn, J., & Tronick, E. (1988). Mother-infant face-to-face interaction: Influence is bi-directional and unrelated to periodic cycles in either partner’s behavior. Developmental Psychology, 24, 386-392.
Perry B (2006). The neurosequential model of therapeutics: Applying principles of neuroscience to clinical work with traumatized and maltreated children, In: Working with Traumatized Youth in child Welfare (N Webb, Ed). The Guilford Press, New York, pp. 27-52.
Perry B (2015). Presentation to the Infant Mental Health PGC Program, U Mass Boston, Feb. 25-26.
The Child Trauma Academy (2015). Overview of the neurosequential model of therapeutics, www.ChildTrauma.org
Tonick E (2007). The neurobehavioral and social-emotional development of infants and children, New York, WW Norton.

 

 

 

Romanian Orphanage Study: Dr. Charley Zeanah at UMB IPMH

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Charley Zeanah presented to the group on September 21 and 22. He has been involved in Romania for 14 years. The Romania initiative traces its beginning to a movement started by the 1909 White House Conference on Children that declared its opposition to the institutionalization of dependent and neglected children. Now institutionalization of children whose families cannot take care of them is rare in the U.S., but not in other parts of the world. Romania is a unique story. The research group was invited to study there in the context of a policy debate about what to do with all the children institutionalized by Ceausescu’s government. Under Ceausescu, the official position was that the State could do a better job in raising children than many mothers could, so mothers who were struggling with poverty or other adversities were encouraged to give up their children in the maternity hospital. After several months in the maternity hospital, if the child had no obvious problems, he was transferred to a nursery, where he stayed until 36 months. At that point, if an exam determined him to be normal, the child was sent to a children’s home.

Although there was wide variability in children’s homes, there were some important common features, including many factors working against the establishment of individualized attachment relationships with the caregivers. The children were fed around the table with little or no talking, there was a lot of “free play time” with little support from the caregivers, and aggressive behavior and expressions of distress were often not attended to.  Films of this “free play time” revealed painful images of children rocking and spinning. 

The study created a model foster home project in which social workers were trained to work closely with the foster families to facilitate attachment and support the foster parents. Interestingly, one of the main effects of this intervention was an increase in IQ of the children in foster families. Also, these children showed greater expression of positive emotion than the institutionalized children within a few months. When assessment was repeated after 42 months in foster families, a community control group had the best attachment to their caregivers, the foster group had medium results, and the institutionalized group had the worst outcome.  The children in this last group included a high percentage of withdrawn, inhibited kids with Reactive Attachment Disorder. It is interesting to note that the characteristic “indiscriminate” attachment behavior of RAD persisted even after the group in foster care had formed attachments to their foster families.

Later, when psychopathology was assessed at 54 months, 55% of the children living in institutions had diagnosable psychiatric disorders in contrast with 22% of children in the (control) community group. Both foster care and institutionalized groups had higher levels of emotional disorders (such as anxiety and depression) and behavioral disorders (such as ADHD, Oppositional Defiant Disorder, and Conduct Disorder) than the community group.  The improved cognitive outcomes in the foster care children were most significant for children placed in foster care before 24 months. Similar sensitive periods were also found for the development of language, attachment, and indiscriminate behavior. An important finding was that secure attachment at 42 months predicted psychopathological outcome at 54 months. Interestingly, there was a big gender difference, with most of the securely attached children at 42 months being girls and most of the children with psychiatric symptoms at 54 months being boys. 

In conclusion, the research group found that children raised in institutions have compromised development across almost all domains, that attachment status moderates many aspects of psychopathology, and that the socio-emotional effect is more profound than the cognitive effect. When you place these children in good foster homes, you get attachment recovery and some – but not all – recovery from psychopathology. The research group strongly recommends intervening in abusive and neglectful caregiving situations as early as possible.  More specifically, they propose removing children from institutions and placing them in foster homes. 

I noted that this was a beautiful presentation of a study of monumental importance in child development and child psychiatry. The study demonstrates the power of the caregiving relationship to influence development. I pointed out, though, that the Romanian orphanages represent – as Dr. Zeanah explained – a rather unique and extreme caregiving situation, and that there is a problem in that is that this study of Romanian orphanages is being used by some international agencies to promote a one size fits all approach to the problem and laws such as LEPINA in El Salvador that require immediate reunification of institutionalized children with their biological families, with little or no support for their severely disadvantaged and dysfunctional families in the community.

Ed Tronick quoted the “old literature “– the first edition of Jerome Kagan’s book on child development that included accounts of children raised in institutions after WWII. These children did relatively well. How can we explain that? One possible reason is that there was a commitment to these children because of something terrible, morally bad that had been done, enhancing the caregivers’ desire to do something for them. Dr. Zeanah talked about the meaning of the children to the caregivers. In the case of Romanian orphanages, the society’s negative attitudes towards the Roma, who make up of 30% of children in orphanages, though they comprise only 6-9% of the population, may affect the caregivers’ commitment to the children. 

 Dr. Zeahah said that their group is interested in individual differences in response to institutionalization among the children. He noted that there may be a relationship between certain genotypes and indiscriminate behavior. They are looking at alleles that are very sensitive to experience and those that seem impervious. In that case, if you have the impervious alleles you fare well no matter what the environment and if you have the sensitive alleles you may struggle in an average expectable environment. Readers of the blog will recognize the “orchids versus dandelions” metaphor.

Apropos these last comments, I had a number of thoughts. First, I would underscore the importance of the meaning of the child to the caregivers. For example, a religious or spiritual mission to minister to children in need may allow caregivers to see the child as deserving of loving care and to recognize the unique value of each child, while also sustaining the caregiver through the frustrations and disappointments involved in their tasks. For example, the message that each child is precious to Jesus – no matter what he looks like or how much he achieves – is a powerful message indeed.  It is also important to remember the orchids and dandelions story. This story emphasizes the individual characteristics of each child, including the ability – innate or acquired – to take in the good in their environment and make it part of themselves. These thoughts remind us of the complexity of development and of how important it is to continue to search for a repertoire of solutions so that we can find a unique approach to each unique challenge. 

References:

Kagan, J. (1962). From Birth to Maturity, John Wiley and Sons, Inc.

Nelson, C.A., Zeanah, C.H., Fox, N.A., Marshall, P.J., Smyke, A.T., Guthrie, D. (2007). Cognitive recovery in socially deprived young children: The Bucharest early intervention project. Science, 318:1937-1940. 

Nelson, C.A., Furtado, E.A., Fox, N.A., Zeanah, C.H., The deprived human brain: Developmental deficits among institutionalized Romanian children – and later improvements – strengthen the case for individualized care (2009). American Scientist, 97:222-229.

Whetten, K., J. Ostermann, R.A. Whetten, B.W. Pence, K. O’Donnell, L.C. Messer, N.M. Thielman, The Positive Outcomes for Orphans (POFO) Research Team. “A Comparison of the Wellbeing of Orphans and Abandoned Children Ages 6-12 in Institutional and Community-Based Care Settings in 5 Less Wealthy Nations.” PLoS ONE. 4(12):e8169. 2009.

Plus the new OVC researcher community at http://www.ovcwellbeing.org/