Monthly Archives: March 2014

Supporting “The First Relationship” in Northern India III


After the presentation of the book, Your Baby is Speaking to You (Nugent, 2011), I introduced the workshop by stressing the importance of the role as nurses in scaffolding the healthy development of children through their support of the “first relationship”. I told them that (1) Babies are speaking to their mothers; (2) mothers can listen to their babies; and (3) they, as nurses, could help mothers learn to listen to their babies in a way that could make a great difference to the future health and wellbeing of the children. Ginger and I stressed the importance of making the mother feel that she can gain competence in listening to her own baby, that she can become the expert of his communications.

Then, using Kevin’s book as a guide, we introduced some of the basic ways that infants communicate through manifestations of their state – quiet, alert, crying, fussy, deep or light sleep, etc. We talked about the way babies make transitions among these states. Then, we talked about how individual babies have different and characteristic ways of making transitions, and how through learning how to “read” these communications from the baby, the mother can comfort her baby’s natural distress as he moves through transitions. At that point, without our original plan for demonstrating the NBO in the maternity ward, we had to improvise. It occurred to me that Ginger and I could play the roles of mother and nurse, and when I suggested this to Ginger, she immediately and enthusiastically rose to the occasion. I had not previously realized that my teammate was such a good comedian and creative improviser.

Ginger snatched up her small cloth purse to represent “the baby”. Playing the nurse, I pretended to enter the room and greet a mother with her newborn. “You have a beautiful baby!” I pronounced. Ginger smiled, but then told me, “But he is crying all the time!” I suggested to the group that the natural response of a nurse to a crying baby might be to pick up the baby and comfort him. Then, I asked the group how they imagined the mother might respond if the nurse picked up the baby and was able to comfort him. One student answered that she thought the mother would be pleased. We then acted this out with my taking up the baby and comforting him, and Ginger making a woe face to indicate her feelings of inadequacy at being less competent than the nurse at comforting her own baby. The students laughed and seemed to understand our point quite well.

Then, Ginger told “the nurse”, “I think my baby is uncomfortable, and I don’t know what to do.” Ginger – who has a more substantial background in the NBO and also in home visiting mothers and infants – was luckily cueing me at every step. In response to her cue, I responded, “How does your baby like to be held? Do you think that if you held him in a different position he might be more comfortable? Why don’t you try some different ways of holding him and see what you discover.” Ginger pretended to hold her baby in different positions and did indeed “discover” a way that made him more comfortable. I congratulated her on “knowing” her baby.

Ginger then said, “But even so, my baby seems to cry a lot of the time.” I responded – again to Ginger’s cues (which actually were quite transparent and often elicited a laugh from the students), “Maybe you have a sensitive baby. Have you noticed that he is sensitive to light?” Ginger said, “Yes, I have noticed that he makes his eyes go like this (squinting) in the daylight.” Another appreciative laugh. I said, “Well, let’s lower the window shade and see what happens.” I pretended to do so, and Ginger agreed that this seemed to have a positive effect and seemed pleased at this new knowledge about her baby. The street noises were very loud and sometimes drowned out our speech, so it was easy to play out a baby who was sensitive to loud noises. This elicited more laughter, as the noises of trucks and motorcycles and the banging of construction intruded into the room.

My favorite part was when we wanted to demonstrate a mother discovering that her baby needed to be swaddled. Ginger made her soft purse strings flap around until she and I decided to swaddle the baby so that his little “arms” were held close to his body. Continuously, we repeated the necessity of helping the mother feel competent, and as if she knew her own baby better than anyone else.

The workshop was a very enjoyable experience for us, and I did have the impression that the students learned something important. I was touched by the sign in the nursing school, listing the qualities of a nurse: N=nobility; U=usefulness; R=righteousness; S=simplicity; E=efficiency.


photographs by Ginger Gregory

Supporting “The First Relationship” in Northern India II


During our first visit to the Christian Hospital last year, Ginger and I were introduced to the nursing school and also visited the maternity ward and saw several women who had just given birth. As I considered this visit, I thought that a potentially valuable offering to the hospital would be to give a workshop to the nursing students, much as I did for the orphanage caregivers in El Salvador. The subject of the workshop to the nursing students might be the value of the “first relationship” and their potential role in scaffolding it.

Communication with the hospital by email was spotty, and though in a late message from Dr. HJ Lyall, he mentioned a workshop, I was not at all certain that he or the nursing school had any interest in such a program. I became concerned that my proposal would be received as an obligation, rather than as a benefit. Just before I left, I wrote to reassure them that I was prepared to do something “casual” and to respond, upon my arrival, to whatever they let me know was their interest or need.

Thursday afternoon, on our arrival, Dr. Nina Lyall gave us a tour of the hospital compound and visited the maternity ward, where a new mother proudly cradled her infant son. Later, Dr. Lyall, asked us what time we would like to give the workshop the following day, and after some discussion, we settled on 10 o’clock. That would give the nursing students time to finish their morning tasks and would give us a chance to attend the morning service in the chapel, something we were eager to do. That evening, we had a lovely dinner with both Drs. Lyall, their son, Himanshu, who has a graduate degree in hospital administration and has built the eye department into the substantial program that it is today, and his wife, Sonia.


The next morning, after a good sleep, we rose to hot tea and prepared for the church service before breakfast. Dr. HJ Lyall accompanied us to the service. As we approached the chapel, we were greeted by the music of song, a keyboard instrument, and the tambourine. I suppose this loud and rhythmic music was a hymn, though not like any I am used to. It was clearly religious and very enjoyable to listen to and had the quality of a melding of Christian ritual with indigenous culture that I have noticed in El Salvador and other parts of the world. The small chapel was packed with the nursing students – row after row of light blue dresses and white cap atop neat black hair, pulled back. As I sat in one of the back rows, I saw several of these young women adjust the pins in their hair to settle their hats more firmly on their heads or to secure a stray lock of hair. Dr. L introduced me and Ginger to the community in the chapel.

After chapel, we joined the Lyalls for a delicious Indian breakfast and then headed for the nursing school. Dr. Nina Lyall had volunteered to translate our words into Hindi, something for which we were very grateful. We were hoping that we could take the students into the maternity ward and use a version of the NBO as a way of demonstrating to the new mother – as well as the nursing students – the way mothers can learn to “listen to” their newborn babies (Nugent, ) In this example of the Touchpoints model, nurses caring for pregnant women or new mothers in the maternity ward can offer something like the kind of intervention described in the previous posting. They can show mothers how to become expert in understanding their own babies, and grow in their confidence and comfort as mothers. We now know that this kind of intervention can reduce the occurrence of post partum depression, a significant risk factor in child development (Brandt & Murphy, 2010, p. 185).

The Head of the School of Nursing, Mr. Jinson Mathew, had discussed with us and with the Lyall’s how to structure the workshop so as to accommodate the number of students, and we had decided to give two consecutive workshops in the same relatively small room. Nevertheless, when we were greeted with about forty students in the first workshop, we were taken aback. Of course, we realized that we could not take them all into the maternity ward to see the one new mother and her baby. It was with pleasure but also some apprehension that we surveyed the fresh and eager faces of the young women in the room and wondered what we were going to do instead, how we were going to engage them. We calmed our anxiety by presenting them with two copies of Kevin’s book.

In the next posting I will describe the actual workshop.

Brandt K, Murphy JM (2010), Touchpoints in a nurse home visiting program, in B Lester J Sparrow (eds), Nurturing Children and Families: Building on the Legacy of T. Berry Brazelton, Wiley-Blackwell, pp 177-190.

photographs by Ginger Gregory

Supporting “The First Relationship” in Northern India I


After our time at Deenabandhu, Ginger and I flew to Delhi from Bangalore. We were headed for the hospital we had visited briefly last year. This year we hoped to give a workshop to the nursing students but because of poor email connection, we were not sure that this would be possible. During our stay at Deenabandhu we received a welcome email from Dr. Lyall, inviting us to give the workshop and assuring us that they would take care of our accommodations and also provide for our driver. We were relieved and excited, but we still did not know what to expect.

Our trip to the Christian Hospital of Kasganj surpassed my expectations. The hospitality of Drs. Hamilton J and Nina Lyall, and the reception of the nursing school, was heart warming. Yet it started out on a less than fortuitous note. Our friend and driver, Harvinder, programmed his gps to guide our way, and the British accented female voice on the gps directed us on the shorter route from Delhi to Kasganj. Yet, the road seemed to be almost unnavigable. In fact, I was reminded of a sailing trip my husband and I took a couple of years ago on the Pas de Calais in stormy weather. The road was an old fashioned washboard of bumps and ruts, and the small towns on either side were teeming with people on foot, on bicycles, trucks, and motor scooters who had to be avoided by swerving movements. Whenever I was able manage my motion sickness well enough to open my eyes, I looked out at the fascinating view of busy humanity tucked into tiny workshops open to the street – tailor shops with sewing machines, welders, clothing shops, produce shops with red carrots and yellow and green peppers and cucumbers stacked in artistic designs. Most of the time, however, I sat quietly with my eyes shut and waited for the trip to be over. Finally, as if by a miracle, the British “woman” announced that we were at the hospital.


The Christian Mission Hospital is a cluster of attractive old brick buildings. The dim corridors reminded me of the buildings of the old Peter Bent Brigham Hospital during my med school training. Our van was directed into a courtyard, where we were welcomed by the old man who had looked after my aunt many decades ago, when she worked at this hospital as a nurse. Julia, who had suggested to me that I become a doctor and come to India to work with her, died in my first year of medical school. I will tell more of her story in a future blog post. The next person to meet us was the charming Dr. Nina Lyall. A small attractive woman in a sari, Dr. Lyall was so warm in her greeting that we felt immediately at home. Dr. Lyall, who also has a master’s degree in public health from Johns Hopkins, was accompanied by one of her lovely daughters in law, a pathologist. Dr. Lyall had prepared a room for us in her home and had also found a room for our driver.

The workshop idea was inspired by the U Mass Boston parent mental health course, of whose core faculty I am fortunate to be a member. My friend and teammate, Ginger Gregory, is a graduate of the first program in Napa, where I have also taught. This  wonderful program in Napa is celebrating the tenth year since its first graduation was held next month. What Ginger and I have learned from the infant-parent course is that one of the “best bang for your buck” interventions for helping an underprivileged population is to support the mother-infant relationship. This intervention is designed to add protective factors to the mix of risk and protective factors influencing the infant’s developmental trajectory. It is based on the principle that increasing protective factors and decreasing risk factors in an infant’s life will positively affect the infant’s immediate wellbeing and future development (Shonkoff and Phillips, 2010). In the late 1990’s doctors at Kaiser Permanente conducted the famous ACE study demonstrating that adverse life events in childhood account for risk factors for illness and death in humans of all ages. Research in neurodevelopment has also documented the effect on the developing nervous system of adverse life events in early childhood (Hunter & McEwen, 2013; Perry & Hambrick, 2008). For example, traumatic events or periods affect the developing stress regulatory system with some specificity according to which part of the brain is developing at the time of the trauma (Perry, 2006). Continue reading

More on Executive Function:



Executive functioning (EF) is a real “lumper”, as in “lumper or splitter”, term. That is, it refers to a very broad class of skills that we use to get through the day at home, at school, and at work. Not only that, but for executive functioning to work well, all these skills have to be coordinated with one another. It is conceptually confusing to try to collapse all this complexity into one “thing”, but since it is frequently used to describe children, we will use it here too. EFD has a big overlap with ADHD, as you might imagine.

EF is used to help plan, organize, make decisions, and shift between situations or thoughts (make transitions), control emotions and impulsivity, and learn from past experience. It includes cognitive processes referred to as “working memory”, in which facts that are needed to solve problems – in academic tasks, social situations, or tasks of living, such as what is involved in getting ready in the morning – are kept accessible for use when necessary. A figurative image that is often used for working memory is facts on a shelf in the front of the brain, so that if a child is trying to solve a math problem, she may need to be able to find the multiplication tables right away and not stumble as she tries to retrieve them. Or if he is in a tricky social situation, he may need to recall a fact about another boy he wants to play with – such as that this boy does not like to be called a certain nickname – if he wants to make a good connection.

A child with EF difficulty, “executive function disorder” (a term I dislike because of the word “disorder” since there is no discrete “disorder”), has difficulty with organizing his life. He often has difficulty with handwriting (visual motor integration), trouble managing the multiple transitions of his daily life (getting ready in the morning, going from one activity in school to another, managing the bedtime routine), making sense of the complex social communications of the playground, inhibiting impulses (“using your words instead of your body”). Children with this type of difficulty also often have trouble with team sports in which you have to coordinate with multiple other players as well as manage your own body.

What can you to help your child who struggles with executive function problems? Well, to begin with, consider not that you are helping him “compensate” for deficits (which may be true in the immediate situation, of course) but rather that you are “growing his brain”. You are helping him to develop more robust capacities than he has, and you are doing that by making it possible for him to use his less developed capacities in a less demanding situation (so that he can be successful) and practice them over and over so that they can become stronger and more versatile. You are helping him build good habits. You are helping him expand his repertoire of competencies. You are helping him grow his brain.

You would like to ensure success through these considerations:

1. Context – The first thing to do is to identify the contexts in which your child can most easily succeed. Some kids can regulate themselves well in a highly structured setting such as many school classrooms. Others require the reduced stimulation of a small group of children. Some may be able to sustain attention on a simple, structured task such as simple Lego kits or simple academic worksheets, but get frustrated and fall apart with less structured writing assignments or more complex Lego kits. It is common for some kids to do well on tasks requiring information that the child has learned well by practice but be unable to grasp novel concepts easily. Often children with these challenges are more vulnerable to physical or emotional distress interfering with their concentration – a cold or a conflict with a friend. Recognizing the context means you are empathizing with your child, which is at the core of successful parenting of a challenging child.
2. Take Your Time – No matter how much hurry you are in, slow down. Rushing will make everybody anxious and make matters much worse.
3. Break it Down– Then break down the information you want the child to learn into small enough pieces that he can take it in. Directions should be simple (“First, hang your coat on the hook.”); beware of multi-step directions (“Hang your coat on the hook and put your boots, and then come into the kitchen to have your snack.”). Or, teach morning routine in pieces, such as (1) use the toilet; (2) brush your teeth; (3) wash your hands and face; (4) put on your clothes; (5) come down to breakfast.
4. Make Checklists – Help your child by making checklists. Often these children get so preoccupied by making the first decision, that they cannot even start working on the task they have decided on. Setting out the requisite tasks in order ahead of time can make all the difference in a smooth transition. Checking off all the steps can create an experience of mastery. It is also helpful to do as many of the tasks involved in transitions ahead of time, such as laying out the clothes for the next morning the night before, putting everything in the backpack, making the lunch.
5. Write it Down (or Make Pictures) – For younger children, it is helpful to make a schedule strip of Velcro with words, or pictures (depending on the maturity of the child) to document the child’s daily routine. For older children, weekly planners are very useful.
6. Routines are Your Best Friend – Routines establish a comforting predictability that ease tension by making transitions easier. When children know what is coming, the momentum of the schedule can carry them into activities that they would otherwise refuse. Routines help you practice, and practice is essential to building a bigger repertoire.
7. Rewards – I think of rewards – stickers, treats, or special time with parents – not as bribes but as acknowledgement for an accomplishment hard won. Especially for kids with attention problems, rewards given quickly after a good effort can promote motivation.

Photo by Ginger Gregory