Celebrating Pediatricians’ Embrace of Early Relational Health

When I set out to practice pediatrics over 30 years ago, I felt that my privileged spot at the birthplace of a new family made me ideally situated to promote healthy emotional development. Following excellent training that included a fellowship in developmental and behavioral pediatrics, I landed a front row seat in a busy small-town practice where I attended deliveries in the middle of the night, often meeting families even before the arrival of a new baby. Yet again and again, despite being in the right place at the right time, I, and the families I worked with, experienced a sense of frustration and failure when problems arose. It wasn’t until I discovered a field, relatively new at the time, that focused on promoting parent-infant relational health, that I began to learn tools with direct relevance to my day-to-day work.

So, I was thrilled to see in the August issue of Pediatrics two new policy statements from the American Academy of Pediatrics that validate this perspective. The first, Partnering with Families to Promote Early Relational Health draws on the wealth of research at the interface of developmental psychology, neuroscience, and genetics that offers compelling evidence of the role of early relational health in promoting health and buffering the effects of adversity in childhood. The second, Trauma-informed Care in Child Health Systems compliments the first with its statement that “TIC (trauma-informed care) is fundamentally relational health care, the ability to form and maintain SSNRs (Safe-Secure Nurturing Relationships.)” Both reference The Adverse Childhood Experiences study demonstrating the link between childhood adversity and a wide variety of long-term negative health effects. The Frameworks Institute (that also developed the term “toxic stress”) wrote in a recent report: “Early relational health, although a new term, does not designate a new field nor a series of new discoveries. In fact, early relational health builds upon decades of research from the fields of child development, infant mental health and neurodevelopment that has established the centrality of relationships between caregivers and very young children for future health, development and social-emotional wellbeing.”

When I first began my journey of discovery, one of my greatest guides and mentors was child psychiatrist and psychoanalyst Anna Ornstein. A student and colleague of Heinz Kohut, an American psychoanalyst who placed empathy at the core of healing, she brought this perspective to her work with children and families. Her brilliant paper “Parenting as a function of the adult self” forms the groundwork of all the ideas that followed in my own writing and clinical practice. Thus, this statement from an article in Pediatrics accompanying the two policy statements jumped out at me.

“Discussion can begin by focusing on the caregiver’s and child’s strengths and noting the constructive aspects of the relationship while providing the caregiver with empathy. When attachment is strained, caregivers have often lost empathy for the child. The positive regard and attuned attentive listening provided before and while raising concerns supports the caregiver. The empathy provided to the caregiver thus allows the opportunity for them to reattune to the child.” 

I’m profoundly grateful to continue to work with Dr. Ornstein who, well into her 90’s, has a mind as alert and inquisitive as ever. When I sent her this quote she replied, “Wonderful quote Claudia: parental empathy is the answer when you lose your way.” A book published in 2020 The Anna Ornstein Reader includes the article that so influenced me all those years ago. In it she writes:

“The parent who is capable of parental attunement is one who developed an adult form of empathy-a capacity in which an adult man or woman can immerse him or herself into the inner life of a child without this threatening his or her own sense of separateness and without the parent injecting his or her needs into the interaction with the child. This is a more complex and difficult task than is generally acknowledged.”

This paragraph contains the roots of many core concepts that inform the practice of infant mental health. As a faculty member of the UMass Chan Medical School Fellowship in Early Relational Health I have had the opportunity to learn directly from leading researchers in the field while teaching fellows from a variety of different disciplines from all over the world. My book The Developmental Science of Early Childhood (Norton 2017) represents my effort to bring this knowledge to clinicians who work with parents and children.

I especially appreciate the wisdom of Dr. Ornstein’s statement that “this is a more complex and difficult task than is generally acknowledged,” an observation that applies more broadly to these two AAP policy statements. Contemporary developmental science supports placing early relational health at the core of not only of pediatrics but of all health care. However, this paradigm shift necessitates fundamental reorganization of medical education and reimbursement structures. In the field of infant mental health, the term “reflective supervision” secures a central role for listening to the clinician. In the trauma-informed care model “secondary trauma symptoms (STS)” captures the effect of failure to provide this listening. The Pediatrics article accompanying the new policy statement recognizes this truth. “Acknowledgement that these [STS] are issues and providing resources to address them, with attention to leadership and supervision have been cited as the most important first steps.”

My first book Keeping Your Child in Mind grew from a wish to share this world of knowledge and research that had so fundamentally transformed my practice with my pediatrician colleagues. It concludes with recognition of the parallel process of listening to clinician, parent, and child.

“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… Policymakers, communities, educators, and healthcare professionals all have a role to play. If resources are allocated for care that supports parents in full proportion to their critical role of raising the next generation, then we as a society could be said to be holding all our children in mind.”

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