Three-year-old Bella’s frequent tantrums since the birth of her baby sister Julia brought the family to my behavioral pediatrics practice. Her father Jose began our visit with an explanation. “She’s jealous and is trying to get attention.” He even had a solution. “Maria (their mother) just needs to spend more special time with Bella” and “She needs to set more firm limits.” I felt as if he had read the book; reciting the lessons I’d learned years ago in my developmental and behavioral pediatrics fellowship.
But beneath this typical framing lay a multilayered story of meaning. It emerged after about thirty minutes into an hourlong visit when we all sat together on the floor in a safe space of play and discovery. Jose had come to the United States from El Salvador as a young boy and spoke English well. Maria had joined him more recently and so relied on Jose to be her interpreter. I needed to intentionally pause to be sure that she had heard and understood my questions and responses.
We began the session with a period of observation of three-month-old Julia in Maria’s arms while Bella explored the box of toys. I noticed the delight mother and infant took in each other when Julia, in a quiet alert state, captured Maria’s gaze. I commented on how Maria supported her daughter through fussing to nursing to sleep with a calm confidence.
The first sign of the underlying story came when Bella, losing interest in the new setting, suddenly approached her mother who sat in a chair with the sleeping baby in her arms. I saw Maria’s entire body flinch as she pulled away. She appeared startled, making an abrupt motion with her arms as if she intended hit her child. But Jose quickly intervened, blocking his wife’s movement while taking Bella’s hand and distracting her with a book.
In the few moments of quiet that followed, my mind began to formulate possible new explanations for the presenting problem. Into the silence Maria softly began to weep. When I waited for an explanation, she told a story of violent discipline, typical of her home culture, with which she was raised. This personal violence occurred against a backdrop of community violence which she had sought to escape in coming to America. When Bella’s behavior provoked her, she had learned to adapt by literally leaving the room. The reaction I had observed was her body shifting into a state of fear. Fortunately, as we had established a safe space in the preceding time together, she did not dissociate. She remained present to share her experience.
But I then prematurely shifted into advice mode. All those years of training in the medical model of expert instruction had left their mark on me. Holding in my mind Bessel van der Kolk’s concept that “The Body Keeps Score” and psychiatrist Bruce Perry‘s mantra of “Regulate, Relate Reason” I asked about what kind of movement she enjoyed that could help her body to feel calm. When she said “bailar” I knew from my own Zumba experience she meant dance. I asked if she might be able to turn on music and dance when she felt provoked by her daughter’s behavior. She smiled and nodded.
The situation was saved by Jose who also apparently felt safe enough to shift out of his protective stance of expertise. He opened up about the deeper problem. “I tell her she can’t yell or hit,” he said. “They don’t allow that in this country.” While Jose was a US citizen, Maria was undocumented. The invisible yet real threat of deportation, layered beneath a fear of child protective services. informed every moment. Jose had been raised in the same putative culture as Maria. Seeing Maria lose her temper with their daughter provoked a similar embodied response. But rather than act out in relationship with his children, he yelled at Maria. Filled with shame, he now acknowledged that he on occasion he made the same involuntary raised hand movement to his wife that Maria had shown toward her child. A neighbor had heard a fight between the two of them and called DCF (Department of Children and Families.) While the case had been dropped, their baseline sense of isolation and fear escalated dramatically.
I imagined my former self not learning this story but simply given them instruction about special time and time out. Fortunately, I have had the privilege of being exposed to a body of knowledge and research in psychoanalysis and infant-parent mental health not typically available in pediatrics training. From my studies together with my clinical experience, I’ve distilled two core lessons. First, protect time and space to listen to the story, with attention to the impact of loss both current and in previous generations. Second, approach every situation from a stance of “not-knowing.” My privilege also lies in not being the primary breadwinner in my family. The combined time and financial pressures of primary care practice would never have allowed for such creativity and exploration.
While I am heartened by calls in pediatrics to embrace Early Relational Health (ERH), it’s important to consider that for over 50 years the field has been trying to make this change, with minimal success. Renowned pediatrician Robert Haggerty first used the term The New Morbidity in the 1960’s. He recognized that with the availability of vaccines and treatment for infectious diseases, pediatricians dealt less with life threatening illness and could turn their attention to development, behavior, and social functioning. But little changed in terms of practice or training, as noted in a 1993 article in Pediatrics. Next came The New Morbidity Revisited in 2001 calling for renewed commitment. A 2019 commentary in Pediatrics in Review: Robert Haggerty, the New Morbidities, and the Dissonance between Education and Child Health Needs revealed the ongoing struggle. The specialty of Developmental and Behavioral pediatrics appeared but remains embedded in a medical model of disease with primary focus on treatment of autism and ADHD. All these efforts coincided first with the arrival of managed care, followed by the Resource-Based Relative Value Scales. The pressure on primary care pediatricians to see more and more patients in less and less time steady grew.
The population-based data of the Adverse Childhood Experiences Study offers compelling evidence that disruptions in early caregiving relationships have serious long-term effects on both physical and emotional health. Not an extra, Early Relational Health is at the core of promotion and prevention that characterizes primary care. We need to learn from past failures. Major shifts in both training and pay structure are required. Clinicians coming from a broad range of disciplines with knowledge and experience in ERH need to be on the front lines. If we don’t make this change, voices like those of Maria, Jose, Bella, and Julia will continue to be silenced.
I wonder if our country’s reckoning with centuries of brutal oppression and white supremacy, in the context of a mental health crisis within a global pandemic, will prove to be the motivating forces to make fundamental changes to they way we care for children and caregivers. A powerful new model named “At The Feet of Storytellers” was presented at the Zero To Three annual conference in October. Rooted in investigation of thoughts, observations, and experiences of African American families, the model of “Early Relational Health Conversations” puts time and space for non-judgmental listening at its core. A pilot study of implementation in pediatrics practice showed significant impact, with publication of findings forthcoming. Intentionally not a “screening tool,” it places the clinician literally on the floor, to learn about strengths of the family system and identify vulnerabilities and needs. Such a model insures that rather than listening from the perspective of a dominant narrative, we listen from a stance of curiosity, of “not-knowing,” to stories of children and their caregivers. It gives every voice a chance to be heard, starting from birth.
Nothing brings hope like witnessing connection between caregivers and their newborn infant. If we can harness that energy, we might be able to seize this moment of unprecedented uncertainty to facilitate meaningful change.