Podcast

The most important ingredient for a healthy child is a healthy caregiver. -Nadine Burke Harris, MD, MPH, FAAP

Robert Sege: Welcome to the HOPEful Conversations about Child Development podcast series. I’m Bob Sege, a pediatrician and director of the HOPE National Resource Center at Tufts Medicine.

Baraka Floyd: And I’m Baraka Floyd, a community pediatrician at Stanford and HOPE Facilitator and Champion. The Healthy Outcomes from Positive Experiences, or HOPE framework, emphasizes the Building Blocks that children need to thrive: relationships, environments, engagement, and emotional growth. In this podcast, we interview leaders in child health and development in order to learn more about how to support families in creating positive childhood experiences for their children. You can learn more about Hope by visiting our website, positiveexperience.org.

Sege: On today’s episode, we’re talking to Dr. Nadine Burke Harris. She’s an award winning pediatrician, researcher and public health leader who has spent her career tackling some of the toughest health challenges of our time. As California’s first ever Surgeon General, she helped guide the state through Covid, co-led vaccine allocation efforts, and launched a groundbreaking statewide initiative, training more than 20,000 clinicians to screen for adverse childhood experiences, bringing trauma-informed care into everyday medicine. Her work has always centered on vulnerable communities. After training at Harvard and Stanford, she founded a clinic in San Francisco, Bayview Hunters Point, where she identified childhood adversity as a major driver of poor health and helped develop one of the first clinical ACE screening protocols. She later founded the Center for Youth Wellness, led landmark research on toxic stress, and helped transform how pediatric medicine and society responds to childhood trauma. Dr. Burke Harris is the author of “The Deepest Well”, creator of one of the most watched TED talks of all time on childhood trauma, and a leading voice on the science of resilience and health equity. Her work has shaped national policy, public awareness, and how we care for children now and for the long term. Dr. Burke Harris, welcome to HOPEful Conversations.

Nadine Burke Harris: Hey, thank you so much for having me.

Sege: In your TED Talk, “In the Deepest Well”, you share narratives of patients’ experiences with early childhood trauma and some of the impacts on their bodies. Can you share a story of trauma and resilience that sticks with you today?

Burke Harris: Yeah, absolutely. You know there is a story that I share in “The Deepest Well” which I think is just, like, it’s one of my favorite examples, and it was a patient who had come to see me and she was a 2-year, 9-month old girl who came in for a well-child check, and her parents’ only concern was that she was little, she wasn’t growing very well, and, you know, when I plotted her height and weight and all of that stuff, they were right to be concerned. She was below the third percentile for height, weight, and head circumference. And, in fact, her previous pediatrician had made a diagnosis of failure to thrive and had prescribed PediaSure. Right. Like the number one treatment for failure to thrive, nutritional supplementation. But, it didn’t seem to be working. Her mom said that it didn’t, she still wasn’t growing. And, in my clinic at the time, we did one important thing that helped us get additional information that informed what was going on with the patient, but also our treatment approach. And that was the ACE score. So, it turned out this two-year, nine-month old girl had an ACE score of 7. And, what that told me was that she was at high-risk of having a dysregulated stress response. And, we know that one of the impacts of a dysregulated stress response, biologically, can be on growth. So, for that patient, in addition to usual care, right, we also prescribed child-parent psychotherapy, CPP, an evidence-based intervention. It’s a dyadic intervention, and it’s really about helping to enable parents to actually be able to deliver protective factors and positive childhood experiences. Right. Because we know that every parent wants to give their kids positive childhood experiences. But, the reality is that, for many parents, their own history of adversity can be impacting their ability to create safety in the home, to be able to have those moments. So, in addition to PediaSure, we added CPP, really built capacity for, in this case, the caregiver was the mom to be a buffer to her child’s stress, and her growth rate went from 2.3 cm per year to 7 cm per year. Right. So, when we’re talking about resilience and the body’s ability to get back into that biological balance, like, literally we saw it physiologically in this child who then, you know, we saw it in her growth rate, in her body’s ability to lay down long bone, you know, but, it really was biological resilience which was, it’s one of those things that just makes me so exciting because that is the power of buffering care. Right.

Sege: I love this story because it shows how those positive experiences can help somebody heal. Even though already at that tender age she had suffered adversity, she could heal and grow again. And also it really talks about the multi generational approach. You can’t just take a two-year, nine-month old baby and say get better the parent cycle. Parent-child psychotherapy really works for the parents as well. Can you just make a comment on how the mom did with that? Did was there a change in her personality, her enjoyment of life?

Burke Harris: So, it was really interesting because when I did the ACE screen and initially when I saw that it was a 7, the ACE score was 7. I literally thought mom accidentally put her own ACE score down instead of her child’s. And, when I explained like, oh, you know, let me say we’re asking about these exposures for your child because we understand it can affect her biology. Her mom was like, “Yeah, absolutely. I noticed that when there’s stuff going on in the household, when her dad is upset, that, that really impacts her.” Like, it made intuitive sense to this mom. And, one of the power of this work was when that mom was able to understand the dynamic between violence in the home, like stress and trauma. And, I said to that mom, “The most important ingredient for a healthy child is a healthy caregiver.” And, that mom was able to understand that how she was doing had actually had a profound impact on how her daughter was doing. Over the 18-month treatment period, we saw not only a transformation in mom, right, which is, like, amazing, right? The idea of her own safety. Because, for mom, there was a lot of work that we had to do. Child-parent psychotherapy really helps to explore the parents’ history of adversity and helps them to be able to set boundaries, right? To be able to put in place the structures so that mom could have her own safety. So, that was transformative. But, for this particular family, what we also saw was that dad got insight into his ACEs. So, mom had lots of ACEs and that was part of the process. And, so doing this dyadic intervention helped to support mom in supporting her own safety and well-being. So, we saw a huge transformation in mom. But, interestingly, in this, ultimately for this case, I ended up writing a letter to the court because CPS ended up getting involved. I ended up writing a letter to the court saying, you know, dad’s, what was going on in terms of the violence at home was actually impacting the child’s health. And, the court mandated dad to be able to do trauma therapy for himself. And, that dad, ultimately, was able to say to his child, “I know that because of what I did that that was really harmful and daddy is working on healing.” So, we actually saw whole family transformation in that particular situation.

Floyd: That’s amazing. And I think about just how much you opened access to the positive childhood experience of relationships for that child. Identifying that ACEs score of 7, connecting that child to child-parent psychotherapy, seeing that change in the family, building that strong relationship between the child and her mom, the child and the dad, and then availability of trauma therapies, for adults, really helping to open up healing for dad as well. That, in and of itself, is really kind of all around. And, then thinking about how that probably had a big change in that child’s environment and that Building Block of environment as well. I mean, like, over the moon.

Burke Harris: This is exactly right. And in order to change the environment, this is one of the pieces that was so key to be able to say to kind of everyone in this family system. Right. So for mom, it was because of what your daughter has experienced, her body’s making more stress hormones than it should, and it’s affecting her growth. So, that’s why the safe and stable environment at home is so important. But, that’s not where it ends. The next step is mom, because of what you’ve experienced, your own ACEs that can impact your ability to establish safety in the home. And, so we are going to address your stress response. Right? And then the next step was with dad saying, because dad’s ACEs was the highest. Right. And so he said, dad, because of what you’ve experienced, your stress response is dysregulated. And how does that show up? That shows up in you. Something happens, you feel threat, you respond with this huge surge of stress hormones, and that ends up in violence. You know, your executive functioning goes offline. Right. And so here are tools to help you, dad, when you are feeling that overwhelm and your stress response is getting really activated. And, so for everyone in the household, underpinning our interventions with an understanding of the biology was absolutely critical for, especially for the parents to be able to have empathy for themselves and to be able to understand why environment is so important, why the power of the relational interaction. So, the idea that what was happening in the home was actually arresting this child’s growth, that biological understanding was something that, you know, this mom said she had never heard before.

Sege: Nadine, you mentioned the surge of cortisol, but we’ve talked about this, the other thing that happens when you fall in love or you see a new baby or you have one of these wonderful interactions and is you get a surge of oxytocin. So, what we know is that our brains respond to all of our experiences. And, that’s the beauty of your story, is you started with all the stress stuff, but then all these other things happened. And, seeing the family heal was amazing.

Burke Harris: So, this is exactly right. And this is one of the things that we shared with this family is that when you have, when you have that snuggle, when you have that sweet time, that parent-child interaction, it releases oxytocin, and oxytocin directly inhibits the activation of the biological stress response. And so, that truly is the antidote to trauma, but it has, how do we do that in a way that is supporting families so that is sustainable, so that they get enough of a dose of these supportive relationships, interactions, and environments?

Sege: I think it’s so beautiful that the body is so complicated, that there are, in all of us, mechanisms for healing as well as mechanisms for trauma. And, that listening to these stories is just, it’s wonderful being a doctor because we get to see all these things play out in real time.

Floyd: Yeah, I, one of the things I think that is so important to bring to the forefront is during your tenure as California Surgeon General, you made sure that in screening for adverse childhood experiences, that we didn’t overlook the social determinants of health, including discrimination. And, I think as we’re thinking about addressing adverse childhood experiences in treating and preventing toxic stress, I would love for you to share with my audience why that was important. I mean, I have my thoughts, and obviously it’s clear that I am aligned with the decision that you made.

Burke Harris: Yeah, so, the ACE data, like, when we look at the traditional 10 ACEs, it doesn’t include discrimination. Right. And, but, what it does do, it gives us a powerful understanding, like ACE, we understand when we look at the science is that ACEs dramatically increase the risk of developing a dysregulated stress response. And, we know that that’s associated with changes to brain, immune system, hormonal system, even the way our DNA is read and transcribed. And, biologically, we understand that as the toxic stress response. But, what the science shows is that ACEs are not the only risk factors for the development of the toxic stress response. And, ultimately, the ACEs Aware Initiative was, the whole point of it, was to do early detection of risk of toxic stress and then treating that underlying biology. If we know that discrimination is a risk factor for developing the toxic stress response, we want to identify that and connect individuals and families to services that can help to address that underlying biology. Because, like, ultimately came to this work the way that I even started reading the science of ACEs and all of this other stuff was, the focus of my clinic was around addressing health disparities. Like, I was working in this underserved neighborhood in San Francisco, Bayview, Hunter’s Point, shout out to HP, and what we were seeing over and over again. And, this is why understanding discrimination as a risk factor for toxic stress is so important. Is that not only do we know that experiencing that sense of threat and that absence of buffering can, can lead to dysregulation of the stress response, we also know, and I saw this in clinic over and over again, was that when a person shows symptoms of a dysregulated stress response, poor executive functioning, difficulty with impulse control, right, for certain communities and particular, let’s just say like black and brown communities, they’re much more likely to be met with harsh, harsh punitive responses. So, we have a biological problem that’s viewed through this social lens and the consequence I just saw it over and over again in my patients. Just outsized consequences. And, so being able to respond to, particularly to communities of color and moving from that what’s wrong with you to what happened to you frame and supporting, doing early identification to support kids and families with those evidence-based buffering interventions. That is what it’s all about.

Floyd: So, really telling the truth through the lens of the evidence that we see.

Burke Harris: And also, I think it’s really important, like, I think that early identification and early connection to supports also has the ability to transform outcomes.

Floyd: It does. It can completely change the trajectory. Like, I think all three of us on the call have seen that.

Burke Harris: That is what your work and HOPE is all about. Right? Is that when we do early detection and we are connecting kids and families to support, that literally is…

Floyd: It’s literally what it’s all about.

Burke Harris: What it’s all about. Yeah.

Sege: So, Nadine, I want to add a friendly amendment. I think everyone needs support even before they experience trauma,

Burke Harris: 100%.

Sege: I don’t want to have playgrounds that are set aside for children who need to recover from trauma. Every child needs the opportunity for child centered play. And, I think as a society we can really do this and make people more resilient and help prevent some of the toxic stress that you spent your career working on. And. I know you do a lot of work on prevention, but just to emphasize that positive experiences aren’t just for some people, they’re for all people. And, that’s, it’s really one of the, one of the things. In our next episode, we’re going to talk with you about how we make systems change. So. we’ve heard a lot from you today, about your work with patients and what you’ve learned about ACEs and toxic stress and the healing power of positive experiences, which has been great. So, I hope people tune in next week when we have the next episode and we get to talk with you about how we develop systems that can help us have more resilient children and help us all heal. Thank you so much, Nadine, and looking forward to seeing you next week.

Burke Harris: It’s my joy. Thank you for having me.

Sege: The HOPEful Conversations About Child Development podcast was produced by Kris Markman and Patricia Reyes at the Tufts Clinical and Translational Science Institute. Funding for this podcast was provided by the Freedom Together Foundation. For more information, a transcript, and resources related to today’s HOPEful conversation, please visit us at positiveexperience.org or follow us on LinkedIn.

“What we try to help them understand is that the meaningful unit of relational connection is literally seconds long. It’s not 45 minutes, once a week. You know, you don’t have to give them a psychotherapy session. You just have to see them. You have to be present with them and have a sincere, engaged moment. And, that’s a physiologically powerful thing.” – Bruce Perry, MD, PhD

Robert Sege: Welcome to the HOPEful Conversations about Child Development podcast series. I’m Bob Sege, a pediatrician and director of the HOPE National Resource Center at Tufts Medicine.

Baraka Floyd: And I’m Baraka Floyd, a community pediatrician at Stanford and HOPE Facilitator and Champion. The Healthy Outcomes from Positive Experiences, or HOPE Framework, emphasizes the Building Blocks that children need to thrive: Relationships, environments, engagement, and emotional growth. In this podcast, we interview leaders in child health and development in order to learn more about how to support families in creating positive childhood experiences for their children. You can learn more about HOPE by visiting our website: positiveexperience.org. Bruce, I really want to thank you for coming back for this episode.

Sege: In our first episode, we had a really wonderful and far-ranging conversation about all the factors that influence how children grow up. Of course, adversity, child abuse, all those things are terrible for kids. But, you also mentioned how relational health and rich interaction of relationships can really support children, and, in many cases, counteract some of the difficulties that they face. Now, I’d like to direct the conversation towards practical ideas for providers who are using the HOPE framework in their interactions with children. And, we’re thinking of parents, teachers, human services providers, pediatricians, pretty much everyone, coaches who interacts with kids. So for the next 20 minutes or so, let’s talk, let’s get down and dirty and talk about how those of us who care for children, including children who have some emotional issues, can best use positive experiences and the work we do to help them heal. So, welcome back.

Bruce Perry: My pleasure. Yeah, you know, the practical application of some of these concepts is surprisingly easy. And, you know, one of the things that we spend a lot of time trying to help people appreciate a little bit more deeply is when we talk about how important it is for you to be present for a child or to interact with the child or to value a relationship, and, you’re a teacher, and you’ve got 25 kids in your classroom, it’s terrifying, it’s overwhelming that, oh my God, I’m, you know, being present for 25 kids. How am I supposed to do that and also teach algebra at the same time? What we try to help them understand is that the meaningful unit of relational connection is literally seconds long. It’s not 45 minutes, once a week.

You know, you don’t have to give them a psychotherapy session. You just have to see them. You have to be present with them and have a sincere, engaged moment. And, that’s a physiologically powerful thing. It makes somebody’s stress response quiet down. It makes somebody’s reward neurobiology activate. And, it literally has a whole cascade of positive neuroendocrine effects. And, if you have the gift of a relational milieu where there are a lot of people who will give you these little rewarding and regulating interactions throughout the day, you essentially are in a very rich, developmentally positive environment. And, it’ll be easy to learn, it’ll be easier to interact.

But, we talk about these P’s: present, parallel, patient, and persistent. Those are the qualities that just as an adult making your way through the child’s life, they end up, they determine and control the nature and the intensity of the dyadic interaction. Right. If you’re driving in parallel with your teen and they start talking, and that’ll be way different than if you sit across from the table and say, how was your day at school? They go, “Fine.” “What’d you learn?” “Nothing.” “You learn nothing? I’m going to call the school. Don’t be a jerk .” You know, that’s the interaction with the teen. But, if you’re driving them and in parallel, and there’s this pattern, repetitive, rhythmic, pretty soon they start talking because they feel more regulated. But again, it’s these moments. And, that’s what I think is so powerful and important for folks to feel safe with. It’s okay. You don’t have to be like a super therapist parent all day long. Just be, find a moment, let them know you love them, you see them, you’re present, and you’re around.

Floyd: Bruce, I love that. One of the things I think about, especially for school-aged or young children, is the opportunity that parents have for small things like Reach Out and Read, for example, that we use in pediatric offices and taking those few minutes a day, just to read with their child. Because that allows you to be present, that allows you to have a physical connection. It allows you to do an activity with your child, and it helps their brains develop and grow. And, it just reinforces how important it is not just for us to say it’s important to read, but really how it builds that relational connection. So, you have a good foundation as that child turns into that teen that might not want to talk to you very much.

Sege: And, the other thing, going back to the other providers, we go and give workshops all around the country to people and we talk about HOPE and positive experiences. And, you would not believe, maybe you would, how many times people cite a single teacher or a coach or someone who saw them for who they were. Of all the dozens of people who you interact with when you’re a child, all it really takes is one person to make you feel seen and heard. And, people remember that for decades of their lives, that so-and-so saw me. And, it’s just, it’s a wonderful thing. And, I love what you’re saying about those are the little moments of interaction that really make it, make it.

Perry: Yeah.

Floyd: What that reminds me of is the saying, “You might not remember what someone said to you, but you’ll remember how they made you feel .” And, just how important that relational connection and those four Ps, Bruce, that you brought up, can be.

Perry: Yeah. You know, and I think everybody, if you sort of think back on your life, there are these moments where it’s one person, one coach, one teacher. And, I’m, even when you said that, Bob, I thought, came directly to my mind, one teacher and I had been, you know, no surprise to you, Bob, but I used to sit in the back of the class and goof off all the time. I’ve been in board meetings with Bob. He’s like… Anyway, but he came up to me, and he made me stay after class, and he said, “Listen, you know, you have to stop what you’re doing .” And I said, “Okay.” And he said, “But, you really need to keep writing.” And I was like, “Really?” He said, “You should. Yeah, you’re really good at writing .” And it was like, wow, just that, that one thing motivated my interest and my willingness to keep writing as an undergraduate, into college and then beyond. But, if I hadn’t had that little bit of encouragement, I just don’t think I would have ever even kept it in my head that I should do this or that I should practice, I should keep trying. And, I think that those moments are just powerful.

Floyd: Yeah, it is.

Sege: But, I think that going back to something we’ve talked about is that for all of us and even human services providers, people who have sort of a limited interaction with families, those can be really important. And, I think that all of us as professionals who work with families have heard stories about how people were treated in all the various billion things you have to do for your children. So, I like where this conversation is going.

Perry: Yeah. Yes. I get asked a lot by people that we work with. You know, when we do a lot of teaching about how the brain changes and how important repetitions are and that kind of thing. So, the obvious question comes up. Well, I only see somebody for 15 minutes. You know, how am I supposed to have an impact on their life? That’s where you have to sort of back up and say, listen. The quality of the interaction can have incredibly indelible impact if somebody truly feels that you are respecting them, you’re listening to them, you are seeing them, and it really has much more impact than you tend to appreciate. And, I think all of us, as clinicians, probably have stories where you had a brief interaction with somebody, and then 10 years later you find out it had some impact, and you’re shocked, and it’s like, really?

But, I’ve had so many incredible stories other people have told me about the power of, like a policeman interacting with a six-year-old kid in a domestic violence situation, simply by saying, “Hey, you know, I feel bad for you. Things are going to get better for you. Here’s my lucky coin. I’ve had this .” And he gives him a quarter, right. So, this kid is now a principal of a high school, and he pulls out the quarter and says, “Every time I feel bad about stuff, I pull this quarter out, and it’s my lucky quarter .” I’m like, crazy. And he gave me that as an example of how powerful these moments can be, even though they’re very brief. And, I think that that’s so true about, whether you’re a caseworker or a teacher or you’re supervising kids at lunch, they remember you if you interact with them in this specific way where you truly see them and they can feel your compassion.

Floyd: I really appreciate you highlighting a police officer example because it just highlights the fact that each and every one of us can have a positive impact on the children around us, simply by being present. And I think we don’t say that enough. I think for our local communities in general, just thinking about all of the different types of people that can interact with a child in the course of their day or in the course of their life. And, thinking about it in that way makes it easier, I think, for people to get past the activation energy of, well, “How do I help? How do I contribute,” just simply being present.

Sege: Can you give some ideas of exercises that people can do when they’re beginning to feel burnt out or they’re doing their job, and it doesn’t bring them joy, how they can help do that little mental switch? Because, the most important thing that we’re talking about is a change between the ears of the people who interact with children.

Perry: You know, part of what has helped us when we interact with folks that do this hard work… And, it really is hard work. You know, you get beat up by the system. You have all kinds of regulatory impediments. You are forced to do things that you know are not the best way to do. And the truth is, almost all of our systems are set up to induce moral injury in the people that do the frontline work. And what we try to encourage the people we work with to do is to think about the bubble around the areas that you can control. That, even though all around you, it can be sort of this mess, you can create a bubble of effectiveness and of positive concern. And that’s a big part of your job, to recognize where that barrier is. So, if you keep complaining about the change and suit, you’ve got a new leader, and he has these ideas and blah, blah, blah in your system, you can’t change that. So don’t, you know, you can mention it, and it can bother you, but don’t let it dissolve the barrier. Spend your energy maintaining this bubble of effectiveness. And within that, you have agency.

You make a change. Even if you see somebody for 10 minutes, in those 10 minutes, you can interact in a way that will make their life better. And they’re going to take that out of your interaction and they will pass that on. That’s just the nature of the neurobiology of social contagion. And so, we keep reminding people that they’re much more effective than they think they are. And help them understand, listen, you’re obviously not going to be effective to change your new boss. You can’t change him. He is the way he is. But, you do control what happens when somebody comes in, sits in front of you. And that’s actually a much more important area of impact anyway because they’re going to leave this organization, they’re going to go out in the neighborhood, interact with their kids, and their kids are going to act with other kids, and you literally are going to create this billiards game of positive energy, and it’s going to make a difference in the world.

And, I think one of the biggest things about burnout and moral injury is when you feel like you have no impact, you know, that sense of helplessness, you can shift that. I mean, if people recognize you’re not helpless, you are an agent, you’re an effective agent of change. You may not see all of it, but it’s going to happen. So, that’s a big part of what we do. It’s kind of psycho-educational. We try to give people little mental exercises to kind of go, all right, what are you upset about? What’s important to you? Can you change that? All right, put that in that bucket. And then, you go, can you influence some stuff? Maybe. How do you do that? You can write a letter. Okay, write a letter. But, what can you control? And so there are these three different circles, if you will: one is where you have no impact. The other one is sort of you have influence. And the inner one is you; you have control there. And when you have a sense of efficacy, it really does help.

Floyd: Sorry, go ahead, Bob.

Sege: Bruce, I love what you just said. And, also when we think about relationships, they’re not one way. And, I find myself when I’m in practice and I start asking these questions, it brings a joy to me because I can see what parents have put in, what their strengths are, all the good stuff, as well as my checklist of problems. And, I end up admiring people and feeling better at the end of the day because I think the thing we forget about relationships is we’re not just doling out relationships like we dole out penicillin. We’re entering into a relationship and it can bring some of the joy back.

Perry: Exactly. Yeah. That’s so true. I just think the most important thing that people need to hear is that what you all are doing about centering positive relationships and the power of connectedness and being in connection, that’s central to the problem-solving process. For every field that we have right now, all the things that we’re trying to deal with, whether it’s mental health, child welfare, juvenile justice, whatever system you’re in, whatever activity you do, if you don’t center the positive relational stuff we’ve been talking about, you’re going to be frustrated by your problem-solving process. It just, you will tinker around the edges, but if you don’t center this stuff, it won’t lead to big change.

Sege: Thank you so much.

Floyd: So, thank you again for spending time with us today. I want to make sure that we recap the high points for our listeners. So last week, you told us about how children’s brains respond to positive and negative experiences and experiences of all kinds. One of the things that you highlighted was despite the fact that we have all of these ways of virtual connection, the in-person connections and relationship building is so very important for children because it activates different parts of the brain, and that repetitive interaction is very important. And, building community is important to build engagement for relational interaction, and also to help take some of the load off from parents so that they’re not having to do everything because we’re meant really to live in community.

The other thing you highlighted that I thought was really interesting was the power of proximity, and how when we place people in the same place, it really allows for social contagion to happen by building relationships. And then finally, I just want to highlight you talked about these four P’s: being present, being in parallel, being patient, and being persistent, and how that allows for you to tap in with a child for a short period of time. And, that practical application of supporting the relational health of a child is actually easier than we think. And, I really appreciate that because so often for me, especially as a pediatrician and talking with families, they’re often like, “But, I don’t have time .” And, so I think that’s one of the things I really want to speak into my practice.

And, then the last thing I want to highlight is thinking about burnout from the perspective of the bubble of effectiveness and positive concern, and how when we think about the things that we actually can control and leaning into the positive experiences, positive interactions is really the way that we make change. And, that’s why we all started this work in the first place. So, thank you so much for taking the time to be with us today.

Perry: My pleasure. Thanks for having me.

Sege: The HOPEful Conversations about Child Development podcast was produced by Kris Markman and Patricia Reyes at the Tufts Clinical and Translational Science Institute. Funding for this podcast was provided by the Freedom Together Foundation. For more information, transcript, and resources related to today’s HOPEful conversation, please visit us at positiveexperience.org or follow us on LinkedIn.

“As we looked at this in a really systematic way, one of the things that we found that’s very powerful, and I think not well appreciated, was that the history of relational connectedness was a better predictor of current function than their history of adversity.” -Bruce Perry, MD, PhD

Robert Sege: Welcome to the HOPEful Conversations about Child Development podcast series. I’m Bob Sege, a pediatrician and director of the HOPE National Resource Center at Tufts Medicine.

Baraka Floyd: And I’m Baraka Floyd, a community pediatrician at Stanford and HOPE Facilitator and Champion. The Healthy Outcomes from Positive Experiences, or HOPE Framework, emphasizes the Building Blocks that children need to thrive: Relationships, environments, engagement, and emotional growth. In this podcast, we interview leaders in child health and development in order to learn more about how to support families in creating positive childhood experiences for their children. You can learn more about HOPE by visiting our website: positiveexperience.org.

Sege: To kick off our HOPEful Conversations podcast series, it is my pleasure to introduce our guest, the renowned psychiatrist Dr. Bruce Perry. His bestselling books about trauma and its effects on children introduced the concept of a neural developmental approach to understanding the effects of childhood trauma. His book, “The Boy who Was Raised as a Dog and Other Stories From a Child Psychiatrist Notebook” has become a classic. In 2021, he co-authored a bestseller with Oprah Winfrey called, “What Happened to you: Conversations on Trauma, Resilience and Healing.” Bruce’s work has introduced millions of people to the lifelong effects of childhood trauma and ways to help children recover. Bruce and I met when we were both on the board of Prevent Child Abuse America. We’ve had many opportunities to discuss the effects of childhood experience on lifelong health. Last summer, we had a chat about how best to incorporate an understanding of positive childhood experiences to complement our understanding of the effects of adversity. Bruce offered the terrific advice that HOPE create a podcast series built around conversations that dive into our understanding of how children’s brains and psychological health respond to their experiences. Not only did I take Bruce up on his advice, but he was gracious enough to agree to be our guest on today’s episode. Bruce, you’ve written books that describe how adult mental health is affected by childhood trauma. The HOPE National Resource Center focuses on the four kinds of experiences that children need to thrive: Relationships, environment, engagement, and emotional growth. I wonder if you can tell us a story about a child whose positive experiences help them with recovery from trauma.

Bruce Perry: Thanks, Bob and Baraka. It’s nice to be here. I appreciate the opportunity for having a little bit of a conversation about this. Yeah, it’s interesting. The only reason I’ve been able to kind of stay in this field without burning out is that I have so many wonderful stories about how children have come through terrible times with the help of other people and the attention and the care and the love of a parent, a coach, a grandparent. I think as a lot of people in medicine, when we first start studying anything, we kind of focus on the bad stuff. We focus on pathology. And so, when I started looking at the impact of experience on development, we were looking at the impact of bad experiences, negative experiences. One, for example, had really very little easily identifiable trauma in their history, but they had lots of problems with attention and relationship into maintaining healthy relationships and all of the kind of classic things that you’d expect from developmental trauma. And then, there would be another child who had really incredibly terrible adversity, physical abuse, abandonment, neglect, multiple repetitive physical assaults. And that child would be doing better than the other child.

And I was like, what in the hell is going on here? Because it doesn’t make sense if you’re trying to sort of create this linear causality relationship between adverse experiences and outcomes. And quickly, what I started to do—and I would recommend anybody to do this—is I started to listen and learn about the history of the child. What’s their story? Where’d you come from? How did this happen? And in the case of the child who had terrible adversity but was doing pretty well, he was doing well in school, he was better at forming relationships. He struggled, but it was nowhere near as much as this other child that I was working with. And what happened was, even though he had one parent who beat the hell out of him, who humiliated and did terrible things to him, he had another parent who was attentive, who was supportive, who was protective as much as she could be. And he also benefited from a tremendous community of connection in his neighborhood and in his classmates and in his after-school sports teams.

And it was at that point I realized that these relationships have protective effects. They’re able to help buffer these terrible adversities and provide opportunities for healing. And from that point forward, rather than just simply measuring ACEs, or adversity, and then looking at mental health functioning or whatever we’re looking at, we started to look at the presence of positive experiences, predominantly relationally mediated positive experience, connection to family, to community, to culture, and looked at how they counterbalanced all these adversities. And, as we looked at this in a really systematic way, one of the things that we found that’s very powerful, and I think not well appreciated, was that the history of relational connectedness was a better predictor of current function than their history of adversity. And certainly now if you kind of just scan through social media and the literature, people are focusing a ton on ACEs and adversity, and not as much on this other part of the scale. And I think that that needs to be changed. And that’s one of the reasons I think the work you guys are doing is so important.

Floyd: Thanks so much, Bruce. So what I heard in the story that you just shared is really that this attentive supportive parent of our relationship building block and then having an after-school program, community, supportive school community, really helped kind of counterbalance and help this child recover from the trauma that they were experiencing in their home. Bruce, I’m curious what happens when children miss opportunities for positive childhood experiences, because I’m hearing that they’re really important in helping promote recovery and long-term health.

Perry: Yep. You know, that’s actually an area that we’re very focused on and concerned about. And it’s essentially we kind of refer to it as relational poverty. That we’re seeing in the last 40 years, a tremendous shift in the relational opportunities that all children are having. There’s more screen time, there’s more dilution of the ratio between teacher and student, there’s a lot more transience in neighborhoods. And again, one of the dilemmas we’re struggling with is that more and more people are having experiences of social isolation, loneliness. They’re not connected to a community of faith, they’re not connected to culture, they’re not connected to their extended family.

And what we’ve found, and this we’ve looked at over 200,000 individuals now: When you look at a person’s developmental history and you find people that don’t have that much adversity, you know, it’s not a whole bunch of bad stuff developmentally. But if they have relational poverty growing up, their risk for all of these bad outcomes are the same as if they had a tremendous number of adversities. So, what we’re finding is that if you don’t have relational connectedness, you are at tremendous risk for social problems, mental health issues, and I think physical health problems as well. And I think this, again, this is something that the World Health Organization has identified as a key issue. It’s something that our previous Surgeon General wrote a whole book about—about loneliness. And it’s something that we have to figure out because our modern world, we have all these new remarkable things, the technologies we have and ways to kind of create new exciting communities and ways to do transportation and ways to do work virtually.

What we haven’t figured out really is, and or really yet solved the problem around, is that a lot of these things actually are exacerbating that relational poverty. And I think that the first step towards solving that is actually being much more aware of it. And again, I think that’s one of the things that you guys are doing that’s so important, is when you point out how important after-school programs are, all of these positive things, you know, positive childhood experiences, almost all of them can be connected to relational connectedness in some way. And I think that that’s something that once we sort are more aware of it, you know, human beings are good problem solvers, but I think right now not enough people are as appreciative of this as they should be.

Floyd: Bruce, it’s so interesting that you are talking about relational poverty in a space where people feel that they’re so connected because of technology, allowing them to connect to others from different areas, different cultures, and different identities. And I think it’s fascinating that though we have all of this technology to connect us, it’s really, it sounds like that interpersonal in-person connection is really what’s missing.

Perry: What I will say about that, is that I actually love these new technologies in many ways. I mean, we’re able to do things that are pretty cool. You know, we’ll have a kid in isolated parts of northern Canada who we can problem solve with a pediatrician in New Orleans and a child psychiatrist in Texas, and we can get an occupational therapist from Arizona, and they can all problem solve and help this child. But, what we do know about these virtual communication things is different parts of the brain are activated, and are involved in Zoom interactions compared to in-person interactions. And particularly for a developing child, the parts of our brain involved in reading and responding to other people, the parts of our brain involved in forming and maintaining healthy empathic relationships requires repetition with real experiences with real people, with real conflict, with real solution. Kids playing a spontaneous pickup game, making their own rules and compromising about what, you know, you’re a lot bigger than me. So when you hit that far, that’s a ground rule double. But when I hit it that far, it’s a home run, right? That kind of interpersonal negotiation you can’t do as easily virtually. And I think you can’t get the same neurobiological impact.

Sege: Bruce, I love what you’re saying. And just to have a comment first, I love the concept of relational poverty because, in my work, I’ve had the privilege of taking care of patients who are wealthier than me and patients who don’t have two nickels to rub together. And I think relational poverty is different than material poverty. And it’s really important to think about that because I think all across society and the factors that you mentioned really contribute to that. Because I just want to add, because you know me, I do public health stuff and I’m kind of a nerd. Just two studies that I really loved, the Chicago Neighborhood Study, showed that they had these people, they had research assistants looking at city squares and playgrounds and watching what happened. And the children did better in communities where people who were not blood relatives of them yelled at them when they misbehaved. I thought that was like such a classic thing. And another work, Judy Langford and her colleagues at the Center for Study of Social Policy were trying to identify markers for high-quality childcare. And you know that there are all these things you can look at and checklists. What they ended up finding is that they opened a closet door and there were full-size chairs so adults could come and participate in some way. That was a marker. There were enough adult participation they had to buy folding chairs. That was a good thing. And I love those little markers because that’s all about the interrelationship, what you call the relational richness that goes on and supports kids. And they’re not things that you can actually—they just happen organically in those environments.

Floyd: Bob, the other thing that makes me think about, is the fact that when we look at it that way, it really gives people an opportunity to engage in a way that’s organic, like you’re saying. Right. And it doesn’t feel so heavy when we’re asking people to solve a problem for a family or solve a problem for a child. That feels like a big ask, but when it’s really being a part of a community, building a relationship with the child and simply saying, “No, please don’t run in the street. I don’t want you to get hit by a car,” that’s different. Like, that’s just being part of a community. And I think it gives an opportunity for everyone to contribute to the relational richness for each child and for the children in that space.

Perry: Yeah. You know, we use a term called the power of proximity. And really what that is referring to is that if you just put people in the same space, there will be this natural process that begins to evolve that is ultimately good for everybody. And some of my favorite examples have to do with co-housing or just putting in proximity a retirement population with an early childhood population. And when those are co-housed, all kinds of relational things start to happen that are good for the children and good for the retired population as well. And I think that that’s one of the reasons that, you know, somewhat counterintuitive way, I think that things like urban planning are some of the most important things that you can do when you’re thinking about population health.

And again, a study, you know, being a nerd, one of my favorite studies about that is this study about the housing projects in Chicago. There were three big Cabrini Green, these big 20-story towers. And one of the things that they did is they went into one of the projects and created a little garden and a playground and put some benches up for people to sit on. And in that tower alone, not other towers, the violence and violent crime plummeted by 30% and stayed that way. And they tried—like again they tried to figure this out. And a lot of it was basically it was the power of proximity. People got to know each other, people got to see each other’s faces, people were greeting each other, people were nodding to each other. And there’s this tremendous power, there’s this neurobiological pull to belong and to be connected. And it really has physiological consequences that are important. And I really think that again as we think as all the different folks trying to solve these problems, I really do think that what you guys are talking about in terms of recognizing how important positive experiences are and how do you create, how do you increase the probability that there will be a positive experience? Well, the power of proximity is part of that. We have to put people together.

Sege: Yeah. Bruce, I love the story you just told about Cabrini Green. And I think that when we talk about HOPE, one of our Building Blocks is environment. So children have places to live, learn and play. And you described a really simple environmental change in one part of Cabrini Green that led to this richness of interaction. And I think as we go around the country and speak with so many people who are working, that sort of solution is really inspiring because that’s not a multi-billion dollar thing that has to be allocated by the President and Congress. That’s a tweak that can be done because people love their children and as you said, when we interact with each other and we end up developing affiliations, those little things really matter. And I just want to thank you and thank you for this session on your work. I want to invite our listeners to stay tuned. We’re going to have another session also with Dr. Bruce Perry and Dr. Baraka Floyd and myself. And we’re going to move to practical advice for people who care for children and their families. And Bruce, thank you again for this first installment of our conversations with you.

Perry: Pleasure.

Sege: The HOPEful Conversations about Child Development podcast was produced by Kris Markman and Patricia Reyes at the Tufts Clinical and Translational Science Institute. Funding for this podcast was provided by the Freedom Together Foundation. For more information, a transcript and resources related to today’s HOPEful conversation, please visit us at positiveexperience.org or follow us on LinkedIn.