It's not a "band-aid" treatment: Relationship-based therapy grows the brain in a sustainable way!
I often find myself wishing I could offer a quick fix, and I understand why people come to me looking for a quick fix. When we are in pain, whether emotional or physical or when we are at the end of our rope, we are hard-wired to seek immediate relief. However, though it may offer some immediate relief or change, Relationship-based therapy is a longer-term, bottom up (addresses “holes” in development and works to heal those) approach. It’s a long haul, because we are rewiring neural connections rather than simply attempting to apply one-size-fits all strategies to fix a behavior in the short term.
You want relief! Whether it’s relief from constant fights, meltdowns, and tantrums that seem to bring out the worst in you, or whether it’s relief from your own inner turmoil or struggle in relationships. But sometimes relief takes time, especially if pain is due to deeply intrenched and habitual patterns in relationship or even in developmental differences like ADHD, Autism, or another diagnosis that impacts every part of the way you experience the world.
Today I want to talk more about the value of relationship and of relationship-based therapies to grow your child’s brain and work towards those outcomes that you and your school, family members, and even society, value in children. I’m going to start with the term executive function.
Impulse Control, Planning Ahead, and All the Skills are Built in the Brain!
Executive Function is defined as the neurological capacity for impulse control, working memory, and mental flexibility. Who doesn’t want those capacities? They are vital in surviving in our western culture today! Executive function capacities are related to ability to follow directions, attend to a task, talk about past events, think and plan ahead, and control behavior depending on context.
Infants do not come into the world with a fully developed executive function system—genetics and environment determine how this system grows. Shonkoff (2011) writes that our genes provide the blueprint for cognitive abilities, but “early environments in which children live leave a lasting signature on those genes.” In other words, it’s a combo--there’s a genetic component, bio parents pass on capacities to their children genetically, but relationships, living situations, and culture also play a huge role in shaping executive function.
Predictors of executive function capacities include relationships, activities, environment, adverse experiences, and policies and programs (Center on the Developing Child, 2011). Zero to Three (2009) reports that early experiences directly predict how well we think, communicate, and problem solve—how well a person does in high school is related to academic skills in kindergarten, which are related to cognitive abilities in the preschool years.
Adverse Experiences in Childhood Impact Brain Growth
There is extensive research on how Adverse Childhood Experiences negatively affect not only the immune system but also cognitive structures in the brain (Carrion & Wong, 2012; Carrion, Weems & Reiss, 2007). Toxic Stress, developmental trauma, and prenatal trauma as well as genetic differences cause deficits in executive function skills (Felitti, et al. 1998; Maughan, A. & Cicchetti, D., 2002; Sanchez, Ladd & Plotsky, 2001 ).
Given this, the concept of “scaffolding” executive function is extremely relevant in both preventative care but also in responsive care for vulnerable infants and families. Experts in child development and child therapy can help parents create a scaffold to help children grow through adversity. The Center on the Developing Child provides a host of resources for facilitating executive function as well as a list of areas of focus for early intervention providers.
The body of research around toxic stress and ACES is rapidly growing and is becoming mainstream in early childhood education, yet many early childhood practitioners have yet to integrate research on this topic into practical interventions and treatment plans. There is a need in the Infant Mental Health and Play Therapy fields to integrate current neurodevelopmental research on executive function into work with children and families (Zero to Three, 2009).
As a professional integrating work from both of these fields into my practice, I want to learn what specific early infancy and childhood experiences foster development of executive function skills? My current opinion is that a big theme within genetics, environment, activities, policies, and programs is the child’s experiences of safety and attunement.
The caregiver-child relationship and early experiences in particular change the executive function system in the brain! And early childhood practitioners like myself can use relationship to successfully scaffold growth of the executive system in children 0-3 who experience disabilities, early childhood adversity, or toxic stress.
As a relationship-focused therapist I’m biased to argue that relationship, attunement and co-regulation can be intentionally used to decrease likelihood of behavioral and academic struggles in later childhood and adulthood.
In my experience, educators and behavioral health staff as well as mental health clinicians often view problems from the top down—seeing behavior as the problem rather than seeing behavior as communication of underlying differences or needs. Zeanah & Zeanah (2005) write that since early childhood caregiving relationships affect child’s cognitive abilities, preventative care across the continuum of ITMH services are to enhance the ability of caregivers to nurture children more effectively.
The neurobiology research (skip this section if you don’t love brain science!)
Attunement and connection in healthy attachment relationships actually jumpstart executive function capacities (Zero to Three; Zeanah & Zeanah, 2005; Feldman, 2007). Brain areas implicated in executive system include the prefrontal cortex, anterior cingulate, parietal cortex, and hippocampus. How a child responds to perceived stress and threat influences these networks, and vice versa. If a child has well-developed capabilities in these areas, they can better manage stress (Rueda, Posner & Rothbard, 2005; Blair, Zelazo & Greenburg, 2005). Well-developed regulation capacities and stress response recovery are linked directly the experiences of synchrony (also called mutual co-regulation or affect regulation) in parent-infant interactions (Feldman, 2007). In particular, mutual gaze, response-time, and nurturing touch of caregiver are aspects of a synchronous experience.
What is Synchrony and why is it so magical when it comes to building the brain?
Synchrony is that lovely, feel-good experience when two people really connect and “get” each other. They are vibing each other’s vibes! Have you ever had this moment with a baby when you two are just cooing back and forth to each other and just joyfully connecting, really “feeling it?” That’s Synchrony!
Amount and frequency of Synchrony between parent and infant actually predicts regulatory and cognitive outcomes in children ages 3-5. Feldman (2007) cites Landry’s (1995) study of full-term and preterm infants and their mothers, which indicates that “the mother’s social and non-social stimuli provides an important foundation for the development of attention, cognition and executive function in infancy and childhood” (p.342). Feldman’s review of the literature focuses on the regulatory function of synchrony in the parent-infant dyad, and acknowledges that risk factors such as feeding difficulties, biological differences, maternal depression, being a triplet, or being a sibling of an autistic child all correlate with decreased synchrony between parent and infant, which in turn correlates with decreased regulatory capacities at age 3.
Feldman’s (2007) research shows that when parents are physically close to and interact with their infants, it serves a co-regulatory function which integrates the neurobiological, sensory, perceptual, emotional, physical, and relational systems.
Rhythmic, face-to-face play, contingency in closeness, and nurturing touch facilitates development of self-regulation, which in turn provides a system better adapted to handling novelty and stress, thus enriching executive function!
My child has experienced adversity, or I’m suffering from a mood disorder--how do I nurture synchrony to build my child’s brain!?
After reviewing the literature I believe that a combination of targeted interventions aimed at increasing caregiver-child synchronous experiences alongside providing parents with education on how to scaffold existing executive function structures will best increase executive function abilities in toddlers and school-age children. In tandem with education around reading infant cues, and providing affect regulation, Shonkoff (2011) provides a basic list of tools for supporting executive function—first, there are specific training programs targeted to facilitate grow in regions of the brain such as the prefrontal cortex. However they are not targeted for early childhood. Shonkoff also writes that preschool interventions are in place to help target this growth, these interventions focus mostly on training teachers to facilitate prosocial behavior, organization and planning. However, Shonkoff hedges that little is known about how these programs produce benefits, and this author argues that these programs lack in highlighting the importance of relationship and education around mutual co-regulation and individual differences. We need more programs and therapies that integrate this for very young children.
Co-regulation proceeds self-regulation and without regulatory tools, an individual cannot engage the executive system. A child with pervasive regulatory differences (such as Autism Spectrum Disorder, ADHD, history of developmental trauma,) requires additional regulatory support to scaffold executive function.
Play and movement help develop executive function
Social play facilitates development of executive function skills.
First, it increases the capacity for attention and motivation. Feldman writes that the repetitive nature of early social play allows mothers and infants to facilitate information intake by maintaining the infant’s attention, then as attention decreases, the parent can “introduce novel stimuli and facilitate cognitive development, mastery motivation and information processing skills” (2007, p. 333).
Second, play allows children a place to test hypotheses themselves, from a “bottom up” experience rather than having a grown up teach verbally life lessons (Badenoch, 2008).
Play also allows infants and children to work through complex social interactions. For example children will often negotiate who gets to be the superhero or the princess, or who gets to be the mother or baby in a pretend play sequence.
Children who struggle with regulation are often unable to attend to these complex interactions and may get pushed out of the play, and often resort to acting out to communicate their frustration (Shonkoff, 2011).
Children with special needs or neurodevelopmental differences may struggle in particular in play, which impacts social and cognitive skills and academic success. In addition, temperament may also affect social play and executive function (Rothebart & Rueda, 2005).
How I integrate the research into my work with infants, toddlers and their families
With an understanding of synchrony, relationship-based play, and routine, elements that nurture executive functioning, I can identify specific interventions to implement in the mental health setting. When working with a child with executive function challenges, the mental health clinician can “start from the bottom up” by using the therapeutic relationship or parent child relationship to provide a synchronous experience, through mutual gaze, vocal tone, or touch/movement. I also work to identify individual differences and specific regulatory needs (e.g. movement, auditory stimulation, deep pressure).
In one-on-one Play Therapy with children, I am also tracking the therapist-child dyad and parent-child relationship and to learn about your child’s capacity for self-regulation and executive function.
When working with children with neurodevelopmental differences or early childhood trauma, it is essential to take a developmental, relationship-based approach, and to use play to facilitate problem-solving and organizational and social skills. Finally, this topic is relevant for dyadic or family therapy in that the clinician can assist families to identify individual differences or areas of adversity, and to become more attuned to themselves and to the infant or child.
What this looks like in therapy and how it builds stronger brains
A mental health clinician can focus on staying connected with a parent, infant or toddlers through play or through empathic listening as a way to access executive function skills. If I, the clinician can create a regulating experience of being in a safe, attuned relationship, then both caregivers and infants will have more access to areas of the brain that promote planning, organizing, and multi-tasking.
Once a relationship is in place, executive function can be scaffolded through providing a predictable routine, engaging multiple sensory systems (visual—e.g. PECS or using movement pointing to an item, rhythm or song). The clinician can model pausing to stop, look listen, to think about outcomes, or to tell a story about something that happened in the past. By instituting these steps along with a relationship-based approach and an understanding of the power of attunement and co-regulation, clinicians can begin the work of nurturing executive function capacities.
Badenoch, B. (2008). Being a brain-wise therapist: A practical guide to interpersonal neurobiology. New York, NY: Norton & Company.
Blair, C., Zelazo, P., & Greenberg, M. (2005). The measurement of executive function in early childhood. Developmental Neuropsychology, 28(2), 561-571.
Carrion, V.G. & Wong, S. S. (2012). Can traumatic stress alter the brain? Understanding the implications of early trauma on brain development and learning. Journal of Adolescent Health, 51, 523-528.
Carrion, V.G., Weems, C.F., Reiss, A.L. (2007). Stress predicts brain changes in children: A pilot study longitudinal study on youth stress, post-traumatic stress disorder and the hippocampus. Pediatrics, 119 (3), 509-516.
Center on the Developing Child (2012). Executive Function (InBrief). Retrieved from www.developingchild.harvard.edu.
Early Experiences Matter. (2009). A Guide to Improved Policies for Infants and Toddlers. Zero to Three.
Feldman, R. (2007). Parent–infant synchrony and the construction of shared timing; physiological precursors, developmental outcomes, and risk conditions. Journal of Child Psychology and Psychiatry, 48(3‐4), 329-354.
Feldman, R. (2009). The Development of Regulatory Functions From Birth to 5 Years: Insights From Premature Infants. Child Development, 80(2), 544-561.
Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14 (4), 245-258.
Mincemoyer, C. (2016) Executive function: What’s play got to do with it? The Pennsylvania State University.
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Sanchez, M., Ladd, C., & Plotsky, P., 2001. Early Adverse Experience as a developmental risk factor for later psychopathology: Evidence from rodent and primate models. Development and Psychopathology, 419-49.
Zeanah, P, Stafford B, Zeanah, C. Clinical Interventions to Enhance Infant Mental Health: A Selective Review. National Center for Infant and Early Childhood Health Policy at UCLA; 2005.