A Relational and Developmental Neurogenomics Approach To Working With Youth and Their Families
The Parent-Child Neuropsychotherapy Protocol™ (the protocol) (Dahlitz & Hill, 2019a, 2019b) provides a framework to address the complex challenges of working with the entire family when a child is exhibiting emotional and behavioral difficulties by encouraging parents to focus on the neurodevelopmental dynamics (i.e., dysregulation of the stress response system) that the child continues to communicate through the challenges, symptoms and behaviors that are causing relational disruptions rather than trying to eliminate the negative behavior.
The protocol is supported by relational and developmental neurogenomics theory & research (e.g., Lavigne et al., 2013; Cicchetti & Rogosch, 2012; Belsky et al., 2009; Hartman & Belsky, 2016; Belsky & Hartman, 2014; Bakermans & van IJzendoorn, 2007; Belsky, 2015; Rutter, Moffitt, & Caspi, 2006; Belsky & Pluess, 2009). The objective of this treatment is to support the development of therapeutic brain-based parenting interventions by providing short-term coaching techniques while encouraging parents to examine how their personal history might be affecting their ability to provide the support and care that their child needs (Siegel & Hartzell, 2003) while “operationalizing empirical research and clinical practice to support the development of fulfillment and purpose” (Veliz, 2019b, para.1).
The protocol was designed with the assumption that in order for the parent to be able to help the child self-regulate, parents need to be able to self-regulate on their own. Only then would parents be in a position to lend their well-developed and regulated prefrontal cortex to the child (Siegel, 2012; Siegel & Payne Bryson, 2011) in order to help the child co-regulate. The child can only learn to self-regulate in a healthy way after he has been co-regulated by a self-regulated adult caregiver. Eventually, as children become adolescents, they need less co-regulation from the parent as neural connections between the limbic system and the prefrontal cortex develop and strengthen resulting in the transfer of the self-regulatory executive control from the amygdala to the ventromedial prefrontal cortex (VMPFC) (Baylin & Hughes, 2016).
The Child’s Symptoms Communicate What the Child Might Not Have
While child and family therapists are aware that the dynamics that result in children’s challenges usually reside within the family system, in many cases the “one-person psychology” (Schore, 2002, p. 436) based traditional model of psychotherapy gets in the way of providing the most efficacious treatment for the child and the entire family. The protocol interprets negative behavior as the child’s way of communicating that something is not right and requires attention from the caregiver, as the child is unable to express his discomfort through language. Thus, the child’s tantrum is not a behavior to be judged and treated with a consequence, but rather a symptom to be understood and “joined with” by providing “attention and presence” (Tatkin, 2017, p. 29). Unlike the traditional medical model that drives psychiatry and psychotherapy treatment approaches, the protocol does not directly attempt to treat what the child has (e.g., the symptom), but rather what the child might not have (e.g., security, an upgraded and cohesive narrative of his life, the ability to self-regulate). Thus, the protocol is a “capacity model” (Tatkin, 2017, p. 24) since instead of trying to fix negative behaviors, it focuses on helping dyads to create safe and secure interactions as described in Stan Tatkin’s Psychobiological Approach to Couples Therapy (Tatkin, 2017). In the case of a parent and child, the process of co-regulation is led by the parent in order for mutual regulation, and eventual self-regulation to occur.
Thus, whether the child is engaging in self-harm behaviors, having suicidal thoughts, using substances, or exhibiting anger, anxiety, compulsiveness, hyperactivity, hypersexuality or sadness; the protocol interprets the message from the child as being the same: “There is something wrong with me, and I don’t know how to fix it. I need help! Can you help me? Do you believe in me? Can you please tell me that I am not ‘bad’ even though I feel ‘bad’? Because if you don’t believe in me, I don’t think I can believe in myself either. But please, don’t criticize me, and don’t lecture me. I’ll shut down if you do because I will be overwhelmed by shame!”
My work with youth and their families has taught me that children suffer not so much because of the event or symptoms that motivated their parents to bring them to therapy (e.g., divorce, drug use, failing grades, oppositionality), but because they feel criticized and misunderstood by important caregivers in their lives (e.g., parents, baby sitters, educators, coaches, therapists) at sensitive stages in their development when in many cases the child can’t understand himself. In addition, I have learned that parents are following in good-faith traditional cultural parenting guidance that unfortunately emphasizes behavior management at the expense of the development of emotional intimacy (Berger, 2006).
Research Findings Support the Efficacy of Parent Therapy Approaches
New psychotherapy research such as a study published in March 2019 by Yale University researchers (Lebowitz et al., 2019) is starting to highlight the benefits of working with parents as compared to of traditional psychotherapy with the child. The study compared the efficacy of SPACE, an intervention provided exclusively to parents, with that of cognitive behavioral therapy (CBT) provided to children. Not only did the parents in the SPACE intervention group reported a better relationship with their children as compared to that reported by the parents of the children treated with CBT, the first author of the study stated that “regardless of what measure we used to look at the outcomes, children whose parents received SPACE were as improved and as likely to be cured from their anxiety problems as children who had 12 sessions of some of the best CBT therapy available” (Kristofferson, 2019, para. 6).
Part 1 of this article will present developmental and evolutionary artifacts that guide the design and execution of the protocol and background on relational and developmental neurogenomics theory and research, followed by the protocol’s treatment goals, stages, and elements. Part 2 will delve into the curative dynamics including detailed interventions that use safety, joining, and integration to downregulate the child’s stress response system while enhancing his ability to self-regulate. In order to make the content of this article applicable to cases that mental health professionals might be working with, I will to demonstrate how theory and research become operationalized by making reference to the case of Simon throughout the article.
SAMPLE CASE: SIMON – THE OLD SOUL TYPE
Simon is a 14-year-old boy who is described by his mother as very sensitive, kind, insecure, and creative. Simon throws tantrums, yells that he hates his parents, and quickly becomes angry when his parents don’t comply with his demands. Simon was diagnosed with ADHD when he was in second grade as his teacher complained of his inability to sit still and pay attention. He is doing poorly in school, and does not care about how his current choices might affect his future. His parents are concerned that Simon might be addicted to social media, video games, and the internet. Simon has a history of being bullied since he started school, yet he had not told his parents. Since has was a young child he would get upset when his friends would play with other kids, thus he has had difficulty maintaining friendships. Father described Simon’s behavior as defiant, oppositional, disrespectful and inconsiderate. While he was naturally good at soccer and baseball, he would give up and stop attending practice. Simon’s mother noticed that her son had an artistic inclination and prefers individual instead of team sports, and thus encouraged him to engage in creative activities. Simon has a younger brother who is very athletic and plays many team sports including soccer and baseball, and connects with his father who is also a sports fan. During times of anger and frustration, Simon states that he is stupid and a failure, and that nobody understands him. Parents are very concerned because Simon has started to spend more time with a girl that they perceive as more mature and who is possibly using cannabis.
Note: This case is a composite designed to not only protect the confidentiality of my clients, but also to provide a didactive application of the protocol. Also, this article will advance interventions to address issues pertaining to how boys get influenced by societal norms regarding what it means to be a man. For simplicity, I will use male pronouns to refer to children, and female pronouns to refer to the caregiver.
DEVELOPMENTAL & EVOLUTIONARY ARTIFACTS
Disconnect Between Young and Adult Brains
Even though the adult human brain is “by far the most complex system in the known universe” (Paulson, 2012, para. 32), its sophistication is due to the orchestration of a collection of neural systems that evolved at different stages of evolution. Indeed, our logical genius and capacity for deep empathy is built on top of very primitive reptilian and early mammalian systems whose primary expertise rests on its quick mobilization in response to any experience that might be interpreted as a threat (Cozolino, 2016).
These early primitive systems, which mostly drive children’s experiences are fast acting; developed early in our evolutionary history; and have strong connections to our visceral senses, and our ability to quickly move in order to avoid danger. They are mostly unconscious, and their activity become part of what we call implicit memory. As evolution proceeded, we developed more complex systems that allowed us to imagine, collaborate with others, and develop abstract thought. These processes are more conscious in nature, and slow acting as they require coordination of various systems. These more evolved systems appear much later in the development of the child, and are not fully functional until the second decade of life (Cozolino, 2016).
Even though children require critical support and understanding from adults during their formative and vulnerable years, there is usually a mismatch between the way adult and young brains experience the world. Children are driven by these early primitive systems that are more embodied and emotional and less cognitive in nature which might appear illogical and non-linear to the adults proving their care. This disconnect is a source of ongoing conflicts that leave children feeling misunderstood and inadequate in the eyes of their parents as they are incapable of living up to the expectations of the more logical adult brain.
The most important issue in most cases with children that are exhibiting challenges with emotional, behavioral and learning is that adults that care for them focus on the wrong problem. The problem is not fixing the challenge perceived by the adult. Instead, the problem is that adults are unable to understand what the child is trying to communicate through their negative symptoms. In a nutshell, children’s symptoms are trying to communicate that the “goodness of fit” (Grobstein, 2009, para. 18) is not adequate for the level of care and support that they need due to their brain plasticity (Boyce, 2019; Veliz, 2019a).
To the adult brain which is more logical and focused on the present and future, the focus is on the child learning to behave and to “keep it together” so that he is able to be successful in life. The child’s brain is focused on past information to predict the future since during the early years the brain takes in and analyzes past events in order to construct expectations about the future environment (Cozolino, 2014b). Thus, Simon’s father might not be able to understand why Simon is upset and being “difficult” during a weekend family camping trip. Simon might not be able to enjoy the outing with his family because he might be thinking about having to go back to school on Monday as he might be worried about getting bullied again. If this was true, Simon’s parents would wonder why Simon can’t verbalize this. The challenge is that some of these mental dynamics might be implicit (i.e., unconscious). Even if Simon was aware of his discomfort, he might not want to share with his parents that he feels scared, because he might be worried about his father thinking he is weak. Some adults might even expect the child to be able to “temporarily suspend” worrisome thoughts from his mind just like adults are able to.
Safety Before Relating
Thus, there are neurodevelopmental constraints that get in the way of children’s capacity to engage in behaviors that adults expect from them. When a child is born, the most primitive neural structures that include the brainstem and the limbic system are fully developed (Rossouw, 2016). Thus, the child’s actions will be very sophisticated when it comes to self-defense oriented “selfish and manipulative” behaviors. When adults don’t understand that this type of behavior is a normal and healthy part of the child’s neurodevelopmental timeline, and proceed to discipline and shame the child, this results in the child not feeling safe, causing a further upregulation of the child’s defensive strategies which could be interpreted by the parent as a direct “premeditated” defiance against the authority of the parent.
This lack of safety can result in a shift from sympathetic excitement to parasympathetic withdrawal which quickly take on the intrinsic meaning of “’I’m not lovable’ and ‘my membership in the family is in question,’ both of which are life threatening to a child, whose survival depends upon unconditional acceptance” (Cozolino, 2016, p. 10). This dynamic eventually results in core shame, and becomes interwoven into the child’s identity. This is why Louis Cozolino, author of The Neuroscience of Human Relationships, in referring to the evolution of core shame states that: “The fundamental question ‘Am I safe?’ has become interwoven with the question ‘Am I lovable?’” (Cozolino, 2016, p. 11).
Unfortunately, the child gets punished because his evolutionary artifacts are working properly which further strengthens the defensive circuits in his brain making them more automatic since the punishment communicates that the environment is not safe through the process of avoidance learning (Wenzel et al., 2018). As this ongoing misunderstanding continues between the child and adult, the child starts to develop emotional feelings of being constantly rejected by the parent. Ironically, parents are working against what they want; which is for the child to eventually have the capacity to use more of his reasoning capabilities to soothe his primitive defensive system (Baylin & Hughes, 2016). While initially the child’s hypersensitivity might result in challenging behaviors, the child will achieve a better capacity to self-regulate if parents focus on providing the support that the child needs so that sooner rather than later he can transition from a selfish focus on his own safety to a more collaborative and outwardly focused engagement and reciprocity with other family members. This progression highlights the developmental need for the organism to feel safe before it has the capacity to connect, relate and have empathy for others. In a nutshell, if the organism does not feel safe, it can’t love or be a responsible active participant of any interactive group. This is a powerful neurobiological principle that appears to be ignored by traditional behaviorally-based parenting.
Thus, while traditional parenting focuses on setting boundaries and holding the child accountable through discipline, the protocol’s focus is on assisting the child to feel safe. Unfortunately, “setting boundaries” through fearful discipline tactics result in the upregulation of the child’s stress response system which communicates to the child’s limbic system that the environment is not safe. In contrast, when caregivers focus on the child feeling safe through a relationship based on unconditional love, the parent has now earned the child’s trust to provide the much-needed boundaries.
In labeling Simon’s behavior as negative, it is almost impossible to have empathy for him. If father sees him as defiant and lazy, the dominant societal paradigm kicks in and directs father to communicate disapproval for Simon’s actions. In addition, it deploys the dynamics of conditional love through which love is only provided if the child “is” the way the parent wants him to be, and taken away otherwise. Instead, what Simon needs is for his parents to help him process the feelings of inadequacy that are underneath his negative behaviors while communicating unconditional love through acceptance for who he currently is.[Content protected for subscribers only]
This has been an excerpt from The Science of Psychotherapy July 2019 – for the complete article and more interesting content, please subscribe to our magazine.