Dr. David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC, covering topics in mental health, wellness and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.
On today's show, we will be talking with Dr. Anita Remig about child development. Anita Remig, Ed.D., is a practicing clinical psychologist, certified school psychologist and consultant with over 25 years of experience, specializing in learning styles, brain-based research and learning problem interventions.
Her practice is located in Portsmouth, New Hampshire. Dr. Remig also uses biofeedback and neurofeedback as a clinical tool to support learning, emotional growth and executive functioning.
Her articles have appeared in numerous publications, including the "Child Study Journal", "Language and Speech" and the "Journal of Child Psychology". Her papers have been presented to the American Educational Research Association, the American Psychological Association and the Society for Research in Child Development.
Dr. Remig regularly conducts seminars across the country. She's a member of the American Psychological Association and an instructor with the University of New Hampshire. She is a Fellow of the Prescribing Psychologists' Register and a Fellow in Serious Mental Illnesses from the Prescribing Psychologists' Register. Both fellowships are awarded by the International College of Prescribing Psychologists.
Dr. Remig also recently passed the ICCP national examination for psychologists in psychopharmacology and has been awarded a certification as a medical psychologist from the Academy of Medical Psychology.
You can visit her website at www.remigbiofeed.com. Now, here's the interview.
Dr. Anita Remig, welcome to the Wise Counsel podcast.
Dr. Anita Remig: Thank you. It's great to be here.
David: You've got a workshop on child development coming up here in California soon that I'm planning to attend, and in your description you say, and I'll quote you here, "Development disorders are in increasing dramatically to the extent that some researchers are describing the trend as an epidemic." Well, what's going on there? What's this epidemic that you refer to?
Anita: Well, the idea that children are changing, as well the family is changing in our culture and the environment is changing, all comes together to produce some pretty significant changes for children presently. And I'm interested in all those changes and how they impact the developing central nervous system and developing child.
David: OK. And you also say, along the same lines, that research on the stages of brain development demonstrates very early changes in brain growth that lead to developmental disorders. So maybe you can tell us what the story is there.
Anita: Sure. The idea that the child develops a brain as he or she grows is something that we've all accepted. What I think is news is the sensitivity of the developing brain structure to the ongoing and ambient environment, both human environment, interpersonal environment and physical environment.
We didn't understand years ago that in order to grow a brain, a baby requires a human climate that is safe and warm, interactive, supportive and very responsive, based on what the baby needs each minute of each day. As well, the physical environment, in terms of safety, cleanliness, freedom from toxins and chemicals is another aspect of brain development.
David: So you're saying that all of these environmental influences, not only the physical influences but also what you might call emotional influences having to do with the family and the community in which the infant is embedded, those can actually affect the development of the brain?
Anita: Yes, absolutely. John Bowlby, Dr. John Bowlby, back in the early 1950s, began to look at a process that he called attachment and this process, he intuited long ago, was a sensitive dyadic interchange that began at the moment of the birth when the mother and the father look into the baby's eyes. This process of eye gaze, hearing each other's sounds, voice, feeling each other's skin and moving back and forth using these sensory modalities was the beginning of brain growth.
He intuited this even though he didn't have equipment to look into the brain and watch how the baby's brain grew as the attunement process between the parent and infant grew.
It turns out, more than 50 years later, that he was absolutely right. Very important neural circuits emerge the baby's brain based on day-to-day, moment-to-moment interactive sequences.
David: So are they able to actually see those circuits now using the new brain scanning technologies?
Anita: Yes, they are able to see some of the emergence of these executive systems that are growing, and they're able to see in babies who have not gotten what they need from the human environment, they're able to see some of the damage that ensues when the baby doesn't get what he or she needs.
David: And Bowlby really comes out of a kind of neo-psychoanalytic tradition, doesn't he?
Anita: Yes, he does. Very much so. He was able to understand some of the relationships between infants and parents during the very early days of life and look at these interactional sequences as not only structures that set up relationship possibility. He went a step further, which was way beyond the era in the '50s. He began to postulate that these early, nascent structures laid down the fundamentals of brain growth.
One of the structures he didn't know what to call, but we now know what to call, is called the orbitofrontal cortex. It's part of our early developing pre-frontal cortext. It emerges early but it takes about 25 years to fully develop. This orbitofrontal cortext is linked to an area called the midbrain. The human infant grows emotional and social capacities based on the interlocking of the orbitofrontal cortex with the midbrain structures.
This is delicate, this is progressive, this is about neurocircuits becoming interconnected in very complex ways, and it is essential for developing a sense of self and a sense of other and being able to regulate one's emotions around these human interactive exchanges that are the fundamental building blocks of communication and social growth.
David: Boy, it's really interesting to see these different strains of theory and thought coming together. Many of the ideas growing out of psychoanalytic thought, particularly as it's evolved and become more sophisticated, and the confluence of that with these brain studies technologies that are continuing to emerge at a very rapid rate here.
And the old notion of nature versus nurture, we seem to have a much more sophisticated understanding of that now as not either/or, but as you describe it, much more of an interplay between the two. A kind of constant dialogue.
Anita: Yes, you are absolutely right. This notion of nature/nurture that's been around for a very long time is being addressed in all of these kinds of current studies. What is the role of the environment, particularly the human environment -- how adults stimulate and literally grow the brain of the baby?
There are some neuroscientists and I'm going to list a couple for you. Dr. Allan Schore is masterful in describing the process by which the human environment, human responsiveness, the mother and the father's capacity to attune themselves to the infant is going to be able to grow the very early structures and lay down the entire framework of the brain.
When you look at early development in this way, you see the enormous importance of human interaction, human co-regulatory, modulatory interactions that form the essence of the human brain.
David: Very interesting and you said you had a couple of names, who was the other one that you were thinking of?
Anita: A couple of other names -- my favorite authors that contribute to this body of literature would be Colin Traversin at the University of Edinburgh in Scotland, marvelous researcher and writer on this topic. As well, I like to read the writings of Edward Tronnick who is a researcher at Children's Hospital in Boston.
David: OK. Now, I know one of the areas of focus for you has had to do with the impact of child abuse on brain development. What got you into that and what is that you've learned about that.
Anita: Well, I read a book called "Ghost in the Nursery". This book was published in 1997 by, I believe, Elizabeth Hallett. It's a tremendous book and I believe it was important in bringing to the forefront the idea that early misattunement, early lack of responsivity from parents and ability to correct emotional derailment in the first few weeks and months of life has a great impact on the deterring important brain processes.
Before "Ghost in the Nursery" there wasn't direct attention paid to the subtlety needed in human relationships in order to grow the brain. This book helped to usher in the whole era of how neglectful or misattuned or unresponsive parents who don't understand the regulatory co-modulated process between infant and parent may establish communication structures that are not good enough for growing the brain.
David: Do you work with parents and children yourself directly?
Anita: I do. Yeah, I've been a practicing psychologist just for about 25 years now, working with parents and children. I enjoy the...
David: So, how have the ideas that you're describing here -- how did those impact your practice? How do you implement them?
Anita: These ideas are important to me from a theoretical point of view. I've always been interested in attachment theory. I studied developmental psychology as an undergraduate and really was attracted to Harriet Rheingold, Mary Ainsworth and many of those early researchers on attachment and bonding and, of course, John Bowlby being the early writer in this area.
On up to the most recent literature, Mary Main, Linda Solomon, all talking about attachment. The quality of the child's tie to the parent determines in large part the brain structures that get laid down and enable the individual to develop interpersonal concepts that will guide the individual throughout life in terms of how to relate to other people. How to understand self and other in our modulatory relationship.
We all understand that early experiences are going to affect the way we work with people later in life, the way we develop relationships later in life. That's what this literature supports these ideas from a theoretical point of view. In psychotherapy and family therapy, again, I use these ideas to help people understand where they've come from, some of the relationship experiences that were laid down early and how those can be corrected, modified and reworked in order to work better for the person.
I believe we all have this notion, the earned secure relationship. We can all earn back more security than perhaps was laid down early on.
David: OK. I imagine there must be certain skills that you tried to teach parents so that the parent properly -- on piece of orientation that I probably should have given you about this interview and I'm not sure that I did is that our audience will be mostly composed of probably not professionals but of lay people who are interested in these sorts of topics perhaps because they're parents or they have somebody they're thinking of going into therapy or they have a family member who's in counseling or therapy.
So, I'm wondering what sorts of advice or teaching that you give to parents in relation to raising their infants?
Anita: Yeah, I think that, that's the most important outcome from a research that's been done over the decades. How do we use these in order to guide parents from healthier, stronger bonds with their children? And how do we help people who have had some misattunement early on to earn back some of these security and capacity with communication?
I think psychotherapy in particular cognitive behavioral therapy is useful in supporting people and helping people. When I work with groups teaching seminars, there are always parents in the groups and what I like to talk about in these seminars that I do is how to begin to look at type of parenting child relationship in new ways, in more step by step fine tuned ways so that parents can take each eye gaze, face to face interaction, each conversation that involves words and begin to carefully check out how their affect, their feelings, their emotions and their words impact their children.
David: I think it's...
Anita: The most sensitive and attuned parents will respond will great concern and care for the feelings of the child. In whatever interaction whether it's disciplinary or a comforting interaction.
David: Sure. Is it Bowlby who talks about mirroring the...
Anita: Yes. Yes, Bowlby way back early talked about mirroring - the ability to mirror children and help them explore what they are feeling, respond to what they are feeling.
David: And the idea there is that the parent, that the adults - what they mirror back -- they give to child some feedback in their facial expression and other ways that they respond that the child impacts them and then become the sort of communicative feedback loop, is that the idea of it?
Anita: Yes, very much so. A communicating feedback loop, that's a beautiful way to describe it. This happens to parent to child sometimes out of awareness, sometimes parents are not conscious that the feedback loops of communication they create are fundamental to growing the brain.
David: Sure. Sure and that's really the new part -- is really understanding that it's not just an abstract concept about relationship but it's really grounded in the brain and the nervous system. Now, I know you also talked about the importance of the right hemisphere. We've all heard stuff in the popular press about left and right hemisphere. What's the role of the right hemisphere in the -- you talked about its role in the birth process and growth during the first year of life. What's going on the right hemisphere then?
Anita: That's a very good question because new brain research has shown clearly that the right hemisphere is activated around the time of birth and for a full year the right hemisphere is given most effort for growth in the human brain. This is phenomenal. This is huge kind of scientific finding because the right hemisphere is the area of our brain that causes these emotions and social interchange. This means that in our biology we have encoded priority for the part our central nervous system that's going to guide us to interact with other people.
In other words, the right hemisphere must evolve early on because it guides and directs the attachment experience. The attachment experience of being the most fundamental human emotional and neurological system that's got to be elaborated and developed, laid down securely before any other part of the brain gets a chance to grow up.
David: OK, and I notice in your literature, too you talked about the central and peripheral nervous system and the need to gain balance and homeostasis in order for the child to grow an orderly and functional brain. Can you tell us a bit about that?
Anita: Yes, absolutely. A lot of what's going on in the right hemisphere is the homeostatic balance of the central nervous system and the peripheral nervous system. The central nervous system, you can think of as our brain although included in the central nervous system, we mean our spinal cord and our -- or the nerves that insert within the spinal cords just be sent up different messages up to the brain.
Anita: The peripheral nervous system is our exterior nervous system; outside of the brain that takes messages in from the outside world, like touch and sight and hearing, and brings them to the spinal cord in the forma and then sends them up to the brain. So, this interplay between what's going on in the inside of the brain and what's going on on the outside of the brain has to be balanced by some part of us and that part is the right hemisphere.
So, again, the urgency to develop a healthy right hemisphere through coordinated interactions between mom and dad and baby sets the scene not just to understand self and other and social interactions but it sets the stage within the brain to balance the outside neural system and the inside neural system. So that we can respond to the outside if there's an emergency and yet quiet down inside of our brain when there is no emergency and you're trying to think.
We've got to balance these two inner and outer systems, the right hemisphere and these systems like the orbital frontal cortex and the mid-brain system must balance, developed, connect with other parts in order to achieve this kind of synergy, this kind of relativity, that's got to take place moment to moment in all of us for your right hemisphere to balance the two different nervous systems.
David: Fascinating. So what kinds of disorders evolve when there's a breakdown in these early developing systems.
Anita: The first and earliest kinds of disorders that are obvious are the attachment disorders; the insecure attachments. Unfortunately, in our country there are many babies who have an insecure attachment and really what that translates into is the baby isn't developing appropriately in the right hemisphere, in these very early weeks and months of life.
In our country, we have babies who are anxiously attached, who have anxious attachments. Perhaps about 15 percent of the babies here in our country have misattuned early parenting resulting in anxious attachment, this isn't good. Translated in brain terms, this means that there are important centers in the right hemisphere that are not growing and not getting laid down in the right way.
About 25 percent of babies in our country have avoidant attachments. And again, this means that something has gone wrong with the development of interpersonal relationships: mother-child and their father-child, so the child was developing fear, avoidance of people, avoidance of new situations. This again doesn't spell good news for the development of the right hemispheres. These types of insecure attachments: anxious and avoidance will result in tendencies as children grow to become teens and then adults. Tendencies that interfere with social functioning.
Now again, translate that into problems with the way the brain was laid down. Can we change this with psychotherapy and education and special education and good parenting? Yes, absolutely. That's we all are trying to do. Those of us who work in the helping professions.
David: Well, that's good news.
Anita: But we definitely...
David: [laughs] That's good news if there are interventions that are being developed. It sounds like very early interventions, much earlier than we used to think of.
Anita: Right. Right and the more we understand those early interventions -- the most distressing kind of attachment disorder that has been identified over the last 15 years or so -- this is Dr. Mary Main and Dr. Judith Solomon is something called a type D - disorganized-disoriented attachment. This is the most severe attachment disorder that exists. There are no estimates that I've seen of the number of babies in our country that have this kind of serious attachment disorder, but it is the worst kind that leads to all manner of difficulties in children.
Let me list a few of the concerns from our children who have type D insecure attachment. These are children who dissociate, which is a very troublesome, worrisome kind of locked brain state. These are children who are more prone to depression and anxiety. These are children who may have forms of hyperactivity that are not about genetics but are about the environment. These are children who are more likely to have oppositional defiant disorder and conduct disorder. These are children who may hurt other people and these are children who may self-injure.
So, the reason we become very concerned about any form of insecure attachment is that it's associated with later psychopathology. Type D- disorganized-disoriented attachment being the most worrisome form of insecure attachment.
David: Well, at what age would one begin to recognize this behaviorally in the child?
Anita: Usually, insecure attachment is becoming evident 5-6-7 months of age. In experimental studies, they can clearly ascertain attachment status by the time the child is eight or nine months.
David: Really? That early?
David: And they identify this type D that you're talking about that early?
Anita: Yes. Eight, nine, clearly by ten months, type D attachment patterns are evident.
David: That's surprising to me because for example when you talk about a symptom like dissociation, I don't know how you'd recognize that in a baby that can't talk and tell you what's going on. [laughs]
Anita: Well, dissociation is a brain state whereby the right hemisphere isn't able, hasn't learned to balance the central nervous system with the peripheral; hasn't learned to balance the sympathetic nervous system with the parasympathetic nervous system. Dissociation is a locked brain state whereby a baby, a child, a teen, an adult becomes unable to modulate sympathetic, intense hypermetabolism in the form of anxiety and fear. It is a protracted state that then gets bolstered with an equally serious and abrupt parasympathetic discharge, hypometabolized state that leads to literal numbing, paralytic brain.
David: So, I'm still a little bit hung up on this say, eight-month-old infant and how one would know all this or would you able to tell behaviorally by the way the baby's acting or would it be more as a result of doing some kind of brain scan or other type of physiological measurements.
Anita: It's clearly evident in the child's behavior. Let me give you an example. One baby was very frightened of his mother. His father was a good enough caregiver but had to work long hours and wasn't with the baby enough. The mother had an alcohol problem and a drug problem. She did not want to be a mother and she was left with the baby for most of the day. She did not care for the baby. She did not feed the baby properly. She didn't hold the baby, touch the baby, nor did she look into the baby's eyes and speak to the baby. This baby learned to fear her. You would even say this baby was terrified of her. She would sometimes hit her baby.
When he began to crawl, he would be playing with his father in the living room and when the mother came home she would open the door, he would take one look at his mother, he would put his head on the floor and he would half crawl, half slither under a table and put his head up against the wall. His little eyes would be bent forward trying to look to see where she was and, at the same time, his head would be up against the wall, his body immobile and there would be a slight tremor to his whole body.
When the father would go over and say, "Hey buddy, hey buddy, I'm here. I'm going to help you." He would sometimes snap out of it and let his father pick him up. Other times he remained rigid, tense with a non-convergent stare, trembling, in a locked position until something happened to help him come out of it. That would be an example of a dissociative state in an infant.
David: OK, that's a great example. Now you've given me a handle on it. I can see that, in that example, sufficiently dramatic, that yes, somebody could really see that there's something problematic going on there. In your workshop flyer you refer to something called the "triad of disorders." What is that? Is that something...does that refer to these states that you've already told us about or is that something else?
Anita: That's something a little bit different but certainly is exacerbated as a result of the right hemisphere deficits from early misattunement that we've been talking about. The triad is kind of like a triangle of disorders whereby on the top you have obsessive compulsive disorder. The triangle on the right you'd have tics, Tourette's, stuttering and on the triangle point on the left you would have ADHD. Now with this triangle or "triad of disorders," OCD, obsessive compulsive disorder, tics, Tourette's, stuttering and ADHD on the left there, you'd think, "Gee, aren't these three separate disorders?" But, in fact, looking at the underlying neurology of these disorders, they seem to be linked.
Anita: There's high co-morbidity among these. In other words, if a child has ADHD it's highly likely there's going to be some OCD involvement whether it reached clinical level or whether there are some sub-clinical tendencies, it's going to be there. Same thing with movement disorders associated with tics and Tourette's. So this triad, we know, you can think of them as disorders of the basal ganglia. Now that's a complex...I do a whole day on the disorders of the triad.
Relevant to this seminar on early developmental disorders that I'm going to do in a couple of weeks, we are concerned with having perhaps ADHD that comes from the environment and then perhaps this makes problems in early life make the ADHD worse and then maybe even provoke some of these other symptoms. In other words, the basal ganglia as a parallel distributive circuit is going to feed to the brain. When the whole system goes down you're going to get what looks like these clinical disorders.
Again, these are right hemisphere dominant structures. When the right hemisphere doesn't grow right, the child is susceptible to a number, a host, of these kinds of right hemisphere disorders. Disorders of the triad tend to be right hemisphere. I'm sorry, I'm giving you a very brief answer but trying to squeeze in a lot.
David: Yes, we're getting a whole's day worth of input or multiple days worth of input in a short time. One of the things that I'm wondering is if listeners wanted to come to one of your upcoming workshops, I'll be giving the information out after our interview. I'll tell people the dates and where they can go. But, I'm wondering, is that workshop open just to professionals or are parents and laypeople invited as well?
Anita: Parents and laypeople are more than welcome. I enjoy having parents. When we start the seminar we always talk about who's present and what kinds of things people do and what reasons they have for coming and I always identify family members. Then what we do is we say that there are people here as professionals but they are here for family reasons too. So I purposefully make these seminars understandable to anybody who chooses to come.
David: OK, well that's good to know. As we wind down here, maybe you could...for anybody maybe who has some concerns about a child, perhaps needs to have a child diagnosed or treated, what's your advice for finding a practitioner who's as knowledgeable as you are?
Anita: Well I think that's a very important topic. It's...at this point it's difficult sometimes in a community to find the right therapist. Child therapists, child psychologists, child psychiatrists are all informed on these topics and certainly there are many good therapists in every community. It is sometimes useful to find professionals who specialize in childhood when there are problems with children and family so that's the first place to start. Look for specialists in childhood and yet, certainly more general practitioners will know much of this and be able to help families help children.
You can see, based on what I'm saying that taking a family approach to children's problems is very important. It is important that parents regard the child's problem as a family problem and work to help the child in this context of the family.
David: OK, well thank you very much for that advice. Dr. Anita Remig, I want to thank you so much for being my guest today on Wise Counsel.
Anita: You're so welcome. It was my pleasure.
David: I hope you enjoyed this interview with my guest, Dr. Anita Remig. As I mentioned at the beginning of the interview, I will be attending an upcoming six hour workshop that she'll be giving in my area. If you are a professional in need of CE units or a concerned parent who wishes to learn more about child development, you may want to attend as well. During the week of May 29 to June 7, 2007, she will be doing six daylong workshops in various cities in central and northern California. To get more information go to www.crosscountryeducation.com.
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