How do we use the science of early childhood development to implement practical strategies and overcome longstanding barriers in the early childhood field? How can we ensure that families’ voices are heard when we create policies or programs?

To kick off this episode, Center Director Dr. Jack Shonkoff describes what the science means for policymakers, system leaders, care providers, and caregivers.

This is followed by a discussion among a distinguished panel of experts, including Cindy Mann (Manatt Health), Dr. Aaliyah Samuel (Northwest Evaluation Association), and Jane Witowski (Help Me Grow). The panelists discuss how we can break down the silos in the early childhood field, policies affecting prenatal-three, and how policies can change to address the stressors inflicted by poverty, community violence, and racism.

Sally: Welcome to the Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host, Sally Pfitzer. Our Center believes that advances in science can provide a powerful source of new ideas that can improve outcomes for children and families. We want to help you apply the science of early childhood development to your everyday interactions with children and take what you’re hearing from our experts and panels and apply it to your everyday work. 

Today, we’ll discuss how the science we shared in our previous episode, on the early years and lifelong health, can change the way we think about early childhood policy and practice, and what this shift means for policymakers, practitioners, and caregivers. So, I’d like to welcome back Dr. Jack Shonkoff, Professor of Child Health and Development and the Director of the Center on the Developing Child at Harvard University. Hi, Jack. Welcome back. 

Jack: Hey, Sally. 

Sally:  So we talked in the last episode about how the brain is connected to the rest of the body, and especially how the early years really matter when it comes to lifelong health. What does this science mean for policymakers, system leaders, or even caregivers? 

Jack: That’s a really important question, Sally. From the beginning of the early childhood field, it’s always been focused on early learning and improving children’s readiness to succeed in school. In the policy world, it’s in education policy, comes out of the education budget. For people who work in early childhood programs, and for parents, it’s about programs that encourage and provide rich learning opportunities for children to develop early literacy competencies. 

But the mindset shift here is that it’s not just about early learning in school—it‘s about the foundations of physical and mental health. It’s not just about improving outcomes for greater economic productivity—better educational achievement. It’s also about decreasing the likelihood that you’ll develop heart disease or hypertension, or diabetes, or a wide range of the most common chronic illnesses in society. It’s not just a matter of return on investment—asking “So, how much more economically productive will the population be? How much will we save in incarceration?” It’s also how much will we save in the cost of health care. 

Sally: We’ve previously discussed the coronavirus pandemic, as well as the national reckoning regarding systemic racism, and the impact that this current climate has on children and families. Could you talk about how both of those issues are playing out in the context of policy and systems change? 

Jack: From a science point of view, disparities in health outcomes is not a new discovery. But from a public understanding point of view, the COVID-19 epidemic and its gross inequalities in exposure and in infection and in complications and in deaths has really put front and center the incredibly important impact of systemic racism and interpersonal discrimination as it affects health. We know that more people of color, particularly African Americans—but also Latino and Indigenous populations—have greater exposure to the infection because of working in jobs that cannot be done at home, more reliance on public transportation, tighter housing circumstances—all of which make it more difficult to be protected from exposure to the infection.  

But what’s getting less attention is not just rates of exposure and infection, but also rates of complications. We do know that of those people who are infected, people with underlying medical conditions are more likely to be sicker, and in many cases, more likely to die from the infection. And those underlying conditions are not equally distributed across the population. And they are particularly a higher prevalence in populations of color and in people who have grown up in poverty. 

And here, what this new science is telling us is: this is not about adult exposure. These diseases have their roots early in childhood. They have their origins in excessive stress activation—excessive adversity—related to poverty, related to racism, related to exposure to violence, related to unstable housing, and related to food insecurity, all of which present tremendous burdens for families raising young children that increase the risk for excessive stress activation, which early on in life—doesn‘t always affect—but can affect brain development, the development of the immune system, development of metabolic systems.  

On the one hand, the impacts of racism belong on the list of a lot of other sources of stress for families. But on the other hand, there are burdens and hardships that are unique to experiencing racism that we have to start to come to grips with in a very different way.  If we don’t protect children from that, if we don’t provide the support for families to be able to help protect their children from the stresses in the environments in which they live, then what we see is over time, not only influences on early learning affecting readiness to succeed in school, but greater likelihood to have many of these chronic diseases later in life. And this is a rude awakening and an opportunity for the early childhood field to focus much more not just on early learning and school readiness, but to focus on the early origins of lifelong health problems, both physically and mentally. 

Sally: I completely agree with that Jack. And I’d also say that it’s so important that people at the policy and systems level work directly with families who are experiencing these stressors just to make sure they really understand their perspectives and their needs. And up next, Jack’s going to answer a question that’s been submitted by one of our listeners.  

Musical interlude 

Sally: And we’re back! For this segment, we asked audience members who listened to the podcast to send in any questions they may have for Jack. Today’s question involves the role of significant stress on our abilities to use core life skills—the skills that help us manage information, make decisions, and plan ahead to make healthier long-term choices or avoid impulsive risks, reduce stress, and ultimately improve health. Today’s question comes from a listener named Abbi Wright. 

Abbi: My name is Abbi Wright, and I’m a first–year graduate student at Oklahoma State University studying speech language pathology. And my question for Dr. Shonkoff is: how does strengthening core life skills in children affect lifelong health? How can we strengthen those skills in families that are especially vulnerable because of immigration status or racism? 

Jack: So that’s a really important question, Abbi. Let me try to answer in the following way. Building core skills is part of a strong foundation of resilience that will help you deal with stresses and engage in more health promoting behavior over your life course and further decrease the risk for disease. For young children, strengthening those skills helps to build coping capacities. That helps bring the stress response down so that when these systems are developing very early on, they’re not being disrupted. One of the things that we are beginning to understand in a much clearer way is that reducing excessive stress activation in the early childhood period helps to protect all these developing biological systems that not only affect learning, but also affect physical and mental health.  

Part of the way that we reduce stress activation in young children is by the adults who care for them to provide a sense of safety and security and buffer children from the stresses that are present in the lives of their caregivers. Families are experiencing significant stress. The pressures are greater to be able to provide that sense of safety for children—help them build their own coping skills. We know that some groups are particularly at risk, not for their ability to be good parents, but for the level of threat and hardship and burden that is imposed on families because of structural inequities in our society. Systemic racism is one obvious example. Immigrant families in the United States right now are another good example of families who are dealing with more than the usual amount of stress because even for immigrants whose legal status is not in question, there is an atmosphere of anxiety and threat and concern about the discrimination experienced by many immigrant families. So, the basic biology is the same regardless of your life circumstances. The level of threat—the level of hardship—varies based less on parents’ abilities to help build skills in their children, but more in terms of how much of an external burden of hardship and threat is imposed on families in their everyday lives raising their young children. 

Sally: Thanks, Jack. And thank you, Abbi, for that thought provoking question. Up next, our panel will talk more about the implications of this new science for people across the early childhood field. 

 Musical interlude  

Sally:  So, on today’s podcast, we have with us Dr. Aaliyah Samuel. She’s the Executive Vice President of Government Affairs and Partnerships at Northwest Evaluation Association, and a Senior Fellow at the Center on the Developing Child. Thanks for being here today, Aaliyah. 

Aaliyah: Thanks so much, Sally, for having me. I’m really looking forward to the conversation today. 

Sally: Also joining us on today’s podcast, we have Cindy Mann, partner at Manatt Health and former Deputy Administrator at the Centers for Medicare and Medicaid Services, and former Director of the Center for Medicaid and CHIP services. Hi, Cindy, great to have you with us. 

Cindy: It’s a pleasure. Thanks so much for including me. 

Sally: And also, on today’s podcast, we have Jane Witowski. State Director of Help Me Grow South Carolina. Thanks for joining us, Jane. 

Jane:  Thanks so much. I’m happy to join the group today for this very important conversation. 

Sally: My first question is for you, Aaliyah. Could you discuss the policy silos in state and federal government? What mindsets have shaped the current policy landscape? 

Aaliyah: I will say one of the fundamental challenges is really the cross and inter-agency communication. It’s just really important both at the federal level and as well as the state and local level, that we get individuals that represent multiple systems to come to the table and have conversations. That is how we can start to really think about how to blend and braid funding to ensure that we get the maximum number of families—children—getting access to these programs. 

We have seen the evolution over really the last I would say five to 10 years, where it has moved from early childhood being a woman’s issue to a workforce issue and a non-partisan issue. When I was Director at the National Governors Association of the Education Division, we watched the 2018 gubernatorial campaigns very closely. And of the 36 governors that were running at the time, there was not one that did not make a reference to early childhood and its importance to some degree. So, I can say that early childhood and this issue around childcare, families, our youngest citizens, is truly a non-partisan issue, which I think is important to underscore because it creates a recognition that it doesn’t matter what side of the aisle you’re on, this is an important issue. 

I think too as we talk about some of the mindsets or even the current policy landscape, I will say, one of the things COVID has really done is exposed the inequities that were hidden in plain sight. We can’t ignore the data, we can’t ignore the disparities, we can’t ignore the communities and individuals and families that have been hit the hardest, and who have historically been hit the hardest, and will also have the most challenges recovering from the pandemic and all that’s come with it. I think, ultimately, what is really lacking is the voice of those who are impacted the most. I heard a quote once, that I really do believe, which says, don’t do anything for us without us. I think as we start to really think about reshaping the policy landscape to address some of these inequities, we need to make sure that there is diversity at the table of decision makers, but also those who will be impacted the most, and making sure that we’re underscoring their voices.  

Sally: Yeah, that’s such a great point, and leads into my next question for you, Cindy. Can you speak about the policies affecting prenatal to three? 

Cindy: Let me just start by underscoring a point, which is that the country is moving in this direction. I’m seeing all across the country, movements in pediatric practice, in health care, in Medicaid programs, in state government, in local communities along these paths. So, I really do think these are all achievable. 

Everybody has to have access to health care coverage. Start there. That is not the case now. And while children are more likely to be covered than other groups, the rate of insurance for children has been dropping in the last couple of years. And mostly, they’ve been dropped off in Medicaid and not picked up elsewhere, and there’s a lot of different reasons for that. There’s also groups of children who because of their immigration status are just not eligible for coverage. Also, one of the I think really important tenets of good pediatric practice is to make sure that parents’ needs are met as well. We also have a number of states that have not extended Medicaid to low-income parents, and that really disenfranchises the family in terms of being able to access the kind of care that families need to make kids strong and healthy. 

Some of the other policy issues that need to happen are, is to really begin to integrate behavioral health and physical health. Those two worlds have lived often in very separate silos. That’s not how kids live, that’s not how families live. We need attention to the social and economic needs of families as a very integrated way of addressing those issues in the practice of the provision of health care coverage. A real focus on equity throughout all of the policies that we’re moving forward. As Aaliyah said, there’s no secret to the fact that we have significant structural racism and disparities based on race, and COVID has laid bare and put that, again, in our face, and we need to do something about it. And it really does take a very intentional focus on trying to address disparities to deal with it. 

We also have a financing issue. So much of the recent investments around social determinants—help with homelessness, help with hunger—have been driven by this perception of a return on investment to the healthcare sector. Well, that mostly leaves kids out, because while there is a market return on investment if you invest in young children’s health care, that return doesn’t always happen in a very short period of time, and that return also sometimes happens to other parts of our system. To our education system, to our juvenile justice system, to our child welfare system. So, we need a way of really having cross-sector collaboration in the design and in the financing of the full range of services for kids. 

Sally: And Jane, I’m wondering if you could speak to us from the healthcare and community service perspective, how do the families you work with feel about the policies in early childhood? Is there a sense that change is needed? 

Jane:  Sure. I would characterize the mindset as hopeful and encouraged. And what I’ve experienced is a real desire to work together across sector, and was pleased to hear Cindy bring that up as one of her last points in that cross-sector collaboration how necessary it is. And I’ve seen that at the local level and at the state level. However, it’s accompanied by a real frustration about how to go about it. There’s still a lot of confusion, and also barriers. When providers are faced with funding restrictions, staff capacity, regulatory mandates, and still this mindset of needing to stay in your lane. One of the reasons that I’m hopeful is the Help Me Grow system, which 20 years ago was seen as an innovation and an opportunity to bring together those service providers with the common goal of meeting family’s needs. And so, I’ve seen how it can allow service providers to break down those barriers, and to help make connections that are really meaningful for families. 

Aaliyah: Sally, can I just chime in here? Jane, when you said the flexibility, particularly in the regulations and staff capacity that is so spot on. I do a lot of advocacy work both at the federal and state level. One of the things we are advocating hard on is allowing for flexibility in the regulation so that at the community level, the funds can be used in the way that best fits the community needs. We fundamentally have to take a step back and stop being so prescriptive on what we think communities need, and create the funding structure to then package it to a community to make the changes and provide the supports that they need. 

And also, it’s ironic when you mentioned the innovation piece or staff capacity. It’s so hard to be innovative when you’re pumping out reports, when you’re seeing families one after another. And so, we have to think about how do we create the place and space for innovation to happen. And that takes time, that takes time to plan, it takes time to collaborate across systems. We can’t keep expecting do what you’re doing with no additional funds or support, and then be innovative on top of that. It just doesn’t happen that way. And you can have the most well-intended people who have the passion and the ideas to innovate, but if they don’t have the capacity it’s not going to happen.   

Cindy: I’d love to jump in on this part of the conversation as well. Another important point is to build the infrastructure in the community to be able to help connect people—health care sector—to community-based organizations and other resources. You can’t expect that a pediatrician is going to figure out where to send their families if they’re homeless or if they’re hungry. Or maybe you can send them, but you can’t necessarily do the follow up that’s needed to make sure that those needs get met. So, increasingly different communities are coming up with and states coming up with integrator organizations. They can be Accountable Communities of Health, is what Washington state calls them. North Carolina is planning to set up lead entities to help coordinate community–based organizations in certain regions and connect them to the healthcare sector. 

So, we absolutely can’t do this just on the fly. We’ve got to create systems—systems of financing and systems of working together—that are adequately funded so that this can work. And let me just also underscore a point made before that I neglected to raise, which I so firmly believe in the importance of families being not only at the table, but really in leadership to really figure out what those priorities are, and whether the system is working well, and whether the system is not working well. So, both at the policy table, and then as real time monitors of how well the system is working for kids. 

Sally: How can policies change to address the stressors inflicted by poverty, community violence, and racism?  

Aaliyah:  First, we have to acknowledge that they exist. That has to be step one. The stressors, the impacts of racism, bias, violence. What is real to someone who exists and has to exist in those communities, versus those who only have a perception based off of what their realities are, what their community is. It creates that disconnect. And the realities of families at all levels are different, and we have to acknowledge that. We can’t turn a blind eye, we can’t say, well, I’ve never seen it, so, I don’t think that that’s true. I will say—I‘ll give a personal example. I have two sons, but my youngest son has some really significant health care needs. I didn’t understand the challenges of being a mom with a child with special healthcare needs until I had one. I was an educator, I have a master’s degree in special education. But it’s very different when it’s your child and you’re trying to navigate the education system, the health care system, and advocate for your child who is struggling. 

There’s two parts. One, policymakers have to be more intentional in bringing in the voices of the people most proximate to these issues. And really include their voices, not just into the considerations, but into the actual decision making. I also think from the community aspect, we really have to hone in and recognize that policymakers work for us. They work for us. And it is okay as a community to stand up and require our policymakers to not only adhere to their campaign promises or challenges within the community, but recognizing that in their role, it is their fundamental obligation to hear from the constituents. And so, whether that is writing a letter, whether it’s writing an email, whether it’s having a phone call, all of those small actions at a community and individual level do matter. The more active we are at the local level and really elevating our voices and the needs, it makes policymakers pay attention. We have to recognize that not addressing racism, stress, poverty, has a multi-generational effect. It doesn’t only affect the adults right now, but it affects the children and even the children’s children. And so, if we really want to start breaking these cycles of poverty and racism, we have to start addressing them now. 

And so, I think holistically, it’s just time to take a step back and think about how do we really ensure access to these support programs, to health care, and what that means so that we can really start to address and see the changes around improving wealth outcomes for families, health outcomes for families, and really educational outcomes as well. 

Sally:  To follow up on that, I have a pretty big question for this panel, which is, what does an ideal future look like from your perspective in this cross-policy system space? 

Cindy: That is a big question. So, let’s imagine a world where first of all, everybody has a source of payment for their healthcare needs. That seems to be basic, it’s true in most westernized countries, it is not true in the United States. So, let’s start with that. And then, let’s go to the narrow world of healthcare, and let’s break down those lanes—those silos. I think it was Jane that mentioned everybody’s in their lane and it’s hard to break out. Well, children and families, they don’t live in lanes. They live in the community, they live in their homes, they live in their real life, and we need to meet them where they are. So, let’s start with having an integrated healthcare delivery system where we treat the whole family and the whole child. And then, let’s go beyond the healthcare system. Let’s look at all of the agencies and departments and entities that are really in very close regular contact with kids, and think about how they can work together with the healthcare sector. That’s schools, that’s child care, that’s the juvenile justice system, that’s parks and recreation. What do we need to keep kids and families healthy? So, beginning to work together. 

And then working—as I mentioned before—with community-based organizations, who really do have a lot of expertise on how to address homelessness and hunger. They may not have all the resources they need for sure, but they need to be working together in concert both to deliver the services and to have everybody advocate for more resources to the extent that more resources are needed.  

We need to have a very intentional equity lens as we go about these collaborations in the delivery of services and the thinking about where the financing should be prioritized. And we need to have all of this with the construct of families in the lead. And particularly, communities of color, given the health disparities. I’ve had the occasion of working with community-based organizations that are led by the community, and I’m taken by Aaliyah’s reference. I never learned more about the system as when I’m talking to parents of kids with special health care needs. They are so expert not just on what their kid needs, but on what works and what doesn’t in the health care system. 

So, if you’re really wondering how to get smart on all of this, sit down with some families that have really been trying to navigate the struggle, whether it’s because they’re homeless and they’re trying to get care for their kids, or whether their kid has special health care needs. They are the experts and they really need to guide us as we go forward. 

Sally: I really love this thread and I feel like it’s been followed through our entire conversation today. Really just making sure you have the right voices at the table—not for them to just for react to something that’s already been created, but to be there to actually create these things, and I think that’s extremely important. And Jane, I’m wondering if you could talk a bit more from your perspective about how these silos that everyone’s been referring to throughout the conversation truly impact families and communities. 

Jane: I would like to tell you the story about a family we worked with, a lower income family who identified themselves as Latino. Dad worked in construction, mom was home with four children. The older children were in school. And she had reached out to Help Me Grow because she had some real concerns about her youngest child—lack of language skills primarily, but also some behavior issues, which may have been associated with those communication challenges. 

The family lives in a rural part of our state, which while services are available in a nearby city, transportation is not available. And the mom and the child were connected with our early intervention to have an evaluation. But when we did some follow up with them, we understood they missed the appointment. Why? Because the car that they were using broke down, and the family had no money to get the car fixed. So, the story could have ended right there with the child in need, a frustrated parent, and a frustrated service provider not truly understanding what was going on. But it didn’t thank goodness, and I think that shows the resiliency that this mom had in understanding that she really had a child who had some needs and she wanted to get help for her child. And a care coordinator at Help Me Grow, who really understood the social and environmental challenges that that family was facing, and who came up with some innovative solutions to make sure that the child and the mom could get to the appointment. So, we ended up with a child who was evaluated and qualified and is still receiving early intervention services. And I just feel like that’s an example of how we can work together in a coordinated fashion to have a positive impact on outcomes for children. 

Imagine a community where children and families could access services without any restrictions. A community where every individual member shared a common goal of improving outcomes for all children, and where programs and resources and services that families might need, such as the health care, early learning experiences, healthy nutrition, would work together as a coordinated system. I do see one challenge, and I’d love to hear some thoughts that Cindy might have around this, is that historically, child health care providers haven’t been viewed as full participants in this community network. And yet, ironically, they are the very first service providers for children, and really continue to see the majority of children on a regular basis throughout their earliest years. 

And so, I think one of our goals should also be to intentionally embed child healthcare practitioners seamlessly into this network of community providers. Think about this provider network as an electrical power grid. So, when the grid is really functioning well, there’s this reliable flow of resources, and families can access them and plug in whenever it is that they need to. Help to keep children healthy and really provide opportunities for them to be successful, and for their families to be well. There’s work to be done on building and maintaining such a strong grid because it’s complex and it often requires some work to untangle pieces of the grid so that there is a guarantee that we won’t experiences any outages. 

But I think that that is an opportunity for us, if you think about how we can provide access to multiple resources and have a reliable flow of resources for families so that we can have some influence on that lifelong healthy trajectory that we want children to begin with. 

Aaliyah: Sally, if I could just build on that. Jane, I so see the same future and community that you just outlined. That is the world that I not only want to exist in, but I want for my sons as well. For those who would say, well, you know what, I don’t have kids, why should this matter? And for people who respond in that way or have that question, my response is, we are all connected in some way, shape, or form. None of us exists in isolation. We all have a mother, a brother, a sister, an aunt, a cousin, a coworker, somebody that we care about. And our communities are all interconnected. We have to think about not only the health and well–being and safety for those in our immediate concentric circles, but thinking about how those concentric circles are nestled within others. And if we don’t really think about the support of all, that as a whole, as a community, as a state, as a nation, we are not going to be able to succeed. 

Cindy: I want to jump in too at Jane’s invitation to talk a little bit about the issue she raised, which is our children’s health care providers not really given the resources and the voice that is commensurate with the importance of the work that they do. We really do need to build the mechanisms to hear from those pediatric providers, to support those pediatric providers, and to bring the families, again, into the discussion and into the dialogue. We’ve got the future of the nation and children in our hands, and we’re being very short-sighted by not devoting the kind of resources that’s needed. 

Now, there are a lot of advances in this area. We’re really seeing some additional investments put into those practices. Extra dollars to help with care coordination. Extra dollars to make sure there’s family navigators, child navigators, to really help families make their way through the health care system, but also beyond the health care system. If they need to apply for SNAP, if they need to have assistance in terms of housing subsidies. So, the design is not a mystery. Help Me Grow has that design, other pediatric practice innovations have that design. We need to value it and to put our resources in it. 

Aaliyah: When you mentioned the care coordination, that was the game changer for us with our youngest son. Between the age of nine months and three, he had over eight specialists in two different states. And I was a working mom, I had a four-year-old, and I was trying to consistently figure out which specialist, track medications, give the referral. I mean, it was a true nightmare. And finally, at the age of three, we finally got a care coordinator who managed all five of the primary specialists that my son was seeing at the time. That was when I could finally take a step back and breathe because I had someone helping me navigate this complex health system. 

Cindy: Thank you for sharing that. We need to really have a much more family-centered system of care management, where the alliance of that care manager is to the child and the family, not to a particular institution, not to a hospital or a rehab center or a specialty practice. But I am here for the child, I am here for the family. We also need to not just put all the burden on the families, we also need people in power positions to align with those families’ voices, and to say, yes, it is time to put a different balance in our investments in this country. And that’s healthcare sector leaders, that’s business leaders as well really stepping up to the plate and saying we’ve got to do things differently. 

Many, many years ago, I was working with a pediatric clinic in Boston Medical Center. And they were seeing a system—a lot of no shows as they call them, in terms of people not coming for their appointments. And they did a survey. They reached out and asked their patients, what’s going on in your lives? Why aren’t you able to make appointments? In a non-judgmental way, really trying to find out what was happening. And of course, not surprisingly, the two issues were, I didn’t have childcare and I didn’t have transportation. I was desperately trying to come into the appointment. It was really high priority, it’s not that it wasn’t a priority for families, but they had very concrete barriers of lack of transportation and lack of childcare. And then the institution said, fine, we’ll develop some shuttle buses. And they developed their own system of transportation. It couldn’t solve everybody’s problem, it wasn’t perfect, but it was a really important step forward in the community. And they also set up childcare in the clinic so that a mom could come and bring her other children and not worry that they weren’t going to be attended to or that they would be bored or otherwise get into trouble. And so, it really became a family center. 

 So, it really goes to the point of listening on a one-on–one basis to the family, and also soliciting their advice and respecting that they very much want to be full partners in the system, and mostly care so much about the well–being of their children. Instead, entities have imposed copayments, saying, well, people don’t appreciate care unless they pay money. Well, that will be a barrier to care. So, listen to what people want and construct your policies accordingly. 

Jane: As a service provider, we have to be not just engaging parents, but really listening to parents. And include them in the work we do, the plans that we make. Too many times, I think parent engagement is looked at sort of as a have to, check the box, we do it. But, that’s not enough.  So, I would definitely put that out there as an opportunity and sort of a mandate, a challenge to all of us who are not truly in a meaningful way, including that voice at the table. 

Aaliyah: I think the only thing I would say is as we continue to move towards equitable outcomes, we have to really understand that moving towards equitable outcomes is not going to confirm equity. There are two different things. By trying to make sure everyone has access, that doesn’t mean we’ll get the outcomes that we need. There are some that are resting back and kind of sitting back and saying, well, they could access that program if they wanted to. But if we don’t really unpack it, like the perfect example that Cindy just gave, then we’re not going to get to the outcomes that we’re really trying to drive towards. 

Sally: Thank you all so much for joining us. I really enjoyed this conversation, and especially, the different perspectives that you each brought to the table. When we come back, Dr. Shonkoff and I will be discussing another common misconception about early childhood development and lifelong health. 

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Sally: I’m joined again by Dr. Jack Shonkoff, who’s going to help clear up another myth that exists in the early child development field. So Jack, we’ve talked a lot about how interactions between genes and environment shape human development and lifelong health. And yet, when some people talk about adult diseases, the conversation can turn to being about whether the disease that person has or this person has is a result of genetics or if it’s a result of their lifestyle choices. 

Jack: The reason why that’s a myth is that it’s basically telling us that if you develop a chronic disease as an adult, particularly the most common chronic diseases like heart disease and hypertension, diabetes, addictions, depression, that it’s either genetic or it’s because you are not living a healthy lifestyle. And that kind of setup is a really important myth to burst. Because what we do know is that all health outcomes are a mix of differences in genetic predispositions, and whether we’re living health promoting or health disrupting lifestyles. Not to say that it doesn’t matter how well you exercise or how well you eat. It’s also not true to say that there’s no genetic contribution to the greater risk to have a particular health impairment. 

Very, very few, and none of these common chronic conditions are primarily genetically determined. And many of these conditions that are found to be associated with not very healthy lifestyles, you don’t exercise, you eat poorly, you’re overweight, your blood pressure’s up and you have a heart attack, people can look at that and say, well, yeah, that’s your own fault because of the way you live. What we’re missing is that the relatively higher risk or protection against these diseases starts very early in life. It starts prenatally and the first few years after birth. And that’s why it is so important that we try to protect children from excessive adversity, and why we want to help bring down excessive stress activation because it affects these developing systems very early in life, when they are relatively immature, that can have an effect on the greater likelihood of good health or the greater likelihood of being at risk for many common diseases. 

Musical Interlude 

Sally: And we’re back with Dr. Jack Shonkoff to wrap up today’s episode. Jack, we’ve talked a lot about changes that need to happen at the policy level, the systems level, and even the program level. What would you say to parents or caregivers who are hearing this information and thinking, well, I can’t wait for these changes to happen, I need to help my child now. Why should this new science make our listeners more hopeful that these changes can occur, and what can we be doing in the meantime? 

Jack: Let me answer first by saying that not being hopeful is never an alternative. Ever. If we’re talking about the health and wellbeing of young children, both our own children, if we’re looking at it from a family perspective, or all of our own children, if we’re looking at it from a community or societal perspective, there’s no room for hopelessness.  

I think the most important message for parents about this new mindset is that all of the things that you have been doing right to provide an environment for your young child that promotes early learning, healthy social and emotional development, and prepares your child to come to school ready to succeed, you don’t have to do anything differently to build a strong foundation for your child’s physical and mental health. A lot of attention has been directed in the early childhood field to the importance of responsive relationships, the need for serve and return interaction between young children and the adults who care for them. The importance of buffering children from stresses in the lives of families who work really hard to help build their children’s ability to be able to adapt to the stresses of everyday life. The importance of building skills to help to deal with stresses and hardships. The importance of building resilience that then transforms into being able to cope with adversity and to learn effectively and do well in school. That same resilience, those same kinds of coping skills, not only protect the developing brain, they protect the developing immune system. They protect developing metabolic systems. All of the wonderful things that parents do for their children. It used to be done in the service of early learning without even thinking about you doing the same thing to protect your child’s health now and in the future. 

The reason to be more hopeful about this is that we have a very strong science-based explanation for why what happens early in life influences all of the things that make for a healthy, productive, successful, engaged population for society. It’s very hopeful to think that if that science message gets out with the credibility that it deserves, that a broader part of the population will understand what a terrible missed opportunity is to not invest very early in the lives of children whose families are facing significant adversity and to understand that we will all benefit at the end of the day. Doesn’t mean that there isn’t a lot of hard work to be done at the policy level, a lot of hard work to be done at the service delivery level. A lot of hard work to be done to help families with young children across the population to be empowered, to advocate for what families need to kind of raise healthy and competent children. All of that to me presents a lot of hope. It doesn’t underestimate the struggle to change policies, but we have more information and knowledge to work with. 

Sally: Absolutely. There’s clearly a lot of work that needs to be done. But hearing your perspective as well as the voices of our panelists earlier in the call definitely makes me feel optimistic that change is possible. I’d like to once again thank our guests, Cindy Mann, Dr. Aaliyah Samuel, Jane Witowski, and Dr. Jack Shonkoff. And thanks to Abbi Wright for your question. I’m your host, Sally Pfitzer, and we’ll see you next time. 

The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu, where we’ll post any resources that were discussed in this episode. We’re also on Twitter @Harvardcenter, Facebook at Center Developing Child, Instagram @developingchildharvard, and LinkedIn Center on the Developing Child at Harvard University. Brandi Thomas and Charley Gibney are our producers. Bridgette Cyr is our audio editor. Our music is Brain Power by Mela from freemusicarchive.org. 

How do our biological systems work together to respond to chronic stress? What do these responses mean for early learning and lifelong health? And when we say that early experiences matter, what do we mean by early? This episode of The Brain Architects podcast addresses all these questions and more!

To kick off this episode, Center Director Dr. Jack Shonkoff describes the body’s stress response system, how our biological systems act as a team when responding to chronic stress, and the effects chronic stress can have on lifelong health.

This is followed by a discussion among a panel of scientists including Dr. Nicki Bush (University of California-San Francisco),  Dr. Damien Fair (University of Minnesota),  and Dr. Fernando Martinez (University of Arizona). The panelists discuss how our bodies respond to adversity, inflammation’s role in the stress response system, the effects of stress during the prenatal period and first few years after birth, and how we can use this science to prevent long-term impacts on our health.

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Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host Sally Pfitzer. Our center believes that advances in science can provide a powerful source of new ideas that can improve outcomes for children and families. We want to help you apply the science of early childhood development to your everyday interactions with children and take what you’re hearing from our experts and panels and apply it to your everyday work.

In today’s episode, we’ll discuss how early experiences, especially during the prenatal period and first few years after a baby is born, get inside the body and can have long–term impacts on lifelong health. Here to help us dig into that science around the early years and lifelong health is Dr. Jack Shonkoff who is the Professor of Child Health and Development, and the Director of the Center on the Developing Child at Harvard University. Hi Jack. It’s really great to have you back. 

Jack: Hi Sally. Great to be with you. Thanks very much. 

Sally: Let’s dive right in. In previous podcasts, we’ve discussed the impacts of stress and specifically you referred to this term of toxic stress, but we never really went too much into the detail about the body’s stress response system. I’m wondering if you could explain how the body responds to stressors or adverse experiences and environments. 

Jack: Yeah. That’s a really good question. For starters, the fact that we have a stress response system is really good. It’s protective for us. It actually can be lifesaving. It’s built into our body because this is how we deal with threat or challenges or hardships. This is the basis of the fight or flight response. So, what’s going on inside our body? Well, when we are stressed, a number of systems in the body get activated. Stress hormone levels are elevated and distributed all through the body. Our heart rate goes up, our blood pressure goes up. This is controlled by signals from the brain to the heart and the cardiovascular system. Our immune system is activated and there’s an inflammatory response. Our metabolic systems are activated to produce more energy for our body—more energy for our muscles, if we have to run or if we have to fight or more energy to think more clearly. 

The important message here is that the stress response is not just in our brain, it’s in all of the biological systems in our body that are constantly communicating with each other. They’re all reading the environment, they’re getting feedback, they’re communicating with each other. And this is what allows us to deal with challenges, to deal with an acute threat. The best way to think about this is to think about your brain and your immune system and your metabolic system and your cardiovascular system as all different members of a team. Success as a team depends upon each member of the team having a specific contribution to make. And a successful team depends upon interaction and alignment with each other. If any one part is not pulling its own weight, that affects the whole team.  

The immune system is another one of those team players. It is our body’s defense against infection. It’s our body’s ability to respond to injuries that require wound repair, and also helps us to be protected against other kinds of toxic exposures that might come in. Inflammation is the first response of the immune system to the threat of let’s say infection, or let’s say a wound like a cut. Think of it as the mobilization of the kind of first responders of our biological system. Now, everybody knows what inflammation looks like outside the body. When you have a cut or some kind of an injury that’s bleeding, and as it starts to heal, you notice that the area around the cut is red, it can be warm in the beginning, it may be particularly sensitive or painful. That’s the inflammatory response that is actually fighting against germs coming in. It’s kind of cleaning out body tissue that may have been injured by bacteria or viruses or trauma, physical trauma and it is beginning to initiate the healing process. And then over time the redness goes away and it’s less painful and the wound is healed.  

Well, that inflammation also can happen internally in the body. Now, in the beginning in a stressful situation, inflammation is very helpful internally. It mobilizes your body’s defenses against infection, and it’s meant to then deal with that acute injury or threat and suppress it. But what happens if the stress continues? This is what we refer to as toxic stress. So, in the beginning, it’s protective, but over time, that inflammation can then start to have a wear and tear effect on the body. It can actually start to disrupt organ systems. Here’s one or two examples. We know that inflammation accelerates atherosclerosis, kind of forming plaques that can clog up your arteries around your heart. Inflammation can also affect metabolic systems leading to insulin resistance internally and increasing the risk for diabetes. Individuals who have severe depression have elevated inflammatory markers in their body, evidence of elevated inflammation.  

We know that chronic inflammation internally doesn’t automatically mean you’ll get any of the diseases that I just mentioned, but it means that it increases your risk, which is now beginning to help us understand what is it about chronic severe stress that makes people more likely to develop chronic diseases, not just mental health problems, but physical health problems. 

Sally: That’s really interesting. And hearing you talk about how early experiences of chronic stress can have more of a long–term impact, I’m imagining that these impacts are not likely evenly distributed. Right? And I’m wondering if you can talk a little bit more about that. 

Jack: We have a very serious problem certainly in this country of unequal access to healthcare and unequal treatment in the health care system. And those are very important and clearly need a lot of work. But that’s not the whole story about disparities in health outcomes. Before we get to issues about healthcare, how does it happen that we have inequalities in the prevalence of many stress-related diseases like heart disease and hypertension and stroke? The new science is helping us get inside the body and say what is it about chronic stress and chronic hardship that leads to health problems? How does that happen? Some of this we’ve talked about already, which is the chronic activation of multiple parts of the stress response system that can have a wear and tear effect on different organs and biological systems leading to the most common and the most expensive chronic diseases in adult life. 

So, when we think about that problem of chronic adversity, and we know there are some very consistent and predictable differences in terms of racial and ethnic disparities in health outcomes, starting with prematurity and low birth weight, and then extending all the way up to obesity and heart disease and type 2 diabetes and a variety of other chronic disorders. So how do we understand this? Well, here is some of the things that are very important for all of us to focus on. Number one, the differences by race and ethnicity are not genetic. There may be for some individuals, a greater risk for some diseases related to genetics, but from a population basis, certainly for race, race is a social construct, there’s no biological basis for race and certainly not when we’re talking about illnesses. 

This gets us back to the discussion that we’ve been having about how chronic stress and chronic stress activation lays the foundation for greater risk for health problems later in life. Often, we make a list of sources of chronic adversity. We talk about poverty, we talk about racism, we talk about exposure to violence, we talk about a serious mental illness in a family, a young child living alone with a mother with severe depression who loves her child as much as any mother does but can’t be consistently responsive because of depression which is an illness. The body’s stress system and its response is the same regardless of the source of the stress. 

There’s something about systemic racism and the kind of interpersonal discrimination that’s part of the daily lives of people who are subjected to structural inequities, things that are built into society, that really requires us to take a careful look and say on the one hand, racism is a source of stress like many other sources of stress, but on the other hand, systemic racism and being constantly subjected to the indignities of discrimination raises a different question, which is: what do we do about that? How do we protect young children from the racism that their families and other caregivers have to deal with? 

The real solution to this is to go upstream and to deal at the source with the hardships and the threats of systemic racism that are bearing down on families, rather than focusing on helping families to cope with that racism. This is prevention in its true sense, which is not just to kind of put a band–aid on things, but to go to the source. I think the increased consciousness that we have in our society right now about systemic racism in a way that has always been known to families of color, but has sometimes been invisible—many times been invisible to families who do not know what it’s like to be victimized by chronic racism presents a really important opportunity for us to be much smarter and much more effective about how we think about this issue. 

Sally: You brought up some really important points. And we’re actually going to be getting more into the policy and system solutions in the next episode, so stay tuned. But can you tell us a little bit more about why early in childhood development is so important? So, I know we say early a lot, but what does that actually mean? 

Jack: Yeah. This is a really important question about what we mean by early and this is one of the real game changers about connecting the brain to the rest of the body. There’s an increasing public understanding that chronic stress activation can affect the development of the brain and ultimately affect your readiness to come to school prepared to succeed. But what this new science is telling us as we connect the brain to the rest of the body, is it’s not just about early learning, it’s also about the foundations of lifelong health. 

And if you think about the way we approach early childhood policies and early childhood programs, we have over the years realized that kindergarten is a nice time to start school, but actually it’d be better to start school earlier especially for children who are living under difficult circumstances. We have been increasing our investment in preschool for three and four-year-olds. Makes a lot of sense, good decision in terms of public policy. But for the children who are experiencing the most severe stress, that’s not early because the effects of this serious adversity begin very early. 

In fact, they begin even before you’re born. A pregnant woman who is in an environment where there’s very little support, where there’s constant stress activation, and also may be problems with inadequate nutrition, exposure to pollutants in the environment, these kinds of stressors and adversities can actually affect the development of the fetus before a baby is born. And certainly, in early infancy in an environment that is constantly stressed, this can really affect the environment of relationships in which very young children grow up. 

When we start to talk about health and not just learning, and we think about how all of these biological systems are responding to the environment, the science is sending us a very clear message. In the face of significant chronic adversity, we need to begin way before age three and four, in terms of providing an environment that’s more supportive of healthy development to reduce those sources of external stress. Metabolic systems and the immune system begin to show effects that may be more difficult to change later as early as the prenatal period and certainly in the first two years after birth. 

And so, that’s the important message of this new science for the early childhood period. It’s about health as well as about learning. And early in the face of severe adversity means prenatal and the first two or three years after birth. The bottom line for all of this is we are now learning that what happens early on prenatally and in the first couple of years sets you on a pathway to be either more at risk for some problems or more protected for some problems. But it’s not an absolute prediction. It’s never too late to make things better, but in the long run, you’re always better off by having the best health-promoting experiences as early as possible. 

Sally: Yeah. I’ve often heard you use that phrase that early is better, but it’s never too late. And I’m really glad to hear that continue to come up in our podcast because it’s such an important message for listeners to take home. When we come back, we’re going to have Jack answer a question that was submitted by a listener, and we’re going to dive into that question together. 

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Sally: And we’re back, and now we’re going to answer a question from one of our listeners. I know how much I enjoy getting a chance to ask you questions, Jack. And this time we thought we’d ask the audience. Here’s one from Sid Gardner. 

Sid: Hello. I’m Sid Gardner, President of Children and Family Futures. And my question for Dr. Shonkoff is the impact of prenatal substance exposure is mentioned briefly as one item in the list of toxic effects. How does this affect physical and mental health and what can we do about it? 

Jack: Sid, that’s a really important question and I really appreciate it. There’s a very well-described phenomenon of fetal alcohol effects or fetal alcohol syndrome that exposure to alcohol at different times during pregnancy can have significant effects on brain development and also physical features that are very noticeable after a baby is born. 

We have lots of examples of how certain exposures to substances that are particularly disruptive to different organ systems based on where they are in their development before birth can have significant consequences after birth. This is about sensitive periods in development, which by definition are periods when that particular organ or that particular function is optimally responsive to environmental influences, even the environment in the uterus. And so, positive experiences promote healthy development and adverse experiences or exposures can disrupt development. That question about prenatal substance exposures, substance abuse is a critical question because it’s the poster child for how we need to pay attention to making sure that we promote a healthy environment in which pregnancy takes place.  

All of the systems, the biological systems that we’ve been talking about, the brain, the immune system, the metabolic system develop over time. And when we’re very young, including before we’re born, these systems are relatively immature and they are developing their capacities and they’re developing their structures in part on a timetable that’s genetically determined. When things develop is pretty much genetically determined, but how they develop is literally shaped by the environment in which that development is taking place. 

So, if we think about alcohol, whether this is threatening or not to health depends not simply on exposure, but on the timing. And so that’s why from a prevention point of view, the more we know about when are the sensitive periods and how can we prevent exposure to substances or infections that can influence later development, that’s how we promote and preserve good health and promote healthy development. It’s about timing and it’s about the differential sensitivity, the different levels of sensitivity of different parts of the developing brain and developing body as the normal processes of growth and development take place. 

Sally: Thanks Jack. And thanks Sid for that great question. Remember if you have a question for Dr. Shonkoff, you can always send us a message on one of our social media channels. We’re on Twitter, Facebook, Instagram, and LinkedIn. Up next, our panel will dig even deeper into the science of early childhood development. 

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Sally: Joining us on this podcast today is Dr. Damien Fair. Dr. Fair is the Redleaf Endowed Director of the Masonic Institute for the Developing Brain, Professor in the Institute of Child Development, College of Education and Human Development, Professor in the Department of Pediatrics at the University of Minnesota Medical School and a 2020 MacArthur Fellow. Thanks for being on the podcast today, Dr. Fair. 

Dr. Fair: Thanks, Sally. Glad to be here. 

Sally: Also joining us is Dr. Nicole Bush, Associate Professor in the University of California, San Francisco Department of Psychiatry and Pediatrics, the Director of the Division of Developmental Medicine and the Lisa and John Pritzker Distinguished Professor of Developmental and Behavioral Health. Welcome to the podcast, Dr. Bush. 

Dr. Bush: Thank you. It’s a pleasure to be here. 

Sally: We also have Dr. Fernando Martinez, University of Arizona Regents Professor of Pediatrics and the Director of the Asthma and Airway Disease Research Center. Nice to speak to you, Dr. Martinez. 

Dr. Martinez: Nice to be here. 

Sally: I’m going to start by asking this question to you Dr. Fair. Science is now telling us more about how the brain works with other systems in the body to respond to adversity, and could you say more about what’s actually happening in a child’s body developmentally among these systems? 

Dr. Fair: That’s a great question. Now, some would argue that the two most complex systems of the body are the brain and the immune system. Of course, I’m a neuroscientist so I always put the brain at number one. But unlike other organs in the body, like the heart or the lungs or the gut, which are located in very specific parts of our body, the immune system is simply everywhere. Immune cells and the chemical messengers flow freely through our bloodstream. They wiggle their way into different parts of our body everywhere. 

For many years, it was very difficult to identify or even think about how the brain might interact with the immune system in response to stress or adversity, anxiety, things like that. And it’s now quite clear that they interact in lots of ways and very specifically in development. For example, immune cells, and again, the chemical messengers that are generated in these immune organs like bone marrow, the spleen, lymphatic system, which kind of cleans out a lot of stuff related to the immune system, all have very intricate ties to the brain. 

And we know that stress in particular has a very large effect on the immune system in development. The highest vulnerabilities are likely in younger ages. The immune system is critical for normative development. It may actually come to some surprise to most, but all the neurons that we’re ever going to have for our lives typically are at their final resting place right about the time that we’re born. 

And then by the time we’re two, you have this proliferation of connections that go throughout the entire brain related to all those neurons. And then over time, over development, we slowly start to prune away these neurons and these different connections. That’s what it means to mature. Now it’s almost like a sculpture where you’re slowly chipping away to get the final product. Well, it turns out that the immune system is really important for that pruning and that cleaning things up. It probably doesn’t come to too much surprise that the changes in the activity of the immune system have very big impacts on brain development over our lifetime. 

Dr. Martinez: I think it’s important to stress what Damien was saying. There’s no one system that reigns. We are one thing. And therefore, while we’re developing, if there are extreme sources of stress, it is the whole system that responds wrongly. That’s why none of these effects are on just one organ. Of course, they may be more important for one organ, for example exposures to pollution may affect more the lungs, but now we know that it affects all other organs, including the heart, the brain, of course, the immune system and so forth. That’s an important concept, that we respond like a whole body, not like a single organ. 

Sally: That’s actually a really good segue into the next question which I have for you Dr. Martinez. Could you for our listeners go into more detail about inflammation’s role in the stress response system and how it can help or actually hurt us, especially young children whose systems are still developing. 

Dr. Martinez: Well in the face of exposures, the body has a system of recognition of these exposures. This process of recognizing what is out there that is not dangerous and what is out there that is dangerous. The response is that of activating the cells that are there, that are part of the immune system that are kind of the first stage of response. That first stage of response is perhaps the most primitive that we have, but it’s very effective sometimes and it’s enough for this danger to go away.  

When we are unable to completely clear that first stage, then the second stage occurs. And during that second stage, other cells come from other organs, and a full-blown response develops. Inflammation then is the result of these two phases of the response. Its main objective is to get rid of an acute insult, whatever that insult may be. But when these insults become chronic, in other words, when they develop for a long period of time, or when we have learned not to recognize what is acute and what is dangerous, we start developing what is called a chronic inflammatory response. It’s almost as if we are overdoing it as thinking that we have to be defending ourselves constantly. And that is what is called the chronic inflammatory response.  

It’s important to understand that there are these two dimensions of inflammation. One is inflammation as a good thing. Inflammation is a way in which the body responds to an insult to get rid of the insult, to control the insult, to destroy bacteria, viruses, whatever it is that is attacking. But there is a second aspect to it which is this chronic aspect. When you have all these chemical signals and all these cells hanging around the organs that are affected by chronic inflammation, what starts happening is that the organ starts something that we call remodeling. In other words, it starts reorganizing itself. And this is very important during development when the organs are growing. Because now, together with the normal signals of growth and development, you’re seeing these other signals that are interfering with the normal signals that tell the organs how is it that they have to grow. And they start growing “the wrong way.” Asthma, for example, becomes a disease that has transformed the organ. And now we don’t only have to reverse the inflammation that caused this in the first place, but we have to reverse the remodeling of the organ, the remaking of the organ. That’s why it’s important to understand that avoiding the factors that determine chronic inflammation is very important because it has long-term consequences for the individual. 

Sally: Dr. Bush, what does the science say about the effects of adversity and stress during the prenatal period and the first few years after a baby is born? 

Dr. Bush: It’s a great question. Young children’s brains are remarkably malleable and they constantly are seeking and absorbing information from their environments that their brains need and use to adapt. And this helps ensure their survival and optimize capacity to learn and thrive. But childhood adversities have the potential to affect these systems in a way that leads to impacts on things such as cardio-metabolic health, depression, diabetes, and multiple other health domains across the life course.  

People have been getting kind of earlier and earlier in the chain of development to understand where can we make the biggest impact? Where can we understand both the influence and opportunity for intervention? And so, some folks are leaning closer towards thinking their priorities should be focused on the first 1000 days of life. Adversity during this period has strong prediction of a variety of health outcomes. That’s why early safety–net programs, paid parental leave, and high-quality childcare and preschool are so critical to our nation’s health.  

Something that hasn’t received as much public attention is that an increasing number of studies are demonstrating that children’s biological systems begin to be shaped in the womb during pregnancy, and at this developmental stage, they’re substantially influenced by their mother’s biology. Most people recognize that a mother’s pregnancy nutrition or her exposure to cigarette smoke is something we really need to be careful about because they’re so important for the baby’s development, but also things like her sleep health and experiences of stress actually affect her physiology in a way that programs the fetus’s development, and then influence that fetus’s risk for a range of developmental, emotional and physical health problems throughout their life course. 

One of our team’s studies of low-income families just recently showed that mom’s reports of feeling overwhelmed by stressors during pregnancy predicted major increases in number of infants’ infections and non-infectious illnesses. So basically, babies of stressed pregnant mothers were sicker and they required more care from their pediatrician in the emergency room. And findings like this point to how critical it is for us to take care of pregnant women, not just for their own health and wellbeing, but for that of their children.  

Recent evidence that it isn’t just maternal stress during pregnancies that’s transmitted, but a mother’s own adverse childhood events, her ACEs, or her traumatic experiences during her own childhood appear to affect her biology through her adulthood in a manner that affects her baby’s development in utero. So, to put that in another way, a mom’s own childhood stress can 20, 30 years later have a programming influence on her offspring’s early and later life mental and physical health. This shows a truly trans-generational inheritance of the experiences of major environmental stressors, and it also shows us that intervening to help children either by preventing trauma or supporting them in coping with it after the fact can impact future generations’ health too. 

Sally: Our listeners may be hearing this and they may be thinking something along the lines of, if my children experienced a lot of adversity or stress early on that they might be in trouble in terms of their development. Or even if I experienced a lot of stress and adversity early on that I might be in trouble. What could you do to prevent chronic health conditions from developing or to help build resilience? 

Dr. Bush: Well, since I just ended with some stressful news about pregnancy stress, I’m really happy to point out that we are finding out a lot about how pregnancy is also an incredible window of opportunity to improve maternal and child health. We have findings showing that a stress reduction intervention in pregnancy leads to improved stress physiology, function, and more adaptive, emotional, and behavioral responses in infants. And we’re also finding that high–quality parenting in the first year of life buffers infants from prenatal stress effects. And another study showing that parental understanding of infant development and having appropriate expectations for infant or toddler behavior completely buffer one-year-olds from the risk of prenatal stress associations. Although more importantly, data suggests that if we were to reduce or eliminate major stressors like racism, poverty, food insecurity, and abuse, we would prevent the need to focus on building up those protective factors, and it would certainly have major cost benefits for society. 

Dr. Fair: I will add to that great discussion and just highlight that the early brain, the child brain, just as it’s vulnerable to certain types of changes with regard to stress and factors that we’ve been discussing here, the time is also when it’s most malleable, plastic, and resilient. Meaning the interventions are going to be more effective at this early age as well. And it provides an opportunity for us to really try to change thetrajectory by correcting things that may have gone wrong in the past.

Dr. Martinez: It’s also important to understand that for anything that we’re exposed to, there is a very high diversity of responses in the population. There are many sources for this diversity, which is also called heterogeneity of response. Among these sources, there are exposures and behavioral changes and so forth that Dr. Bush was saying counteract other exposures and other effects. It’s not written than the person who is exposed to a very significant amount of distress during the first years of life is condemned to have chronic inflammation and to have remodeling, reorganization of the organs, and there’s nothing to do about it. Quite surely, there are people who live in that situation but come along and don’t develop those responses. That may be in the future a way in which we counterbalance those negative effects by this resilience that is also so marked as a characteristic of human beings.

Dr. Bush: I love that Dr. Martinez highlighted the kind of individual differences in who has adverse outcomes after experiencing a lot of chronic adversity. At the same time, a lot of people are remarkably resilient for a variety of reasons, some internal, some external. And what we want to do is promote that resilience, but also not frighten everyone into thinking they’re doomed to cardiovascular disease because they had a difficult childhood. The flip side, also very glad that Dr. Fair highlighted how malleable we are for positive changes in early childhood. We have some really exciting evidence across a range of studies that show you can reverse the harmful effects of traumatic events on child biology, through evidence-based therapy interventions. In some cases, the children receiving therapy actually show biological repair and healthier outcomes than some control group kids. And so, there’s lots of reasons to be hopeful that our bodies have the capacity to not only survive and cope with adversity, but rise above sometimes doing better in the end.

Dr. Fair: And the good news is there are a whole host of things that our policy makers can assist to make sure the trends are good. Individual and family support structures, strong access to good education, economic security, all those social factors have a large, large impact on long-term outcomes in our kids, depending on some of the things that we’re talking about today. 

Dr. Bush: In addition to caring for children and their parents, it’s also really important for listeners to recognize that adversity and trauma do harm children and families across the entire socioeconomic spectrum. We need to address those directly for all people, all communities by screening in early childhood, screening in pregnancy and screening in adulthood for histories of trauma, so that we can address these social needs of individuals. I’m really hoping that we can make efforts to help insurance providers see the benefit of evolving their understanding, how to care for children, and that that includes caring for their caregivers, both family caregivers, and preschool and early childcare, reimbursement for screening and follow-up for treatment. The data are really compelling that in addition to those solutions being both just and right, that investments in prevention and early treatment could save incredible amounts of money in our societies. 

Sally: Thank you all for being here. We really appreciate hearing your individual expertise and also how your knowledge can really build off of each other to give us a full picture of what’s going on. When we come back, Dr. Shonkoff will be discussing a common misconception about early childhood development and lifelong health. 

Musical interlude

Sally: I’m joined again by Dr. Jack Shonkoff, who’s going to help clear up some myths and misconceptions in early childhood development. So, Jack, we’ve talked a lot about how early experiences can affect health many years later, but many people wonder how it can be possible that experiences we have before we can even remember them could affect lifelong health. 

Jack: It’s really one of the most important myths that we need to bust. And the simple answer to that is that we may not have conscious memories of things that happened very early in our lives, in our infancy, especially traumatic experiences or significant adversity, but what the science is telling us is, the body doesn’t forget what’s happening in these very early months and years. We’re not talking about inevitable poor outcomes,but significant stress activation well before a young child tends to have any sense of what’s going on, creates physical changes, physiological changes, inside the body that affect brain development, can affect the development of the immune system, the cardio-metabolic systems.

So, people who may be a little bit skeptical that something that happened when you were an infant can affect your mental health later, but at least you could begin to see the connection. There’s no logic for people to think that that would have something to do with whether you get heart disease 50 years later. But what the science is telling us is that those biological changes early on can increase your risk for these physical health problems later on. That’s one of the most important messages coming from this new science that is compelling us to connect the brain to the rest of the body. Because what happens early on is not only important for learning and social and emotional development and school achievement, but it’s an important influence on your physical and mental health for the rest of your life. 

Sally: That’s such an important point Jack. And I think today’s myth was a particularly dangerous one.  I’m really glad we had an opportunity to discuss it at greater length and that you were able to bust it.  

Musical interlude

Sally: We discussed a lot of important issues today to explain why the early years are so important and especially why intervening early is so important. And I’m sure we gave our listeners a lot to consider or at least I hope we did. I’d like to end by asking you, Jack, to give our listeners one key takeaway that they should leave this podcast with today. 

Jack: I think what’s really important about the big picture for what the science is telling us is a couple of things. Number one is, there are no perfect brains, there are no perfect immune systems. How we grow up, how we learn, what our health is like is related to the interaction between how we are individually wired to begin with and what our life experiences are about. And the important part of our life experiences, the most important, is the environment of relationships that we grow up in. And then also of importance is the physical environment in which we grow up. How safe is it? How protected or exposed are we to toxic substances in the environment, lead, mercury? How much space do we have to move around? So all of these things together, interacting with how everybody is unique from a genetic point of view results in a wide, wide range of normal development.

Our role as parents, as other caregivers, as a community and as a society is to do whatever we can to provide a health-promoting and growth-promoting environment for children, recognizing that everything we do that’s supportive will increase the likelihood of a very successful and fulfilling life. 

The bottom line for all of this is it’s a matter of balance. The more the pile up of risk factors and threats, the greater the risks. The more we build up protection and support for the environment in which children grow up, the smaller the likelihood of problems. The important thing to remember is that the way biology works, it’s always trying to make things right. When things happen in the environment that threaten health, all of the systems in our body are reading the environment and they are responding to try to keep us healthy, they’re responding to get us back on track. These new scientific insights should really be a source of reassurance for us and at the same time, a wake-up call about the kinds of life experiences that are threatening so that we can protect children as early in their lives as possible. 

Sally: Thanks so much for your time again today, Jack.  

So how can we protect children and promote healthy development and lifelong health as early as possible? In our next episode, we’ll discuss what this science means for listeners, including caregivers, policymakers, practitioners, and system providers. 

I’d like to once again thank our guests, Dr. Damien Fair, Dr. Nicole Bush, Dr. Fernando Martinez, and Dr. Jack Shonkoff. And thanks to Sid Gardner for your question. I’m your host, Sally Pfitzer, and we hope you’ll join us next time!  

The Brain Architects is a product of The Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu, where we’ll post any resources that were discussed in this episode. We’re also on Twitter, @HarvardCenter, Facebook, @centerdevelopingchild, Instagram, @developingchildharvard, and LinkedIn- Center on the Developing Child at Harvard University. Brandi Thomas and Charley Gibney are our producers. Bridgette Cyr is our audio editor. Our music is Brain Power by Mela from freemusicarchive.org.

While some countries and U.S. states are beginning to reopen businesses and other gathering places, the pandemic is still very much with us. Physical distancing will likely be a way of life until a vaccine for COVID-19 is widely available. So much change, including the threat of illness, and grief of those who have lost loved ones, means that mental health is a great concern.

Fortunately, there are things we can do to support our mental health at this time, especially when caring for young children or other family members. In this episode of The Brain Architects, host Sally Pfitzer speaks with Dr. Karestan Koenen, Professor of Psychiatric Epidemiology at the Harvard T.H. Chan School of Public Health, and Dr. Archana Basu, Research Associate at the Harvard T.H. Chan School of Public Health, and a clinical psychologist at Massachusetts General Hospital. They discuss what supporting your own mental health can look like, as well as ways to support children you care for at this time. They also talk about what mental health professionals all over the world are doing to help take care of our societies in the midst of the pandemic, and how they’re preparing for the challenges that come next.

Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host, Sally Pfitzer. Since our last podcast series was released, things have changed drastically as a result of the Coronavirus pandemic. During this unprecedented time, we’d like to share resources and provide guidance that you may find helpful. So, we are creating a series of podcast episodes that address COVID-19 and child development. This episode is the fifth in our series, and todays guests are Dr. Karestan Koenen, Professor of Psychiatric Epidemiology at the Harvard T.H. Chan School of Public Health, and Dr. Archana Basu, Research Associate at the Harvard T.H. Chan School of Public Health and the Clinical Psychologist and Massachusetts General Hospital. Thank you both for being here I’m really looking forward to the conversation.

Dr. Koenen: Thank you Sally. It’s great to be here.

Dr. Basu: Thank you so much.

Sally: So Karestan, what makes this pandemic different from other traumatic events that many people have experienced in terms of mental health?

Dr. Koenen: There are a number of characteristics that make the COVID-19 pandemic different than other traumatic events, even than other disasters. I actually lived in New York City during the 9/11 terrorist attacks, and I’ve seen some similarities in terms of this in that things were shut down, there was a pervasive feeling of threat, there was loss of life, and it was very disruptive and it was something that people really – in New York, anyway – talked about for a long time. It persisted and affected everyone in the city. What’s different about this is the length of time people are being affected, how pervasive it is in terms of our community but the state, nationally, and globally it’s the first time that I’ve had experienced a traumatic event that my colleagues in Africa are experiencing some version of it, my colleagues in Mexico, and then I think because it affects so many different aspects of our lives. We talk about trauma, and we think of things that are unpredictable and uncontrollable and overwhelm our ability to cope. This has certainly been unpredictable; a lot of things feel out of our control and on top of that we have other things that can in themselves be traumatic like unexpected bereavement, job loss, a stigma people are experiencing. I think the sheer pervasiveness of it – how it’s affected every aspect of our life. Finally, I think one of the things we know about disasters is that social support is so important for resilience, for people’s recovery, and to buffer them from the effects of disaster. In the middle of this, we’re being told to physically distance to prevent the spread of COVID, and that really cuts into our ability to get social support or to socially support each other, so that is something certainly different than I’ve experienced before or anything I’ve studied actually.

Sally: So Archana, I know you work with children and families on all of these issues around grief, which I know we were just kind of referencing. I’m wondering if you can talk a little bit more about the different kinds of grief that families might be experiencing at this time.

Dr. Basu: I guess I’d like to start by acknowledging that loss is a very common part of human experience, even outside of the pandemic. As an example, in the U.S. each year more than 600,000 people die of heart disease alone. This is not to minimize the losses that we’re experiencing now, but only to say that we as humans are used to experiencing losses and adapt to it on a pretty ongoing basis, and there’s a large body of evidence to suggest that we are adaptive and resilient. This is especially true for children because child development inherently offers many opportunities for change and positive adaptation with appropriate support. That being said, as Karestan highlighted, there are many unique elements to the pandemic in terms of the pervasiveness and the unpredictability as well as the limited or lack of access to typical support systems or resources, for instance due to physical distancing requirements. That certainly makes it unique and challenging. As of today, more than 80,000 fatalities have been reported in the U.S. alone. Families are certainly worried about their own health, their loved one’s health and well-being, or are coping with a death of a loved one. Right now, with travel restrictions, not being able to come together as families or with friends, that’s definitely a pretty big challenge. Many families have been unable to engage in typical funeral rituals, and parents are wondering how to support kids, and some are even wondering whether to say something. Generally, the research supports the idea that open age-appropriate communication can be very valuable in helping children. There are some specific helpful resources; really practical tips in terms of what language or words parents can use to explore how their kids are understanding these experiences, what worries they might have, and we can certainly provide links to that in perhaps the website to our podcast. Briefly, I will just say that open communication really helps to understand what children are observing and experiencing and can help them not be alone in their worries. I would say that would be the number one goal is to help children recognize what they’re feeling, validate those emotions, and for them to feel that they are not alone in this experience. The other element is what you referred to in your question is outside of bereavement, all of us are experiencing losses in our everyday lives. I think one way in which we support each other through tough times is by reaching out and connecting with our friends and family, by holding hands, by giving each other a hug, and we can’t do that right now. Also, I’ve been hearing from younger adults graduating; seniors in college, that they’re experiencing a pretty tremendous sense of loss around routine rituals that form a sense of community like graduation ceremonies. They don’t have that sort of eager anticipation as they’re launching into adulthood. Overall, I guess I would say children can be resilient, but the way forward may not always look and feel that easy. They’ll be moments of frustration and confusion. We would expect that – there is nothing normal about what we are experiencing, so to acknowledge and validate even these everyday experiences of loss would be quite valuable in supporting kids and families.

Sally: I’ve been thinking so much about how so many different people that I know have been experiencing this grief in different ways. You think, “Those high school students – that’s so hard”, or you think, “Oh, those college students – that’s so hard.” There’s so many different traditions and cultural pieces that we are missing right now, and that just changes how we are in our society. Karestan, I’m wondering if you could provide some specific examples; our listeners have often found it helpful to have some concrete ideas about how mental health experts are supporting families now, and then also how they’re preparing for those long-term health impacts.

Dr. Koenen: So, what’s been remarkable to me in terms of the pandemic is how the mental health community, and I mean that in academics, but frontline practitioners and students and people just interested in mental health, or companies that are interested in mental health have really stepped forward to offer resources from something like Headspace is offering free services to health care workers, and we’ve been offering these mental health forums at Harvard Chan School of Public Health. ADAA and CDC are offering all kinds of mental health resources. People have really stepped up to put those resources online, and I think that’s been unparalleled. I’ve never seen, again I worked in New York after the 9/11 terrorist attacks, and there was a cooperation around the mental health community, but I didn’t even see it at this scale then. I guess the other piece is the global collaboration I’ve never seen before. I’ve been on email chains with colleagues from Italy, China, South Korea; some of whom I knew before, some of them I didn’t. Figuring out what they are seeing and what has helped in terms of mental health locally. One center that I am affiliated with at Harvard decided to have a panel of people from China and South Korea talk about going back to work. Using the fact that it is global, and that countries are in different stages to problem-solve some of the things that would come up. Not that necessarily whatever they do would work here, but it would at least perhaps give us some ideas. Another thing has been a sort of rapid move to telehealth, which is something that actually insurance providers have been quite challenging to get reimbursed prior to the pandemic. It seemed like within weeks people had moved their practices to some form of telehealth, which could mean video, or it could mean telephone. That is something that I think has made services to people, especially to people who already had them, more accessible. Those are some things the community has done, and I think is a really positive thing going forward.

Sally: Absolutely. I’m wondering if you could help us think about what parents and other caregivers could do, specifically what they could do right now to support children’s emotional and mental wellbeing.

Dr. Basu: Foremost, readjusting expectation. Whatever little the parents can do to support themselves really matters because they are right now in fact the primary support system for kids. Obviously, parents are the most influential in terms of child development, but right now when kids don’t have access to other support systems, I would say it is even more important. As parents, we are not that great with prioritizing our own needs. It’s sort of kids, and work, and what everybody else needs in the household. Maybe, their own parents, and then if you get 5 hours of sleep, you’re lucky. I get that this is not an easy thing to focus on, but it’s sometimes just helpful to remind ourselves that every little bit counts even if it’s just twenty extra minutes of sleep, if it’s seven minute cup of coffee in the morning, maybe that sets the tone for the start of the day – simple, deep breathing. Another element could be focusing on what kids and families can control. So, thinking about your own routine – what’s helpful for yourself. Doing what works but keeping it simple – basic stuff. Managing sleep routines, eating, exercise, maintaining virtual social connections through technology. All of those things help. So, readjusting expectations and taking the time to sort of figure out routines that can be helpful, help us think about what we can control, and talking about it and checking in to see what’s working. These are some of the basic things I would highlight, and of course one of the biggest advantages right now to telemedicine is that it is more accessible if you have a phone, a computer, or a tablet. Get in touch with a primary care provider to seek guidance and support if this remains challenging, which would be quite understandable.

Dr. Koenen: Outside of COVID, providers are being underutilized. My colleagues who study health care services report that I think that it is down to somewhere 30% of capacity for non-COVID related medical calls, so thus, people should not hesitate as providers are actually available. One of the things that Archana and I have talked about, because we both have sons but they are very different ages, is that kids tend to be most concerned about what directly affects them, while adults we can get concerned about all of these things that might be abstract. One of the examples we have given is that when my son’s school was cancelled, the first thing he worried about was whether the homework due on Monday was going to be due, and whether it is going to be graded, and if they’re going to have to go to school longer. These very specific things, not to say he doesn’t worry about other things, but they are specific things. The younger kids – the playground that they usually run up to there’s yellow tape around it, so there’s these very immediate things. I think as a parent myself, I sometimes can trivialize these things. I find myself being like, “You’re worried about that, we’re in a pandemic, why are you worried about that?” But kids do worry about what is most direct and sometimes most concrete, and so by acknowledging and responding to those concerns which may seem kind of silly in our adult heads, that can provide a lot of comfort to them too.

Sally: Absolutely. You’ve both touched quite a bit on this, but I think I’ll throw this question to both of you to answer. We’ve been talking a little bit about how you’re saying that kids are responding to things that are most direct in their environment, and we know that the toll in this pandemic hasn’t been evenly distributed and will likely continue to not be evenly distributed. Some people are at much greater risk for both medical and economical consequences, and are you seeing that to be true for emotional and mental health consequences as well? If so, what could be done about that?

Dr. Koenen: Great question. When some of the groups we are seeing as most at risk for mental health consequences are 1 in 5 people in the U.S. – adults in the U.S. – live with a mental health disorder, so people who already had a prior mental health disorder or mental health condition, the conditions of the physical distancing for people with a mental disorder removed social supports and things that also may be accessed to other care groups – day programs, etc. Those people have been particularly affected had they already been socially isolated. The Kaiser Family Foundation came out with some statistics, and some of it’s not surprising. It’s families, actually parents, parents are reporting more mental health issues and people who experience economic downturn or job loss. We know from the 2008 recession that job loss and foreclosure are associated with increased risk of mental health issues. Thirdly, low income in communities of color have been disproportionately affected. I saw some data from a colleague published in New York which showed that higher mortality from COVID was related to income. We know that there’s been disproportionate mortality for communities of color. Also, in such communities, there is a greater digital divide, so we talk about a lot of these resources have been put online and there’s a lot of virtual support. But, we also know that 15% of Massachusetts households kids don’t have computers or didn’t have computers before this. And those again tend to be disproportionately in low income and communities of color. Those are some of the people I think disproportionately affected with risk of mental health problems who are disproportionately experiencing the COVID as well as the financial consequences.

Dr. Basu: I think the family focused care piece is really critical, and this is again very consistent with the Center’s philosophy around multi-generational models to support kids and families. I can’t really say this enough – I think supporting kids also needs to involve a model that supports parents. I would say that type of family focused care as one possible model moving forward is very key. The second one that Karestan and I and others have talked about, and maybe Karestan can chime in on this, is the aspect that there are many other communities or system within which kids and families live, work, and develop. That includes schools and community-level organizations, and faith-based organizations. I think part of supporting mental health care would involve partnering with these community-based organizations. This might include formal leaders and key stakeholders, but also potentially developing collaborations with more informal key stakeholders. There’s a lot of evidence that we can provide effective mental health care by not just working with specialists like psychologists and psychiatrists which is absolutely necessary, but also with more community-based healthcare workers, for example, and Karestan can speak of what we can learn in terms of the global context.

Dr. Koenen: Sure. Something that I hope that can come out of this pandemic is the better recognition that mental health is critical as the foundation of all health and the foundation of a healthy society. Rather than treating mental health like a side issue that we deal with when it’s an apparent big problem, we think of it more proactively. The burden isn’t left on individuals or even on families to seek help when things get to the crisis point. I think one of the things we can learn from our global partners and countries, where there may be 60 psychiatrists in the entire country treating a population and very few other trained medical professionals, is people having to introduce other models where community health workers or just leaders in the community, people who the community would acknowledge they look up to, training them in mental health practices that can then be disseminated into the community.

Dr. Basu: I think what Karestan highlighted in her previous comments is that there is also a lot of research to suggest that longstanding systemic issues can manifest in mistrust of health systems and beliefs about mental health that can impact engagement with care. So, engaging in the ways that Karestan highlighted, where people trust. Those are really valuable ways to engage people in just thinking about social and emotional health – engaging and starting that conversation.

Sally: Interesting. A lot of times at the Center when we’re talking about stress effects or stress response, we also like to talk about resilience. I’m wondering what you would say in terms of resilience around this pandemic.

Dr. Koenen: One of the things that has come up for me in terms of resilience is flexibility. We’re being called on to be very flexible, and we don’t always think of that in terms of resilience, but I think in this it is particularly true. I give my own example, one of my main coping strategies that works tremendously well 95% of the time is that I am a planner and I can see my plan backwards. I really had to be like “I plan, God laughs right now”, because so many things change all the time and as a parent now, we don’t know what this all brings. Having to be flexible myself, and model flexibility for my son who’s doing online school, he doesn’t know what the week is going to hold. The schedule is different everyday for his school, etc. Learning to roll with it and change your expectations. The other thing is I’ve been trying to figure out is, “What are the things that are most important to me? What are the priorities for my family, for myself”, and keeping them simple and only having a few of them. The normal expectations of everything we’re going to get done is not going to happen, and I also think that as a parent you have to choose your battles. An example is, well if your kids doing all their work and been on their Zoom calls for school and did all of their homework without complaint, does it matter if they got dressed? Maybe it does, maybe it doesn’t, but do you want to fight over what they’re wearing? Maybe you do, maybe you don’t. There are probably other things about having to choose what you’re going to focus on, and are you going to let go of some of the things or some of the time to make it more manageable.

Dr. Basu: To follow up on one of the things that Karestan started with was this idea of flexibility and it’s really something in our work with kids and families we talk up front about. One of those ideas is developing a toolbox of things that work for you as a family, and really think about what works for your child. I will often ask parents and older kids, “what has worked for you in the past?” So, we may not have been in the pandemic before, but we certainly experienced transitions and stressors and challenges in other ways. Asking them what has worked for you in the past and then thinking about how we can adapt those for right now. Also, recognizing that especially with kids, what works this morning, may not work at night or the next day, so thinking of it as a toolbox of skills or ideas they can use to cope is very helpful and certainly along the lines of having a flexible approach and definitely underscoring readjusting the expectations. I would definitely agree with both of those. I think the other thing that I would say is that individual resilience partially depends on systemic resilience. Really thinking about what are ways in which we can support families and schools and some of the other community-based organizations because those are the contexts in which children and families and all of us live our lives. There’s a recent study that found that among adolescence who received any mental health services between 2012-2015, that for 35% of the kids the only point of contact for getting mental health services was from their schools. So, forming partnerships with schools is actually really important because kids may not even access care through hospitals or specialists, but for a large portion of kid’s, schools might be the only point of service for them.

Sally: Excellent. I think that there are so many listeners who are especially going to relate to that readjusting expectations piece. That one really resonated with me as well. Well, thank you both so, so much.

Dr. Basu: Thank you so much.

Dr. Koenen: Thanks, Sally.

Musical interlude

Sally: I’m your host, Sally Pfitzer. The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu. We’re also on Twitter @HarvardCenter, Facebook @CenterDevelopingChild, and Instagram @DevelopingChildHarvard. Brandi Thomas is our producer, and Charley Gibney is our producer and audio editor. Our music is Brain Power, by Mela from FreeMusicArchive.org. This podcast was recorded at my dining room table.

Shelter-in-place orders are meant to help protect our communities from the current coronavirus pandemic. But for some people, home isn’t always a safe place. For those who are experiencing domestic violence, or believe they know someone one who is, what options are available to stay both physically healthy and safe from violence?

In this fourth episode of our COVID-19 series of The Brain Architects, host Sally Pfitzer speaks with Dr. Tien Ung, Program Director for Impact and Learning at FUTURES without Violence. Prior to her work at FUTURES, Tien spent five years as the Director of Leadership and Programs at the Center on the Developing Child.

Tien discusses important, practical steps those at home can take to keep themselves and their children safe, as well as strategies others can use if they think someone they know may be experiencing domestic violence. She also addresses the resilience of survivors, and what our communities can do both during and after COVID to listen to and engage in real responsive relationships with adults and children alike.

The next episode of this special podcast series will focus on the mental health implications of a global pandemic. Subscribe below via your podcast platform of choice to receive it as soon as it’s released.

A note on this episode: If you or someone you know is experiencing domestic violence, you can contact the National Domestic Violence Hotline: 1-800-799-SAFE (7233) or the National Sexual Assault Hotline: 1-800-656-HOPE (4673).

For a list of state/territory/tribal domestic violence coalitions, please visit:

Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host, Sally Pfitzer. Since our last podcast series was released, things have changed drastically as a result of the Coronavirus pandemic. During this unprecedented time, we’d like to share resources and provide guidance that you may find helpful. So, we are creating a series of podcast episodes that address COVID-19 and child development. A quick word about today’s episode: as you’ve probably guessed from the title, we’ll be discussing the subject of domestic violence, including mentions of sexual violence and abuse. We just want to give a heads up to those who may be sensitive to this subject matter so you can make an informed decision about whether this topic is right for you at this time. If you or someone you know may be experiencing domestic violence, you can contact the National Domestic Violence Hotline at 1-800-799-SAFE, that’s 1-800-799-7233, or the National Sexual Assault Hotline at 1-800-656-HOPE, that’s 1-800-656-4673. This podcast is the fourth in our series, and our guest today is Dr. Tien Ung, Program Director of Impact and Learning at FUTURES Without Violence. Prior to her work at FUTURES, Tien spent 5 years as the Director of Leadership and Programs here at the Center on the Developing Child. Thank you so much for being here with us today Tien, we’re really glad to have you.

Dr. Ung: Thank you, Sally. I’m glad to be back here to talk with you all about this.

Sally: Just so our listeners know, we’re recording this podcast today on a video call, so the sound quality may be different from what you’re used to hearing when we typically record this podcast in the studio. I’m going to start us with this first question. Tien, what are you seeing and hearing from your local partners, law enforcement, and families about indicators of domestic violence since stay at home orders started?

Dr. Ung: Sheltering in place does present very unique circumstances and challenges for people who are not safe at home. We know for example, that 1 in 4 women experience violence by an intimate partner in their lifetime. We know that 2 out of 3 children are exposed to trauma and violence. We know recently from the Rape, Assault & Incest National Network that for the first time in 25 years, their national hotline is receiving calls from minors, such that more than half of their calls coming in over the last couple of months have been from minors. We also know that at this time, reports of abuse and neglects against children are dropping. We know at least in Massachusetts, and I suspect in other states across the U.S. as well, that 80% of reports that come in from mandated reporters about child abuse and neglect are coming in from health professionals, educators, first responders, people who do not have eyes and ears on what’s happening behind closed doors at home right now. We also know very recently that phone calls to police stations across the nation are rising in response to domestic disputes. I think in fact, just today, we learned that a mass shooting in Canada had roots in domestic violence, which highlights, actually, what we’ve known for quite some time, that there is a strong correlation between domestic violence and mass shootings. Current stay in place orders present very specific challenges to people who are not safe at home. There’s also good news. While it is true that communities of care serve as an organic system of surveillance and monitoring bringing attention to harm that’s being done behind closed doors, we also know that those same communities serve as protective factors for children and victims of family violence and domestic violence. Faith communities, social communities, health and medical communities, as well as human service and educational communities, and legal and judicial communities—they all come together under normal circumstances to create a system and an ecology of care and protection. Those are things that I think will be important for us to unpack a little bit on the call today.

Sally: This is obviously a really challenging time, and if someone is experiencing domestic violence and they are a parent, what might they be able to do to escape that given we are in the shelter in place?

Dr. Ung: Because parents don’t have access to their normal pathways for connections, it really is very hard for them to reach out and get the help and support they need. It goes back to basic safety planning; things like making sure survivors know to put their hair in a bun rather than in a ponytail, because when your hair is in a ponytail there is more to grab onto which can cause injury. Making sure they are scanning their environments and looking for places to shelter in place in their homes where there’s not easy access to knives, for example, so don’t run into the kitchen. Doing a quick scan to see what they can use as shields or whatnot to protect themselves and reduce the likelihood of serious injury if a fight does breakout. We’re really back to basics, Sally, which is hard to believe. Some of the things we marvel about are the ways in which, and this is something that I think the Center knows well and talked about a lot when I was there, that survivors in children are incredibly resilient, and they know how to keep themselves safe, and they know what to do to manage the episodes of violence and aggression in their homes. It’s just really about giving them the support and letting them know that if things are really, really bad and they need to get out and get out quick, finding ways for them to have that. Every state, for example Sally, has a state collation for domestic violence. They are the people who know what services are in place for each state, what shelters are up and running, and what, importantly, batterer intervention programs are also up and running. They also have wonderful relationships with local law enforcement and the courts and are really good partners.

Sally: Those resources that you were saying that each state provides, how would someone get connected to that if they weren’t aware? Is that a website, or how would someone find that information?

Dr. Ung: That’s a great question. It is a website. I can make sure you all have information to that as part of this podcast so that you can put it on your website for people. It is split out by national level resources, as well as youth specific level resources, as well as resources specifically for the LGBTQ community. (Editor’s Note: That website is available here: https://ncadv.org/state-coalitions)

Sally: That’s really helpful, thanks. I’d like us to think a little bit more about what listeners or friends and family and neighbors could do to help prevent increases in domestic violence from affecting more kids.

Dr. Ung: I think that’s a good place to move into. We developed, actually on our website you can find a tip sheet of 10 simple steps that friends and family can take during this time if you’re worried about a loved one sheltering at home, or specifically about the safety; the physical, psychological, sexual, and emotional safety of someone sheltering in place. Some of them involve continuing to reach out and check in. We are sort of punctuating the notion that social distancing really isn’t the goal, physical distancing is the goal, but social connection should not go away in the face of requirements around physical distancing. We’ve been trying to practice ourselves by using the concept of physical distancing to promote the idea that finding ways to connect socially and support socially is really important. Checking in and reaching out to your family member and your friends are really important. Asking them what they need on a day to day basis, asking them if they’re okay, asking them directly if they are feeling safe. We like to encourage family members, and also community based social groups, like faith-based groups, to come together and think about how you might support families that you know are more vulnerable by preparing meals, by pulling dollars and helping families with real concrete, basic material needs. We’ve been encouraging family members and friends to reach out and offer parents relief from 24/7 parenting by offering to read a young child a book on the phone, or get on Zoom and do some crafts with someone, or even just getting on Zoom and watching a movie, or finding ways to engage in just fun. You can take your iPhone, for example, we’ve talked to people about playing hide and seek with young people with the iPhone around the house. Finding ways to offer some respite, relief, and support and connection. We’ve invited family and friends who know there might be family violence at home to find safe ways to have private conversations and establish a code word. Some of the words that some of our shelters are using have to do with “masks needed please,” so the survivor at home who’s not safe might text a service provider a code word: “masks needed please,” and that would indicate that that provider needs to initiate a police response to the house. Finding code words like that, so people can have strategies where they can get help and support in the height of the state of emergency is something we’ve talked about as well.

Sally: I love the concrete examples that you gave how you can interact with people who aren’t actually in that space. Although, I do imagine some families don’t even have access to technology, which might compound that even more.

Dr. Ung: Yes, I think that’s absolutely true. I think in those cases, families have their networks. The friends and neighbors of families who don’t have access to technology—they find ways to communicate and stay in touch, so what we’ve been inviting people to do is to find ways to maintain those connections to check in on people, and first and foremost to offer support. Anything that we can do to reduce stress and reduce burden is really important right now.

Sally: So, back to the resilience piece, obviously you spent a lot of time when you were at the Center helping us craft this curriculum around the 3 Science Principles. We were curious if you could talk a little bit more about what the science of child development tells us about what we need to do to prevent or alleviate the problems you were just describing.

Dr. Ung: You know, we know that the experience of trauma like exposure to domestic violence for children has three broad-level impact levels on children. They have biological impacts, which I think at the Center we talk about as the ways in which adversity gets under the skin and impacts children’s health system—raising risk across the life course for negative impacts in learning health, and behavior. We also know that it has psychological impacts, relative to influencing how young people think, feel, act, and interact with others. Lastly, we know that the exposure to prolonged trauma like witnessing domestic violence or experiencing family violence in the home can lead to negative social impacts, interfering with how children and young people relate and make decisions in the context of interpersonal health and engagement. In that context, we’ve been trying to draw a lot on the science that the Center organizes and produces to help people design strategies and programs and policies that buffer impacts in those three areas. When this is all said and done, which seems to be a very relative framing, there will be – we all anticipate—a long period of recovery. A lot of the conversation right now, Sally, is focused around the stress and the trauma of sheltering in place when home is not a safe place, but we’ve been paying a lot of close attention to near-term and long-term stressors that families that were already vulnerable before COVID are going to be facing sort of burdens and levels of stress. There have been 58,000+ deaths in the U.S. right now, and that number is going to continue to sore while we live through all of this. It’s not just family members of young people and children and youth who are dying, but teachers and coaches and people who represent really important relationships in the lives of young people. That’s a wave that we’re really trying to get ahead of and prepare for now. We think the best systems of care pre-COVID, during-COVID, and post-COVID ought to be organized around creating experiences and conditions that help young people and their families thrive, survive, reduce burden and stress in their lives, and create and sustain meaningful, interactive, positive relationships. A lot of that is promoting people’s capacities and skill in terms of being able to have very authentic and genuine conversations with their service providers, with their neighbors, with their faith communities, with their family, about what it means to be in a safe and healthy relationship, and to really promote that as doorways to service deliveries and service provision, rather than business as usual, which is the only access to serve this provision a vulnerable children in a family can have is through a surveillance and a monitoring system, which only produces stigma and also decreases, I think, the likeliness that if you need help and want help you can actually get it. Nobody wants to get help when help comes with the conditions of needing to be labeled a victim or a batterer, frankly.

Sally: It’s so challenging to take such a huge topic and cut it down into 15 minutes, so thank you for allowing us.

Dr. Ung: Thank you for inviting me.

Musical interlude

Sally: I’m your host, Sally Pfitzer. The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu. We’re also on Twitter @HarvardCenter, Facebook @CenterDevelopingChild, and Instagram @DevelopingChildHarvard. Brandi Thomas is our producer, and Charley Gibney is our producer and audio editor. Our music is Brain Power, by Mela from FreeMusicArchive.org. This podcast was recorded at my dining room table.

While the current coronavirus pandemic is affecting all of us, it isn’t affecting all of us equally. Some communities—especially communities of color—are feeling the brunt of the virus more than others, in terms of higher rates of infection as well as economic fallout, among many other ways.

In this third special COVID-19 episode of The Brain Architects podcast, host Sally Pfitzer is joined by Dr. David Williams, the Florence Sprague Norman and Laura Smart Norman Professor of Public Health, Harvard T.H. Chan School of Public Health, and Professor of African and African American Studies, Harvard Faculty of Arts and Sciences. Dr. Williams discusses ways in which the coronavirus pandemic is particularly affecting people of color in the U.S., and what that can mean for early childhood development. He also pinpoints the importance of creating “communities of opportunity” that will allow all families to thrive—both during and after this pandemic.

Upcoming episodes of this special podcast series will focus on domestic violence, and the mental health implications of a global pandemic. Subscribe below via your podcast platform of choice to receive all new episodes as soon as they’re released.

Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host, Sally Pfitzer. Since our last podcast series was released, things have changed drastically as a result of the Coronavirus pandemic. During this unprecedented time, we’d like to share resources and provide guidance that you may find helpful. So, we are creating a series of podcast episodes that address COVID-19 and child development. This episode is the third in our series, and our guest today is Dr. David Williams, the Florence Sprague Norman and Laura Smart Norman Professor of Public Health – Harvard T.H. Chan School of Public Health, and Professor of African and African American Studies -Harvard Faculty Arts & Sciences. Thanks for being with us today, Dr. Williams.

Dr. Williams: Thank you, it’s good for me to be here with you.

Sally: Just so our listeners know, we’re recording this podcast today on a video call, so the sound quality may be different from what you’re used to hearing when we typically record this podcast in the studio. So, the data that’s coming out now that we’ve been seeing continue to reinforce the research that you have been doing for many years around racial disparities, and we’re seeing that this virus is disproportionately effecting people of color. What are you seeing now in terms of the data?

Dr. Williams: We are seeing in multiple states more than half of all deaths from the Coronavirus are African American, and in virtually every state the percent of deaths of African Americans who die from the Coronavirus exceeds—it’s larger than the percent of African Americans in the population in that state. So, there is a disproportionate negative impact on African Americans in New York City, and we see a similar pattern for Hispanics. I think the important point I would like to make at the onset is that first, this is not a surprise. Two, this reflects a longstanding pattern, not just for Coronavirus but for virtually all of the leading causes of death. And that this pattern does not reflect failures on the part of the individuals, the families, and the communities that experience such disproportionate losses.

Sally: I think a lot of times when we’re hearing about this data coming out, there is a missing component where people are hearing this is disproportionately affecting communities of color, but there is not a lot of talking happening right now around the ‘Why?’. Could you share a little bit more about what the underlying causes of this disproportionate impact actually are?

Dr. Williams: Sure. Before we talk about underlying causes, I think it’s also important to emphasize that when we see one group in our society disproportionately affected, it affects all of us. It is about all of us. We are all connected. Higher rates of death for one population effects the entire profile and the entire risk for all of the population. In terms of what are the causes of these patterns? We’ve known for a long time many of the culprits. Number one I would mention is lower income, lower education, lower occupational status. In virtually every country of the world, persons of lower levels of education and income have higher rates of disease and death than those who are better off than they are. And when we say race and ethnicity in the United States, we are talking about groups that really vary dramatically in economic resources. I’ll give you two numbers that makes this very concrete. If you look at the latest income data for the United States, published in 2019 by the U.S Census Bureau1, we find that for every dollar of household income White households receive, African American households receive .59 cents. That .59 cents to the dollar figure is identical to the racial gap in income in 1978. Most of my students think we have made a lot more progress than that. As bad as the income gap is, it dramatically understates racial differences in access to economic resources. Because income captures a flow of resources into the household, it tells us nothing about the economic reserves that households have to cushion short falls of income. We get that from data on wealth. The latest report from the Federal Reserve Board indicates that for every dollar of wealth White households have, African American households have .10 cents, and Latino households have .12 cents.2

So, we are looking at groups that are disproportionately, economically disadvantaged; number one. And in multiple ways that raises the health problems and challenges that they will face. COVID-19 really illustrates this phenomenon very powerfully. What we know is that minorities have early onset of disease, early onset of chronic conditions, hypertension, diabetes, heart disease, all occur at younger ages. Part of this is driven by the lower economic status and higher levels of stress. Also, persons of color disproportionately in jobs where they have to go to work in order to get paid. We are working in jobs that don’t provide benefits, often don’t provide healthcare benefits, which lowers access to medical care. In New York City, for example, the hardest hit area of the pandemic, 60% of the essential workers in New York City are persons of color.3 Research also documents that in disadvantage communities, even if you get access to primary medical care, many of those primary care providers do not have admitting privileges at the best academically based or private health care systems where the best specialists are, so that those populations are also limited in the access to quality care. More generally, there is at least one study since the COVID-19 epidemic has begun that looked at a data from multiple states and that reported for testing for COVID-19 that African Americans, with the same symptoms as whites, showing up requesting a test were less likely to get the test.4 We also have evidence of the persistence of discrimination in terms of access to tests in addition to the fact that most of the testing sites are in suburban communities and there are fewer testing sites in central city communities that have a larger unrepresentative minority population.

COVID-19 is a perfect storm in terms of having a disproportionate negative impact on disadvantaged populations in the United States.

Sally: A lot of what you’re describing reminds me of that saying, “a person’s zip code has more to do with their health outcomes than their genetic code does.” What does that mean and how does that relate to this current situation?

Dr. Williams: I think it’s important to recognize that challenges these communities face are long standing and it didn’t happen by chance – they are not random events. They actually reflect the successful implementations of social policies. We had social policies implemented in the United States, but residential racial segregation being one of the most profound of them in terms of its far reached negative effects that still persist today that restricted a way a person lives based on race or ethnicity. That has had a dramatic effect in reducing access to opportunities – opportunities in early childcare and good early childcare environments. Access to good early education, access to employment opportunities. Opportunity in terms of the quality of neighborhood and housing environments and whether it’s easy or difficult to get exercise safely in your neighborhood. Whether it’s easy or difficult to have access to good primary care in your neighborhood. Across a broad range of factors that drive opportunity and success and society, we have large segments of our population restricted by these historic inequities.

Just to illustrate how powerful some of these effects are; a national study led by Harvard economists showed that if we could eliminate residential segregation in the United States overnight, we would completely eliminate or erase black and white differences in income, in education, and in unemployment, and reduce the black white differences in single motherhood by two-thirds.5 All of those differences driven by opportunities linked in place. What we need to think is how can we create communities of opportunity? Communities with high-quality early childhood programs, where every child is given a fighting chance to be successful—not only prepared for school, but also prepared for good health – a good foundation for health for the rest of their life. What can we do to reduce childhood poverty? What can we do to enhance employment opportunities for parents? One of the ways we can improve outcomes for children is by enhancing opportunities for their parents. How can we improve housing and neighborhood conditions?

The good news is there are examples of programs in the United States that are doing these things right now, and many of the studies show that these programs not only work but they will save society money. There is a range of opportunities of things we could do now to make a difference. When we take care of all of us and all of us have the opportunity, we not only build a more educated, a more productive workforce, we not only enhance the economic productivity of our society and the global economic competitiveness of our nation, but we also do something more that is profound, and that is we take care of all of us. We are all in this together, and what hurts one of us hurts all of us. It is in our best interest to work together to create a society that provides opportunity for everyone.

Sally: You mentioned stress as a factor contributing to the racial disparities and outcomes. Would you mind talking a bit more about how stress can affect communities and long-term health?

Dr. Williams: Sure. I want to talk a little bit more about the fact that minorities; African Americans, Latinos, Native Americans, have higher rates of underlying chronic conditions. The question is why? Is it their fault? Is it all linked to the bad choices that they are making? What the research points to is that you are looking at populations that are experiencing higher levels of stress. In some of my own work, I have found that the most of common stressors—stressors like loss of a loved one, unemployment, financial difficulties, violence in a neighborhood—all of these occur at higher levels among African Americans and among U.S. born Latinos.6 Not only do they have higher levels of the individual stressors, but they have greater clustering of stressors, so if you have one you are more likely to have multiple. What research is pointing out is that living out of the conditions of high levels of chronic stress leads to a physiological dysregulation across multiple biological systems. There is a body of research suggesting that at the same chronological age, racial ethnic minorities may be biologically older than Whites in the United States.7 It reflects the high levels of exposure to psychosocial as well as physical chemical stressors.

Let me give a practical example of the physical chemical stressors. There is one recent study done by researchers at Harvard University documenting that persons who live in areas with higher levels of air pollution, which are disproportionate minority, those persons if they get COVID-19, it is more severe and they’re more likely to die.8 The air pollution, this chemical stressor, has a negative effect in terms of adversely impacting health. In addition to higher levels of the chronic stressors, one of my areas of research has also been looking at stress of racial discrimination. I have developed measures to capture discrimination. One of them that is very widely used around the world is called The Everyday Discrimination Scale.9 It captures minor indignities – being treated with less curtesy and respect than others, receiving poorer service than others at restaurants or stores. The research documents that these little indignities accumulate and adversely impact physical health, mental health, the quality of sleep. It predicts early onset of multiple chronic diseases and even adversely impacts how individuals access and utilize medical care. If you’ve been treated badly in multiple domains of society, then you become less trusted in even the healthcare context. What emerges is a picture of the cumulation of negative experiences of chronic stress that have long term negative impacts on health.

The challenge, though, is that most Americans are unaware that racial ethnic disparities even exist. Raising awareness levels is really important, because if we don’t even know a problem exists, we are not mobilized to address it. Maybe COVID-19 provides us an opportunity to become more informed and hopefully to become more committed to working together to create a better future for all.

Sally: So, we’ve talked a lot about racial disparities in physical health related to COVID-19, but could you talk a little bit more about other ways in which people of color may be disproportionately impacted by this pandemic?

Dr. Williams: COVID-19 is an unprecedented challenge that we are all facing together as a society. This unprecedented challenge is a physical health problem, but it is going to produce a large scale of economic devastation, which we have touched on to some degree. It also will have large scale, negative emotional consequences. One of the things that we really need to think of is how do we provide support for all communities, but especially those who are already suffering disproportionately from the economic effects—those who are suffering disproportionately from the loss of loved ones. When we say that African Americans and Latinos are experiencing higher rates of death, that’s people losing mothers and fathers, grandparents, brothers and sisters. This is a community that will also be experiencing higher levels of grief and loss in addition to all of the negative effects of the pandemic. So, we really need to think of how can we enhance the access to emotional resources that helps people cope, and how all of us as individuals, even as we socially distance, we do not emotionally distance. That we do reach out to others and be supportive and be helpful, so that people can still have that sense of caring from others and that sense of emotional support from others.

Sally: I’m imagining that many listeners might be wondering what they can do, and how we might be able to help change this for the future?

Dr. Williams: Sure. I think when it comes to stress and environment, there are things that individuals who are suffering now can do that can protect them from some of the negative effects of stress. So for example, even the research on stress in general, but also research on discrimination in particular, points out that individuals who are embedded in close-knit, emotionally supportive relationships, the quality of social ties can reduce at least some of the negative effects of stress on health. There are some research suggesting that higher levels of religious involvement can also protect individuals from some of the negative effects of stress on health. There are things that can be done at the individual level. At the same time, what can we do to create environment where stress levels are lower? How can we create high quality neighborhoods so we will reduce the levels of neighborhood stress? How can we promote greater civility and respect of others as a value, so that we reduce the occurrence of discrimination in the first place? How do we make workplaces more friendly and more stress free than they currently are today? So, I think we do need to think of the high-level policy solutions that create environments that are low in stress, even as we empower individuals to more effectively cope with and deal with the stresses they face.

Sally: I really appreciate you taking the time, I know it’s incredibly busy and I know there are a lot of people asking for your time, so thank you so much for the opportunity to interview you.

Dr. Williams: You’re very welcome.

Musical interlude

Sally: I’m your host, Sally Pfitzer. The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu. We’re also on Twitter @HarvardCenter, Facebook @CenterDevelopingChild, and Instagram @DevelopingChildHarvard. Brandi Thomas is our producer, and Charley Gibney is our producer and audio editor. Our music is Brain Power, by Mela from FreeMusicArchive.org. This podcast was recorded at my dining room table.

1U.S. Census Bureau 2019 Income Data

2https://www.federalreserve.gov/econres/scfindex.htm?mod=article_inline

3https://comptroller.nyc.gov/reports/new-york-citys-frontline-workers/

4https://rubixls.com/2020/04/01/health-data-in-the-covid-19-crisis-how-racial-equity-is-widening-for-patients-to-gain-access-to-treatment/

5Cutler, David M., and Edward L. Glaeser. 1997. “Are Ghettos Good or Bad?” The Quarterly Journal of Economics 112(3): 827–72.

6https://scholar.harvard.edu/files/davidrwilliams/files/williams_dr_pearlin_paper_stress_mental_hlth_jhsb_2018.pdf

7https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197001/

8https://projects.iq.harvard.edu/covid-pm

9Everyday Discrimination Scale

In the midst of a global pandemic, pediatricians are serving a unique role. While the coronavirus is generally showing milder effects on babies and children than on adults, there are still health concerns and considerations for infants in need of scheduled vaccinations, and kids who are home all day with parents who may be facing stressful situations.

In the second episode of our special COVID-19 series of The Brain Architects, host Sally Pfitzer speaks with Dr. Rahil Briggs, National Director of ZERO TO THREE’s HealthySteps program, to discuss how pediatricians are serving their patients during the pandemic, including using telehealth; why caregiver health is child health; and what she hopes the healthcare system can learn as a result of the pandemic.

Upcoming episodes will focus on racial disparities in the effects of the virus, and domestic violence. Subscribe below via your podcast platform of choice to receive all new episodes as soon as they’re released.

Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host, Sally Pfitzer. Since our last podcast series was released, things have changed drastically as a result of the Coronavirus pandemic. During this unprecedented time, we’d like to share resources and provide guidance that you may find helpful. So, we are creating a series of podcast episodes that address COVID-19 and child development. This episode is the second in our series, and our guest today is Dr. Rahil Briggs, the National Director of ZERO TO THREE’s HealthySteps Program. Good morning, Rahil.

Dr. Briggs: Good morning, Sally.

Sally: And just so our listeners know, we’re recording this podcast today on a video call, so the sound quality may be different from what you’re used to hearing when we typically record this podcast in the studio. Rahil, what are you starting to see out in the field with pediatric practices effected by this virus, particularly in the HealthySteps locations, and how are the pediatricians starting to respond to the Coronavirus situation?

Dr. Briggs: Sure, thanks Sally. It’s an excellent question and honestly, depending on when listeners are catching this it may have already changed by now. The American Academy of Pediatrics is really our guide star for figuring out what’s going on and what they’re recommending, but a couple of facts on the ground really remain the same. That pediatric primary care is the main system we have for reaching young children. In a normal time, whatever that was and may be in the future, pediatric primary care reaches nearly all young children in our country. Right now, the American Academy of Pediatrics in recognition of the importance of vaccinations, and in recognition of the importance of really high quality newborn pediatric care continues to recommend actually, that families bring newborns, and bring infants and toddlers who need vaccinations into the primary care practice. So, that is pretty extraordinary and speaks to the importance of those services even with the Coronavirus swirling around. As you know, there are about 12-13 well child visits in those first three years. 7 of them occur in the first year of life, and a big chunk occur in that newborn period where they are checking everything from the bilirubin levels to maybe redoing the newborn blood stick to the weight gain and all these really critical pieces. So to your question – what are we hearing now and what are we hearing from our HealthySteps specialists who work side by side alongside the pediatricians in these practices? We’re hearing that babies still need vaccinations, and parents are more stressed than ever. That really needs attention. All of this discussion about how children are saved by the worst impacts of the medical parts of the Coronavirus, they are at home often with parents who are incredibly stressed and really looking for new approaches and ways to just frankly get through the day. So that is where our HealthySteps specialists are really coming in handy. I’ll leave you with one particular point that has really stuck with me. We had one of our HealthySteps practices in Colorado say that they were going to move to drive through vaccination services, which sort of boggles the mind, but I suppose that’s the world we are living in right now. And as they grappled with that and went back and forth with whether or not that was the right thing to do, they decided they weren’t going to do drive through vaccination services. One of their driving pieces was knowing how important it would be for the family to still touch base with the HealthySteps specialist. They’re hearing that families are running out of diapers, families are struggling to get formula, families are struggling to get needed medications for children with special healthcare needs. The HealthySteps specialists are doing so much of that care coordination and that systems navigation because as we know this is disproportionately affecting those who are impacted by poverty.

Sally: Would you mind giving us a really quick summary of what HealthySteps is for the listeners who may not know about the program?

Dr. Briggs: Sure. HealthySteps is a team-based, evidence-based primary care program where we add a new team member to the primary care network, which is a HealthySteps specialist who is an expert in child development, focusing a lot on parent-child relationships, focused on infants and toddlers; babies, toddlers, birth to three. We are an evidence-based program and have a three-tiered system of intervention with a universal level of services that include needed screenings for family concerns and child concerns and follow up on those screenings. And then a tiered level of intervention based on need for families with young children.

Sally: That’s really interesting, and you’re actually teeing us up for our next question. How are pediatricians helping families manage stress with all that’s happening right now, and what advice would you be thinking about giving to those families that are dealing with the highest adversity and stress?

Dr. Briggs: It’s a great question, Sally. I think a couple of things remain true, even though we are living through pretty extraordinary times. We know that there are two main ingredients for happy families with healthy children, and those continue to be safe, stable and nurturing relationships and a sense of routine and predictability to some extent. So obviously right now people are very stressed, and families are worried about lost income or even about not having enough groceries on the table. We also know from some of the great work that’s been done that babies pick up on that stress. They’re like recording devices that are always on. We don’t get to choose whether they record just the good or some of the bad, it is always on. So, what do you do and what can pediatricians do to help families during this time? I’d say three important things. One, and again this remains true no matter what time we are in – take care of yourself so that you can take care of your children. It’s about going easy on ourselves. Recognizing that nobody can overnight, turn into a perfect stay at home employee, pre-school teacher, care coordinator, systems navigator and parent when you’re not sleeping because you’re worried about trying to get food on the table. It’s about asking for help and organizations are scrambling to try to figure out the best ways to help families – moving to telehealth and moving to much more nimble service delivery options. Two, some semblance of a daily schedule. I think again this is a moment to go easy on yourself. It doesn’t have to be color coded and beautiful and every 5 minutes mapped out, but some daily schedule where there is some play time, time without screens and hopefully safe outdoor time. We’re advising families to expect that behavior will change and you may see in young children sleep disruptions or feeding difficulties. One thing we know for sure is that they’re going to be sensing the worry in the house and the stress in the house and needing a few extra hugs. And three, connecting with children when parents are in a good place. When they feel that they can be that safe, stable and nurturing environment for the children, and if not then to take a break and to ask for help. Maybe one of the best parts of being a toddler is that favorite books are just that and can be read every single day and multiple times a day. There’s not that exhaustion. Being able to just spend that 5 minutes. Depending on the age of the kid and how good their receptive language and understanding is, we can also explain to them a little bit about what is happening here in a developmentally appropriate way, but they rely on parents to interpret the world around them. If parents are sort of saying ‘no, no it’s fine, it’s all good you have nothing to worry about’, that’s going to feel discordant to a young child. So I would say really helping parents develop the language to explain that there is a virus and it’s making some people sick, children are not getting very sick from it, we’re staying home to help keep other people from getting sick and what can we do to really make sure we stay well? We have to wash our hands and not give hugs to prevent the spread of the virus. And we have to focus on our youngest patients to ensure that there are healthy and resilient families in the future.

Sally: Yeah, I hear a lot of what you are talking about also kind of swirling around mental health needs. I was wondering if you could speak a little more to what families and friends and neighbors and communities could do to help support the entire family’s mental health needs in the current situation.

Dr. Briggs: I was reflecting back I think earlier this week when a friend of mine who is a social worker himself, and someone that I’ve always thought of as very mentally healthy. He hasn’t seen struggle with depression or anxiety, and he is one of those folks who can be the calm within the storm. We were chatting and he told me he had a panic attack. He’s 45 years old, never had a panic attack before in his life. These are pretty extraordinary times and so they are taking a toll on folks. I think with all of this worry that we are hearing it’s incredibly important for parents to be that home base, for parents to be able to provide some of that calmness routine. They don’t need the latest game, they don’t need the latest app, it’s not about the latest and greatest sort of interventions. It’s about just some level of safety and stability in this highly stressful situation. Self-care is not selfish. It’s the best way that we can take care of ourselves and our children. There are plenty of resources out there that used to be fee-based and now are free, like Headspace and Calm. Physical activity to the extent we can get it; walking, jogging, jogging in place if need be, dancing, whatever it is that feels good and can be done safely. Cooking, journaling, taking a bath, having a cup of tea, chatting with friends, getting on a video chat. If you’re not a member of a HealthySteps practice and don’t have access to that mental health support right there in pediatrics, there are also other support organizations that have moved completely to an online service delivery model and are free. The Erikson Institute’s Fussy Baby Network is one of them. They’re starting to, I think starting last week, providing online support, video home visits, parent web support groups, they’re launching Facebook live sessions for infant massage and baby yoga and play and connection ideas. So, all sorts of options. And again, just asking for help. One thing that I’ve learned through this last month already is that we’re all just doing the best we can and we’re all struggling in one way or another. We have a section on our website on healthysteps.org on caring for yourself during Coronavirus, and there is also a zerotothree.org for tips for families Coronavirus if that could be helpful.

Sally: What are the pros and cons of health services that are delivered by technology instead of in person?

Dr. Briggs: Telehealth is emerging as this wonderful solution to so many of our problems, and it is absolutely a vehicle that can really help us reach families right now. There are some challenges to telehealth, not the least of which is that the guidelines around telehealth vary state by state. So you have 50 sets of guidelines about how to use telehealth, who can be reimbursed, what qualifies as a telehealth visit and then when we think about infants and toddlers, if you’ve ever tried to get an 18 month old to just stand in front of the camera for a 20 minute telehealth visit – good luck, right? I think as much as it’s an extraordinary platform and we can really extend the reach of services through telehealth, we’re going to see limitations both because we don’t have a national infrastructure around this and because infants and toddlers are not great at sitting still for the camera. We’re losing some of that key interaction piece of the parent and the child together perhaps and creating even more stress for a family because Dad is worried making sure that the baby stays in front of the camera for this visit. So, we are thinking a lot about yes, the promise of telehealth and the unique challenges particularly related to infants and toddlers.

Sally: You’re definitely speaking to the fact that our healthcare providers are being seen as real heroes right now, and we are wondering what should our healthcare system learn from this experience in order to adapt and improve the system for the future?

Dr. Briggs: Maybe, we finally recognize that we absolutely need a healthcare infrastructure for everybody in our country, and maybe we finally recognize that that healthcare infrastructure includes mental health. That there is no health without mental health. That there is no child health without caregiver health, and that goes for mental health as well, and that developmental wellbeing is a key construct in there. I am thinking so much about our increased understanding of all of these drivers of health. We’ve known for a long time that you can’t solve all problems within those four walls of the medical practice. That if someone goes back to unstable housing, if someone goes back to community violence, that those things are going to undo the important health interventions efforts we’ve made. My first decade of work was at Montefiore Health System in the Bronx, a borough where people are dying from COVID at twice the rate of their neighbors and the rest of New York, due largely to pre-existing health conditions and other risk factors associated with poverty. There is a higher incidence of asthma in the Bronx, largely based on a higher incidence of air pollution in the Bronx. And so, my greatest hope for all of us is that we recognize what heroes healthcare workers are and we recognize that we need a massive rethinking of the healthcare system to focus on those drivers of health that have to do with safe housing and environmental justice and safe and stable and nurturing relationships that are going to really create the foundation for health for folks, whether they’re facing this virus or another one down the road. We’ve got an extraordinary moment to get this right coming out of it, and it’s about whether or not we’ll have the courage to do so, the will to do so, and the resources to do so.

Sally: Thank you so much, Rahil for taking the time to be with us today. You’ve articulated so clearly the importance in making sure healthcare, including mental healthcare, is available for all. And that as you said, caregiver health is child health. We’re really grateful that you took the time to speak with us today.

Dr. Briggs: Thanks, Sally.

Musical interlude

Sally: I’m your host, Sally Pfitzer. The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu. We’re also on Twitter @HarvardCenter, Facebook @CenterDevelopingChild, and Instagram @DevelopingChildHarvard. Brandi Thomas is our producer, and Charley Gibney is our producer and audio editor. Our music is Brain Power, by Mela from FreeMusicArchive.org. This podcast was recorded at my dining room table.

While the coronavirus pandemic has changed many things around the world, it has not stopped child development. In this series of special episodes of The Brain Architects podcast, we aim to share helpful resources and ideas in support of all those who are caring for children while dealing with the impacts of COVID-19.

The first guest of this special series is Center Director Dr. Jack Shonkoff. He and host Sally Pfitzer discuss how to support healthy child development during a pandemic, including the importance of caring for caregivers. They also talk about what we’ve already learned as a result of the coronavirus, and what we hope to continue learning.

Upcoming episodes of this special series will focus on how pediatricians are responding, racial disparities in the impact of the virus, and more. Subscribe below via your podcast platform of choice to receive all new episodes as soon as they’re released.

Sally: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m your host, Sally Pfitzer. Since our last podcast episode was released, things have changed quite drastically as a result of the Coronavirus pandemic. We hope you and your loved ones are safe and well. During this unprecedented time, we would like to share resources and provide guidance that you may find helpful, so we’re creating a series of podcasts episodes that address COVID-19 and how it relates to child development. Our guest today is Center Director, Dr. Jack Shonkoff. Jack, thanks so much for joining us.

Dr. Shonkoff: Thank you, Sally. It’s always a pleasure.

Sally: So just so our listeners know, we’re recording this on a video call, so the sound quality will be a little different from when we are in the studio. We hope these conversations will be useful anyway. Especially to those parents, childcare providers, social workers, teachers, healthcare providers and any others who are with children every day during this crisis. So, I’ll start with the first one. Jack, how do you think the pandemic may be affecting very young children, so the infants and toddlers? There has been a lot of attention to the need for distance learning for older kids. But, what do you think about what these younger children might need?

Dr. Shonkoff: That’s a really important question, Sally, because this pandemic is different from anything that any of us have experienced around the world. Basic principles of child development, basic concepts of the science that we know don’t change, then I would say from my perspective try it on both the best science we have and the best common sense that once again this is all about relationships. This is all about the environment of relationships in which young children are developing and which they are growing up. So, the risk of the conversation is how do we feel that in this context, but it’s not a difference science, it’s not a different understanding of what children need, it’s just a different world right now.

Sally: Yeah. So, I am sure many of our listeners have heard this term “social distancing,” but I know that it is also lately being referred to as the need for physical distancing. Can you talk a little bit more about the science behind that, and what it means for children?

Dr. Shonkoff: Yeah, this is the question that I’m most concerned about. There are two different bodies of science that we are talking about right now. Normally, we talk about the science of early childhood development—science of brain development—and now we are also dealing with the science of infectious disease. It’s really physical distancing that we are talking about. Actually, social distancing is exactly what we don’t want if social distancing means that we get further apart in terms of our interactions socially as opposed to physically. Let me just talk a little bit about each. So, why is physical distancing so important? Because this is the way we stop the spread of this virus. This virus is incredibly contagious. It can jump from one person to another over a six-foot span. Everybody has heard about keeping 6-feet away. And, because it is so contagious and spreading all over the world, and without a treatment and without a vaccine, the only real strategy we have to stop the spread of this virus is to not have people be close enough to each other so they can pass the virus from one person to another—it’s a population issue, it’s a community issue. So yeah, we have to do that. We have to minimize the physical contact to stop the spread of the virus. They’re saying time—social connection, hugging, being together— is one of the most critical dimensions of healthy development. It is the heart of serve and return interaction between young children and the adults that care for them. So, that’s a core concept for healthy development. Physical distancing is a core concept for stopping the spread of a virus. The challenge is: how do we reconcile those two? If we just come together physically, the virus doesn’t stop. If we separate physically and don’t find a way to stay connected, then we are creating an environment that is undermining the healthy development in young children. I have to say, I want to express tremendous solidarity with the parents, the caregivers, service providers, who are struggling with this tension between the need to get connected and the mandate to stay physically apart.

Sally: Would you have any recommendations for any family members of caregivers who are experiencing that tension that you were just describing?

Dr. Shonkoff: Absolutely. So, I think the first thing—and this is again, a good example of where basic principle in development under normal circumstances doesn’t change—in a crisis, development goes on, even though the crisis is here. So, one really important thing to remember is that interaction between young children and the adults who care for them and serve and return responsiveness is not something that has to happen every minute of every waking hour. The issue is not all or nothing. And the extent to which it may be more difficult—not because people don’t have opportunities—because adults are really struggling with the pressures and the tensions that they’re feeling. I think many parents out there, many of the caregivers, all of us know that when we’re feeling significant stress, anxiety, unease and maybe even depression about what’s going on, that you don’t have as much energy to be on your best game all of the time. In this particular crisis, it is very important for people to understand that it is okay, and it is important for adults to have a little bit of downtime and pay attention to their own needs. It’s all a matter of balance, right? So, the first thing to think about is what your child needs is a reasonable amount of attentive interaction with you during the day, but that you also need time for yourself. You need time to have your needs met, and that’s also very true in non-crisis situations. In fact, one of the cardinal principles of the science of early childhood development is that if we want to create the best kind of environment for learning and healthy development for young children, we have to make sure that the adults who care for them are having their needs met as well. You know, people often use the example of the airplane: ‘parents put your own mask on before you put your child’s mask on.’ That’s not: ‘you’re more important than your child.’ It’s a way of saying, ‘you can’t take care of your child if your basic needs aren’t met.’ So this is where social relationships—networks—this is where parents supporting each other by smartphone, by FaceTime, or whatever. Interactions that parents have with other members of extended family, their community, their faith-based organizations, service providers you have a relationship with. All of these are necessary, not just to help you meet your child’s need, but to help you meet your own needs. In this particular crisis we are in right now, meeting the needs for the adults who care for children is the only way to meet the needs of children. You can not bypass the needs of the adults.

Sally: So, I think one of the things that’s really obvious about this pandemic is that it is affecting everyone, and every person has some connection or story or something that they are grappling with. I have been thinking about a lot of families that are dealing with economic distress, and wondering if the children who are living in those families are more at risk for toxic stress, and if we can think more about how we might instead try to build resilience.

Dr. Shonkoff: Let’s talk a little bit about toxic stress first, before talking about if you’re more or less at risk for it. It’s very important to start with that toxic stress does not refer to the cause of the stress. It refers to the body’s physiological response to the stress: your heart rate goes up, your blood pressure goes up, your stress hormones are activated. The difference between toxic stress and what we call tolerable stress is the extent to which people can manage the stress and feel some sense of safety and control, which brings your stress system back down to baseline. So, for young children—babies, toddlers, preschoolers—obviously their capacity to manage their own stress is not entirely up to them, it’s up to the adults who care for them, who do two very important things that make toxic stress tolerable. One is to provide a sense of safety in the children—a sense that you are being taken care of in spite of what is going on around you by the adults who are caring for you. So, once again, we come back to the fact that the adults who provide that sense of safety have to feel that sense of safety themselves. And, none of us—none of us—are capable of feeling safe and secure all by ourselves, all of the time. It doesn’t matter how much money you have, how much education you have—we all need relationships to help us deal with stress. Now, the other part that turns toxic stress into tolerable stress is helping a child develop a sense of being able to cope. So, it’s not just protecting the child from the stress, but helping to build the skills that really make for resilience. It’s basically having some sense of regulating your activity and being engaged in things, but maybe you feel some sense of mastery. That’s why play is so important. Play is probably the most important thing. For those parents out there—anybody who is involved in childhood programs already knows this—let me tell you from a science point of view that if you’re concerned about how a young child can manage and learn to cope with the stresses going on around a family, create opportunities to play with your child, create opportunities for your child to play alone and not necessarily having always to play with an adult. Focus on: ‘how do I provide an environment in which my child can play?’ Because that kind of play is the way the brain builds strong circuits for resilience—for mastery. Give your child and yourself a break. Be comfortable with playing with your child and following your child’s lead and engaging with serve and return interactions will be tremendously protective for your child’s brain and the rest of the body. Your question, Sally, was is this even tougher for families who are more economically insecure, and certainly for families whose economic insecurity under normal times is not very stable, in these times right now, the pressures are immensely greater, So, what we have to do as a society—as human beings— is to recognize that some people are going to need more help from others to create that sense of safety and security in their homes while everyone is being isolated, and to be sure that we are protecting the developing brain, the physical and mental health for young children. Why is that important? It’s important because it’s the right thing to do. What kind of human beings would we be if we didn’t do that? It’s important also, because that’s how we are protecting society by making sure we are promoting healthy development in everyone so that we all benefit later because we have a healthier population and a more productive population. So, yes, some people need more support than others, particularly families who are dealing with housing instability, families who are dealing with food insecurity—those very basic bare essentials. There are a lot of families dealing with those kind economic insecurities now who have not dealt with this before. We absolutely have to pay attention to the needs of families who need extra support, who don’t have the reserves or the resources themselves—it’s an absolute imperative certainly for the well-being of the children. Give families security and stability, and they will provide a protective and safe environment for their children.

Sally: I’ve certainly heard you say—and I know others have often said— that small things can make a big difference for kids and families. As I’m listening to you talk, I keep thinking it would be helpful to get again some concrete examples of what families, friends, neighbors, communities could do at this time to support each other, just to get us through with the least, long-term harm to children’s development.

Dr. Shonkoff: I’m going to start mostly with what adults can do for each other. I really think that the answers for what—in this crisis—what adults can do for children is very basic and simple: provide a sense of safety and security, provide opportunities to play, engage in an interactive way—serve and return interaction—and your child will get through this just fine. So, the concrete things that can be done to protect the development of children come down to a pretty standard list of things that basically adults need to feel safe and secure. I can mention a few of them, but I think the most important thing for starters is to say just like when we think about experiences and finding experiences for young children, there is no one size fits all, right? So, what do adults need to feel a sense of safety and security in the face of this tremendous anxiety? Before we go to services, let’s start with what people informally provide for themselves. You have friends. You have neighbors. You have extended family. They may be close by, they may be far away—ironically, in the world we are living in right now, it doesn’t matter how far they are away. You can’t be that close to them physically, so you have a telephone and a smartphone, you can look at people with whatever that media would be. People need to be able to share with each other what they need—generally emotionally, and socially—and be ready to give to each other what we’re each asking of each other. And that includes informal arrangements with communities that could include the house of worship and the community around that you may be affiliated with. It could be a mother’s group or play group, it could be whatever. So, that’s for starters. Some people really have a rich network of relationships to draw on—independent of income or education. But then there are people who either don’t have a rich network to start with, or have it and it’s not meeting the needs, and that’s where we could provide more assistance through services. This is a great investment, especially now, by us as a society to provide a safety and support and reassurance for families who don’t have the informal supports that are needed. There is no shame in asking for that and there should be no hesitance in providing that. Stress reduction, right? You need ways to reduce your stress, but different things work for different people. The list of the usual things that work for most people in some way in combination, start as simple as taking deep breaths. Especially if you’re feeling like you’re getting very stressed out. It’s not just a mindset thing, it’s actually physiologically—it’s helping to bring your blood pressure down, it’s helping to bring your heart rate down, so a deep breath and a slow exhale. Some people have learned how to do meditation. That’s important, that’s good. If you need a few minutes to do that, do it, and don’t worry about the fact ‘oh my goodness I am not interacting with my child’. Let your child play while you just go off on the side and relax. Music—dancing—could be a great way to reduce stress. And for some people, stress reduction is just getting on the phone with a good friend and pouring your heart out, and in the end saying, ‘thank you for this conversation, I feel so much better.’ So, stress reduction, finding what works for you—there’s no one size fits all. You’re giving yourself a little bit of space from your child during the day. Because at the end of the day, it’s all about us helping each other. So, the concrete things are not hard to remember and they’re not complicated. There is a lot of heavy-duty science behind it, but it can just point out to a few things: take care of yourself, figure out how to reduce the stress you’re feeling—the stress you’re feeling is normal, if it’s feeling out of control, then get some help. Don’t be afraid to ask for help, we all need help. The bottom line being is that it varies from person to person. This is the time to really be in touch with what works for you.

Sally: So Jack, even though we are still in the really early days of this crisis, and I think it’s really important to emphasize that right now we’re completely, as you said, just try to get through day to day and understand the science behind this. It can also be tempting to start thinking about if there might be any long-term lessons that we could have in mind as a society that might eventually emerge. Again, recognizing fully that we are just at the beginning.

Dr. Shonkoff: I think that is a really important question, and for me, the first answer to that lessons learned is not so much a new lesson to be learned, but an old lesson that maybe we will learn this time in a way we haven’t before. We are all in this together. Everybody is affected by what is going on right now. The extent to which we share responsibility and help each other get through is really important for all of us, right? I mean, in some ways COVID-19 is an amazing example of how we each need everybody to behave responsibly and protect everybody else. This is not just about what is good for you. Let’s just take the physical distancing, right? If people don’t do it, other people are hurt by that. And if other people don’t do it, you are hurt by that. So, if we all share the responsibility, we all benefit. And if some part of the population is indifferent, doesn’t care, doesn’t pay attention,  is just focused on its own needs, then we all pay a price for that. I mean, what great messages and lessons to take out of this crisis for how we should be under “normal circumstances.” Fast forward, at some point we’ll go back, and we will know that everybody with young kids is doing the best they can to raise healthy kids, and we all depend on that as a society. And some people are struggling more because they have less money, they have less education, they have less economic opportunity. We all benefit if we all take care of each other and do our job, and we all suffer, and we all pay a price if we don’t take care of each other and share the responsibility. I’d love that lesson to come out of this pandemic.

Sally: Thank you so much, Jack for taking the time to be with us today. I really appreciated your concrete advice, and I also especially appreciated the remarks you made about how this might be affecting different families in a variety of ways. I know at the Center, we’re trying to think of ways in which we can support our community, and some of that, of course means that we’re asking. But it also means that we’re trying to be responsive and put out resources that we hope will be beneficial. In that way, we hope whatever was said here will be helpful. We recognize that it might not be beneficial for every person listening, but we hope that today we could have hit on something that might help someone through this time. We’re really looking forward to continuing to hear from some of your friends and colleagues, Jack, in upcoming episodes of this short podcast series we’re doing on COVID-19. And we’re really grateful for your time, so thanks again.

Dr. Shonkoff: Thank you, Sally. I’s always a pleasure to have these conversations with you. Thank you very much.

Musical interlude

Sally: I’m your host, Sally Pfitzer. The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu. We’re also on Twitter @HarvardCenter, Facebook @CenterDevelopingChild, and Instagram @DevelopingChildHarvard. Brandi Thomas is our producer, and Charley Gibney is our producer and audio editor. Our music is “Brain Power,” by Mela from FreeMusicArchive.org. This podcast was recorded at my dining room table.

What is “serve and return”? What does it mean to have a “responsive relationship” with a child? How do responsive relationships support healthy brain development? And what can parents and caregivers do in their day-to-day lives to build these sorts of relationships? This episode of The Brain Architects podcast addresses all these questions and more!

Fortunately, there are many quick, easy, and free ways to create responsive relationships with children of any age. To kick off this episode, Center Director Dr. Jack Shonkoff describes the science behind how these interactions—known as “serve and return”—work.

This is followed by a discussion among a panel of scientists and practitioners including Dr. Phil Fisher, the Philip H. Knight Chair and Professor of Psychology at the University of Oregon, and director of the Center for Translational Neuroscience; Patricia Marinho, founder and CEO of Tempojunto and co-founder of Programa BEM; and Sarah Ryan, director of Life Skills at Julie’s Family Learning Program. The panelists discuss what it looks like to serve and return with children on a daily basis, and how to encourage these interactions.

Articles

Sally: Welcome to The Brain Architects, a new podcast from The Center on the Developing Child at Harvard University. I’m your host, Sally Pfitzer. Our Center believes that advances in science can provide a powerful source of new ideas that can improve outcomes for children and families. We want to help you apply the science of early childhood development to your everyday interactions with children, and take what you’re hearing from our experts and panels and apply it to your everyday work. In today’s episode, we’re going to dive into the science behind serve and return interactions and we’ll learn how important responsive relationships are to healthy development. Later in the podcast, we’ll incorporate these positive interactions into ordinary moments throughout your day. Here to discuss serve and return is Dr. Jack Shonkoff, who is the professor of Child Health and Development and the director of the Center on the Developing Child at Harvard University. Hey, Jack, we’re so glad to have you back.

Jack: Great to be here.

Sally: Today we’re going to dig into this concept of serve and return, so I’m wondering if you could start just telling us a little bit about what serve and return is.

Jack: Serve and return is a very simple phrase that tells us about how important the back and forth interaction is between very young children, actually beginning immediately after birth, and the adults who care for them. Serve and return, as we’re using it now, refers to how parents, or other adults who care for young children, exchange vocalizations. They make sounds, they look at each other. There’s back and forth interaction that occurs naturally between babies, very young children and the adults who care for them. These are things that parents and other caregivers do pretty naturally. Even if you haven’t had a course in child development, we are biologically wired to be engaged in that kind of serve and return interaction because it is necessary for healthy development. If we didn’t do it, if it required a course in child development, millions of years ago we would have become extinct as a species because babies’ brains and young children’s brains wouldn’t have developed in the way they do. It’s the essence of what promotes healthy brain development very early.

Sally: Why is that important for healthy development of a child?

Jack: It’s not simply important, it’s critical, because the brain is wired to expect this kind of back and forth serve and return interaction. It’s really the way the brain builds its circuits, the way the brain develops the capacity for different skills. Here’s a really good example. How do birds learn a song? Very similar to how do humans learn their language, which is speaking. A really elegant experiment was done once. Newly hatched baby songbirds who, at that point, didn’t know their songs. They removed them from the adult songbirds and raised them in cages with very high-fidelity recordings of the song for that songbird. You can guess what the punchline is here. Those birds never learned to sing, ever. Even though they heard the song beautifully, there was no opportunity to practice it and interact and get feedback from the adults.

Sally: That’s so fascinating. I’m imagining, as a listener, my first question might be, am I supposed to engage in this serve and return interaction at all times with children? If I’m busy doing something else, am I missing a really critical moment to build the child’s brain?

Jack: The best general answer is extreme on anything is usually not good. As much as it would be really bad for a baby or a young child to be ignored, most of the time, it is not helpful to be interacted with all of the time. That’s not the real world and children of all ages need some time to process what’s going on by themselves. It’s a balance issue. Is there anybody out there listening to this who don’t want a break at some point from all the nice chatter and interaction? We all need a little bit of a break.

Sally: We all need a break.

Jack: Absolutely.

Sally: Absolutely.

Jack: The important thing is when children are young and they don’t really understand a lot about what’s going on, that is not a time to say, “Well, it doesn’t really matter.”

Sally: Can you give us some examples? Not necessarily of how to serve and return, but how specifically does that serve and return interaction build a strong foundation?

Jack: It actually works in two ways. One is how it helps to shape and model brain connections. The other is the extent to which, if a baby doesn’t get that kind of responsive interaction, it triggers a stress response. The serve and return interaction is both important for its positive, it’s what scientists call experience expectant development, the brain is expecting it, but the other part of it is that because the brain is expecting it, when it doesn’t get it, the stress system gets activated because it’s biologically dangerous for a baby.

Sally: So when it comes to serve and return interactions, how do you know what might be too much, what might be too little?

Jack: Like everything else in development, there’s no one size fits all model for this, but at the end of the day it’s about knowing your baby and knowing your own style and finding a comfortable way of interacting. That fits in a very, very wide range of normal. And I think we also ought to talk about the stresses on parents. Some parents are working full time and have less hours in the day to spend with their child. I think one of the worst phrases we’ve ever imposed on parents is this issue of the importance of quality time in the evening, to make sure you get that quality time and if you’re working all day, well, guess what? There’s probably no time in the 24-hour daily cycle that’s more challenging for everybody than kind of early evening at the end of a long day. Some parents are struggling with a lot of stresses in their lives and there are many parents who are dealing with depression. Postpartum depression is a very real thing. People are overwhelmed by lots of problems. They can have a hard time summoning up the energy. And what, really, people need to understand is you don’t have to spend hours and hours a day with rich interaction. It’s the time you spend together. If there’s very little interaction, then you can’t summon that energy, then it’s really important to get help. But if the time you spend together includes a reasonable amount of positive interaction, you’re there. You don’t have to worry about whether there needs to be more.

Sally: Thanks Jack, I really loved hearing about serve and return and how it can be important to build responsive relationships in the children in our everyday lives. And when we come back, we’ll have a few experts on serve and return who are joining us for a panel discussion.

Musical interlude

Sally: Here to help us talk through the implications of serve and return, we have Dr. Phil Fisher, who is the Philip H. Knight Chair and Professor of Psychology at the University of Oregon and the Director of the Center for Translational Neuroscience. Hi, Phil.

Phil: Hey, Sally. Great to be here and connect with you.

Sally: Also joining us is Ms. Patricia Marinho, who’s the founder and CEO of Tempojunto, and cofounder of Programa BEM, who’s from Sao Paulo, Brazil. Hey, Patricia.

Patricia: Hi, Sally. What a pleasure to be here with you.

Sally: Also joining us is Ms. Sarah Ryan, who’s the director of Life Skills at Julie’s Family Learning Program here in Boston. Welcome to the podcast, Sarah.

Sarah: Hi, Sally. Thank you so much for having me.

Sally: Okay, let’s go ahead and get started. Sarah, this first question is for you. How have you used the concept of serve and return in your work?

Sarah: I work with young mothers and we have their children actually on site in our childcare center. I have them for one hour every day and we do a parenting or life skills curriculum, so I actually get to teach serve and return and touch on it every single day with them and talk about specific examples: what their child offered, what they offered back, and talk about enhancing or pointing and naming or adding one thing, adding a color, adding a shape.

Sally: How have you seen that impact your families? Does it help them get a better understanding of serve and return interactions or just how their child is developing?

Sarah: Well, I would say all of the above. Then they feel this sense of competence and mastery. My young moms don’t have their high school diplomas. They’re working on those. And they often haven’t thought of themselves as valuable teachers, as competent, as capable, and many of them didn’t receive high quality, consistent serve and return in a nurturing way. So when they realize they can do it and they have every tool they need already to grow their children’s brains and to develop them, it’s really empowering. It’s really exciting to watch parents and the young moms really come alive and then get excited about doing more of it and reporting back what their children do and feeling so much pride in that.

Sally: Right. It’s that positive reinforcement cycle, right? They understand that they actually already have all the skills that they need to do this. And, Phil, that actually reminds me a lot of your work and I’m wondering if you could share a bit about results that maybe you’ve seen–how people, when they start to better understand what serve and return is, how they are better able to interact with their children.

Phil: Sure. I’d be happy to talk about that. First of all, I think the whole concept of serve and return has really had a huge impact in how we communicate about the science of early childhood in the sense that it’s just a really straightforward and vivid way to convey this idea of back and forth interactions being so central. In our own work, one of the things that’s been really essential has been to clarify that the serve and return process is most impactful when it begins with the child. So that is the extent to which the child is exploring the world, is using language or vocalizations and the adult notices the child serve and then returns it. But what’s really transformative, I think it’s pretty clear that we’re pretty hardwired to notice what children are doing and respond, but it can still go beneath the radar for people to have awareness of what they’re doing and that’s why a lot of us, I think, are now gravitating toward techniques like video coaching that can really make it apparent to people how they are participating in the serve and return process and therefore should just do more of it.

Patricia: I’d like to add on something. I think that the word transformative is very powerful in terms of thinking of serve and return. And I’d like to give my testimony as a mom because I think the first encounter that I have with this knowledge of serve and return was thinking about the way I personally act with my kids. It was amazing to see, to really understand the metaphor that the child was ready to explore and I would be the one helping them. I discovered the knowledge of serve and return and decided to apply in my personal life and I found this transformation both in myself and in my relationship with my kids and with my children. So I think this transformation aspect is really very, very powerful.

Sally: Yeah. And it picks up on what both Sarah and Phil were saying that once parents have the opportunity to see how serve and return can actually be building their child’s brains and be building that positive relationship, it’s self-perpetuating. You want to do more and more of it. Right? Sarah, I’m wondering if you could speak a little bit to if there’s an adult that might be in your program who says, “I actually never really experienced this serve and return interaction with my own parent and now I’m expected to engage with it with my child and it feels overwhelming and maybe it’s a science concept that I don’t really want to dig into too much.” What would you say to that parent to increase that interaction between them and their child?

Sarah: You know, I have had women who say, “That wasn’t my experience at all. I was not to be heard,” or, “My parents were busy working to provide and we didn’t have that.” They want something different. And I really just start with their strengths. I very often have seen them with their children and so I will bring up an example and point that out and then they sort of take it from there. They very consistently expand upon that and how great that moment was or what happened next or what preceded that before I happened upon them. And then we go from there. They feel the success, they feel the relationship and they want more of that. So, really, it’s not difficult to get folks to lean into that as powerful and as meaningful.

Sally: Absolutely. Patricia, have you seen similar interactions with the mom’s that you work with?

Patricia: As Jack said, we are biologically wired to serve and return. So when we just start to pay attention to what we’re doing and see the lights in the eye of the kid when we are interacting with them and the pleasure that you feel when you are responding to them, so whenever the family has the opportunity to lead that, they want more. We can help people find back the pleasure of being a parent. We spent so much time talking about the struggles and how hard it is. And it is something hard. It’s an art to raise a kid. But when we help parents go through the route of finding the pleasure of being a parent, and for instance, in my field of work, we work a lot with play and we put play as a center place in terms of making parents really have back and forth interactions with the kids and everything we do in terms of play, everybody ends up smiling. So whenever we can close the gap between the concept and something that makes people’s lives better, it’s almost always easily understood and applied.

Sally: So I’m imagining as a listener something that might come up might be someone saying, “Well, I’d love to be doing the serve and return interaction all the time. I want to build the strongest brain and the best foundation for my child, but I’m also extremely busy and I’m juggling so many different things throughout the course of my day.” Could any of you respond to what if you’re a busy parent, how can you make sure that you’re increasing the serve and return opportunities or finding ways to look for this in your everyday lives?

Phil: I’m happy to talk a little bit about that. First and foremost, serve and return is a process that can happen in seconds. It’s not an idea that you need to set aside an hour or two per day, so any opportunity to notice what the child’s doing. Think about it in terms of how are they serving and how you can return the serve is going to benefit the child in the long run. I think that’s probably one of the most important things to think of. The other is that serve and return happens in the context of everyday things that are going on in people’s lives. So whether it’s mealtime or whether it’s time where you’re getting into the car or driving somewhere, if the child is with you at the grocery store. So it’s not about like, “Do this for a certain amount of time every day.” It’s just when you have the opportunity to do it, these are moments that are really building healthy brain architecture.

Patricia: I love to use the expression, “Playful parenting,” to describe an attitude that we can have in our daily lives so that we can really enjoy all this moments that Phil just described that happens all the time. So you spend some time with your kid, maybe it’s not so much, it’s not enough or it’s not all the time that you’d like to have, but instead of complaining about the lack of time, because we would all be doing that and we have the playful parenting as a concept, you’ll see that you can really find joyfulness and you can enjoy every minute you have with your kid, if you are in the right frame of mind.

Sarah: I would just like to add something that Patricia mentioned: playful parenting. My parents always identified that they want a good relationship with their children, so this is a simple way to teach them. The serve and return interaction teaches them a way, a concrete way to start developing a relationship that is back and forth, that will develop and evolve into the children’s teenage years and adolescence and it’s going to be this continuous back and forth. The relationship starts now, and I tell my parents, “Your children are babies, but you want them to talk to you when they’re teenagers about what’s going on in their lives and that back and forth starts right here. You’re already starting that relationships with them.” They want to be able to have their children come to them and talk to them.

Sally: I noticed we’ve been using the term parent a lot in these conversations and, Phil, I’m wondering does this have to be a parent that’s doing the serve and return interaction?

Phil: The idea of what serve and return can really involve is that it’s an adult in the process of returning a child’s serves and those can be exploration, but they can also be that the child’s upset or crying. It’s really any adult with whom the child has a meaningful relationship where the serve and return process is so critical. So you can think about this in terms of other adults in the family, whether it’s a cousin of the parent or whether it’s a grandparent. It can be foster or adoptive parents, for sure. And it can also be, and this is extremely important, it can also be in childcare and preschool settings. That adults who are the child’s educator or teacher can be ones that are instrumentally involved in returning children’s serves. So it’s really any adult with whom the child has a meaningful relationship where that serve and return process is going to be especially beneficial.

Sally: Great. Up next our panelists are going to answer some of your social media questions.

Musical interlude

Sally: Now we’re going to open it up to some of our social media followers who submitted questions to the Center. I will start with this question to you, Patricia. This is a social media question from light.annika from Instagram and they ask, “Is serve and return better for infants and toddlers or can it also work with older kids?”

Patricia: It can definitely work with older kids because the basics of it is understanding there is a person and establishing communication. So when you start from your kid, your infant, paying attention to what they’re looking at, their serve and return is based on that. Later on, you will be a better listener to your older kid, your teen kid, and you’ll be a person that will make sure that you listen first and speak later because you understand there is a communication process.

Sally: Here’s another one from light.annika and, Phil, I’d like to address this one to you. “Should I explain to a baby everything we do and see?”

Phil: It’s absolutely not necessary to explain to a baby everything we do and see. In fact, a very young baby isn’t going to have the capacity to understand everything that is seen and done. It’s really a question of noticing what the child is doing and then responding. And you can respond either by using words to respond, to name what the child is expressing or looking at. Or you can also use other kinds of acknowledgement. Some of them can be just nodding your head or saying, “Um-hmm,” things that help them to understand that you see them and you hear them and you understand what they’re focused on.

Sally: It’s all the stuff I’m doing right now that you guys can’t see. I’m nodding and acknowledging and I’m returning your serves, I promise.

Phil: We can tell that you’re listening by your response.

Sally: Excellent.

Phil: And the other thing I want to put in as a really important note here is that parents often are interested in understanding this idea of if a child is focused on one thing and then they shift their attention to another, if the serve and return process involves following the child’s lead and kind of going from the end of one thing to another, is that what you should always be doing? Or are there times when it’s helpful to kind of encourage the child to stay at what they’re focused on? The concept of serve and return is really built around the idea of following what it is that the child is doing and I think especially for children under age three, this idea that there’s a point at which they’ve had enough of focusing on a particular task and that their attention shifts to something else is really critical. And that one of the things that parents can do that’s most helpful is to just wait and see what the child is doing and follow their attention from one thing to another. As children get older it may be possible to direct their attention back to something that’s a task at hand, that is important to focus on. Whether it’s eating or something else that might be important to have sustained attention. This idea of noticing what the child’s doing, mapping onto their serve and then returning their serve doesn’t mean that all day, every day parents should just be following what the child’s doing. There are plenty of times when you’re needing to leave the house, the child has to be put in their car seat, you’re walking across the street where it’s not up to the child to do what they want to do. The adult really has to be the one who’s determining what’s happening and that’s just fine. There’s in no way an effort to say, “Only do what your child wants to do.” It’s more about, as we’ve all been saying, noticing the situations where you have the opportunity to let the child lead, to notice what they’re doing and then to return their serve that are particularly helpful for brain development.

Sally: Here’s another one. This is from ellemeez from Instagram. Sarah, I’ll address this one to you. She asks, “I have two little boys who are almost four years apart. What’s the best way I can engage them both?”

Sarah: Sure. There’s some things that are just so universal. What is important to you? What do you have fun doing? What do your children have fun doing? And following them. So if you have a dance party in your house, this is good for everybody. If you are enthusiastic when somebody starts to dance and then everybody’s dancing. If you take what the older child is capable of doing and let them start the serve and return with the younger child, the younger child is always so much more interested in whatever the older child is doing than with the parent is doing, most of the time. Anytime you can have that magical moment where the older child is engaged with the younger child and they’re both leading the way and back and forth and then the parents just hop in occasionally in that. There’s so many natural moments to let the older child engage the younger child.

Patricia: I want to say something else about this question. When she says that the best way I can engage with them both, there’s for me something behind that is investing some time to understand your kids, who they really are and what they like. Sometimes we forget to do that, to not come up with our own ideas of how to engage them. But just to work with the things that they like to do and if you know that it’s not that hard to engage them.

Sally: That was a really great conversation and I just really want to thank all of you for your time being here and for giving us your expertise on these topics. And up next, Dr. Jack Shonkoff will be here to debunk another early childhood development myth.

Musical interlude

Sally: We’re back with Dr. Jack Shonkoff. We’ve been talking a lot today about the need for active engagement between child and a caregiver in that serve and return interaction that you were sharing and it sort of reminded me of that expression that we often hear people use in our line of work, where people will say things like “babies are sponges” or that “their brains are always absorbing,” but from what we heard today, that doesn’t seem to be a correct analogy.

Jack: I’m really glad you use that analogy, Sally, because we do talk about babies as sponges a lot. From a scientific point of view, sponges is probably not the best way to describe babies because a sponge kind of sits there and passively absorbs what’s coming. What’s different about serve and return is that the baby is, or any young child, is an active agent of that interaction. It’s not just passively absorbing, it’s also serving. It’s feeding into that interaction and that’s the key difference. So we are not passive sponges, even though we soak up everything around us. We are active agents in our own development.

Sally: We are not passive sponges. That’s the sound clip I’ll take away from this.

Jack: Parents who buy educational videos for babies like classical music or show you beautiful art, that that’s been studied and it’s been found that it has no effect on children. Why? It’s only one-way. There’s no serve and return. You’re just passively listening. That’s not how kids learn to talk. A lot of research on language development shows us that at birth the brain is capable of learning and speaking any language in the world fluently. And in the beginning it’s listening. It’s kind of listening to all that chatter going on around. It’s beginning to differentiate sounds. By 9 to 12 months of age, research is very clear that children are already losing the ability to differentiate sounds in languages they’ve never heard. The brain is pruning away that ability and focusing on just the language it’s heard. So whether it’s language development, whether it’s learning about cause and effect, whether it’s learning just about everything in the world, it’s the back and forth interaction, studied in animals, studied in humans, that comes out to the simple term of serve and return. You can’t just feed information into a baby’s brain. You have to engage in an active back and forth serve and return interaction where the baby is playing a role and the adult is playing a role and you influence each other. That’s how healthy brain development happens. That’s serve and return.

Sally: Thanks, Jack. Another myth busted. Up next, how do we add serve and return interactions to our already busy lives?

Musical interlude

Sally: We’ll leave you with some really simple ways to get started with incorporating serve and return into your everyday lives. And it can be as easy as playing peek-a-boo or where’s baby, a game where there’s back and forth between you and a child.” Or you can just take a few seconds to notice what a baby or toddler is looking at and then talk to them about it. So, for example, if you’re looking at a toy, you can say something like “That’s a ball” Or a doll, or a block—whatever you’re looking at, it’s just important that you’re sharing the attention. And then you would describe it in words. You might say something like “it’s round and green.” You’d wait for their reaction and then you’ll share that interaction back and forth. So if you’re not used to talking through everything with a baby, don’t worry. It does get easier with practice. And even these really simple steps are making amazing connections in a child’s brain. I’d like to, once again, thank our guests, Dr. Phil Fisher, Ms. Patricia Marinho, and Ms. Sarah Ryan and Dr. Jack Shonkoff. I’m your host Sally Pfitzer and we’ll see you next time. The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu, where we’ll post any resources that were discussed in this episode. We’re also on Twitter at Harvard Center, Facebook at Center Developing Child, and Instagram at Developing Child Harvard. Brandi Thomas, Charley Gibney, and Kristen Holmstrand are our producers. Bridgette Cyr is our audio editor. Our music is Brain Power by Mela from freemusicarchive.org. The podcast is recorded at PRX Podcast Garage in Allston, Massachusetts.

What is toxic stress? What effects can it have on a child’s body and development, and how can those effects be prevented? What does it mean to build resilience? This episode of The Brain Architects explores what “toxic stress” means, and what we can do about it.

Host Sally Pfitzer is once again joined by Center Director Dr. Jack Shonkoff as they dive into the different types of stress, including what makes certain stress “toxic,” while other stress can be tolerable or even positive for children. They discuss the effects that toxic stress can have on developing brains, as well as what it means to be resilient to sources of stress, and how parents and caregivers can help encourage that resilience in children. Dr. Shonkoff also emphasizes the point that, even for those who may have experienced toxic stress, “it’s never too late to make things better.”

Then, listen to a panel discussion featuring Pediatrician Dr. Kathleen Conroy, Community Mental Health Worker Cerella Craig, Professor and Researcher Dr. Megan Gunnar, and Training Director for Rise Magazine Jeanette Vega, as they discuss the various ways in which they encounter toxic stress and its effects in their work. The panelists speak openly about how toxic stress can affect families and children—including ways in which the systems set up to help can be the cause of further stress—and how to talk about toxic stress in a way that doesn’t make things feel hopeless to those who have experienced it. They also dig into strategies they employ in their various fields to help children and families deal with stress, and move what might be toxic stress back to tolerable levels. Download the episode and subscribe to the podcast today.

Sally: Welcome to The Brain Architects, a new podcast from the Center on the Developing Child at Harvard University. I’m your host, Sally Pfitzer. Our center believes that advances in science can provide a powerful source of new ideas that can improve outcomes for children and families. We want to help you apply the science of early childhood development to your everyday interactions with children, and take what you’re hearing from our experts and panels and apply it to your everyday work. In today’s episode, we’re going to explore this concept called toxic stress, which is a buzzword you may have heard and potentially used incorrectly. So we’re going to discuss what toxic stress is and what it can do to a child’s body and development, and we’ll learn a little bit more about what we can do to counteract its effects. Here to discuss this topic of toxic stress with us is professor of child health and development and the director of the Center on the Developing Child, Dr. Jack Shonkoff. Hey Jack.

Jack: Hey Sally.

Sally: So glad to have you back with us today.

Jack: Great to be here.

Sally: Today, we’re digging into a topic that has quite a bit of research around it and a lot of different ideas out there in terms of what it actually is and how it affects children’s brains. And this is the topic of toxic stress. So from your perspective, could you just give us a little bit of background on what is toxic stress and how did the term come to be?

Jack: This is a really important one to talk about. The story starts with

Sally: Could you talk a little bit more about what you mean by resilience and is there a way that we know how to actively build that in brains?

Jack: Resilience is learning coping skills, it’s learning adaptive skills, it’s being able to feel a sense of control over what’s going on. But when children are very young and they feel less control and the resilience is built by adults creating a sense of safety and protection and then modeling for children. There isn’t a day that goes by for any child at any age where there aren’t challenges and what parents are doing in terms of building resilience without calling it resilience is they’re helping the child develop a sense of what scientists call agency, a sense that you have some control over your own life. It’s things like what you eat and whether you only eat candy or will eat some reasonably healthy foods, whether you learn to share your toys. The critical issue for children is are the adults who care for them able to provide a sense of safety? Sometimes the adults are so traumatized themselves that they can’t without help. This is why when you’re on an airplane and they say if the oxygen masks come down, put your own mask on first before you assist your child. That’s based on good scientific understanding. Adults have to be capable of providing that. If you have at least one secure relationship that is, gives you a sense of safety and security, you are on your way to building resilience. ‘Cause, it’s those relationships that provide safety and help model coping behavior that are the active ingredients in building resilience.

Sally: As challenging as it can be to talk about and as uncomfortable as it can be to really think through, could you tell us a little bit about what does actually happen to a brain of a child who’s experiencing toxic stress? I think it’s really important for listeners to understand the biological implications of what this trauma can really be doing for children.

Jack: Yeah, I’m really glad you asked that question because different parts of the body that are dimensions of the stress response system have different effects in different ways. So for example, very high levels of stress hormones, particularly one that’s called cortisol, which in the acute situation is very protective, it helps make you more alert and it helps you deal with stress. If that stress hormone stays up for a long period of time, it actually starts to have a negative wear and tear effect on parts of the brain. So, the parts that are most vulnerable to chronically elevated stress hormones are a parts of the brain that affect your memory, that affect your ability to regulate your emotions and behaviors. There are other parts of the stress system, for example, elevated inflammation. If that stays very high, that can affect parts of the brain that make you more at risk for serious cognitive thinking problems and actually later in your life increase your risk for dementia, but at the same time it’s affecting other parts of the body. Inflammation creates heart disease. It increases the risk for a lot of chronic illnesses like arthritis. It’s the wear and tear effect on the body of this stress activation, which actually accelerates aging. But remember, every time we talk about this, this is not a doomsday scenario because stress is normal. Stress is part of our everyday life. It’s not about whether you’re experiencing stress, it’s about whether there are adults to help you learn how to deal with it and help you feel safe.

Sally: Yeah. If a child experiences toxic stress or if a listener is thinking about the toxic stress they experienced in their childhood, what would you sort of say to them about these outcomes that you’ve described?

Jack: Anytime I give a lecture anywhere or a presentation, there are always people in the audience who are sitting there saying, “Oh my goodness, this is me.” I know that because they come up to you after you’ve given a presentation and people will say, “I’m really understanding what’s been going on in my life in a different way.” For some people it’s very frightening. For some people it’s a relief to say, “This isn’t my fault. I’m not a weak character. Now I understand.” But what’s most important is that none of us is perfect, none of us has a life without challenges, but the brain and the rest of the body is always trying to get back on track. That’s the other thing about biology. If you’re weighted down with risk factors and problems in your life and you find supports and you find ways to build better skills to cope, the brain can’t wait to get back on track, it is always trying to do that. We know this is something that we don’t have to passively sit by and accept. We can always do something. We can always make things better, always. Better to get it right early, the first time. Better to prevent problems than try to figure out how to treat them later. But it’s never too late to make things better. It’s never too late to improve outcomes.

Sally: Jack, as we wrap up here, I wanted to think a little bit more with you about how parents or caregivers or anyone who’s really interacting with these children who might be experiencing stress can make sure that these stress responses are more tolerable as opposed to more toxic.

Jack: Yeah. This is a really important question because there’s so many times when we oversimplify the story. I think the key difference between tolerable and toxic stress at any age is not the cause of the stress, but how your body is dealing with the stress. And the younger you are, the more you depend upon adults to kind of provide that protection. Although there’s no age at which we do it by ourselves. So we’re always looking for support. Um, I think what’s really important for, particularly for parents to understand and, and providers of, of early care and education who spend lots of time with kids is that very often the challenges facing the children may be more than a parent or a childcare provider alone can deal with. And there’s no shame in saying I need help. I need help to protect my child. I need help to make sure that my child is protected in the face of these circumstances we’re dealing with, or I need help to be able to help my child develop better skills, to cope, and to be more resilient. I think one of the most dangerous things and one of the most harmful things that we do is to basically send a message to parents and childcare providers and others who are facing serious challenges and tough circumstances to kind of say to them, you know, “This is all on you and, and, um, if you don’t do a good job, you know, X things are gonna happen.” I think one of the healthiest and most promising ways for any of us to deal with, with threat and challenge is to be able to say when we need help. And so it’s not just the help that children need from adults, um, can only best be given when adults who need help themselves to do that are comfortable enough and we make it easy enough to provide that help for the adults. The relationship is between the young child and the adult is critical. Adults thrive in their own environment of relationships. None of us can do everything by ourselves. And if we understand that importance, then we will minimize, if not eliminate toxic stress in the lives of everybody.

Sally: Thank you, Jack, for being here and for talking with us about this really important concept. I think it’s especially important to note that while toxic is extremely serious, it’s also not the end of the road for anyone and that there’s lots of things we can do to mitigate against the effects. When we come back, we’ll chat with a few special guests to discuss the work that they do to actually prevent toxic stress and support those who’ve experienced it.

Musical interlude

Sally: Joining us today to talk about toxic stress is Professor Megan Gunnar. She’s the professor and director of the Institute of Child Development University of Minnesota. Hey Megan.

Megan: Hi, it’s wonderful to be on this conversation.

Sally: Also on the call we have Jeanette Vega, who’s the training director at Rise magazine. Hi, Jeanette.

Jeanette: Hi. Thank you so much for inviting me on this podcast today.

Sally: Also here is Dr. Kathleen Conroy, associate clinical director, Boston Children’s Primary Care and assistant professor at the Harvard Medical School. Hi Kathleen, glad to have you.

Kathleen: Thanks so much for having me.

Sally: And also joining us is Cerella Craig who’s a community mental health worker, New Haven, Connecticut. Welcome to the podcast, Cerella.

Cerella: Hi, happy to be here. I’m looking forward to speaking with you all today.

Sally: Cerella, I’m wondering actually if you could provide some insight for us on if you see the effects of toxic stress in the work that you do directly with families.

Cerella: Yes, so one of my primary responsibilities as a research assistant and community health worker is recruiting people who are at high risk for toxic stress into mental health services. What for me that sometimes looks like is a mom who’s very untrusting or who is very skeptical and almost as a result of losing trust of systems that have constantly failed her. We’re not talking about the type of neglect that may have come from a parent. It’s a different neglect. So we’re talking about a neglect from systems that have failed to serve these moms. Now, what I see is really a lack of trust, a lack of belief that there’s the ability to help.

Sally: Jeanette, I’m wondering what you have been seeing from your perspective.

Jeanette: I’ve been working with parents for the past 15 years that were affected by the child welfare system, the school system, hospital systems. They were telling us that they were facing toxic stress themselves. I lost my son, I ended up losing my job, I had to quit going to school. I ended up losing family members and it just felt like my anger would jump from a hundred to a thousand on a daily basis because these things were constantly happening to me and they were repeatedly happening for a long period of time. That’s what families face when they face child welfare and when we’ve been studying this at Rise, how the child welfare system is giving parents toxic stress, they’re giving parents five different services to do in a week and they have to visit their children weekly and do therapy and parenting and anger management classes.

Sally: Kathleen, are you seeing a similar situation? I know you work a lot with young parents, and I’d be curious to hear if you have seen similar distrust as Cerella described, but also what the effects of toxic stress have been on some of the children that you’ve been working with.

Kathleen: We see a lot of families who have been failed time and time again or challenged time and time again by trying to access systems that should be set up to help them, systems like public benefits, school systems, childcare systems, the healthcare system, which often put a lot of barriers in people’s way. We know there’s a ton of implicit bias in these systems. We know there’s a ton of negativity in these systems and often people who are particularly low-income people are trying to access resources in these systems and spending a lot of their time doing that, I think this can become a form of trauma and in of itself for folks. Indeed, I think we spend a lot of time attempting to build trust and repair in some cases. I think one of the advantages we have in pediatrics is that we get to have longitudinal relationships with patients, which is one of the things that’s really joyful about it. But sometimes we see things develop over time with families where we’ll see an infant who appears to be thriving with a family because they’re meeting their gross motor milestones and they’re going along through their first year of life. And it’s only later that we start to see some developmental outcomes that might not be as ideal and recognize that often these kids were experiencing a lot of stress and that we’ve maybe missed the opportunity to help parents work on that with their child. That’s one of the things that we’ve started to pay a lot of attention to in pediatrics is how do we talk to families about the stress their children are experiencing? How do we acknowledge that children experience stress? How do we distinguish tolerable from non-tolerable stress? And how do we help parents best work with their kids and promote their development? Since we know that parents are working so hard on that, how do we help them in the best way that we can?

Sally: Yeah. Jeanette, I’m wondering if you have any guidance from your work that you do in communicating directly with parents and thinking about how they talk about this toxic stress and how they are able to kind of work through it with their children.

Jeanette: At Rise, we’ve been working into getting knowledgeable about toxic stress. I ran that statement science tells us that healthy brain architecture depends on genes and environment by my parents’ staff this week, and a parent says it just sounds like scientists are saying that if you are a person of color—referring to the genes—and if you live in low-income communities—referring to the environments—that your family members are just screwed and you will get toxic stress.

Kathleen: I think that Jeanette, you’re pointing out such a wonderful and really important point that if we start talking about certain circumstances as determinative, right? Like, oh, if you’re experiencing this or that, then there’s this irreparable harm done and it’s a simple equation. And in fact, if we’re portraying it that way, we’re selling both the idea and people short, right? Because what we know is that many, many parents are parenting really well despite facing significant adversity–they’re modeling building relationships, they’re modeling emotional self-regulation under difficult circumstances. And I think we need to remind parents that when they are showing those amazing skills to their children and when they’re portraying as much love and consistency as they can under difficult circumstances, that’s actually building their children’s life skills, right? They’re actually giving their child something. I think it’s a really good point that if we’re talking about things being determinative, we are going to lose our audience for this message and we’re going to be very incorrect.

Sally: Yeah, Megan, I’m wondering what you have been seeing from your perspective as a scientist directly working on this research, responding to both of those questions that were posed.

Megan: Oh boy, these are very big challenges and precisely some of the ones that we were worried about as we worked on the language. It is really to try to translate the science so we can change what we know children need and what we do for kids, really on the structural level of societal change. The original reason to talk about it as involving both genes and experience was to get away from the idea that if you weren’t doing well it was because you were born that way. Now we have this massive problem for as a society we need to remove the barriers or reduce the barriers for families and children who are growing up in situations or living in situations that are not supportive of brain health. Right? It’s not that nobody in those environments will experience brain health because families are amazing at what they are doing to try to compensate for everything that’s coming down on them. But as a society we should start removing some of those barriers. So it depends on your experiences, but parents are great. And even in these difficult circumstances, most parents are doing well. The problem is the complexity of this and trying to get the message weighted appropriately so that we acknowledge the fact that there are inequities in our society and those inequities are increasing the risk of harm to our kids and to our future society, while not, at the same time, going deterministic. So I think that means that when you’re working with individuals, you say, “Look, we understand. None of this is going away until we make the structural changes that makes our society more just and equitable for everyone. But in the meantime, what can we do to help you protect, buffer and support your child?” Right?

Cerella: Megan, what I’ve seen a lot of that comes around teaching people skills that they can use in real time. I think in a perfect world, this change would happen a lot quicker than in reality. It’s going to happen, so in the meantime, what we need to do and what I’ve seen to be effective is to send parents home with skills, with tools that can teach them how to do either meditation practices or breathing exercises or steps to learn problem solving techniques. Some of these structures at home where they can promote their own wellbeing and that of their children. I think that’s really the best shot we have at ensuring some of the wellbeing of mothers and children around toxic stress because it’s not going to go away, so we really have to teach some concrete skills that can be used in the moment, that are easy, that are cheap, that are accessible. I think that’s one way parents can be encouraged to promote health within their home.

Megan: Oh, I agree completely. Yes. And it’s just combined with the message that we know this is not your fault, is the piece that sometimes, I know you all are giving, but I’m not sure that we are making it really clear when we talk about toxic stress that we don’t think it’s the fault of the families. What we believe is it’s the fault of the way we’ve constructed society, but what do we do to help families mitigate those negative influences?

Sally: Yeah. Cerella, I really appreciated your specific examples of resources that parents or caregivers can use. I think a lot of people listening to this podcast may have experienced toxic stress themselves. They may know children that are experiencing toxic stress and what we want to make sure we do is leave people with the impression that there’s hope, there’s opportunity to build resilience. I’d be curious to hear from others what kinds of skills and resources you’ve given to parents or caregivers or worked with them to develop that might be beneficial for others listening.

Jeanette: What we found helpful at Rise and what parents have said has been helpful, even for myself, is definitely having at least one person who’s very supportive. Having that peer-to-peer support with someone who understands what you’re going through has been amazing and just parents overcome little situations.

Cerella: I can definitely support what you said around social support being a tool that you’ve seen parents use. You’ll hear people say the best part about this intervention was hearing that there were other women going through the same things that I’m going through. Outside of just that anecdotal evidence, can any of the scientists speak to some of the implications of social support and has that from a toxic stress perspective been shown to be helpful?

Megan: So one of the most powerful buffers of stress is supportive relationships. We call it social buffering. It works across the mammalian species, whether you’re a rat with another rat, a parent with a child or two adults. So having another person with you who is emotionally supportive is a very powerful stress buffer. It’s the best we got, which is why the kind of history that you might have that makes it hard to trust others is something to be of concern and where we might want to help families or parents repair so that they can find people that they can trust. The work you’re doing and the way that you’re going about doing it, it is relationships, right? Relationships are the key thing across all of human development, child into adulthood.

Cerella: Can we talk a little bit about how a lack of basic needs served as a barrier and how those things need to be addressed first. Very specifically, if you have a family who’s hungry, we can’t start a conversation about resilience until I can focus enough to hear what you’re saying if you’re my pediatrician.

Jeanette: I’ve been doing surveys here from parents. What are their basic needs and what is it that drives their families to stress or crisis mode? I was shocked to find out that the first thing most parents say is food, lack of enough food to last me the whole month, they say public assistance doesn’t provide enough food stamps to last the whole month. They get like, “I’m hungry. I’m not thinking straight. I’m not planning for my future. I’m just thinking about when am I getting that meal for my children and myself for tonight?” I don’t think parents can even focus on bigger issues unless we start acknowledging, like you said, and being aware that when parents are facing basic needs issues, they’re not going to focus on the bigger issues that are causing them any stress in their life. Another strategy that we use is breaking down what’s going on in your life. Like I said, I work with parents affected by the child welfare system. What I tell them is, “If you’re feeling toxic stress, let’s break down what’s going on in your life and prioritize what you need to do. So let’s say you don’t have food and you’re also about to get evicted from your apartment, let’s concentrate on getting food on that table for today and tomorrow and then next week let’s get working on the eviction.”

Kathleen: The other thing we have to do is just making careful that we ask parents what it is they want to focus on, right? Because I think sometimes you guys are talking about this concept of hierarchy of needs, right? And I think the hierarchy of needs on some level is deeply biological, right? None of us function well when we haven’t eaten or slept, when we don’t feel safe, right? And so of course it makes sense that we need to meet our most basic needs first. I think sometimes in places where we’re prepared to meet more than one need, we also just want to make sure that we’re not assuming where somebody is coming in and we want to ask them what the needs are that they want to work on. That’s something I think healthcare needs to do a lot better on is to say, “Can I let you guide?” Which is the part that’s most important here and something that I think many of us are trying to get better at in our practice.

Sally: Up next, our panelists are going to answer some of your social media questions.

Musical interlude

Sally: So now that you’ve answered a lot of my questions, we’re gonna have an opportunity to answer some questions from our social media followers. This first one I’m going to address to you Megan. This comes from Fishlovesphoenix from Instagram, who asks, “What about babies who were born with medical issues? My baby had to sleep away from me for two months after he was born premature and I’m stressing over the lifelong effects. What can I do to minimize them? Or is it too late? He’s three now.”

Megan: Well, it’s never too late. Ever. Even, it’s not even too late for me and I’m in my 60s. The issue of premature birth and needing to be in an NICU for a period of time is a significant issue. This is not the environment that we evolved to develop in and there’s been a lot of work in neonatal intensive care units on how to make that environment more supportive of the infant’s development. And some of that has had to do with as soon as the baby is stable, being able to support the development of that infant with the parent. Now the part that’s important for the baby, it probably doesn’t have to be the actual parent, it’s the touch and the stroking and the holding and so on, once the baby’s stable. But for the parent it’s that it’s critically important. It is important to help the parent feel that they’re able to take care of that child and do well by that child and that when the child comes home they are going to be able to provide for what the child needs. There is a great deal of plasticity left in development and many, many, many babies who were born prematurely go on to do just incredibly well.

Sally: Yeah, that’s great. Kathleen, do you want to address the same question from your perspective as a pediatrician?

Kathleen: Well, I just really agree with everything that Megan said. This notion that she introduced of plasticity just means things are changing and have the capacity to change and improve over time. I think that parents do a tremendous amount of good when their children are in the NICU and they are able with a stable baby to hold and do the skin to skin with that baby. And I know parents often really enjoy that and the kids enjoy it too. Then I also think about for these folks who you have so many nights after you take that baby home and you are instilling all the good, caring, and attachment during that time period. For folks who’ve had to have that experience or at an older age with a medically complex child providing that wonderful consistency when the child is able to have it goes a long way.

Sally: Great. We have another question from Fieryboots2, who asks, “What can I do right now to help protect my child against the harmful effects of stress?” And I’m wondering, Cerella, if you could give us some ideas that you’ve seen with your work.

Cerella: I think the best that we can do to really model some of those healthy practices coming to mind when we’re talking about parents and children. I think breathing exercises, and I keep going back to that because it’s simple, it’s easy and I think some of the scientists will attest to the fact that it’s almost like a physiological reset within your body when you are feeling these really intense feelings. It’s a quick method that you can use to bring yourself down and there are a ton of ways that you can do this with your child as well and get them into the practice of bringing themselves off that ledge when they’re really hyped up in terms of big feelings. I think the more that we can just try to model some of those healthy coping mechanisms for our children, that could really go a long way.

Jeanette: As a parent myself, I think nothing is more powerful than just love and compassion to the children and just understanding what the child is feeling and actually talking to them about it, depending on their age level, has been very helpful for some families also.

Megan: I agree with everything that was just said. One of our challenges though I believe is making sure that we’re protecting them from the potential impact of toxic stress versus protecting them from stress. Stress is actually an important part of growing up and experiencing and learning to handle it and not having people take care of it for you completely is critical to be enabled to develop resilience and we talk about that as positive stress. Positive stress doesn’t look like you’re happy, it often looks like you’re very unhappy, frustrated, angry. And as parents and teachers and so on, we sometimes have great desire to take that pain away, whereas it’s normative pain. So, we’ve been talking about toxic stress to really identify the serious stress issues that many children face.

Kathleen: I’ll just say I think whenever we’re thinking about whether we need to shield our kids from stress, I think we should be asking is there a life skill my child is trying to build here that I want to give them the opportunity to build? Whether that’s learning to go to sleep on their own or learning to walk into school by themselves, things that we really want the child to be able to do and thrive in versus protecting the child from something that’s in fact traumatic. And I think when we can test it a bit with that question, we may be able to sort out the difference between tolerable stress and life skills promotion versus toxic stress.

Sally: That was a really great conversation and I just really want to thank all of you for your time being here and for giving us your expertise on these topics. And up next, Dr. Shonkoff is back to discuss a common misconception people have about toxic stress.

Musical interlude

Sally: And we’re back with Dr. Jack Shonkoff, we’re talking about toxic stress. And Jack, this is a particularly favorite part of the podcast for me, we’re thinking about myths and I think there are many of them when it comes to toxic stress. So for you, what is the most important myth that you would like to dispel related to this issue?

Jack: I would say the biggest misconception of toxic stress is when people talk about it to describe the cause of the stress, rather than understand it’s the biology of the stress response. It refers to what’s going on inside your body when your stress system is activated. Toxic stress is not referring to what’s toxic about the cause of the stress activation, it’s how does the body deal with serious threats. Toxic stress is how your body is responding and nobody is helping you feel safe. Think about some of these school shootings. Everyone has experienced the same trauma, but there’s tremendous variability in how people respond to it. That’s the way we need to think about toxic stress. It’s not the trauma, it’s the response and the response is wide. And most people do not experience toxic stress because most people have somebody to turn to. It’s not in any way minimizing the horror of the event, but that’s not what toxic stress is about. And toxic stress is when you’re all by yourself for more than a day or two, or more than a couple of days, it’s when you’re all by yourself for weeks and months.

Sally: When you’re talking, I’m thinking about the situation at the border, which is so heartbreaking thinking about that sometimes children are being separated from their caregiver for such a long stretch of time. You can just imagine that system being activated for–

Jack: Right. But here’s where a misunderstanding can work on either side. So let’s stick with the border separation, or we could take survivors of a school shooting because it’s the same. From a toxic stress point of view, it’s the same. So if someone wants to pull out from that, some child who has done remarkably well and survived, and puts up as an example of, “You see that kid over there? Look at what that child went through and that child is really okay. So the rest of you should also be that strong.” That’s just so wrong, not to mention unfair. But scientifically it’s wrong because, yeah, there are people who get through.

Jack: In the same way that if a child is completely incapacitated and devastated with life-long, serious mental health and physical problems, it would be equally wrong to say, “See that child? That’s what we have done to every child who’s been separated from parents. That’s what we’ve done to every child who’s been a survivor of a school shooting.” It’s just not true. So, if there’s one thing the science is just screaming at us, it’s about human variation, it’s about you can’t over-generalize. But the concept of toxic stress is real. It’s real. It’s physical. It’s biological. The threat of toxic stress and what it could lead to is real. No scientists disagree with that.

Sally: I really appreciate you being here Jack and for sharing that really important information. Up next, we’re going to talk a little bit more about how to apply this information and have conversations about toxic stress with people in your lives.

Musical interlude

Sally: So, if this conversation left you wanting to discuss toxic stress further, we thought that it might be helpful to leave you with some meaningful ways to talk about it. If you bring up the subject, make sure to always talk about toxic stress alongside the idea of resilience. The two always go hand in hand because recovery from the effects of toxic stress is possible, though it is hard work. You can say something like, “Toxic stress can be harmful to healthy development, but there are always ways to heal from it and no one who’s experienced toxic stress is damaged beyond repair.” The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu, where we’ll post any resources that were discussed in this episode. We’re also on Twitter @Harvardcenter, Facebook @Centerdevelopingchild, and Instagram at @Developingchildharvard. Brandi Thomas, Charley Gibney and Kristen Holmstrand are our producers. Bridgette Cyr is our audio editor. Our music is Brain Power by Mela from freemusicarchive.org. The podcast is recorded at PRX Podcast Garage in Allston, Massachusetts.

Why are the early years of a child’s life so important for brain development? How are connections built in the brain, and how can early brain development affect a child’s future health? This episode of The Brain Architects dives into all these questions and more.

First, Dr. Jack Shonkoff, director of the Center on the Developing Child, explains more about the science behind how brains are built—their architecture—and what it means to build a strong brain.

This is followed by a panel discussion with Dr. Judy Cameron, professor of psychiatry at the University of Pittsburgh; Debbie LeeKeenan, an early childhood consultant and former director of the Eliot-Pearson Children’s School at Tufts University; and Dr. Pia Rebello Britto, the global chief and senior advisor for the Early Childhood Development Program Division at UNICEF. These panelists discuss the practical side of building brain architecture, and what any parent or caregiver can do to help give children’s brains a strong foundation. Download the episode and subscribe now!

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Sally: Welcome to The Brain Architects, the new podcast from the Center on the Developing Child at Harvard University. I’m your host, Sally Pfitzer. Our center believes that advances in science can provide a powerful source of new ideas that can improve outcomes for children and families. We want to help you apply the science of early childhood development to your everyday interactions with children, and take what you’re hearing from our experts and panels and apply it to your everyday work. In today’s episode, we’re going to dive into the concept of brain architecture and learn a little bit more about the science behind it. We’ll learn why the early years are really important for brain development, and think about how connections are built in the brain, and what a strong or weak foundation in the brain can mean for a child’s future health and development. Here to help us explain brain architecture is Dr. Jack Shonkoff, professor of child health and development, and director of the Center on the Developing Child at Harvard University. Welcome, Jack.

Jack: Hey, Sally. Good to be here.

Sally: We have a lot of questions to dive into today, but first, can you explain where the idea of brain architecture came from? I’ve heard you use the metaphor of a house before, which I’ve found to be really helpful in really thinking about that foundation that’s set in the early years.

Jack: Almost 20 years ago, the National Scientific Council on the Developing Child realized that we needed metaphors to take very complicated science and present it with a phrase that would capture what it was about, and would be remembered. What came from our early conversations was this very simple fact that brains are built over time. We latched onto this concept of brain architecture, and any building begins with a strong foundation. If the foundation is strong, the building will last a long time, and if the foundation has a crack in it, or it’s weak, the building may not fall apart, but you won’t be able to build on it very much over time without having to deal with some of the weaknesses. Think of the building communities where multiple houses are built, that they’re all exactly the same. But then people move in, and they bring their own decoration, and they’re own style to it, and every house that’s built with the same basic design ends up looking very different. The more we got into the architecture metaphor, the more we realized how powerful it is in terms of understanding this process of brains being built over time.

Sally: As I’m listening to you, it’s making me think about the nature/nurture argument. I know that the current science has a lot to say around that. Is brain architecture determined solely by our genes?

Jack: I love this question. This whole idea of how much is genetic and how much is the result of experience used to be a very fierce argument among scientists. We now know that there’s a very strong genetic and a very strong experience influence. To stick with the architecture metaphor, think of the genetic contribution as the architect’s blueprint, before you begin to build a building. That’s the way genetics contributes. It’s why most children, they sit up at a certain age, walk at a certain age. But how those skills develop, how they’re built, how strong they are, what the design looks like, very little of that is influenced by genetics. It’s influenced by, it’s the world in which kids live, the experiences they have, the environment of relationships they live in, that shape the development of the blueprint for that individual. Genes determine when circuits get built. Experience, individual differences in people’s life experiences determine how those circuits get built. Together, they both explain the development of brain architecture.

Sally: That’s so fascinating. I know a lot of our listeners are folks who are working directly with kids. I’m wondering if you can give them some examples what that building responsive relationships looks like, and also how that actually goes into building brain architecture.

Jack: Another great question. The key feature of what we mean by “environment,” and what we mean by “experiences” that shape brain development really come down to the nature of the interaction between very young children and the adults who care for them. The brain is wired to expect interaction with other people. It’s not looking for interaction with tablets, or mobile phones, mainly because those stimulus sources are not interactive. This need for interaction is built into our biology, into our genes. It comes from eons and eons of evolution. If there wasn’t a reason for it, it wouldn’t appear over and over again over eons. From a developmental point-of-view, somebody has to be there engaging and interacting, and providing experiences from which you can learn, in order for your brain to build strong circuits. If the brain is getting bad input, the brain struggles to learn how to deal with it. If the brain is getting no input, it’s an all-signal alert that the world is crashing down on you, not because it’s harming you, but because it’s ignoring you. Positive experiences strengthen brain circuits. Threatening negative experiences weaken brain circuits, at the time that they’re being made.

Sally: One last question. I can’t help but ask, given what you’ve just described about how detrimental some of these things can be to a developing brain, and I’m thinking about listeners who have either experienced this themselves, or have had children that have experienced this, and that sense that they might have of “This is a doomed situation. My foundation is crumbling and completely weak, and from there on, I’m not able to continue to build my house.” I just wondered if you could address that.

Jack: I’m really so glad you asked that question, Sally, because there are no perfect brains. The best parents in the world do a dozen things wrong every day. There’s a lot of science about brain development, but raising healthy, competent children is much more a bumbling art than it is a precise science, right? There’s a core concept in biology about adaptation and resilience over time, so that it is never too late to strengthen the brain’s capacity to do things. Anybody who says, “Past a certain age, there’s nothing you can do,” is ignorant of what science has to say. On the other hand, it’s not true that early doesn’t matter. It’s a balance. Having problems early on, perhaps having a weaker foundation, is not a doomsday scenario at all. It just means that some things are going to have to be worked on a little bit harder. They would have been easier if we had gotten it right the first time, but it’s not too late. The take-home messages here are earlier is always better than later, prevention of difficulties is better than trying to remediate difficulties later. But it is never, ever too late to strengthen capacities. The brain is always trying to get things right. If it goes off-track, it’s always trying to get back on-track. That’s the beauty of the science. It’s also the beauty of the magic of human development.

Sally: Thank you so much. I’ll leave you with that. “Earlier is better, but it’s never too late.” Thank you so much.

Jack: Thank you, Sally. I appreciate it.

Sally: When we come back, we’ll welcome a few special guests.

Musical interlude

Sally: Here to discuss the implications of the science of brain architecture, we have Judy Cameron, Ph.D. Judy is a professor psychiatry, University of Pittsburgh, and the CEO of Working for Kids: Building Skills, LLC. Welcome to the podcast, Judy.

Judy: Thank you. I’m really happy to be here.

Sally: We also have Debbie LeeKeenan joining us. Debbie’s an early childhood consultant and former director of the Eliot-Pearson Children’s School at Tufts University. Hi, Debbie.

Debbie: Hi. It’s an honor to be here. I’m looking forward to the conversation.

Sally: Also joining us on the podcast, we have Pia Rebello Britto, Ph.D. She’s the global chief and senior advisor, Early Childhood Development Program Division, at UNICEF. Welcome, Pia.

Pia: It’s a pleasure to be on. Thank you for inviting me.

Sally: I’d like to start by asking why is it critical for parents, teachers, and even policy makers to understand the importance of brain architecture?

Judy: It’s important that people, all people who interact with children, understand brain architecture, and how brain architecture is made. Because experiences play a really strong role. The brain is genetically programmed to make connections, but whether those connections stay, become strong, and are permanent and there for the child to use their whole lifetime, depends on having experiences that strengthen them. You want parents to strengthen children’s brain circuits. You want teachers to do that. At the policy level, you want policy makers to vote for things that will give all children that opportunity.

Pia: To complement Judy, I want to focus a bit on the policy makers, in terms of their understanding of brain architecture. Ultimately, as we know, for these positive experiences to occur between children and their caregivers or parents, these adults in the child’s life need time. They need resources. They need services. All of that enables them, then, to be able to engage with their children in a meaningful manner. Policy makers, employers in the business sector, all of them create the right policies and enabling environment to then give the parents that time, that space, the resources they need. Their understanding of brain architecture, and the value it holds and how it occurs, is very important, then, to enable parents to engage in what they love the most, to engage and interact with their children.

Sally: Great. Debbie, I know you’ve been in the field for quite some time, in a variety of roles. I think our listeners would like to know what are some specific things that teachers, parents, and caregivers can do to actually help build a healthy brain?

Debbie: We know that young children learn through everyday play and exploration in safe and stimulating environments, and with relationships with their families, teachers, and caregivers. Young children learn when they’re using their whole body and senses. Giving opportunity for young children to explore open-ended materials that can be manipulated and combined in different ways, these provide unlimited play and learning opportunities. We’re talking about blocks, little figures, animals, toy cars, balls, spoons, buckets, pans, baskets, or recycled materials. Through all of that, the early childhood brains are opened to new experiences, and children are testing new theories, and changing old theories when they learn something new. This kind of constructive play allows experimentation, problem solving, higher-order thinking, and as well as language development and social skills. They develop new ideas and schema. It helps them with language development, cognitive skills, problem solving, and taking on other perspectives and self-regulation. All of these things are a way that teachers, parents, and caregivers can help the brain develop from very young ages.

Judy: I think that what Debbie has said is exactly right, and one thing parents are always asking is “How can we fit this into our everyday life?” Giving them examples of what they can do while they’re cooking dinner, what they can do while they’re driving in the car, what they can do when they’re just hanging out with their kids, so that they can begin to be creative. They have ideas that anytime can be a learning time for a child.

Sally: Great. Judy, you were part of a team that created a whole game around the concept of brain architecture. Could you tell us a little bit more about that game? Who plays it? What do you think people actually learn from it?

Judy: The Brain Architecture Game, people work in small groups. They have a task of building a brain. They roll the dice to get their genetic background. That gives you the structure of the base of the brain. And then, they draw Life Experience cards, and the Life Experience cards might be a good experience, a really bad stress, which we would call a toxic stress, or a tolerable stress, a stress that can be good for the growth of the brain or not, that it could be toxic, and it really depends on how much social support. A key issue in the game was to get people to understand that social supports are really important. They build their brain out of pipe cleaners with the supports being straws, and they debate with each other, “Okay. Where am I going to use this support? How tall can we get it? Do we need a little bit more of a sturdy base?”

Sally: Yeah, Judy, I’ve facilitated that game a few times, and I’m always struck by how many times I hear the term ” that’s not fair” when people are watching their brains collapse.

Judy: That’s true. I’ve played it with over 12,000 people. I remember playing it at a legislature at one point where the whole legislature decided to take an hour out of their day. One legislator came in the room, and he said, “I’m going to build a fantastic brain. I really care about children, and I’m a good architect.” And I said, “Excellent.” And then, his brain collapsed. And when I asked him what happened, he said, “Oh. It wasn’t my fault,” and I didn’t say anything. I just looked right at him, and he said, “Oh, my gosh. That’s what you’re trying to teach us. It’s not children’s fault.”

Sally: I always think that’s such an interesting concept that, of course, that’s part of what you’re trying to teach throughout these experiences. Pia, I’m wondering from your perspective, if you can share why the concept of brain architecture is so important for us to consider internationally, and do you have some examples of how this concept is being used all around the world?

Pia: Yeah. This is actually a very seminal concept for us to build on internationally and build on globally because the situation of children really calls us to take serious actions. So, I’m not sure if you’re familiar with but a few numbers to help you contextualize how important this is. The first is that over 250 million children around the world, especially in low- and middle-income countries, are at risk of not achieving that developmental potential. And when we look further into that number and understand what’s going on, we know that in 2018, 29 million babies were born into conflict affected areas where they’re born into these areas where they are exposed to high degrees of toxic stress. We know that over 300 million children live in areas with toxic air that we know can damage the developing brain. So, we know there’s a lot of risk factors in the environment. Okay so, that’s the broad environment. So, what’s going on in the daily lives of children? We find out across sort of our work that only about 60% of children receive that sort of early stimulation and responsive care from their parents and caregivers on a consistent basis. So really, it’s just about over half are receiving that type of care that we know is so integral for brain architecture. So, the case for why we need to bring this, this concept, globally is really important. The whole world community aims to achieve certain goals and targets, and in 2014, to have a very powerful seminar at UNICEF. Judy was there. Jack was there. The world’s leading neuroscientists were there, and they very clearly laid out a case for what happens when you build this brain architecture and what happens when it gets derailed. Now, for the first time in history, there was a goal that looked at child development. There was an indicator and a target that all countries now are accountable for, that they are supporting children to make this happen, and that’s super powerful. We never had that at a population level before. Another example I can throw out really quickly is most parents around the world do not have access to this information of why their engagement with their child matters, why responding to their baby’s cues matter so much. They don’t have access to this information. So at UNICEF, we launched Early Moments Matter. It’s now the largest global campaign. The essence of Early Moments Matter is that babies’ brains are built and they need the active ingredients. They need eat, play love. They need care. They need protection. And we were actually through the Early Moments Matter, we’re able to reach over 2 billion people with these messages.

Debbie: I loved hearing those examples, Pia, with the UNICEF program and those Early Moments. I could give an example locally here in Seattle. I’m involved with a program called PEPS, Programs for Early Parent Support, and the concept here is that the first thousand days of a baby’s life are the most important, and yet many families, many parents feel isolated or have all these other negative experiences. So, this program tries to connect families with other families, creates kind of a small community learning group for parents where they get together maybe a group of 10 to 12 families in different settings, partnering with different agencies to really provide access to all kinds of families. Another point that I thought was important: one of these toxic stress factors is also about the racism and community violence that families and children experience. And one of the things in my work that we’ve found is that as adults in children’s lives, we have an opportunity to choose materials for children, whether they’re books, whether they’re toys, that provide both mirrors and windows for children. This really helps them build their positive social identity development, which happens to begin at birth. And I like this metaphor of mirrors and windows meaning we want to expose children with materials with experiences that reflect who they are, that help them feel good about their identity. And at the same time, you want opportunities to provide materials, books, that may provide windows for children and families to see people that are different than them.

Judy: I also had something that might be worth thinking about. We have been collecting data from communities that we work with, and most of these are very impoverished communities, about child development. We’re checking development of children over a one-year period, so measurements of the stress exposure of the parents and the children, poverty level, education level, as well as videotaping them with their parents and scoring parent-child interactions. And a really interesting finding is that parent-child interactions can be very strong no matter how much family stress is experienced. So, you have parents living in really stressed environments, but if they have very good serve and return interactions, if those are strong from the parents, the child will be doing better even in the face of stress.

Pia: And just building on Judy’s point, one such context we haven’t discussed too much is families who are on the move, migration, refugee status, families who are living through protracted crisis, conflict, and those who are suffering sort of links of humanitarian or climate change-related emergencies. And what we’re finding when we are working with families with young children in these areas is that caring for the caregiver is as important as giving messages to the caregiver about their young child. And in order for parents to feel sort of on top of the game, in order for them to be able to care for children in the manner that’s most suitable for their kids, they need caring as well for their own emotional wellbeing.

Sally: Judy, I’m wondering if you could also weigh in on that question on how to build social-emotional skills, in particular in how it relates to regulation.

Judy: Happy to. So, in the communities we’re working in, there often is a lot of disruption in the family setting, and so we’ve put a lot of emphasis on getting adults in a community to think more broadly about who can provide kids with the skills that they need and with learning environments. And we think of this as charging stations. We talk about the fact that you need to plug the phone in in order to function. Each of us needs to have a support in order to function, and we start by talking to adults about, “What is your charging station? What do you do when you really need to feel better?” This connects very closely to what Pia said earlier about taking care of the parents and making sure that the adults that are interacting with children are taken care of also. But then, we expand it to, “What are the charging stations in your communities that can work to help children?” And that gets people to think much more broadly about the fact that it’s not just parents. It’s not just childcare providers. It’s not just teachers that have an impact on children in children’s development. Everybody in the community can play a role. The matter is getting everybody in the community to realize that they can play an important role in helping children learn skills.

Sally: Excellent. Up next, our panelists are going to answer some of your social media questions.

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Sally: Since our panelists have answered all of my questions, let’s move on to some of yours. So, haleyraepearce from Instagram asks, “How do we make sure young children are successful in their transition to school?”

Debbie: Preparation is always important, but I also like to say not too early because typically in the early childhood years, children don’t have a good concept of time. So when we talk about preparing children, we’re not talking about months in advance but maybe a week in advance what’s going to happen, and you want to do it in a very concrete way, maybe visiting the school, reading stories about going to school. I also think always bringing something from home to school is also a good strategy that helps with transitions. I think that a key idea is preparation but doing it in a concrete way and kind of figuring out the when to start that preparation, not too early and not too late.

Pia: Just adding to that. The model we use at UNICEF is children ready for school, parents ready for school, but school’s ready for children. So, I want to build on what Debbie presented. Preparation is key, and preparation is key on the part of the school as well to be able to receive children in. And in many of the contexts in which we work, we have a lot of different issues linked to school readiness, for example, multiculturalism, multilingualism. So many of our children are for the first time coming into schools where maybe the language spoken at home is not the language that is being spoken in the classroom or part of the curriculum. So, a lot of the focus and emphasis is also on preparing these teachers and the school administration to be able to receive children to sort of smooth and ease their transition.

Judy: I can also comment on this from a much broader perspective. So, Debbie and Pia have talked about the literal transition from living at home in your family to starting to go to school. But what’s really important to remember is how well children do in that transition, and in school is going to be very dependent on brain development earlier in life. So throughout their time growing up. And so it really behooves parents and those who are interacting with children to try to help them build strong social-emotional skills, strong problem-solving skills, a strong image of themselves so that they are ready to make that transition.

Sally: I love the variety of perspectives there. We had sort of some really concrete specific examples, and then zoomed out to more global and then thinking about how that all relates to brain architecture will be really helpful for our listeners. So attipay61 from Instagram asks, “I’m a teacher of one -to two- year-olds, and in your opinion, what is a good timeframe to expect children of that age to grasp, understand and remember a concept? Simple examples, hands are not for hitting, or food goes in your mouth. Some days things are a little challenging because it feels like this is what we say all day.” I bet some listeners will relate to that.

Debbie: And I’m chuckling here too, as I take care of my grandchildren this age. I’m thinking about that. First of all, there’s these first two years of life, is what we call the sensory motor stage. And often infants are busy discovering relationships between their bodies and the environment, and this is actually how they’re learning. When we say don’t put things in your mouth, yet, that’s how they learn through sensory experiences. Through their seeing, hearing, smelling, tasting, touching, et cetera. I think we can also through simple words, repetition, signs, gestures, a 12-month-old can understand the concept, what we put in our mouth, food goes in our mouth, toys we put in the bucket or in the basket. But instead of saying, “No toys in the mouth”, we’ll often say, “Put the toys here, we’ll eat our snack in our mouth.” Things like that. So being concrete and yet understanding that this is where they are developmentally, what their brain understands, so it’s not like it’s a misbehavior I always say, but a typical behavior.

Judy: I would have a different perspective, that is that what we really have to remember is the way brain development happens is that the genetic program tells neurons, brain cells to make connections. And what causes those connections to be strengthened and become a stable brain circuit is experiences that use the connections. I get asked many times, “How many times do you have to use a connection to increase the probability of it being permanent, and really strong?” And the answer is thousands and thousands of times. And so you have a teacher or a parent who’s working with one- and two-year-olds who says, “I’ve told them over and over again about this. Why do they still not get it?” They really have to have used that part of their brain thousands of times. And we need to understand that it really takes a lot of work on the part of the growing brain to form a strong, stable pathway.

Sally: Thanks to our panel for offering that expertise and thank you to our social media followers for submitting some great questions. Up next, Dr. Shonkoff is back to debunk an early childhood myth that may have actually heard.

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Sally: And we’re back with Dr. Jack Shonkoff, and we’re going to talk about a myth that exists in the early childhood field. This is a segment I’m particularly excited about, because I think there are a lot of myths out there. I know you are particularly passionate about, and it is that 90% of a child’s brain is formed by the age of three. So could you tell us a little bit about that myth and why it is not a correct fact?

Jack: Should I start with why this drives neuroscientists insane? Let me just start with something simple, which is why that’s wrong. To say that 90% of the brain is completed by age three, or age four or age five is to completely misunderstand the very basic concept of a developing brain. Is there anybody out there who could make some sense of the idea that a three-year-old now has 90% of all of the competence and skills and knowledge that you’ll have for the rest of your life? From a common-sense point of view, that’s just ridiculous. If we’re talking about brain development, we’re not talking about how big your brain is, or how much it weighs. We’re talking about its circuitry. You don’t have to be a neuroscientist. Ask anybody who knows anything about kids, how much of a difference is there between what a two-month-old can do and what a five-year-old can do? But here’s why it’s damaging. If 90% of your brain development is completed by age three or four, what does that tell us? What it tells us is not only to get hysterical about the first three or four years of life and drive yourself crazy, it also tells you, okay, you’re four, you’re five years old now, you’re there, it’s done. It implies it’s too late to do anything. It implies there’s not a whole lot you need to do to promote healthy brain development afterwards, because most of it is over.

Sally: It also implies that at some point you get to 100%, which contradicts exactly what you just said earlier, that we’re still developing.

Jack: Exactly. It creates a lot of misperceptions and misunderstandings that could affect the way we think about how much of an impact can adults have on children? But let me tell you why it’s continued. I was speaking at a conference once, and I was on a panel with some people, one of whom who got up there who made this comment about how 90% of the brain, and I said, you know that’s wrong, right? You know what he or she said to me? That person said, “I know, you’ve told me that, but do you see the look on the audience’s face when I say that? Do you see how jazzed they get? Do you see how much they understand the importance of the early years? I know it’s wrong, but it’s effective.” And perpetuating that myth is terrible. Not only because it’s wrong, it creates ideas in people’s heads that end up being damaging to how we can help children all through their lives to be who they can be. Sally, to your point about it never reaches 100%, this is the other side of the coin. People ask this question about how flexible and adaptive is the brain? We know that resilience also is something that’s built over time. If you have a weak foundation early on because you hadn’t had time to develop resilience, you can develop resilience later, and you can get better and things can be better. So then the question becomes, is it ever too late? It gets harder the older you get. But if there’s anyone out there listening to this podcast who’s 103 years old, who learned one thing from this podcast, goes to sleep and tomorrow wakes up and remembers it, a new connection was made in the brain.

Sally: Thanks Jack. Up next, how can we take the science of brain architecture and apply it to everyday situations?

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Sally: We’ve learned about the science of brain architecture, and its implications, and we’ve learned that your brain is never fully developed. We’re always learning. Now we’ll leave you with something that you can do today, tomorrow, or even next week to promote healthy brain architecture. Do you have to go pick up groceries this week, for example, while your little ones tag along? Well, when you’re searching for ripe apples, ask your child if they can point out all of the green ones. While you’re picking out cereal, maybe ask them if they can find all the cereals that start with C. Simple games like these require children to understand rules, hold those rules in mind and then follow them. So while you’re shopping for groceries, they’re actually building their brain. I’d like to, once again thank our guests, Dr. Judy Cameron, Professor Debbie LeeKeenan, Dr. Pia Britto, and Dr. Jack Shonkoff. I’m your host Sally Pfitzer, and we’ll see you next time. The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu, where we’ll post any resources that were discussed in this episode. We’re also on Twitter @HarvardCenter, Facebook @CenterDevelopingChild, and Instagram @DevelopingChildHarvard. Brandi Thomas, Charley Gibney, and Kristen Holmstrand are our producers. Bridgette Cyr is our audio editor. Our music is Brain Power, by Mela from FreeMusicArchive.org. The podcast is recorded at PRX Podcast Garage in Allston, Massachusetts.