Infants in Danger: A Conversation with Infant Psychologist Alicia Lieberman

Most adults can recall a moment when they’ve been afraid. Danger, or the presumption of danger, jacks up both our senses and our stress hormones and lingers in our memory.

It was once assumed that infants lacked similar sensory awareness. Not true, says Alicia Lieberman, PhD, a UCSF professor of psychiatry, who has spent her career trying to prevent and undo the emotional damage inflicted on very young children stuck in violence-prone homes.

Left untreated, this damage thwarts development, stunts IQs and spawns anxiety that can last a lifetime. This is to say nothing of the damage to social harmony and community life or the impact on productivity and crime rates, all of which we pay for in one way or another.

Lieberman has not stood on the sidelines simply decrying this state of affairs. She has instead designed interventions that mend and cement the healthy and loving relationships between mothers and their young, troubled children. Moreover, in a follow-up study, she has found that the relationship-based interventions she designed had lasting, positive effects.

No wonder then that she was asked to speak about her work and her findings to the Dalai Lama and 8,000 other guests at a recent meeting in Seattle. To those who take the long view, it is clear that the seeds of compassion – and the experience of violence – begin in the womb. Lieberman has codified that balance. And maybe if we listen really hard, she can teach us all how to behave.

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Related Links

Child-Parent Psychotherapy: 6-Month Follow-up of a Randomized Controlled Trial (PDF)

American Academy of Child and Adolescent Psychiatry, 2006,

Toward Evidence-Based Treatment: Child-Parent Psychotherapy with Preschoolers Exposed to Marital Violence (PDF)

Child Adolescent Psychiatry, Dec, 2005

 

 

Podcast transcript

Jeff Miller: Hello I’m Jeff Miller and welcome to Science Café, today I am with Alicia Lieberman, Director of the Child Trauma Research Project at San Francisco General Hospital, and a professor in the UCSF Department of Psychiatry. Welcome Alicia.

Alicia Lieberman: Thank you for having me, Jeff.

Miller: I’d like some background information to begin with, how long have you been at UCSF and maybe more specifically, at SFGH?

Lieberman: I’ve been at UCSF and SFGH since 1980.

Miller: And always as a professor of psychiatry?

Lieberman: I started as an assistant professor and then worked my through the ranks.

Miller: so, psychiatry… Certainly there were a lot of other fields you might have been tempted by, so why did you end up here?

Lieberman: I’m actually a psychologist, so I could have been in the department of psychology or an academic institution, but I’m very interested in treatment of children and families that have emotional problems. And so UCSF seemed like the perfect place and SF General hospital, because it’s located in the Mission and serves families with many many stresses-

Miller: So for those who might not know, the Mission District in San Francisco is a mix of lots of ethnic groups, began primarily with Hispanics but now contains people from all over the world at this point.

Lieberman: Correct.

Miller: So did you come from a family of scientists?

Lieberman: My father was a pediatrician and my mother was a dentist and both of them had their offices at home in my native Paraguay. So I spent a lot of time during my childhood in the waiting room, talking with the children who were coming to see my father who was renown as somebody who said “love and vitamins” as the ingredients for healthy development.

Miller: Love and vitamins? I love that.

Lieberman: (laughter)

Miller: Families have continued to be the focus of your work, particularly the violence in families and its effects on young children. But before kind of narrowing the focus, I wonder what is your opinion of the state of family today, particularly as it relates to violence?

Lieberman: I believe that families reflect the gap between the haves and the have-nots in our society. There are families who are doing very very well, who are wealthy, healthy, loving and affluent and who provide their children with all the conditions they need to develop optimally, and there are a large number of families that are falling behind because they have fewer and fewer resources to support themselves and their children. And as a result, the U.S. ranks third in a list of 25 industrialized countries in the number of children who die as result of maltreatment. So the situation in the U.S. is very dire when it comes to protecting young children.

Miller: Youth in America is described as a fairly long period of time, but you’ve chosen to select infants for your particular area of focus, why is that?

Lieberman: Infants represent the period of life where the fastest changes occur, both in brain development and in learning. And in infancy, also, parents are particularly motivated to look at themselves; experience themselves in relationship with their children, and try to make changes in the way they respond.

Babies have a very transformative effect on people. And when somebody becomes a parent there is a sense of new beginnings and I want to take advantage of that opening to create positive change.

Miller: In your years at SFGH where you attuned to rising levels of violence – and I want to go back to something you said earlier, were you speaking about economic resources as being the primary stress in the lives of people causing an increase in violence, or is it something else in addition to that?

Lieberman: Economic resources go hand in hand with psychological resources and sociological resources, and we know for example that violence is growing in many neighborhoods, and in those neighborhoods there is a concomitant decrease in resources such as safe streets, clean parks, playgrounds for children, grocery stores that serve healthy food, environments that do not have toxins like lead and other resources that are made possible by financial funds.

Miller: The stress and violence in the home – I would imagine we’re not speaking, always, of physical violence to infants – can it just be an atmosphere of danger and hostility that the infants pick up upon and transform that into some form of behavior?

Lieberman: There is a lot of research indicating a child does not have to be mistreated, him or herself, to suffer from the effects of violence. For example, children who witness domestic violence without being maltreated themselves have IQ scores significantly lower than a comparison group that did not witness domestic violence.

Community violence is also very destructive although it has not been studied as systematically as domestic violence. So the mere fact that children are witnesses of violence is already damaging to their well being.

Miller: Even when they’re infants, and some assume they’re not absorbing this atmosphere, in fact they are?

Lieberman: One of the most important findings over the last 30 years is that there is no such thing as a baby not noticing what is happening. And babies who are exposed to violence have difficulties eating, sleeping, gaining weight, learning, that can thwart their developmental course in very dramatic ways.

Miller: Is that true during gestation as well?

Lieberman: We are now working with pregnant women and finding that babies born to women who have been battered have a higher rate of perinatal complications, and this is not just our finds, there’s a lot of research showing that actually, exposure to domestic violence during pregnancy can have more deleterious effects than physical conditions that are routinely screened for such as, exposure to toxins and other medical problems.

Miller: So what would be some of these effects that one would see?

Lieberman: Low birth weight; premature birth; perinatal complications during delivery; difficulty being soothed; and there are some studies showing the cortisol level in babies, the stress hormones in babies born to depressed and battered women is higher than the cortisol level of babies born to women who are not either distressed or battered.

So there is some evidence that the physiological state of the mother affects the physiological state of the fetus.

Miller: So we’re talking about an enormous social problem, these infants born compromised, and then growing up, perhaps, in a climate of violence, or even if not, they start out with a problem, and this is then multiplied over time – so what do you see as the price to society for this type of neglect -- without blaming anyone of course, just curious?

Lieberman: The price to society is the decline in social climate, including a decline in productivity. There is data showing on the contrary, that investment in the first three years of life has the best predictive role in creating positive change, so the infancy years are very important in shaping the kind of society we live in.

Miller: You have seen this problem first hand at SFGH and then you decided to conduct some research into an intervention, I believe, into how this cycle might be stopped?

Lieberman: The two latest articles documenting the efficacy if the treatment we developed have been published in the Journal of American Academy of Child and Adolescent Psychiatry in 2005 and 2006.

Miller: Why don’t you describe the first study, and then the follow up?

Lieberman: The first study showed that when we intervene with preschoolers and their battered mothers by focusing on the relationship between mother and child, not only the children improve on their behavioral problems and the incidents and intensity of post-traumatic stress disorder, but the their mothers have much better scores in measure of depression, anxiety and post-traumatic stress. And the conclusion we dried from this is that focusing on their relationship benefits not only the child but the mother as well, relative to the intervention in the comparison group that was directed individually to the child and individually to the mother. Our conclusion again is that relationships are very important in the first years of life and that is where the focus of the intervention should be.

Miller: Can you describe the type of sessions that would go on between the mother and child, what was actually happening between them?

Lieberman: The sessions took place either in the home or in a playroom here in our offices and we would bring the mother and the child together and sit on the floor and play. Through the play children invariably reenacted the violence that they witnessed.

Miller: How would they do so?

Lieberman: For example they would have the father figure beat up the mother figure when they were playing with dolls, they would have a little child doll scream Help! Help! they would have dinosaurs scoop down and eat up all the baby animals in sight, and sometimes they disrupted their play and became aggressive themselves.

And when they became aggressive the mothers often responded by saying ‘you are just like your father’, and this kind of exchange led us to start reflecting with the mother and the child about the difficult circumstances they’d gone through.

Miller: So the discussion of these circumstances, was that enough? Or where there actual tactics and strategies the mother is left with at the end of the session about how to cope better, or what?

Lieberman: It depended a lot on the mother’s own capacity and creativity to come up with her own resources. Some mothers had a hard experience watching their children enact the violence they witnessed, and they said ‘I had never realized that my child was so frightened, I never realized they even witnessed it.

Miller: And how old were these children?

Lieberman: Three to five years old for the randomized study, but we’ve also done studies with children one and two years of age. And had very similar results.

Miller: How quickly into these sessions would the children start reenacting these violent moments in the home?

Lieberman: Individual differences are really very pervasive, and some children started enacting the violence in the waiting room, other children never enacted the violence because they responded to the violence by becoming very withdrawn, sad and lethargic. And so for those children, we actually needed to have an alternative tact which was to entice them to become more expressive of their feelings and what they enacted was fear rather than aggression in their play.

So the treatment we developed is very individually tailored to how the parent and the child experienced their situation.

Miller: So there was this period of these sessions that concluded and then I believe you did a follow-up study to see if the benefits persisted, and what were your findings in that study?

Lieberman: The findings persisted for the children, and the mothers continued to improve six moths after follow-up without treatment, relative to the control group. So that the mothers in the treatment group receiving the relationship based intervention were actually less depressed, less anxious, relative to how they were at the end of treatment.

And we believe this has to do with improvement with the relationship with their children, and with the fact that their children were so improved that they became easier to deal with and more pleasurable in everyday interaction. And we know that mothers derive a great deal of their own self-esteem from their sense of how good they are as mothers. So we believe them feeling that they’re better mothers with healthier children enabled them to improve in their individual mental health as well.

Miller: Can we assume that the economic circumstances or the violence in the home has not changed, because those circumstances might be beyond the control of the mother and child, correct?

Lieberman: Absolutely. We did the study with women who had chosen to leave the violent relationship, because we believe that ongoing violence is a major obstacle against improvement as a result of treatment. And we wanted to see weather we could assuage the long-term consequences of exposure to violence rather than work with ongoing violence.

Miller: So these women had made a commitment to change their lives before they even agreed to participate in the program?

Lieberman: Correct. One of the good findings of the study is that the mothers tended not to return to their violent relationships both in intervention and in the control group, and remember the control group also had intervention. And this in turn taught us that providing a safe place for mothers to be supported helps them not to return to violent relationships. In general the data shows many many women return to violent relationships when they do not have alternative sources of support.

Miller: Well I know you have become an expert in his area and you have a long association with an organization called Zero to Three, I’d like to talk to you about that for a minute and then explain the relationship with that organization to your recent presentation to a session in Seattle with the Dali Lama.

Lieberman: Zero to Three is the national center for infants, daughters and families, it is an organization that is based in Washington, D.C., and it has the goal of improving the expertise both in intervention and in public policy towards the wellbeing of children in the birth to three age range. And they have a policy center that advocates in congress for public polices that will benefit young children. You have to remember the systems that are in place to help underserved children in need are not up to scale. For example only three percent of eligible children are enrolled in early head Start, and only 50% of eligible children are enrolled in Head Start in site of research evidence showing that these are very good programs to improve children’s cognitive and social development, and so it’s a very important organization on behalf of children.

Miller: And your relationship with that organization and membership on the board actually led to an invitation to the Seattle meeting, no?

Lieberman: The invitation to the Seattle meeting actually came through the organizer’s knowledge of my research and clinical activities.

Miller: So you went to the meeting in Seattle and were actually able to make a presentation?

Lieberman: I had the honor of being in a panel with the Dali Lama, called Seeds of Compassion, which is the name of the organization. The Dali Lama is very interested in learning how science influences knowledge of spiritual pursuits and he has been known to say that if something in Buddhism is not scientifically correct it should be discarded from the religion.

He was very interested in learning about the early origins of compassion. We had a panel where we talked to him about the data showing that babies from the first minutes after birth are able to relate to people, respond to facial expressions, able to imitate facial expressions and are soothed differentially by contact with mother versus contact with others.

In that context I was able to talk to the Dali Lama and to the audience of about eight thousand about the impact of domestic violence on young children’s physical development and emotional health.

Miller: And what do you feel was the outcome of that encounter, both for you perhaps and maybe for the listeners?

Lieberman: I’ve been receiving a lot of emails from people who attended the conference saying that they had not realized very young children are aware of fights between their parents and are frightened by those fights, they said that they thought children did not become aware of violence until 5 or 6 years of age and able to speak about it, and the Dali Lama said he thought the experience of violence begins in the womb. And I think that is a reflection of his wisdom.

Miller: Well you certainly have made us wiser, thank you so much for joining me on Science Café.

Lieberman: Thank you very much.