Back to Basics

Editor’s Note: This article is a departure from our usual review in that it discusses new frontiers in the correlation of brain, mind, and emotions in developing children as well as areas of collaboration between pediatrics and sister disciplines. Dr Schore has adapted a substantial amount of technical information to the viewpoint of the pediatrician. At the same time, many readers will encounter perspectives and language that seem unfamiliar. We urge clinicians to invest the effort needed for a careful reading to appreciate exciting new ways to look at development and emotional coping mechanisms. Readers desiring an abbreviated version will find it in the print version. —LFNWe are in the midst of an exciting period for clinical practitioners, one in which the connections between the basic and applied sciences are being more tightly forged. A powerful engine driving this progression of knowledge is the recent remarkable advance in biotechnology, especially imaging technologies. Noninvasive studies of organ systems have increased substantially our understanding of the biologic processes that underlie various diseases of the body. At the same time, neuroimaging research of both psychological functions and psychiatric conditions has generated more complex models of normal and abnormal operations of the human mind. Another catalyst of the continuing dramatic increase in information is the rapid expansion of collaborative interdisciplinary research. Of particular relevance to pediatrics, this same time period has seen an explosion in infant research that integrates neurobiological studies of brain development and psychological studies of emotional, social, and cognitive development. Developmental studies, which span a spectrum of scientific and medical disciplines, now are serving as a convergence point for complex models of structure and function, brain, mind, and body.A paradigm shift is occurring in the basic sciences that underlie pediatrics. Research in developmental biology and physiology now strongly supports a model of the “developmental origins of health and disease.” (1) Although the role of early expressed genetic factors is an essential focus of current study, it has become clear that genes do not specify behavior absolutely; prenatal and postnatal environmental factors play critical roles in these developmental origins. The social environment, particularly the one created together by the mother and infant, directly affects gene-environment interactions and, thereby, has long-enduring effects. (2) The newer interdisciplinary models, therefore, detail the mechanisms by which “mother nature meets mother nurture.” (3) Complimenting this conception of the nature-nurture problem, studies in neuroscience indicate that development represents an experiential shaping of genetic potential and that early experiences with the social environment are critical to the maturation of brain tissue. Thus, nature’s potential can be realized only as it is facilitated by nurture. (4)In parallel advances in developmental psychology and child psychiatry, attachment theory, initially proposed more than 35 years ago by John Bowlby (5) as a conception of the mother-infant relationship, has become the dominant model of human social-emotional development available to researchers and clinicians over a broad array of disciplines. In his attempt to integrate psychology and psychiatry with behavioral biology, Bowlby speculated that the attachment system, an evolutionary mechanism common to both humans and animals, ultimately would be located in specific areas of the brain. Updated models of attachment theory that emphasize both emotional and social functions and neurobiological structures now are interfacing with developmental neuroscience to generate a large body of interdisciplinary studies.This recent information on the developmental origins of health and disease can be translated directly into clinical practice. It has both expanded the amount of factual knowledge and altered the theoretical constructs that model the diagnoses and treatments of a variety of psychological and physical disorders of childhood. These advances are, in turn, directly relevant to pediatricians’ interest in the normal and abnormal functions of the developing child’s mind and body. The common ground of the expanding body of knowledge in the developmental sciences, therefore, can strengthen the ties of pediatrics to the allied fields that border it: developmental neurology, child psychiatry, and developmental psychology.This ongoing paradigm shift in the basic and applied sciences is expressed in three converging themes. The first arises from the wealth of neurobiological data that became available in the last decade, the “decade of the brain.” These findings strongly support the idea that the most powerful conception of development may come from a deeper understanding of the brain’s own self-organizing operations. Currently, there is an intense focus on the human brain growth spurt, which begins in the last trimester of pregnancy and continues to 18 to 24 months of age. Myelinization of the brain is so rapid and extensive at this time that the brain takes on an “adultlike” appearance by the end of the first postnatal year. (6) Neuroscientists are concluding that the accelerated growth of brain structure during critical periods of infancy is dependent on experience and influenced by “social forces.” Neuropsychiatrists refer to “the social construction of the human brain” and posit that the cellular architecture of the cerebral cortex is sculpted by input from the social environment embedded in the early attachment relationships. These data suggest that “the self-organization of the developing brain occurs in the context of a relationship with another self, another brain.” (7)Furthermore, we now are aware that “the brain” actually is a system of two brains, each of which has very different structural and functional properties. Of particular interest to the developmental sciences is the early maturing right brain, which undergoes a growth spurt in the first 2 years, before the verbal left, and is dominant in the first 3 years after birth. (8) This growth is not encoded totally by the genome, but it is shaped indelibly by the emotional communications within attachment transactions. Because the right hemisphere is dominant for the emotional and corporeal self, (9) the social experience-dependent maturation of the right brain in human infancy is equated with the early development of the self. (10) The early development of the brain-mind-body, the origin of the self, therefore, is a reflection of the development of the right brain and its unique functions.The second theme emerges from transformations within the psychiatric and psychological sciences. All subdisciplines within psychology, from developmental through abnormal, are shifting their focus from cognition to emotion. Research suggests that the attainment of an attachment bond of emotional communication and the maturation of affect represent the key events in infancy more so than does the development of complex cognitions. Models have moved from Piagetian theories of cognitive development to psychobiological models of social-emotional development. Clinical psychology and psychiatry are moving from cognition to emotion as the central force in psychopathology and psychotherapy. This emphasis on emotion also is reflected in: 1) the emergence of affective neuroscience and its focus on the specializations of the right hemisphere for processing affective states, and 2) psychiatry’s current interest in the emotion-processing limbic system, the brain system that derives subjective information in terms of emotional feelings that guide behavior and functions to allow the individual to adapt to a rapidly changing environment and organize new learning.The third theme revolves around the critical concept of self-regulation. The process of development itself is believed to represent a progression of stages in which adaptive self-regulatory structures and functions enable new interactions between the individual and the social environment. It now is established that emotions are the highest order direct expressions of bioregulation in complex organisms, that the maturation of the neural mechanisms involved in self-regulation is experience-dependent, and that these critical affective experiences are embedded in the attachment relationship.In other words, attachment relationships are essential because they facilitate the development of the brain’s self-regulatory mechanism. Studies reveal that these essential self-regulatory structures are located in the right (and not left) brain. (11)(12) Consensus now indicates that attachment can be defined as the dyadic regulation of emotion, that the attainment of the self-regulation of affect is a major developmental achievement, and that normal development represents the enhancement of self-regulation.I now use the perspective of regulation theory (10)(11)(12) to discuss and interpret recent studies on attachment, affect regulation, and development of the right brain. These advances in understanding the neurobiology of attachment are being incorporated into clinical models of the development of childhood mental health and mental illness, areas that are directly relevant to pediatrics. The mission statement of the American Academy of Pediatrics states its commitment to “the attainment of optimal physical, mental, and social health for all infants, children, adolescents, and young adults.” (http://www.cispimmunize.org/mission.html)For a more extensive discussion of regulation theory and an index of the references of studies cited here, the is to two by for the infant during the first postnatal are the of an attachment bond of emotional communication with the and the development of self-regulation. use their expanding coping to with the social environment. In the use their maturing and developing especially and to with the social environment. At around of there is a dramatic progression of social and emotional of the the and infant in and and interactions allow the infant to be to of social and cognitive emotional the mother and by the the the the of their affective behavior within These of in the first of social play and generate of and In these both states and their social and to each to and as a of each the structure of the other and his behavior to that In the with the the mother to the expressions of and psychobiological states, and to the this process of the of their and is The more the mother to the infant during periods of social the more to in periods of The more to the child’s for the more their Thus, the the information processing by the and of the and of to the These interactions the and are to his affective interactions the mother be not so to the child’s behavior as to the of the of his the to systems of the be to own The of the infant to experience of states is and by the and on to in an communication of emotions that feelings in and therefore, as an of the also of in the of the attachment In early an of the of infant states, especially after a a between states, and this for the development of self-regulation. The key to this is the to and own In this essential of and the a in infant through a the and infant his affect in The process of affect experience the child to that affect can be and that can be emerges from an context in which the child and together the from to and to The adaptive of in the of is an of attachment and optimal mental that states of and that states of are the of attachment and its These which the first underlie the of an attachment bond of emotion regulation between the infant and psychobiological and the of are processes that Thus, the attachment is a mechanism for the regulation of biologic within and between data suggest that affect regulation is not the of affective the of emotion. regulation an of emotion, a for more complex The mother of the child not only the states through but also his affective states in affective interactions with a a of and a that the child’s of and physical This is a of adaptive infant mental to emotional states is an essential developmental Because these communications are and it believed that their mechanisms to studies in developmental have to this problem, that during optimal of affective the and individual systems are in a that for regulation of and central systems of both mother and infant by of their with each developmental neurobiological research findings are with the psychological models of early mother-infant communication in the and and body as of that emotional the feelings of and within the created by the to the of a child’s brain growth are adapted for by emotional to the of therefore, are into the substantial in the developing brain. of the brain are by the regulation embedded within various of and in mind that the brain actually represents two unique processing a substantial body of research indicates that the right hemisphere begins a critical period of maturation before the This hemisphere is more than the in from the the of the second postnatal the hemisphere undergoes a growth studies that brain rapidly during the first 2 years after normal appearance is seen at 2 years, and all major can be by 3 than 2 years of right than studies support the that “the emotional experience of the infant through the and that of an early and are in the right hemisphere during the stages of brain The neurobiology of attachment, therefore, is an neurobiology of right brain Although the developing hemisphere most language the early developing right hemisphere is more to the of communication through all stages of support of this right brain communication research indicates that at of intense a critical period is in the cortex during which connections are by as young as 2 months of right on to a and particular areas of the right hemisphere are to be in a and at the very time information that from is being to most by the of information from the especially of and are by the right Studies that the development of the to process information from input to the right (and not left) hemisphere during the first emotional communications embedded within are into developing right that are for and and for processing and emotional The right cerebral cortex is dominant for the processing of individual of and to the the right hemisphere is than the in emotional to the of and and emotional studies reveal that the to an a attachment is an of the right brain. These data support the idea that to emotional are more strongly on the early more right to most to on the of the body. This the of affective into the and and processing in the developing right and the and communications are to the of emotional in the right that this context for within the and that “the role of the right hemisphere is in to the most of and a neurobiological the child is and brain are and and to the child is other are to and interpret as The appearance of the mother a as in The and systems of the right brain become to self-organization of social the and from the and as well as the body of a experiences are developing limbic in the right brain, which are to extensive in the first 18 postnatal Thus, at a the mother functions as a of the environment, and interactions play a critical role during the and of developing emotion-processing limbic The emotional communication that occurs within the attachment relationship has as between limbic Because the early maturing right which is into the limbic system, is in a growth spurt at this time, attachment experiences affect developing limbic and areas of the right brain that are critical to research indicates that the mother functions in the as a of the child’s and in the the child’s to with the social-emotional environment. Although the mother initially an mechanism for the neurobiological by the end of the first postnatal the infant through the maturation of mechanisms to the psychobiological models refer to of the affective with the which can be to its affective Studies are in the child’s maturing brain. the last years, many studies have the of and emotional on the brain development and on emotional, social, and in discussion of the relevant and physiology of the brain is in the to this optimal emotional communications between the infant and the attachment facilitate the self-organization and increased of the right brain. the child’s attachment to the mother in the first the child another attachment in the second to the the child to have and experiences with two different of a of this with the infant models of attachment that are in of attachment to a of an that during of will be These of affect regulation and coping mechanisms for basic regulation and affect in the of environmental The to more complex self-regulatory coping to of psychobiological emerges of its experiences with the social all this right of a model of the attachment relationship, at is to and information and guide in both and the of the the right hemisphere that has and by early experiences is dominant for the and regulation of emotion, essential functions for and social especially Studies suggest that attachment and right brain represent the of three other that are critical to human and development. the right brain is dominant for the regulation of and functions that support and enable the to and with A body of data a between in early of the and postnatal critical periods of brain and health and This is by studies attachment, and childhood attachment with and and research that the right hemisphere a unique role for and of right brain affect not but also essential of coping with both emotional and physical These influenced by optimal attachment are critical of adaptive physical and mental to the right hemisphere is for and and for the processing of (9) an evolutionary role of the right hemisphere in the adaptive a and of a corporeal of and its to the from of a as well as other organisms, and environmental and understanding and to and environment All of these critical adaptive functions are by the second postnatal end of the right brain growth and all are essential of the of mental to the of the of to for and mental health is the developing of the child from to three years to and and the environment and mental health is with social and emotional The of mental health the adaptive of the right brain, the neurobiological of the emotional self. the right brain in and conditions its stages of have an on its development. The postnatal maturation of is influenced by the and regulation of social-emotional experiences within the attachment now that at the most attachment experiences facilitate the brain’s major located in the right brain. studies also that and interactions within the early social environment the for an attachment, right brain and the development of a to psychiatric and that early of the mother-infant attachment relationship has a on brain and to psychopathology is well and of emotional emotional experience may a into a developing of and can the functional of the brain during stages of and of the for an extensive discussion of the neurobiology of of the and of early relationships on the and neurobiological of the over all stages of substantially our of human In the of the last the that there is infant the This developmental psychological conception is in the developmental neurobiological that “the self-organization of the developing brain occurs in the context of a relationship with another self, another brain.” This other brain is the right brain of the the Although have in the a large and body of developmental neuroscience research both human and the central role of the early relationship with the mother in the development and, therefore, social-emotional and of the developing is an intense interest in neuroscience in the of early on brain development in the first 18 postnatal months and in the of this knowledge to child development. These studies indicate that experiences especially early in and they the for use and of the brain and of In the an has defined as a complex physical environment, and the of early on cognitive development. It now is clear that for optimal brain the infant also to with an social environment. The spectrum of affective within a mother-infant attachment relationship an environment more that has a on emotional development and the essential of with these a very recent of and on the relationship and affect in infancy is as a of the relationship, than a of the infant The cited a large body of data that the of the child’s relationship with the as central to understanding the developmental processes from early affective and to to affect in early interactions with their may continuing with affective regulation that attachment regulation of the right brain, and infant mental health to be in the of the pediatrician. This information the to the system of communication and regulation that at the of the mother-infant the social and emotional of the infant and the of the communications within the attachment the use clinical that his subjective right brain as well as brain. The of regulation theory that to the mother-infant relationship also to the to the of the relationship, which the and the for the same of that is essential to the development of the that attachment regulation of the right brain, and infant mental health to be in the of the pediatrician. the for a of clinical of affect regulation and right brain interdisciplinary data on attachment, affect regulation, and the right brain can be applied directly to relevant models of the of normal and abnormal social and emotional development. infant mental an of optimal attachment can be defined as the of and right brain for both and affective states and for coping with and especially The of an complex right brain system for emotion the developing individual to affective states in to in the social environment regulation, a of in both the other infant mental health is in a right brain to into emotional communications with and intense of affect a system, and an to adapt to of the changing social environment in a The is a for coping with the psychobiological in social the is a for of developmental processes and a to the coping that a to These directly to the American Academy of Pediatrics terms “the attainment of optimal physical, mental, and social health for all and the of health in adolescents, and young his of attachment theory, Bowlby that a of complex systems the limbic system and brain areas attachment The neuroscience now to the limbic a of limbic areas in the and and a of emotion of the and on the of brain have a model of the early experience-dependent maturation of the limbic system and proposed a of systems that are by more complex attachment communications and over the first 2 years of human The optimal of these brain areas essential to the child’s emotional development on the regulation embedded within the attachment communications of the mother-infant only the a limbic system that information and and is The right processes within the infant relationship and the of the as well as the of the through At a critical period for the development of the this system to play and and and the of The first also is a critical period of experience-dependent maturation of the right a structure within the that is involved in the subjective of body feelings and and the right a involved in the of the physical and the to from the last of the first postnatal the areas of the a critical period of growth that continues through the of the second year. The the of the limbic system, at the highest of of especially in to emotion, and is to system of have that in the mother is from limbic system into the child’s developing limbic A very recent by and of a of their own brain in the especially on the right (3) These that this cortex a critical role in the of as by that it the of emotions attachment, and that individual in to infant an of studies that the right areas play a role in the of and information and in the of states with environmental processes central to the attachment mechanism. This right cerebral hemisphere is involved in the and in than other of the human the right which an for the right brain, is most directly to the brain’s (5) the regulation of in social and in this a attachment the of from to and of human development suggest that experiences in social relationships maturation and that conditions that affect early in infancy in right but not with experience-dependent most expressed in cortex in by (6) Thus, on a the attachment relationship between the child and is because it the development of the brain’s major self-regulatory the attachment relationship the dyadic regulation of both and emotion the regulation of the developing system communications embedded in attachment experiences the connections between the maturing central system limbic system that processes and social-emotional and the that the of emotion. A body of that the right hemisphere is into the and that more so than the left, both and The the of the is right and the are on the right of the human brain. This hemisphere is dominant for the of and the the that coping that the relationship with the mother the development of the (8) that social behavior with the right hemisphere (9) and that to a of the in the right (and not left) cortex that is in (10)