Interpersonal neurobiology holds that models of effective early intervention during the period of the brain growth spurt are equated with prevention (Schore, 2012). The optimal connectivity of the right brain is the basis of emotional well-being and is the socioemotional foundation upon which all development rests. The attachment relationship sets the trajectory of the development of the right brain throughout the lifespan – attachment experiences influence all later development. The right brain must be a fundamental focus of early intervention and prevention programmes. Schore refers to the work of Shai and Belsky which suggest that early interventions that exclusively rely on verbal processes of reflective functioning do not give a sense of the embodied, relational nature of the parent-infant interaction. Attachment interventions that seek to develop the mother’s mentalizing functions are too focused on the left-brain whereas attachment communication, emotional processing and mothering more involves the right hemisphere (Schore, 2012).
Approaches integrating paediatrics and neuroscience focus on reducing stress and adversity during the early years of life (Schore, 2012). Jack Shonkoff notes that interventions which improve the mental health, self-regulation and executive function skills of vulnerable mothers are likely to be effective ways of protecting the developing brains of their children. Understanding at risk parenting may open opportunities to create targeted interventions that aim to prevent disruptions in the attachment relationship in a more accurate way. Importantly, because development is occurring in the right-brain relational context of nonverbal and implicit communication, clinicians must be adept at attuning to and assessing this realm of the mother-infant relationship. To do this they must become ‘participant-observers’ and join in the intersubjective realm to get a feel for what is happening. Mental health and developmental fields are ‘extremely interested’ in applying neurobiological sciences to optimise the relational origins of the self in early intervention and prevention efforts (Schore, 2019a).
Early intervention would include assessing the attachment dyad’s regulatory and intersubjective functions – in this lies the ontogeny of the well-being of the infant (Schore, 2019). Investing in healthy brain development in the early years can maximise the relation origins of emotional well-being for large numbers of people in a culture. Genetic potential interacts with early experience in complex ways to create neural pathways and connections that serve as the ‘foundation and scaffolding’ for all future development. It is at this time that the child’s well-being, health and development need most to receive protection from society.
Regulation theory offers an “overarching interpersonal neurobiological model of the development, psychopathogenesis, and treatment of the early forming subjective self-system” (Schore, 2019a, p.56). Schore continues to apply the theory to clinical practice to create more effective evidence-based models of early assessment, intervention, and prevention. The assessment model for the theory emerges first from the primary principle of interpersonal neurobiology: that the structure and function of mind and brain are shaped by social experiences and in particular emotional relationships. Secondly, in infancy, the right hemisphere is in a critical period of growth starting in the third trimester and running up until the middle/end of the first year. Attachment transactions influence this “early life programming of hemispheric lateralisation” (p.57). Schore quotes McGilChrist’s work in describing the profound differences between the two hemispheres. When the right is dominant, we experience a live and embodied world of unique beings which is forever changing and embedded in a ‘net of interdependencies’, a world with which we are deeply connected. To this world the right hemisphere exists in a ‘relationship of care’ (Schore, 2012). Schore describes how this ‘essential’ right brain capacity optimally evolves in “the interpersonal context of a secure relationship bond, ‘a relationships of care’” (p.398). The right hemisphere is the primary driver of affiliation needs and social connection, as well as emotional regulation and personal growth. These adaptive capacities emerge from early attachment experiences and they should be assessed in the early critical period.
McGilChrist’s (2010) argument that the modern world is increasingly dominated by the left hemisphere is likely contributing to what Schore (2012) has referred to as a decrement in the culture leading to higher rates of disorders and disease in childhood. Schore’s work clearly highlights the central role that early right brain development plays in the health of the person across the lifespan. This early development contributes to the development of right brain functions like empathy, compassion, morality and intersubjectivity – all essential traits needed to create a healthy society. A culture deficient in right-brain relational capacities means that infants may be entering a world that has less capacity to meet its relational and ‘regulational’ needs, resulting in an increase in the number who are vulnerable to developing a predisposition to psychiatric disorders. The claim has been made that our culture is suffering from a ‘crisis of connection’ and we are suffering from ‘relational poverty’ (Way at al, 2018; Perry, in Narvaez et al, 2012). If this is true, we can assume early developmental environments are also being impacted through impaired early right brain development. Interpersonal neurobiology, modern attachment theory and regulation theory as well as other models (Tronick, 2007) highlight the intense need we have for connection in infancy and a decline in the quality and quantity of connection at this stage will have negative developmental consequences. All of this supports the urgent need to prioritise early intervention.
Schore offers a psychoneurobiological model that can evaluate the attachment system “as it is evolving in real developmental time” (2019a, p.58). This interpersonal neurobiological assessment of socioemotional development observes and documents the impact of right-brain emotional transactions on the right-lateralised limbic system of the infant. Modern attachment theory offers a heuristic model of optimal and less than optimal early right brain development. A growth-facilitating relational environment supports the development of right-brain regulatory systems that create a foundation for emotional well-being. Less than optimal environments “generate altered subcortical-cortical patterns of limbic-autonomic connectivity, or even structural and neuropathological alterations within the regulatory hubs…and thereby inefficient control functions” (p.59). Regulation theory uses the construct of ‘relational trauma’ to “model the role of right-brain attachment trauma in the psychopathogenesis of DSM disorders, like PTSD, borderline personality disorder and antisocial personality disorder”. Regulated and dysregulated ‘bodily-based’ communications can be assessed for the status of the attachment relationship and the infant’s social-emotional development.
Assessing the emotional well-being of the mother in pregnancy is critical because of the fact that the emotional state of the mother influences the foetus (Schore, 2019a). There is now a focus on the dynamic parent-infant interaction instead of isolated behaviours of either member of the dyad. Authors in the field of developmental neuroscience claim that the early period of life is a period of developmental vulnerability but may also be a time when therapeutic interventions would have the greatest positive affect. Regulation theory highlights the ‘potentially optimising effects’ of early interventions in prenatal, perinatal, and postnatal critical periods of brain development and has recently been applied to maternal-infant interactions for reducing allostatic load on premature infants. Developmental assessments of socioemotional development need to focus on ‘rapid right-brain to right-brain visual, auditory, tactile and olfactory’ attachment communications that either facilitate or inhibit the maturation of the right brain (Schore, 2019a, p.82).
Implicit affect regulation must be measured in assessments of infant mental health in the first and second year within the relational context that utilise non-verbal bodily-based measures rather than later left-brain verbal measures like explicit mentalization (Schore, 2019a). These early assessments of high-risk dyads can easily transition to clinical interventions that can expand the mother’s capacities for implicit interactive affect regulation which represents the core of the attachment dynamic. This can create a growth-facilitating environment for right brain development. The interpersonal neurobiological model of regulation theory gives support to the clinical principle that effective early intervention during critical periods of high plasticity facilitate the expansion of the right brain not just in infancy but across the lifespan. Neurobiologically informed early intervention programmes can help optimise emotional well-being and prevent emotional disorders.
Pregnancy and the perinatal period represent an extended developmental stage for women and men as they prepare to transition into a new phase in their lives (Liberman, 2020). There is extensive literature demonstrating the transformational experiences of pregnant women. Men’s experience is also receiving more attention too. The ‘anticipatory psychological processes’ that begin in pregnancy set the stage for the opportunities and challenges in the first year of life. Similar to the developmental stages of adolescence and menopause, pregnancy and the perinatal period bring emotional disequilibrium that, if resolved successfully, creates a redefined identity as schemas of self and other reorganise. This process is crucial for the emotional health of mother and child.
Pregnant women often report increased vulnerability and a fear of losing control in response to the anxiety of childbirth and in response to the transition in their role and identity (Liberman, 2020). Psychological processes from infancy and childhood can re-emerge and are revisited in this new maturational stage. Expectant mothers can develop a preoccupation with their own mothers and the activation of old conflicts particularly if this relationship was problematic. When this process leads to emotional growth new coherence of self as a person and parent is created. Research shows that the pregnant mother’s perception of the mothering she received influences the attitudes she holds towards her child. Psychotherapy can support the resolution of these issues and create a stable reorganisation of identity by the time the child is born. Bonding with the unborn baby goes hand in hand with this.
Lieberman highlights the challenges involved in the developmental transition to parenthood. It is clear that a lot is happening for a person psychologically at this time. From the perspective of regulation theory, we might expect to see structural deficits in right-brain functioning in those with insecure attachment histories emerging in the stress of this transition. Those with secure histories are likely better equipped with the internal resources to cope with this challenge. It is clear to see the important role psychotherapy, or other interventions that promotes reflective function and regulatory capacity, can play in supporting parents at this time. The ACE literature highlights the importance of interventions that impact multiple generations at the same time (Asmundson and Afifi, 2019). This is the promise of parental interventions – supporting parents/ the attachment dyad means improving the developmental trajectory of two generations simultaneously.
Current research demonstrates that not all mothers have been created equal in their parenting capacity (Schore, 2012). Schore quotes Barrett and Fleming who describe the interaction between mother and infant as being like a dance involving misstep, give and take and lots of learning. It can be awkward, difficult or elegant and sometimes, sadly, the dance does not occur at all. Through the therapist’s right brain connection to the right brain of mother and infant she can assess: the dyadic strength and level of attunement through nonverbal expressions; the caregiver’s ability to regulate infant arousal; the caregiver’s support of exploration; impressions of the attachment relationship based on the behaviour of both; knowledge of developmental stages and their connection to brain development; and a strategy for intervention. The assessment technique is not as important as the assessment process.
Gaze, tone and touch
Touch is the first medium of communication and is essential for parent-infant mental health (Schore, 2019a). Tactile communication in infancy regulates arousal as well as communicating ‘valenced and discrete’ emotions. The tactile communication the infant receives emerges within a larger infant-caregiver communication system that is made up of several sensory modalities and this dyadic system represents a ‘dynamic of mutual regulation’. Touch is embedded within Schore’s right brain to right brain system.
Affectionate touch is essential for healthy right brain development and so the clinician is assessing the quality and quantity of sensitive touch the infant is giving and receiving (Schore, 2019a). Left versus right side cradling should be assessed too, as cradling on the right side is linked with maternal stress and depression. Research shows that adults who cradle on the right are more detached and less emotionally responsive and sensitive which is a risk for adverse developmental outcomes. Left-cradling bias is absent in children with autism and is being suggested as an assessment for early identification of children at risk for these disorders.
It has been established the mutual gaze is critical to early social development (Schore, 2019a). The clinician, therefore, needs to assess how often and in what contexts the dyad spontaneously look, and don’t look, at each other, as this is a key indicator of health. Mutual infant-caregiver visual gazing that looks and feels natural means the infant’s brain is probably developing in a healthy way. Neuroscience verifies that infant-directed speech or ‘motherese’ is critical for the development of parts of the right hemisphere that processes prosodic-emotional functions. It is not the verbal content that is assessed but the melody of the mother’s voice. Infant directed speech is critical for the development of the capacity to read emotional tone in the voice of others which is essential in all later relationships.
Assessment of neurobiological regulatory systems
The attachment control system is hierarchically structured as an outer (later developing) orbitofrontal-limbic regulated core; an inner cingulate-limbic regulating core which develops earlier; and an even earlier evolving amygdala-regulated core – all nested like Russian dolls (Schore, 2019a). At 3-9 months the anterior cingulate, which is a corticolimbic structure linked with responsivity to social cues, begins to come online which endows the infant with greater capacities for intersubjectivity and receiving nonverbal communication for interactive regulation. In optimal relational attachment contexts, the vertical axis connecting the right orbitofrontal cortex with subcortical areas develops well which allows the right orbitofrontal cortex to regulate and be regulated by the right amygdala. Amygdala functions contribute to human attachment security while coping with early life stress leads to increased myelination of the orbitofrontal cortex, which controls arousal and promotes emotional resilience. Functional limitations of the orbitofrontal system are present in insecure attachment and a wide array of psychiatric disorders. The above ‘ontogenetic hierarchical model’ highlights the need for right-brain assessments that should be timed to ‘crucial period transitions’ of the three regulatory systems: 2-3 months, 10-12 months and 18-24 months – periods in which there is a complex reorganisation of the emotion-processing limbic system taking place. The secure infant and toddler through repeated experiences of interactively regulated “right-brain visual-facial, auditory prosodic and tactile-gestural attachment communications” (p.67) become ‘holistically integrated’, which allows for the emergence of a “right brain coherent emotional and corporeal subjective sense of self and background state of well-being” (Schore, 2019a, p.68). Attachment assessments focus on the implicit socioemotional deficits and capacities of both infant and mother’s right-lateralised self-system. Left-hemispheric verbal, explicit measures are impotent in tapping into these psychoneurobiological mechanisms.
Clinicians assessing early relationships must integrate developmental psychoanalysis and neuropsychoanalysis literature on the early development of the unconscious mind in relational contexts in interventions, as this is the realm in which attachment dynamics are occurring (Schore, 2012). The clinician seeks to assess the preverbal implicit world in cases where a comfortable relationship does not exist between infant and caregiver.
Schore repeatedly highlights the key point that early development is occurring in the context of the right-brain relational system created by the mother-infant dyad. The right brain, according to Schore, is the ‘biological substrate’ of the unconscious mind (2012). To enter this realm of attachment dynamics a clinician must use their own right brain to attune to the quality of the nonverbal communications. Schore proposes that emotional communication represents the core of the attachment dynamic and this is expressed through touch, gaze and tonicity – the language of the right hemisphere. A left-hemispheric approach will miss a lot of the nuance and subtlety in operation here. The specificity that Schore provides, based on his extensive multi-disciplinary work, offers the promise of matching assessments to important developmental periods and gives clinicians a clear guide for what to look out for.
Berry Brazelton suggests that the inability to regulate strong emotions is at the root of violence (Schore, 2003). Therefore, the developing right brain regulatory and coping capacities need to be assessed throughout the early developmental period. Classifications of disorganised/ disorientated infants need to be made well before 12 months and these infants need to be followed throughout infancy as they are high risk. Harsh touch in infancy is linked with later aggressive behaviour, so early tactile experiences with low-birth weight children need to be evaluated. Screenings for dissociation and withdrawal and low resting heart rate are essential too in these high-risk infants.
A “neurobiologically oriented diagnostic programme” should include “infant right frontal EEG risk markers” (Schore, 2003, p.147). It is known that right frontal system is central in mobilising an adaptive stress response so right hemispheric dysfunction combined with early abuse creates a predisposition towards violence. Neuroimaging investigations of limbic structures (orbitofrontal, cingulate, insula, amygdala) during critical periods in attachment stress and resting states would give a good picture of neurobiological development. Video assessments of the infant capacity for recognising positive and negative visual and auditory expressions need to measure the autonomic response of the infant to the mother’s face in the first year and the infant’s own face in the second year. Assessments that measure brain, behavioural and bodily changes in the dyad would provide information on the right brain regulatory functions that can guide clinical intervention.
Interventions that seek to ameliorate the impact of relational trauma should seek to improve psychobiological communications within the ‘bodily-based’ attachment relationship and aim to optimise the limbic-autonomic circuits and right prefrontal systems involved in affect regulation (Schore, 2003). Treatment programmes that interrupt the intergenerational transmission of traumatic abuse and neglect alter a growth-inhibiting environment that generates negative affect and frequent aggression dysregulation which would reduce the prevalence of personality disorders that are a high risk for violence. Home visitations should be part of these programmes. Infant mental health workers are developing interventions that alter the regulatory capacities needed for effective parenting which improves the attachment experiences and psychobiological development of infants at risk. These programmes transform insecure attachment patterns into secure ones which facilitates that development of the right brain and regulatory ability which enables the person to cope with stress and manage aggression. This effort should be multidisciplinary including developmental researchers working with social workers, child psychologist and psychiatrists, paediatrics and other professions.
It is exciting to think how technology like neuro-imaging might be used as a tool for detailed assessments, however, it would appear to be a resource intensive process that may be a hard sell. In his work, Schore has repeatedly demonstrated how many of the problems that plague societies have their roots in growth-inhibiting environments in infancy. But how can these environments be transformed into growth-promoting ones? What does an optimal or growth-promoting early environment look like? In the next section we will explore what are the key ingredients of optimal growth-promoting early environments and how interventions can facilitate the creation of these, particularly for high-risk dyads.
References
Asmundson, G. J., & Afifi, T. O. (2019). Adverse childhood experiences: Using evidence to advance research, practice, policy, and prevention. Academic Press.
Lieberman, A. F., Diaz, M. A., Castro, G., & Bucio, G. O. (2020). Make room for baby: Perinatal child-parent psychotherapy to repair trauma and promote attachment. Guilford Publications.
McGilchrist, I. (2019). The master and his emissary: The divided brain and the making of the western world (2nd ed.). Yale University Press.
Narváez, D. (2012). Evolution, early experience and human development: From research to practice and policy. Oxford University Press.
Schore, A. N. (2012). The science of the art of psychotherapy (Norton series on interpersonal neurobiology). W. W. Norton & Company.
Schore, A. N. (2019). The development of the unconscious mind (Norton series on interpersonal neurobiology). W. W. Norton & Company.
Schore, A. N. (2003). Affect dysregulation and disorders of the self (Norton series on interpersonal neurobiology). W. W. Norton & Company.
Tronick, E. (2007). The Neurobehavioral and social-emotional development of infants and children (Norton series on interpersonal neurobiology). W. W. Norton & Company.
Way, N., Ali, A., Gilligan, C., & Noguera, P. (2018). The crisis of connection: Roots, consequences, and solutions. NYU Press.