KIM OATES. Viewpoint: “Always say something positive about the child” (Berry Brazelton 1918-2018)15/09/2018
Over 40 years ago, I was fortunate to do some of my paediatric training with Berry Brazelton. He wasn’t famous then, but there was something about him that set him apart from the purely organic focus of most of the senior staff at Boston Children’s Hospital. He was interested in babies as individuals with their own sets of skills. Here was a paediatrician prepared to question the status quo about the abilities of infants and young children who based his views, not on the prevailing dogma, but on careful observation. He was the first to recognise that a baby is a highly developed human, even when just newly born.
I remember him telling me how a nurse in the neonatal unit had been able to predict which of two premature babies with respiratory distress syndrome would recover first. When he asked her how she had done it, she said she simply watched the babies carefully to see which was the more alert.
Eighteen months before I worked with him, he established the Child Development Unit, a training and research centre at Boston Children’s Hospital. Soon after, he developed the Neonatal Behavioural Assessment Scale, a scale that builds a behavioural profile of an infant in the early days of life. The scale, consisting of 28 behavioural and 18 reflex items, shows that newborn are complex, responsive and able to adapt right from birth. He showed they have the ability to control their internal state and become engaged with the world around them or to withdraw from it. He demonstrated how some babies are able to settle themselves, while others need to be soothed. The Neonatal Behavioural Assessment Scale examines the competencies of newborns but also identifies areas of concern and can be used to help parents understand and relate to their infants. It has been used in almost 1,000 research studies. When he took me to the newborn nursery to teach me to use the scale, I was amazed. I had no concept of the ability of a newborn to quickly adapt to a repeated stimulus or to show distress or state of organisation by subtle movements and signs. Berry taught me to observe.
Berry also taught me to observe older children. Somewhat to my embarrassment, he would send me to stand in the playground of a local preschool and just watch children playing and interacting with each other. I would then report back to him, describe what I saw and we would discuss the meaning of these observations. A new world opened up for me.
Berry Brazelton was immensely supportive of parents. In 1974, when I returned to Sydney to set up a Community Paediatric Unit – a unit with emphasis on assessing children with developmental disabilities and integrating their care into the community – we had one rule for every consultation. We called it the Brazelton Rule: “Always say something positive about the child”. I had watched Berry do this in Boston. It was a revelation to see the parent sit up a little straighter, to smile and to realise that here was a paediatrician who didn’t concentrate on what was wrong with their child, but who also made an effort to point out what was right with their child.
Berry Brazelton was the best-known paediatrician since Benjamin Spock. Berry’s impact on parents and certainly on paediatricians was arguably more significant than Spock’s. When he died on 13 March 2018, just two months short of his 100th birthday, the Washington Post obituary headline read: “T. Berry Brazelton, paediatrician who soothed generations of parents, dies at 99”. The obituary in the New York Times was titled: “Dr T. Berry Brazelton, who explored babies’ mental growth, dies at 99”. A day later, the New York Times ran a feature: “How Dr T. Berry Brazelton Shaped Paediatrics”. In that article, one of his colleagues said: “He really caused a Copernican revolution, an entire paradigm shift in our understanding of child development”.
It is difficult for modern paediatricians to understand that the whole concept of child development and the importance of the early years is relatively new. There was a time when infants and children were defined by the things they didn’t know and the things they couldn’t do. It was widely believed that the newborn infant was a blank slate, a tabula rasa, operating at the brainstem level.
It wasn’t until 1930, when the Swiss psychologist Piaget documented the careful observations he made on his own children, that we realised that young children already knew much more about the world than anybody realised. They could work out problems and they searched for knowledge, although they often thought in a different way to adults. Later, the Russian psychologist Lev Vygotsky realised that children use the way their parents react as a tool to help them to solve problems.
Others in the early 20th-century, such as Freud and Skinner, wrote about children but neither actually spent time carefully observing children and babies. Freud largely relied on inferences from the behaviour of neurotic adults. Skinner relied on inferences from the behaviour of neurotic rats. We’ve always had infants around us. Why did it take so long to carefully observe them and describe them by what they can do, rather than by what they can’t do? Part of the reason was sociological. Infants and babies were women’s business. Academia was dominated by men. In some universities, the only way a course could be done in developmental psychology was if it was linked to a course in home economics. Another factor was technology. Once the video recorder and later the digital computer became available, we had the ability to record and observe infants in the newborn nursery and at home and to carefully analyse the results. The pay-off is that we have learnt that babies are far more than a blank slate, knowing nothing. Berry Brazelton was one of the first researchers to use video as a tool to document infant behaviour, including the subtleties of facial expressions. By filming the interactions between mothers and their babies he showed how infants respond to maternal interactions and that when the mother stops responding, the baby becomes upset.
Thomas Berry Brazelton was born in Waco, Texas on 10 March 1918. He attended Princeton, where his passion was theatre. He was president of the Princeton Triangle Club, the oldest college touring musical comedy troupe in the USA, where he played a variety of roles, including females and juveniles. When he received an offer to try out for a Broadway musical with Ethel Merman, his horrified parents threatened not to support him through medical school, thus putting an end to his embryonic singing and dancing career but unwittingly kicking a winning goal for paediatrics.
He found medical school at Columbia University frustrating, saying: “My goal was to understand human beings, and we were learning mostly about diseases”. He did his medical residency at Massachusetts General Hospital in 1945, followed by paediatric training at Boston Children’s Hospital. Inspired by reading Spock, he trained in child psychiatry, this being the only avenue for a medical graduate to study child development even though this was at a time when child psychiatry had little credence amongst most clinicians. Later he worked with Jerome Brunner as a fellow in the Centre for Cognitive Studies at Harvard.
One of his important insights was that development is not a linear, upward progression. With each new skill there is a pause while the infant consolidates this skill, sometimes even regressing temporarily, before going on to master the next milestone. Building on this insight, he wrote the book Touchpoints, including an Australian edition in which I was privileged to write the foreword. In 1993 he founded the Brazelton Touchpoints Centre at Boston Children’s Hospital. The aim of Touchpoints is to reassure parents that they can navigate the predictable spurts in their child’s behaviour, emotions, language and motor development as they occur. The concept helps parents understand that advances in some areas can be associated with temporary regressions in other areas and that, while this can cause anxiety, each of these disruptions is part of the child’s development and an opportunity for parents to grow along with their child. Touchpoint Centres are now spread across the USA as well as internationally.
As his career progressed and he became better known, new opportunities emerged. He was President of the Society for Research in Child Development for three years from 1988 and appeared before many Congressional committees in support of parental leave and day care. In 1988 he was awarded the title of Professor of Paediatrics Emeritus at Harvard Medical School. In 1993, the Brazelton Institute was opened at Boston Children’s Hospital. Subsequently, Brazelton Centres have been opened in Cambridge UK and in Geneva, with the aims of promoting a better understanding of infant behaviour and fostering strong infant-parent relationships. In 2013, President Obama awarded him the Presidential Citizen’s Medal, the nation’s second highest civilian honour.
Berry Brazelton was a prolific writer. His writing is characterised by his focus on the individual differences in infant behaviour. Although he wrote many books, my preference is for his first book Infants and Mothers: Differences in development, describing three different children in three families where each child is normal but arrives in the world with a distinct biologically based temperament that influences how the parents interact with the infant. This book was particularly helpful and reassuring to parents. Writing for a parent rather than an academic audience, Brazelton was one of the first to understand innate differences in infant temperament and to support parents in understanding these differences. His message to parents was one of reassurance and hope. Instead of blaming parents every time something went wrong, he helped parents to understand their infants. Rather than join the many other authors who wrote to instruct parents on child rearing, Brazelton wrote to help them understand their children. “As soon as you share a baby with the parent, you show them the good things first, then you move on to the things they need to work on”, he said in an oral history interview in 1997. He understood the insecurities that plague parents, the anxiety of wanting to be the perfect parent with the perfect child. His aim was to encourage parents, not to make them feel perfect, but to make them feel competent.
I kept in touch with Berry over the years. He was always encouraging. He was a referee for me when I applied for the Chair of Paediatrics and Child Health at Sydney University. Several years later, when he came to dinner at our home in Sydney, he arrived not with flowers or wine but with a beautiful lace handkerchief that he presented to my wife saying: “This belonged to my mother. I thought you might like to have it.” Not just encouraging, but also gracious. He gave Grand Rounds at Camperdown Children’s Hospital, something that must have pleased him as he mentions it in his autobiography.
Actually, we had two rules at the Community Paediatric Unit. The other was the second Brazelton rule: “Always say something positive about the child’s parents”. “My simple wish”, Berry Brazelton said, “is for parents to have fun with their kids”. That’s a good motto for all paediatricians.
Kim Oates is a former President of the International Society for the Prevention of Child Abuse and Neglect and is an Emeritus Professor at the University of Sydney.