Jo Carlowe Hello, welcome to the In Conversation Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a Freelance Journalist with a specialism in psychology. Today, I’m interviewing Professor Sam Wass, Professor of Early Years Neuroscience at University of East London Baby Development Lab. Sam led on the “Annual Research Review ‘There, the dance is – at the still point of the turning world’ – dynamic systems perspectives on coregulation and dysregulation during early development,” recently published in the Journal of Child Psychology and Psychiatry, commonly known as the JCPP. Sam is joined today by Clinical Psychologist, Dr. Celia Smith, who is also an author of the Research Review and Celia is currently leading a practitioner review on this for the JCPP. In today’s podcast, we will focus on both the findings in the science-facing Annual Review on early child-caregiver interactions and on the implications for practitioners. If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with friends and colleagues. All listeners to this and indeed, any of the ACAMH podcasts, are eligible for a free CPD certificate. Do please visit acamhlearn.org for details of this, together with information on how you can access hundreds of hours, free talks, lectures, interviews, all of which you can also get free CPD certificates for. The URL is www.a-c-a-m-h-l-e-a-r-n.org. Celia and Sam, welcome. Thank you for joining me. Can you each start with an introduction about who you are and what you do? Professor Sam Wass Hi, so, I’m Professor Sam Wass and I’m a Professor of Early Years Neuroscience and I lead, as you’ve mentioned, Jo, the BabyDevLab at the University of East London. So, we do lots of research looking at, kind of, typical and atypical development, including typical development, so what we call basic science. And we do a lot of research with, kind of, dyadic neuroimaging, as well as the research with home wearables that we’re going to be talking about today. But the main focus of what we’re going to be talking about today is, obviously, the work with atypical development, that we do work with children in early stages of developing conditions such as autism, ADHD, anxiety, as well as other, kind of, types of high-risk groups. So, the reason I’m based out in East London is particularly, we do a lot of work with socioeconomic diversity, children from diverse backgrounds and looking at how that affects early development, as well as conditions such as pre-term births. Jo Carlowe Great, thank you, Sam, and Celia? Dr. Celia Smith Thank you very much, Jo. Yeah, my name’s Celia and I have worked with Sam for a long time now. I did my PhD with Sam several years ago in developmental psychology. I split between King’s College London and University of East London. And I’m now just currently finishing up some advanced training as a Clinical Psychologist, also at King’s College London, and at the moment, I split my time between clinical work and research. I currently work within NHS Perinatal Mental Health Services in South London and I’m soon moving to a specialist role within the NSPCC. And I suppose my areas of experience and interests and expertise are around parent-infant relationship, perinatal anxiety and other mental health difficulties, and also trauma, so thinking about birth trauma, attachment trauma and also, traumatic bereavement. But… Jo Carlowe Sam, can you start by giving us a brief overview of the methods used to study early child-caregiver interactions? Professor Sam Wass So, obviously, this idea that we start off as a, in Shakespeare’s terms, kind of, a “puking, mewling” bundle, dependent on our parent for everything, and this way in which we transition from utter dependence on everything, to, kind of, adult capable of, kind of, controlling themselves and managing their own mood. Obviously, this idea and this transition has gone back – you know, we’ve been thinking about this and talking about this since, you know, the very earliest stages of humanity. I guess, kind of, the scientific study of early child-caregiver interactions – I just was – organised a conference. We had a wonderful talk from Sally Shuttleworth, who’s a Historian of science, who wrote this wonderful book, “The Mind of the Child,” and she was talking about how Darwin, in a lot of ways, was very – well, one of the first people to, you know, make this into a scientific field. He published this book about his early, kind of, observations of his baby, which then, you know, led to a lot of – the explosion of this type of thing amongst Victorian, mainly male Scientists. And there’s a lovely bit, Sally talks about how women in the Victorian age tried to get in on the act and tried to do some, you know, proper observations of parent-child interactions, and all the men were saying, “Don’t be ridiculous, this is science,” kind of, “man’s job.” But obviously, that gradually changed over time, through to psychoanalysis, so obviously, you know, big field of, kind of, parent-child interaction, kind of, Melanie Klein, that type of thing. And then, you know, in terms of stuff that we really still pay a lot of attention to nowadays, I guess a lot of the really important work in early child-caregiver interactions was, kind of, people like John Bowlby and Mary Ainsworth with her ‘Strange Situation’, which is still very, very, very influential in terms of, kind of, child psychology. Leading onto really important figures, like, kind of, Daniel Stern, Colwyn Trevarthen and so on and so on. But these are almost all based on qualitative observations, or, kind of, Scientists observing children in, kind of, home settings. So, going back to the 70s or early 80s, we brought this thing of bringing parents and children into the lab and videoing them when these technologies first became available and then, observing the, kind of, microscopic details of their interactions. So, you know, this is work by – fantastic work by people like Beatrice Beebe, Dan Messinger, Ed Tronick, Ruth Feldman and Alan Fogel. So, some really, really amazing work going back to then. I guess so far, the two big, kind of, tranches of understanding about child-caregiver interaction come from these two methods. So, qualitative observations over, kind of, long periods and then, these really, really detailed microanalytic observations of short boast – bursts of interactions in the lab. But the thing that Celia and I are going to be talking about today is new method that, kind of, Celia played a big role in pioneering as part of her PhD and we’re using it in quite a few different contexts. And this is about, kind of, using these miniature non-invasive wearable devices. So, the ones we use are just a tiny – you know, about the size of a cigarette box. They clip onto a baby and caregivers in the home settings. You can record for a whole day. They record, basically, everything the child sees, everything that they hear, their physiology, so their heartrate, kind of, GPS, parent-child proximity and lots of other things, as well, that we can put on as add-on. So, this is giving us, kind of, the new ability to make in-depth quantitative long-form observations of how parents and children are interacting over potentially long periods. So, we can, you know, be recording, kind of, days to weeks, to months of data. And what we’re going to be talking about today, really, is how this new method is driving new theory. So, this is a bugbear of mine that, you know, the types of theories that we come up within science are very much predicated on the observation methods that we’re using, and you fit your theories to your data. They’re new observation methods that bring about with them a new type of data, really, kind of, have the potential to both build on our current theories. So we’re going to be talking lots and lots about how the types of things that we can be looking at fit very well with ideas from John Bowlby and Mart – and Mary Ainsworth and that type of stuff, but they also, kind of, drive, kind of, theory in new areas. Jo Carlowe Celia, can you provide us with a brief overview of the clinical interactions currently available focused on child-caregiver interaction in the nought to three age range? Dr. Celia Smith When it comes to child-caregiver interactions, especially during those crucial first few years, the emphasis today does tend to be more on evidence-based, sort of, practical interventions that enhance the relationship between the two. But historically, early interventions around child-caregiver relationships would’ve been more influenced by, as Sam described, more perhaps psychoanalytic theories. So, for instance, these approaches might involve a Therapist helping a – often a mother, explore how her own childhood experiences with her parents might be affecting her current relationship with her baby, aiming to uncover unconscious patterns impacting her caregiving. And though those ideas are still influential today, there was a significant shift in the development of attachment theory by Bowlby and Ainsworth. It focused a bit more on the present, perhaps, observing how a child might cling to their caregiver when frightened, highlighting the need for a secure base. And this perspective has really laid the groundwork for interventions that emphasise, sort of, more real-time interactions or interactions in the here and now, and they focus on the immediate impact, I suppose, of the caregiver’s behaviour on the child’s development. Now, in recent decades, this focus has sharpened a bit with the introduction of more interactive interventions designed to make a tangible difference in the relationship. So, for instance, video interaction guidance, VIG, uses video feedback to enhance interactions. This is where caregivers are filmed while interacting with their child, with the guidance of a trained Therapist, and they review the footage and together, identify moments of achievement and try to reinforce those moments of, kind of, a human connection. The Circle of Security parenting programme is another approach that helps caregivers to understand their child’s needs, both in terms of exploration and security. And that really focuses on helping caregivers to provide a secure base for their child to explore the world, while obviously being available as a safe haven when the child needs comfort, a really attachment focused intervention. Parent-Child Interaction Therapy, for instance, is another key intervention, particularly effective for children who are displaying behaviours that can be quite challenging to other people, particularly the parent. And this approach involves, kind of, live coaching during sessions, where the caregiver receives real-time feedback from a Therapist, through an earpiece, for instance, as they interact with the child. And the idea is that this might help caregivers learn to practice strategies that support and help regulate their child’s behaviour, while still paying attention to the relationship. These are just some examples of contemporary interventions, and they do tend to share overlapping goals and mechanisms, such as enhancing caregiver responsiveness or contingency, but also things like understanding infant cues. And all of these are, sort of, thought to be really important for a child’s healthy emotional and social development. Something that Sam and I will be getting to, sort of, talk about later on is perhaps where these interventions could be built on, could be strengthened, and where these interventions are already using ideas that perhaps we could transpose onto some of these findings that we’re seeing through the wearable technology research. Jo Carlowe Celia and Sam, as mentioned earlier, you are writing a practitioner review on this topic for the JCPP. I understand there are six key areas that you are focusing on, all relating to different processes of coregulation and dysregulation in the parent-infant pair. Can you talk through each of these? Professor Sam Wass I think just to, kind of, start with is the general conception. So, Celia already mentioned that one of the really big focuses, absolutely rightly, of a lot of interventions that are out there at the moment, is this idea of contingency promoting. So, this is this idea that it’s important to be responsive to your child. And, you know, there’s a massive amount of evidence there in a lot of different areas of psychopathology, you know, from caregivers with anxiety and depression, through to things like, kind of, parent-child interaction in ADHD, lots and lots of different things, you know, contingency is lower. So, parents are less likely to, you know, respond to something that their child says or respond to a distress vocalisation from the child, or to respond to their child’s, kind of, non-verbal cues. And that has led to this idea that one of the things that we can usefully do to try to help, kind of, parent-child interactions, where we’re worried that, you know, they’re not developing is – in a typical way, is to improve this contingency, which is absolutely great. We completely agree with that. There’s a ton of evidence, as I say, that supports this. What we’re trying to do is try and go a little bit beyond that, so how can we be more, kind of, nuanced about this idea of contingency promoting? And each of these six areas, kind of, really, kind of, take it in a slightly different direction. So, the first comes back to this idea of one of the really, really early aspects, and Ruth Feldman talks about this beautifully in her work, one of the really important core functions of early parent-child interaction is to help us manage what we’re going to be calling today CNS arousal. So, CNS is your central nervous system and very, very coarsely, your CNS arousal is your overall levels of arousal and alertness within your brain and nervous system. We know that adults have relatively more stable, kind of, daily cycles of fluctuations in their day – in their levels of arousal and alertness. You know, we’re more aroused and alert during the day and we’re less at night. Obviously, a newborn baby not only has, kind of, very different patterns, so they’re much more, kind of, faster cycles, their sleep-wake cycles are much faster, but they’re also much more unstable. So, if you look at, kind of, their patterning, it’s much harder to predict where a child’s arousal levels are going to be, from their historical levels, you know, for a child than it is for an adult. So, the key idea is that there’s a sweet spot. So, optimal arousal isn’t when you’re as calm as possible and it isn’t when you’re excited as possible. There’s a sweet spot in the middle. This is, kind of – Yerkes-Dodson first showed this a hun – more than 100 years ago. And one of the, kind of, key ideas that is, kind of, important for early parent-child interactions is that the function of coregulation, so how parents are helping their children, is by helping them to keep in their optimal intermediate level of arousal as much as possible. Where this is important in intervention research is this idea that, you know, it’s not just about helping your child to calm down. It’s about responding to your child’s arousal state and helping them to keep them in, you know, what some people call the ‘Goldilocks zone’, where you’re, kind of, not too hot and not too cold. The other idea that’s useful is when we’re talking about down-regulating, it’s not just about, you know, keeping calm and helping the child to keep calm when they’re excited. You know, different dyads have different sweet spots. You know, you – some dyads are naturally a more of a, kind of, hyper dyad. You know, we’re quite hyper in my family, my kids are all quite hyper and, you know, when my kids are highly aroused, I find it easier to shift to – from, kind of, high arousal, negative affect, to high arousal, positively excited about something, than you do just to, kind of, get everyone to calm down. So, those are the, kind of, two core ideas. This idea that, you know, arousal is somewhere, kind of, in the middle and this idea that, you know, it’s not just about, kind of, going from high to low, it’s more nuanced than that. Jo Carlowe Sam has described the science behind the first concept. Can you talk through what it means practically in terms of the clinical context? Dr. Celia Smith Okay, so one of the points that Sam was making, based on the findings from some of this research, is that there’s this sweet spot of physiological arousal or, sort of, central nervous system activity that infants – and dyads, perhaps, function and most affect. And that is something that we understand clinically in a different kind of language. So, we talk about the ‘window of tolerance’, for example, and this is a term used to describe the range of emotional and physical states where an individual can function effectively. And when someone’s within their window of tolerance, they’re calm enough to think clearly and manage their emotions, especially, but still be alert and engage with what’s happening around them. What I would say is that this idea of the window of tolerance is often more applied to parents and thinking about parents, helping them to stay in their optimal zone of arousal, or central nervous system activity, and a bit less about helping infants or children to stay in theirs. As children get older, again, we start to see a bit more of those ideas being applied to children, almost as mini adults, but if we’re thinking about really early childhood, that doesn’t tend to be the case. Sometimes we do hear about practitioners thinking with parents about their children’s optimal level of stimulation in terms of if they have neurodevelopmental differences that mean they need a higher level of stimulation, for example, than another child. We might be thinking a little bit about that idea of how do we provide that stimulation, or lower that stimulation, depending on what their baseline is. But it’s not a really dominant idea within clinical practice, I wouldn’t say. It’s a bit more of an idea that we see applied to older children and to adults. Professor Sam Wass Shall I go onto this second one, Jo, or…? Jo Carlowe Yeah, please do, yes. Professor Sam Wass Yeah. Jo Carlowe Thank you. Professor Sam Wass Okay. So, the second one is, you know, this really comes back to the – what we were talking about at the start, about this idea that we have a massive amount of data that is videoing short child-caregiver interactions. The type that you can easily do in a lab or, you know, a Researcher goes and visits them in their home and looks at them for ten minutes. But we have virtually no data on these longer-term rhythms, so these longer-term fluctuations. So, the next idea is this idea, which is quite well discussed in the literature. So, Ruth Feldman’s done some really beautiful work about – you know, as I was mentioning at the beginning, about this idea that an adult’s long-term rhythms tend to be more stable than a child, and how the child, basically, entrains to the caregiver’s rhythms. And, you know, going back to Bronfenbrenner, he talked about – a lot about this in the context of self-regulation, that the adult does the self-regulation for the child and through that, the child, kind of, internalises the expectation of what a, kind of, a well-regulated state is. So, it’s there as the theoretical idea in the literature, but there’s really virtually no, kind of, proper empirical work looking at how an adult’s long-term rhythms influence a child’s, just because we haven’t had the techniques to measure it. The reason that this is really important is because these ideas of stable daily rhythms – there’s one slide that I saw in a talk, it’s one of those things you saw in a slide and I haven’t been able to find out, kind of, the citation for this slide, but it’s imprinted on my memory. Which is just if you look at, kind of, day-day-day-night-sleep, kind of, cycles in typical adults and adults with mental health conditions, it’s incredibly clear how it differentiates that the day-night-sleep-night cycles are less clearly differentiated in a lot of different, kind of, mental health conditions. And this has certainly been – you know, my experience, and I used to do Samaritans and, you know, you’ll constantly be getting phone calls in the middle of the night from people and, you know, you would say, “Well, it’s the middle of the night” and it’s like they’re completely, kind of, unaware of it. So, that’s a really, really important area, because we think, you know, based on these very old theories that have been around a long time, that, you know, parents influence children’s develop very substantially through their own rhythms. But we really have very little data on whether that’s happening and how that happens atypically in an atypical child interaction. So, the other idea, which relates to this idea of long-term rhythms, is that this idea that how you respond to your child is not just predicated on, kind of, you in terms of your static state, but it’s predicated on, you know, what state you’re in at the time that the child is communicating to you. So, this is something that any parent at home, you know, is completely obvious. You know, if you’re in a bad mood as a parent and your kid starts tantruming, you react differently. But in terms of clinical, kind of, literature, it’s really amazingly underexplored, just because, as I say, we haven’t had the methods to measure how these long-term fluctuations in a caregiver’s state affects how they respond short-term. Dr. Celia Smith Yeah, absolutely. So, for some time in the field, we’ve been looking at this idea of well, if we then support the parent with their own emotional, physiological wellbeing, perhaps that will be enough to scaffold their, kind of, caregiver-infant relationship, to enhance those interactions to ameliorate any difficulties that might be coming up there. And Alan Stein did some really, sort of, critical work in this area, especially with depressed mothers and parents, but also with parents with a range of other mental health conditions, as well. And the consensus opinion is that it’s really not sufficient to target the parent, sort of, needs alone. You really have to tackle both the parents’ mental health difficulties or contextual challenges and the parent-child relationship together. If you only focus on one and not the other, the outcomes, the progress is quite limited, and this dual focused approach helps make sure both areas get the attention they need to really improve. And this actually, idea, is really intuitive to lots of families and this idea that even if I’m doing quite well, if my child is really having difficulty, if there’s something in the relationship that’s not quite right, that’s going to make it harder for me to function, to be okay emotionally. So, to, kind of, help both sides out is going to have a, sort of, exponentially, sort of, positive, yeah. There is a big effort to, nonetheless, support parents with their emotional wellbeing or with their overall wellbeing in terms of thinking about things like their sleep cycle or their, kind of, own physiological rhythms, perhaps in terms of nutrition and other lifestyle factors. And a lot of that is provided through psychoeducation, trying to help parents understand how those different lifestyle factors can impact on their own stress levels and in turn, perhaps affect the parent-child relationship. That, kind of, psychoeducation approach is within a number of different interventions, but as I say, that alone is thought not to be perhaps sufficient to really provide the most meaningful outcomes for both the child and the parent. Jo Carlowe Such a huge area, isn’t it? Let’s go onto the third key area, then, for the practitioner review. Sam, do you want to start? Professor Sam Wass So, basically, this is something that we often talk about. So, I do a lot of work, as well as clinical facing work, I do a lot of education facing work and I present this a lot to Early Years Teachers, who think about this a lot in the context of babies and toddlers. Which is if your child that you’re looking after gets upset and they start crying, how do you respond? Try and keep as calm as you possibly can in order to show them the state that they should be in, or do you empathise with them and, kind of, cartoon, a “Ooh, ouch, that looks really, really ouchy” and, kind of, temporarily, kind of, match your state to theirs in order to build this, kind of, empathic connection, and then, from there, kind of, help them to take it down? And it’s really interesting, ‘cause there’s one of those things that they’re – in fact, exactly the opposite response. In the context of talking about with toddlers, so there’s an American Psychologist, Harvey Karp, who talks about this, it certainly works really, really well, with my kids, this idea that when you’ve got a tantruming toddler saying, you know, “I want to pour orange juice on the cat,” just the same thing again and again and again. Rather than doing what most parents do, which is I’m having my authority challenged, so I’m going to be very calm and rational and talk in a very sensible voice and be very logical, he says that’s not the way to, kind of, deal with a toddler. Much better is to match their state, narrate what they’re saying, say, “Yeah, really want to pour orange juice on the cat.” Match your vocal patterns to theirs, match your speech rhythms to theirs, to make them feel like they’re understood, and then, just shift them onto something else. And what we, and a few other people, now, have shown, is that, in fact, with babies – so, really interesting, Gianluca Esposito in Singapore, has done some work, as we’ve done a couple of papers, showing that, in fact, you get quite a similar pattern with babies. So, when a child gets upset, when a baby that you’re looking after, if you’re measuring the stress, the arousal levels in the adult caregiver, you very reliably see, kind of, an up-regulation in that adult’s arousal levels at the time when a child has a peak, kind of, arousal moment. And then we’ve also shown, actually, in three separate datasets now, that the more the parent-child does that, so the more reliably they up-regulate their state to match the child, the faster that helps the child to calm down. So, this is another idea that Celia and I wanted to talk about for this practitioner review, this idea that it’s not just about, kind of, setting a good example. In certain times and in certain settings, yeah, it’s about, kind of, temporarily matching your state to the child and then when the stimulation is no longer needed, then you gradually remove it. Obviously, this opens up tons of questions, can you do it too much? You know, if a parent is getting very agitated with a ba – with a crying baby and they’re, you know, losing their temper and, you know, telling the child to stop crying, you know, what’s the difference between that? And that’s also state matching. So, what’s the, kind of, “good way” to do it and what’s the “not good way” to do it? Celia, do you want to come in here? Dr. Celia Smith Yeah, I think this idea, this, kind of, match and then help down-regulate or then help calm, is something that we see threads of in existing approaches. So, a PACE model, that Playfulness, Acceptance, Curiosity, Empathy model, which was pioneered by Dan Hughes, is a really trauma-informed approach that aligns quite closely with this concept, particularly during moments of heightened emotion. So, if, for example, a child reacts with anger or frustration to a trigger or a stressor, so say they get really upset when they’re told they can’t play on the swings, you know, an immediate typical response from a caregiver, particularly a caregiver who’s, sort of, experienced trauma themselves, might be to reprimand the child for being rude or just dismiss their feelings, “We don’t need to play on those now, go, and what’s got into you today?” Something along these lines perhaps. But the PACE approach encourages caregivers to first, acknowledge and then match the child’s emotional intensity in, importantly, a non-judgmental and rhythmic tone, to capture their experience. So, “Oh, wow, you’re feeling really angry.” You know, “You think I’m being mean by not letting you go on the swings when you really want to go on the swings.” And by doing this, their caregiver, you know, shows empathy, makes the child feel understood, but does so in a voice that facilitates this, kind of, open, like communication, allowing the caregiver to diffuse some of the heightened emotion and bring the arousal down. This idea we also see in a few other clinical practices. So, sort of, Incredible Years, in Parents Inc., New Forest Programmes, which are more grounded in, sort of, social learning theory, and they teach parents strategies for supporting children who are quite prone to, you know, quite frequent, sort of, bursts of dysregulation. psychodynamically and are informed more by psychoanalytic concepts and actually, we can see some of these ideas around matching and then calming with young children, in even some of these really early psychoanalytic discourses. We also see that in terms of Winnicott’s Mirror-role, which is this similar idea of reflecting back the infant’s emotions to them, so that they can see these emotions and gain a sense of self through the parent’s mirror-role, and crucially, the parent doing that rather than expressing their own emotions in that moment. And then, there are also really important Clinician Scientists now, today, who are showing how they apply some of those ideas. Beatrice Beebe talks about how caregivers should stay just slightly below the child’s intensity level during emotional exchanges, to help the child process emotions without becoming overwhelmed. And then, we also have Feldman’s work who talks about a, kind of, acknowledging, imitating, elaborating chain. You know, a process where parents first are, sort of, able to acknowledge what’s going on with the infant, can imitate it, can match it and can then make it bigger, can elaborate it, to support the child’s, sort of, emotional cognitive development. And that’s been shown to be something that’s really linked to an overall sensitive attuned, contingent style of caregiver interaction. Jo Carlowe Let’s move onto the fourth key area. Professor Sam Wass As I mentioned, this idea that contingency is important, so being responsive to your child is something that, you know, we want to be promoting through clinical interventions. And this is, as I said, you know, one way in which I think we can go a bit beyond this. So, Celia actually did some research for her PhD, building on research some other people have shown, about anxious parents can actually be over-contingent. So, with these home wearable data, she just looked at the correlation, so the how much, if a child was in a high arousal state, was the adult also likely to be a high arousal state, too? And she found that the associations between the child and adult’s arousal state was higher in, kind of, a community sample where the caregiver had elevated anxiety. So, that’s one of the areas where we can – talking about, kind of, over-contingency. Another area, which we’re actually going to be getting onto a bit in the next one, is this idea of, kind of, oppositional parent-child interactions in ADHD. So, if you have a lot of parent-child interactions, where, you know, again, you talk to any parent and they’re like, “Oh, my God, yeah, of course,” and this idea that you, basically, wind each other up in a relationship. But again, it’s astonishingly under-explored in the clinical literature, just ‘cause it’s virtually impossible to study. You bring parents and children onto the lab and the way you interact with your children in the lab isn’t – when I’ve got five cameras pointing at me, isn’t the way I interact with my kids at home. And this is one area where we just have virtually no quantitative, sort of, data and it’s really, really key. So, basically, the idea of idea four is this idea that, you know, contingency, it’s not just the case that more contingency is better. You can have over-contingency as well as under-contingency. People like Ed Tronick have been talking about this idea for a long time, but, you know, really important, we think, to be, kind of, thinking about how we can use this idea in intervention research. Jo Carlowe Celia, do you want to add something? Dr. Celia Smith So, this idea that Sam’s talking about is something that aligns with a lot of clinical practice. So, I imagine that a number of listeners will, kind of, recognise the concept of, kind of, good enough parenting within what Sam has described. So, this idea that we’re neither wanting to be, sort of, overly contingent, not under-contingent, but just, sort of, contingent enough. This idea of good enough parenting, Winnicott’s idea, acknowledges that perfection in caregiving is neither necessary, nor realistic, nor perhaps desirable. And rather, what’s needed is a level of responsiveness that meets the child needs, without overwhelming the parent or stifling the child’s autonomy. And I think this, kind of, mid-range model of contingency, which is what Sam’s really describing, reflects this idea, that the best outcomes are achieved when parents provide sufficient support to make the child feel secure, but not so much that it hampers the child’s independence or places strain on the parent. I think we also see a little bit of that parallel in terms of clinical practice with the mid-range model of contingency in various therapeutic approaches. So, in Parent-Child Interaction Therapy, for instance, there’s this phase called the “Child Directed Interaction Phase,” where parents are coached to follow their child’s lead and when they’re playing, sort if, offering positive reinforcement, while avoiding being overly controlling or disengaged. And this helps parents stay in optimal range of responsiveness, where they’re supportive, without being intrusive. And there’s a subsequent phase in this intervention, which further reinforces this balance by teaching parents to manage their child’s behaviour with, you know, consistent commands that are neither, sort of, overly harsh nor overly lenient. By helping parents in this way, this intervention, sort of, is supporting the relationship to develop. I think we also probably are seeing this idea of, like, a mid-range model of contingency or thinking about the potential downfall of overly contingent interaction or under-contingent interaction in video interaction guidance. So, in video interaction guidance, practitioners are, sort of, thinking about moments where perhaps an anxious parent really is engaging with their infant in such a way that the infant’s not getting that much time off. That the infant, perhaps, is giving signals that actually, they just need to look over to the side. They’re actually in an overwhelming level of stimulation and in VIG, although perhaps we’re not necessarily pointing out moments where things aren’t going well, what we might point out is moments where a parent was able to hold back from that level of stimulation. To not be quite so intrusive, and to see what effect that had on the interaction and on baby and whether baby was more able to be, kind of, involved in the interaction in that moment. And then, thinking about how can we get more of this in the interaction? Jo Carlowe Let’s go onto concept five. Professor Sam Wass Yeah, and this is actually quite related in a lot of ways. So, we’re used to thinking of, kind of, the function of the dyad as co-regulation, yeah? So, we’ve been talking a lot about that. So, you know, parents shift their own state in order to help their child to maintain an optimal state, basically, and everything that we’ve been talking to up until now is about this idea of how we do this. But this is this idea that you can actually have parent-child involvement in dysregulation, too. So, if the parent, by responding to the child, can change the child’s state in a way in which further moves the child further away from the optimal state. So, this is quite an underexplored idea in the concepts of dyadic relationships. So, there is some really nice work by Gerald Patterson that talks about this. Apart from that, it’s relatively underexplored area. It’s much more explored in the context of intra-person dynamic. So, in panic disorder, for example, you know, this idea that you get this, kind of, self-sustaining cycle. So, you know, I’m in a high arousal state, which causes me to be hypervigilant to my physiological symptoms, which causes me to become more convinced that I’m having a panic attack, which causes them to increase still further. And you get this, kind of, feed-forward cycle. And it’s basically the idea that exactly the same types of feed-forward cycles can exist, but across a dyad. So, a child is more aroused, so they’ll be more oppositional, which then makes me more aroused as a caregiver, which makes me find it harder to see things from my child’s point of view, which makes me be stricter. Maybe I shout at my child, which makes them more aroused, which makes them more oppositional, and you, basically, as I say, just wind each other up. As I say, very, very hard to observe it actually happening, so consequently, really, really remarkably little work in the clinical literature on this area. Dr. Celia Smith I suppose what Sam’s described there in terms of the panic cycle will be really familiar to lots of listeners in terms of thinking about cognitive behavioural therapy and which usually focuses on how thoughts, behaviours, emotions, physical sensations, can interlink to create vicious cycles of stress, anxiety, low mood, within themselves. And usually, cognitive behavioural therapy is really oriented towards the individual, so it’s, sort of, intra-individual. But what Sam’s describing is perhaps, like, an application of these approaches to the dyad, so an intra-dyadic vicious cycle. And although this isn’t something that perhaps is, sort of, explicitly packaged up as an intervention in clinical practice, you can see that the ideas behind it are perhaps influencing parts of clinical practice. So, if we think about mindful parenting, which is intervention for parents about being fully present with your child, recognising your own emotional reactions and, sort of, being able to catch your own thoughts and feelings as they’re coming up and to, kind of, respond to those in an accepting way, that means you don’t get too wrapped up in them. And we can think about how that might be a powerful tool for breaking out of stressful cycles. Whether or not that’s the case is, sort of, an area where perhaps there might need to be a bit more research to really see, like, what is it that actually breaks down those chains of intra-dyadic vicious cycles? So, that’s one area, and another area that I’ve been thinking about with colleagues recently, is actually within the Circle of Security Parenting programme, which introduces this idea of shark music, which is that uneasy feeling that parents sometimes get when their child behaviour, sort of, triggers some deep-seated fear or anxiety, perhaps because it is reminiscent of something within their own childhood. We’re not really aware of what’s going on for us when the shark music comes. Perhaps that might be a moment where stress is a little bit higher, we’re a bit more likely to behave in ways that can escalate stress within the dyad that can contribute to that vicious cycle. But by becoming more aware of this, which is what Circle of Security programme partly aims to do, the idea is that the parent can better, sort of, manage that emotional tension, that emotionally heightened state, and stay more connected with their child, more in-tune, preventing stress from escalating. Jo Carlowe The final concept that you’d like to highlight? Professor Sam Wass Yeah, so this is this idea about long-term adaptation. So, one of the really popular metaphors when you’re talking about parent-child coregulation is that it’s like a dance. So, when you have a couple who are dancing, both partners are continually adapting to one another, you know, second-by-second, and that’s how you keep in rhythm. And basically, you know, parent-child coregulation is very like that. We’ve been talking about how it’s not just about, you know, that – the parent influencing the child, but it’s also about how the parent is influenced by the child, yeah. So, it’s bidirectional. We’ve been talking mostly about – in terms of the short-term interactions, yeah, moment-by-moment, how you’ve influenced one another, but you also get these interactions happening over a longer timescale, too. There isn’t just an optimal way of parenting, yeah. Your parenting style is influenced by your child, and there are tons and tons of studies that have shown this in different ways. You know, adoption studies, you know, like, other studies looking at parents raising genetically unrelated children, you know, lots and lots of different ways. Just to give an example of this, one really, really important way in which some beautiful research by Jonathan Green at Manchester has looked at parents and raising children in early stages of developing autism, is looking at how a child with autism naturally responds in a different way to social communicative signals from their parents compared to other children. And looking at how that affects, in turn, how the caregiver interacts with their children. And they’re just doing a beautiful intervention, just raising awareness of that in caregivers raising children with autism. You know, just be aware of the fact that how your child responds to you can influence how you, in turn, interact with your child. So, the dyad, kind of, is adapting to one another over time. So, it’s still a dance, but it’s a dance that happens over years, as opposed to seconds and minutes. Jo Carlowe Hmmm, great, thank you, it was really comprehensive. Ideas around caregiver and infant interactions are often based around Western ideals. What do your reviews, so both the research and practitioner reviews, find in terms of cultural bias and how can this be addressed? Dr. Celia Smith So, most research has focused on measuring child-caregiver interactions through things like gaze and voice. However, studies have shown that while child-caregiver pairs in Western societies often interact mainly through things like eye contact, vocalisation and things like showing objects, those in other cultures, African, Middle Eastern, Far Eastern cultures, tend to rely more on bodily contact and physical touch. So, it is worth noting that most infant research has been dominated by Western perspectives, often actually focusing on caregiver led interaction. And significant work in the, I’d say, the 1980s, by Researchers like Tronick, Capone and later by Beebe and Feldman, has actually highlighted the bidirectionality of these interactions, how both the child and caregiver influence each other. It’s not just one or the other. And while this focus on bidirectionality also has its roots in Western research, it is being observed preliminarily in other cultures, particularly in the Middle East and West Asia. So, there are signs that these ideas have broad application, but that said, we do need to remain open to the possibility that these patterns may not be universal and we do need more exploration and focus in these areas to really fully understand how interactions play out across different contexts. And one of the things that we are really interested in is that looking ahead within the field of infant research, data-driven approaches like machine learning and like AI applied to, sort of, multimodal interaction datasets, might help reduce cultural biases that sometimes occur within more traditional research methods when investigating the caregiver-infant relationship. And these newer approaches might give us a more balanced understanding of, sort of, which aspects of interaction are most important to be thinking about in development, without being limited by, sort of, preset ideas. I know that mentioning AI and machine learning also comes with its own, sort of, potential challenges and pitfalls. Jo Carlowe Hmmm hmm. Dr. Celia Smith We know that machine learning is not invulnerable to cultural biases in itself, but this is an area that we’re really interested in developing and within our lab and which some of the PhD students that are working with Sam at the moment are currently pioneering, I would say, to really try and address this issue. Jo Carlowe And a question for both of you, what else is in the pipeline that you would like to share with us? Professor Sam Wass Yeah, so there’s a couple of things that we’re looking at, at the moment and developing on it. So, one is a grant with Carlo Finchengo [means Schuengel] and Pasco Fearon, both of whom are Editors of JCPP, based out in Amsterdam, looking at the early development of attachment. So, this is what causes some children to develop secure attachments to their parent and not, yeah. So, this is a really, really foundational idea, goes back to Mary Ainsworth. What we got some funding to look at with this grant is, can we look at something that, again, amazingly, hasn’t been looked at before, which is how the caregiver is responding to their child’s distress in home settings, how does that then, in turn, affect how the child is communicating to their caregiver over time? And the other thing that we’re looking at in a project that we’re just developing at the moment with Celia, and also with Emily Jones at Birkbeck, is quite a different way of using wearables. Which is can we give these wearables to an individual child-caregiver dyad, record them for, you know, a week-long at home and then, analyse the data to give to your dyad, these are your specific triggers that trigger arousal dysregulation in your specific dyad? So, this idea that you’re actually giving people, within a context of an intervention, feedback, personalised feedback, about what is causing arousal dysregulation in their dyad, is a hugely complex issue. Is this something that we want to do? If so, how on earth do we do it in order to avoid one of – any of the many, many pitfalls that arise from it? So, this is something, you know, we’re just conducting some early-stage, you know, is this possible? And some, kind of – lots and lots of consultations, so if it is possible, is it the kind of thing we want to do? Jo Carlowe So much to explore and very exciting. Finally, both of you, what are your take home messages for our listeners? Professor Sam Wass So, mine would be the dyad is something that we can study scientifically. We can observe and we can make predictions. We can build a computer model to predict how things are going to react within a dyad, but it’s an amazingly complex system. It’s really at the very, very cutting edge of, you know, what we can study and model in dynamic systems theory. So, there’s no one size fits all, optimal way to interact with your child. The optimal way to interact with your child varies in lots and lots of different ways, across lots of different timescales and there are lots and lots of different types of optimal. So, dynamic systems are complex, but it doesn’t mean that we shouldn’t be trying to fix them when they’re developing atypically in the context of clinical science. Jo Carlowe Thank you, and Celia? Dr. Celia Smith I think my takeaway would be this point about the dual focus in interventions. If we’re focusing solely on either the parents’ mental health or parents’ context and we’re not thinking about the parent-child relationship, that’s not going to lead to the most effective outcomes. We really need to be thinking about addressing both to see meaningful improvements and the reason is that these two areas are really closely linked. When a parent is facing challenges, it can affect their relationship with their child and vice versa. So, if you only address one part of the equation, the other aspect might still need attention, and that’s why a dual focused approach is so important. Jo Carlowe Brilliant. Sam and Celia, thank you so much, it was absolutely fascinating. For more details on Professor Sam Wass and Dr. Celia Smith, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.