Relationship-Based Parenting Interventions for Healthier Outcomes with Dr. Katherine Guyon-Harris

The Family Check-Up | The University of Pittsburgh Center for Parents and Children

Family Systems Therapy | PsychologyToday.com

Nurse-Family Partnership

Healthy Families America

Home Visiting Programs | Pennsylvania’s Promise for Children

Home Visiting | Hello Baby Pittsburgh

Guyon-Harris Receives NIH Career Development Award, Will Develop Intervention Program for Pregnant Women with Opioid-Use Disorder | Pitt Pediatrics

Working Model of the Child Interview | APA PsycNet

The emotional tone of child descriptions during pregnancy is associated with later parenting by Katherine Guyon-Harris | PubMed.gov

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Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.

Dr. Arvind Srinath: From UPMC Children's, welcome to That's Pediatrics. I'm your co-host, Arvind Srinath, Associate Professor of Pediatrics in the division of Pediatric Gastroenterology.

Dr. Amanda Poholek: And I'm your co-host, Amanda Poholek, Assistant Professor of Pediatrics and Immunology.

Dr. Srinath: Today we have the honor and pleasure to have Dr. Katherine Guyon-Harris as our guest speaker. Dr. Guyon-Harris is a licensed clinical psychologist specializing in infant and early childhood mental health and relationship-based parenting interventions for children birth to age five. She's interested in supporting positive parent-child relationships during the perinatal period through both research and clinical work. She's particularly interested in developing more accessible and acceptable parenting supports for caregivers coping with mental health challenges and other adversities, particularly substance abuse and trauma.

Her research focuses on the origins of parent-child attachment and parenting behavior and the impacts of perinatal mental health and substance use on these processes. Her research contributions have enhanced understanding of the identification of risk for suboptimal parenting behavior during pregnancy before the child is born and the impacts of maternal mental health and other forms of early life stress on parent-child relationship and child wellbeing. Dr. Guyon-Harris is currently working on securing grant funding to support an adaptation of the empirically supported parenting intervention, The Family Check Up, for use of prenatally with women in recovery from opioid disorder. Thank you Dr. Guyon-Harris for joining us.

Dr. Katherine Guyon-Harris: Thanks for having me.

Dr. Srinath: So can we start with sharing your path to child psychology? And in particularly early childhood mental health and relationship based parenting interventions.

Dr. Guyon-Harris: Sure, yeah. So my path to child psychology really started with an interest in family processes, intergenerational transmission of culture, ways of relating to others. I started out in undergrad studying anthropology in history. That really developed into an interest in psychology. Mostly how we do relate to each other and human development across time.

So I knew I wanted to go to grad school but wasn't quite sure where or how. After being unsuccessful, my first attempt to get into a PhD program in clinical psychology stumbled upon a master's program in clinical psychology, where I met a researcher, Dr. Alyssa Hohbox, who was working on the transition to parenthood. In better understanding how domestic violence or intimate partner violence, in particular, and one's own experience of maltreatment during childhood can impact parenting, and they transition to parenthood. So they were following a cohort of pregnant people from pregnancy into the postpartum period.

She had a background in infant and early childhood mental health, which was my first introduction to that space. And infant and early childhood mental health is really about relationships. So, it's idea of supporting children, birth through about age five with an emphasis on supporting parenting and the development of the parent-child relationship. So we're in like child psychology, we're usually focused on the child and that's our patient, our client. In the adult world, the adult is our client or our patient. In infant and early child and mental health, the relationship is your patient or your client. And you're really working to support that relationship, bringing together the interests of both the parent and the child at the same time.

Dr. Srinath: It's a fascinating area and I feel like there's so much you have to offer and your background is so interesting in setting up for that. It's particularly anthropology, which is unique amongst healthcare providers. But before we start delving into this really fascinating area, can you just give us an overview of the mental state of a child as they're developing in the first few years of life? And the perspective of a parent during that time period. Particularly with regards to needs from both parties.

Dr. Guyon-Harris: Yeah, sure. So when a baby is born, their ultimate goal is survival. So everything that they do, all the behaviors they exhibit when they're born are to survive. Those are to elicit care from caregivers around them. So humans are a bit unique as a species and they are completely dependent on their caregiver at birth and for a very long time, too. Not just for her little bit, for years. We know they cannot survive without their caregiver. So they are hardwired at birth to signal and to connect and to build relationships. Their first goal is to not just survive, but to learn about relationships and how to build those relationships and build trust with their caregivers.

So for a parent, their job is quite stressful and challenging. While the baby's desire to connect and survive is innate, there's bits and pieces of which the caregivers reaction to that is innate. But by no means, does that mean parenting comes naturally to all, or is easy. It's often very challenging, particularly for parents who don't have their own experiences of being cared for when they were little. So when babies are born and learning how to survive and connect, they're really gathering information or like a blueprint for all future relationships in their lives, including when they go to care for their own children, if they have children of their own. So for caregivers who've experienced trauma in their own childhood or growing up across development, who are dealing with mental health challenges or substance use, really any other challenges. It can be incredibly difficult to parent in the midst of those really, really tough circumstances.

Dr. Srinath: Oh, sorry. I was going to say, I love that term blueprint. It really, really, really solidifies that understanding.

Dr. Guyon-Harris: Yeah. It's a foundation, but we like to think of it as a working blueprint. So while it sets up a foundation for future relationships, it's still malleable. So I don't want anyone to walk away thinking, okay, based on my early experiences, I'm then destined for these types of relationships. It's harder and can be more challenging to build healthy relationships if your very first relationships were not particularly healthy. But it's not impossible.

Dr. Poholek: This is so fascinating. So I'm really curious to start with, at what point do you enter that process? So how are your patients referred to you? If it's a parent with a first time pregnancy, how would you gain the opportunity to recognize that I am in the need of this type of prenatal care? Which is probably not standard for everyone. Or is it something that tends to happen post birth and only at that point is the care then recognized as needed?

Dr. Guyon-Harris: That's a really, really great question. So, I'm predominantly research based but I do a little bit of clinical work. And my work currently in the clinic is post postpartum. So I work with children birth to age five, providing evidence-based parenting intervention called the Family Check Up. Which is a family systems-based approach to preventing challenging child behavior problems by building positive parenting skills and positive parenting relationships.

So my referrals are often coming when there is a very clear and demonstrated need for parenting support and guidance because there is a child exhibiting really challenging behaviors.

Dr. Poholek: Got it.

Dr. Guyon-Harris: So I'm usually getting referrals, although I take referrals zero to five, they're mostly in that three to five range, where they're starting to test limits and explore their autonomy. Which are incredibly beautiful and normal pieces of childhood, but can be really challenging for parents. And additionally stressful, there's other challenges going on in the family or there's psychosocial concerns for the caregiver.

What we're trying to do though is intervene much earlier. So much of my research work is around intervening during pregnancy and providing that support before the child's born. So we can help shore parents up and get them the services they need, get them connected, get their mental health to a place that feels comfortable for them, get them the supports they need before the baby comes and it's really challenging. But in doing that, there has to be an identifiable need. So parents have to know that they need that kind of support or would like that kind of support. Then physicians who are caring for them have to recognize that need, as well, which is a little more difficult when there's not an acting out toddler running around the exam room.

So my work right now is centered around individuals who are recovering from opioid use disorder. Because in that population they're dealing with so much judgment and stigma. We've found that connecting around their needs as a parent and thinking about them as a parent and their skills and their supports is really welcome for them, a chance to just think about themselves as a parent and their development and to have that support. So that's where we're trying to move that support earlier and earlier in pregnancy so we can really have them feeling confident and ready to enter parenthood with that support. But it is challenging to understand those or identify those risks.

But really any parent who feels like it's hard, harder than it should be, I would encourage them to reach out and get some support. You could talk to ... if you're currently pregnant and wanting some support, I would encourage you to talk to your prenatal care providers about something called home visiting. Which is a type of program that is often available to families where someone can come to your home once your baby is born and help build positive relationships with you through something called Nurse Family Partnership or Healthy Families in America. There's lots of different models out there to support families. So if you're having some concerns about mental health, feeling unconnected or unsupported in your community or at home. Or just worried about how parenting might go for, I'd encourage you to reach out.

Dr. Poholek: Yeah. I really have so many questions. This is so fascinating. So I guess, one of the things I want to follow up there is before we sort of dive more into the research and a little bit of the clinical service. So then you have to then manage both child behaviors as part of your clinical practice and parents, as well. Then I'm guessing within that, it may not only be maternal parents, but also paternal parents that are also in the home. Can you share a little bit about your approach to that broad clinical practice that you have to then manage?

Dr. Guyon-Harris: Yeah. So I can speak specifically from my experience with the intervention that I provide and I'm working on in my research, which again is called The Family Check Up. It has decades of research support to show its power in preventing challenging child behavior problems including into adolescence, things like risky sexual behavior, a substance use and conduct disorder, through supporting parents in the parent-child relationship. It is a family systems based approach where we are really interested in understanding the entire context around that child.

So they're coming to us, the family's often coming to us with a target child in mind who they're having some challenges with. But a part of the intervention is to do what we call an ecological assessment. Which is understanding the context around that child, not just the family, but as broad as we can. And understanding the experiences of the family in the broader societal context, just to get a really in-depth picture of what's going on around that child. Because our view is going to be a family systems approach where if we can tweak or change or improve any bit of that system, it's going to have reciprocal benefits for the rest of the system.

So even though the child is the one that the caregiver is worried about, we're often intervening through the parent and their parenting skills, interactions with that child to build a healthier relationship, which then has trickled down effects for that child and the rest of the family, too. So we see really wonderful effects for the intervention, not just on preventing challenging child behavior problems, but also in reducing maternal depression, improving social support, improving relationship satisfaction between the caregivers. Then of course, just tons of wonderful outcomes for the children across domains of behavior and academics and school success and readiness, and also, of course, parent-child relationships and improving parenting skills too.

Dr. Srinath: So as a pediatrician, what signs can be a parent when you are seeing children for deficiencies or problems within these interactions, that would prompt a referral, for example, disservices?

Dr. Guyon-Harris: Yeah, so I think it's important to pay attention to a couple of different levels. So in thinking with an infant in early childhood mental health framework of the relationship as being the target for intervention, I would be concerned about any piece of that relationship. So if the child is having significant behavioral challenges, they're very hyperactive, they're aggressive, having trouble at school with peers or at home. Or if the parent is having some mental health challenges or is seeming like they're unconnected to their communities or needing more social support or guidance. Or if you see tensions in that parent-child relationship. If the parent is speaking disparagingly about the child or seems really frustrated or just worn out with that child or overwhelmed by their behavior.

I think each of those would warrant a referral. It doesn't just have to be the child struggling. I think zero to five, in particular, if the parent is having any challenges, they're so essential to that child still, at that young age, that I would want to see them as well and provide some support. Because really concerned about prevention and sometimes if we can help caregivers feel more supported and more confident, we can prevent worsening outcomes for children.

Dr. Srinath: How can pediatricians frame that conversation to parents? Because it's this relationship, if parents within the pediatric age group, it may be a little bit easier. But if the parents older, any suggestions for pediatricians to spearhead that conversation to get them help?

Dr. Guyon-Harris: Sure. Are you thinking specifically with zero to five or?

Dr. Srinath: Yeah, particularly parents with children with zero to five. Yeah, exactly.

Dr. Guyon-Harris: Yeah, that's a really good question. And it's definitely much easier. The child is exhibiting some really challenging behaviors and the caregivers clearly overwhelmed. It's a bit harder when the parent maybe doesn't notice those challenges or isn't as receptive to feedback or a referral. But I just like to wonder with families about the child's behavior if I'm noticing some concerns. Like, oh, they're really active, they're really busy. Or this sounds really hard, there's a lot of big feelings in this room. Is this how it always is? Or is this something new?

I'm really just bringing a lot of curiosity without suggesting there might be a problem. But just sometimes it's helpful for parents to hear that a professional is curious about that. And it doesn't place any blame or suggest that they need some help. It's just a window of opportunity for the caregiver to say, "Oh no, they're hungry." Or whatever it might be. Or, "Oh my gosh, it's always like this and I'm so worn out. I'm so exhausted." Then they might be more amenable to some support if they feel like they've been able to provide that without being accused or judged in that moment.

But it's an incredibly challenging situation to address. I do some training and positive parenting and supporting positive parenting with residents in our pediatric residency program. That's one of the questions they often ask is, what do I do if I'm concerned, but they're not? It is really challenging and I don't think I have a great answer other than just trying to approach it with as much humility and curiosity and care as possible. And sometimes it's just about planting a seed. It's hard sometimes, especially as a resident to have continuity and to be able to follow up with families. But you could still plant that seed for whoever sees them next. Because if your curiosity starts them thinking, "Okay, maybe something might be off here." Or, "Maybe I do need some help." Then they might be more amenable the next time they come in.

Dr. Srinath: Well, thank you.

Dr. Poholek: I'd love to pivot back to the research and talk about The Family Check Up. Can you tell us a little bit about the evolution of that as your research work? Kind of where it came from? Where it is now? And where you hope to see it going?

Dr. Guyon-Harris: Of course. Yeah. So I am not a developer of the model, I'm kind of coming into it after it's being used for decades. So it developed from something called the Drinkers Check Up, which was rooted in motivational interviewing and was for adults struggling with alcoholism. So someone now named Tom Dishion, who was out on the West Coast, decided this would be a really great intervention to adapt for children, for parents of caregivers, of adolescents.

So it started an adolescent as a way to prevent conduct disorder, risky sexual behavior, substance use, challenges like that. Then in thinking about really preventing those challenges, there was thinking that maybe we should be doing this earlier and earlier and earlier. Then Dr. Danny Shaw, who's one of my primary research mentors, he's been one of the main developers of the early childhood version of The Family Check Up. And really spearheaded the implementation of a version of The Family Check Up that began at age two. So really thinking about intervening when toddlerhood is starting and parents are having those really normative but very stressful and challenging times when their children are having growing autonomy and boundaries pushing. It's just been going earlier and earlier, and so why not just intervene as soon as we can? So that's kind of developed into this idea of intervening at birth and providing support to families as soon as we can to really prevent some of these challenges and give parents the skills and confidence they need to raise healthy children.

So I came to Pitt, so I did my clinical training at Tulane University of New Orleans, where I specialized in Infant and Early Childhood and Mental Health. Did a year of clinical residency there, and then also did a two year postdoc and just got really interested in substance use, in particular. I worked in child welfare and many families face shame and judgment and child welfare. It is compounded when there's our substance use concerns in the family. To me, that was the population that we were failing the most in terms of providing support in helping them reunite with their children and in recovery and sustain their recovery.

So I came to the University of Pittsburgh to greater specialize in perinatal substance use and parenting interventions. So I started working with Dr. Danny Shaw and Dr. Deborah Bogan and put in an application for a K23, which is an early career grant from the NIH and it was awarded.

Dr. Poholek: Oh, fantastic. Congratulations.

Dr. Guyon-Harris: Thank you. And the purpose of that project is to take The Family Check Up and adapt it to be used prenatally before the child's born. And we're starting specifically with pregnant people and recovery from opioid use disorder. For many reasons, if we have time, I'm happy to get into those. But mostly this is a population with just a lot of need and a lot of need for support, in that I've really learned a lot about in my training and have come to really just value and appreciate their experience. Especially as they're entering recovery and wanting to do the best for their children. It's been really rewarding talking with them about their parenting experiences and their needs and their challenges accessing those types of supports.

So we've just started in April and we're in the very early stages of this five year grant. But the goal is to do a series of qualitative interviews with pregnant people who are in recovery, so we can get a better sense of their specific needs. We know we want to adapt The Family Check Up, but we want to mindfully adapt it for their needs. We want to hear from them, what do they want from this intervention? What do they think will be helpful or less helpful? How do they want it delivered? Lots of questions like that. And then we'll adapt it and later, in about year three, we'll pilot the intervention.

Dr. Poholek: Oh, okay. Fantastic. All right. So I see the evolution then. So start by creating the intervention and then testing it in the model. So what are your expectations for potential interventions that you think are likely to be something that will be adapted?

Dr. Guyon-Harris: Can you rephrase the question?

Dr. Poholek: I guess I'm just curious if you have a sense already, given your experience working with these populations. What kinds of things do you anticipate will be useful interventions for this population?

Dr. Guyon-Harris: Honestly, I think one of the biggest things is a strength-based approach. That's really what The Family Check Up is rooted in a strength-based approach, as well, where our goal is to identify the strengths the family already has. And to really leverage or utilize those strengths to continue supporting healthy development. We're also going to identify areas of concern that we're worried about, but our goal is to really elevate and celebrate those strengths. That's something that parents don't get a lot. They're not often praised for how well they're doing. They don't often get much positive feedback.

So we find it's a very refreshing model for families that they really appreciate. I think this population in particular that has been harshly judged and has so much shame and stigma around their substance use, particularly if they've been using during pregnancy and the effects that that might have on the baby. For women in recovery, even being on maintenance medication, they have concerns about what that means for the baby, even though they're making amazing steps to support their recovery. I think that strengths-based framework of meeting them where they're at, and riding that journey of recovery with them, and being a steady supportive force for them throughout that process is going to be incredibly important.

The other piece that I think is really essential is having a relationship based framework. So The Family Check Up is relationship based in that we're assessing various levels of relationship, including really paying attention to the therapist family relationship. But for individuals who've experienced substance use or there are high rates of experiences of past violence and trauma, and lots of very legitimate and understandable reasons for not trusting others. So it's incredibly important to build positive relationships, but also identify and leverage any kinds of positive relationships they've experienced in their own lives, so that they can draw from that, those positive parenting role models, that they can draw from in parenting their own children. Because sometimes they're going into that parenting relationship without much history of being cared for themselves. So how can we identify ... even if it was one or two interactions they had with a teacher in middle school, like somebody who showed them they're worthy of love and care. How can they channel that into their interactions with their baby?

Dr. Poholek: Incredible.

Dr. Srinath: So it's almost, they talk about this child directed interaction type approach to children. It's doing similar fashion of working on celebrating the strengths, and reflecting on the strengths with adults, as well. My last question is, aside from the substances themselves and their effect in utero, how do the emotions and the ... for lack of a better word, the emotions of the family, the perspective of a mom affect their relationship?

Dr. Guyon-Harris: So we know that symptoms of depression and post max stress disorder and anxiety, in particular, can impact prenatal bonding and stay with the caregiver if they're not addressed into the postnatal period and affect parent-child interactions. It's a complicated process, the way in which feelings and emotions during pregnancy can impact the parent-child relationship. But our current understanding is that they have an impact on something called the working model of the child. So even in pregnancy, before the baby is born, caregivers have thoughts and feelings about who that baby might be, and there's no baby yet. So those thoughts and feelings are coming from somewhere.

What we're learning or have learned through lots of research is that they're coming from often experiences of trauma in their own childhood or their experiences being cared for. They're coming from experiences of intimate partner violence with that child's other parent at times. Sometimes when you're feeling depressed and hopeless, you might feel depressed, hopeless about yourself as a caregiver and have very little expectations or hopes for yourself and your relationship with your baby. So those feelings can really impact your developing relationship with your baby. We know that these are all things we can measure during pregnancy, which give us a good understanding of who might need some more support. They're all things we can intervene on during pregnancy.

They're often not intervened on until the baby is born and there's challenges already starting to develop. But that's my main passion and my drive is to really get in there in pregnancy and help provide the support before the baby's here. And really give parents the confidence they need to enter parenthood, feeling as ready as they can. Even though it's the time when you don't really feel very ready for much, but as ready as they can and as connected as they can. But yeah, there are definitely ways in which a mother's or fathers or whomever's pregnant past experiences can impact the way they're thinking and feeling about their baby before their baby's born. I personally have done some research looking at the ways in which caregivers describe their child's personality before they're born. We showed that more negative descriptions of the child's personality, like stubborn, mean or stingy in pregnancy, were associated pretty strongly with postnatal parenting behavior at 12 months postpartum.

Dr. Srinath: Wow.

Dr. Guyon-Harris: And that's published in the Infant Mental Health Journal.

Dr. Poholek: Oh, wow. So that's amazing.

Dr. Srinath: Well, Dr. Guyon-Harris, it's just an absolutely fascinating field you have clearly delve deep into. And services that you were providing and aim to provide and aim to enhance. And we just can't thank you enough for taking the opportunity to speak with us and our listeners.

Dr. Poholek: Yeah, thank you so much for the work that you do. I mean, it's so clear your passion for this group of people who clearly need someone like you taking care and saying, "This is a group people that we need to be looking out for and helping." Is really inspiring. Hopefully we can have you back on and we can hear about the outcomes of your research in a few years. We look forward to that.

Dr. Guyon-Harris: I do, as well. And I make one final plug?

Dr. Poholek: Absolutely.

Dr. Guyon-Harris: So for any caregiver residing in Allegheny County who has a child age zero to four, they can access free parenting support through a study called the Pittsburgh Study. So I'm a part of the Early Childhood Collaborative, and we are providing ... it is a research study, but it's not your traditional research study. So the goal is to provide free access to parenting programs or parenting supports that are matched to your level of need. So when the family decides or wants to sign up, they fill out a screen and based on their answers and their levels of current challenges, they're offered a menu of options. If they don't have many challenges, they might be offered something like a texting program or a peer support program. But if they have a lot of challenges, they can get offered The Family Check Up for free.

Dr. Poholek: Oh, fantastic.

Dr. Guyon-Harris: And other really wonderful interventions all along the way. They get to choose and have some agency in picking what they think is the best fit for their family. So they just have to have a child age zero to four, be in Allegheny County. And if they're interested in signing up or hearing more, they can email TPSEC, so The Pittsburgh Study Early Childhood, TPSEC@pitt.edu.

Dr. Poholek: Fantastic. Thank you so much for making sure to include that.

Dr. Guyon-Harris: Of course.

Dr. Poholek: That's really helpful, I'm sure. Thank you so much for your time today.

Dr. Srinath: Thank you, again.

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