Look Who's Talking
Nurses draw on the Touchpoints model of training to help parents recognize the nonverbal cues their infants and toddlers try to communicate

By Glen Fest
September 11, 2003


The infant wriggled helplessly on her stomach, in full view of her 16-year-old mother's stoic, passionless stare.

The 2-month-old couldn't look back at her mother as she flailed helplessly in the crook of a worn couch cushion. The distraught and depressed teenaged mother offered no help, treating her daughter from an unplanned pregnancy as an aggravation to ignore.

Both were trapped in a Napa, Calif., home for troubled young mothers, and the duo represented another sad case assignment for Maura Los, PHN.

"I was trying to pick up a way for her to bond with her child and really make eye contact with the baby," said Los, a maternal child health specialist from the Napa County Health and Human Services Agency. "So I said, 'I want to show you that if you talk to your baby, the baby is going to react to you and to your face.' "

The teenager relented, looking over to her daughter while calling the baby's name. The little girl reacted valiantly, Los said. "The baby used every ounce of energy to turn her head and body toward the mom, and the mom says, 'Oh my gosh, she does know me.'

"She picked up the baby, and she held the baby for the first time in two months, skin to skin. She started crying, 'I never knew she knew me.' "

Odds are, Los believes, the infant knew her mother from their first moments together. Hearing her mother's voice that day invoked a "touchpoint" reference as the newborn formed the earliest emotional bonds with her mother.

Los was employing one of the most effective demonstrations she learned from the Touchpoints model, a training program developed by noted pediatrician and child psychiatrist T. Berry Brazelton, MD. Los has been trained alongside hundreds of Napa County nurses, physicians, social workers, day care providers and other child care-related professionals to teach parents to recognize the nonverbal cues and signals their infants and toddlers communicate to them.

New specialists

Looking at more than baby's first steps or first words, the Brazelton Touchpoints model is resonating with health and child care professionals because of its depth of behavioral knowledge of children from birth to age 3. Touchpoints also is growing in popularity because it's improving the relationship between health care professionals and parents as it respects parents as the true "experts" behind their child's development.

"I think nurses are so busy with things we have to do, like the physical assessments and those 'nursy' things we have to do, that we sometimes forget to point out the wonderful, little incredible baby behaviors that can make a parent zoom in on that baby,"said Julie Smith, RN, a Touchpoints training coordinator with Harris Methodist Fort Worth Hospital in Texas.

Fort Worth and Napa are among the 50 regional areas where Touchpoints training programs are sprouting and moving slowly into the nursing and education practices of hospitals, social service agencies and universities.

For example, nearly 400 direct-service providers in Vermont have adopted Touchpoints for nursing, child care, early education and family support services.

A Houston hospital has incorporated Touchpoints training into its nursing orientation, and the University of Texas at Austin has received a federal grant to teach Touchpoints methodology in the advanced practice nurse degree program.

"It's being integrated into nursing practice pretty widespread," said Ann Stadtler, MSN, CPNP, director of the nonprofit Brazelton Touchpoints Center at Children's Hospital in Boston. "In 1995, this was a pilot program for nurse practitioners. Since then, we've found [all] nurses have really taken to this approach."

The namesake of the program, Brazelton, is an author and professor emeritus at Harvard Medical School. Thirty years ago, he helped establish the pediatric training and research center at Children's Hospital in Boston.

Brazelton, who some credit as the country's most influential pediatrician since Benjamin Spock, MD, is best known in research circles for his development of the Brazelton Neonatal Behavioral Assessment Scale in the 1970s. The "Brazelton" is used worldwide to test physical, neurological and emotional responses in newborns.

Baby highlights

Brazelton's Touchpoints model theorizes a series of milestones that describe the development process of children from newborn to age 3, before language skills develop. Touchpoints also focuses on changes in parents.

For instance, the "newborn touchpoint" is a stage when new babies begin their initial attachment to parents, while the emotions of the mother and father simultaneously depart from the "idealized children of their imaginations" as they grasp the child's gender, size and temperament, according to Brazelton.

At the three-week Touchpoint interval, babies are establishing how they react to parents' caregiving. At the six- to eight-week period, parental self-confidence grows as infant feeding and sleeping habits are stabilizing and the baby begins to engage with its environment.

Touchpoints follows the child through the third year, when talking begins to dominate the child's mode of expression. Instructing parents in Touchpoints ideas provides them with a basis of understanding the fits and spurts of changes they'll experience with their child's early development, according to the program.

Brazelton's reputation is what attracted Smith to the Touchpoints program. She went to Boston for the individual training session offered by the Touchpoints Center, and later returned to be trained as a Touchpoints instructor herself.

Harris Methodist's Education Center formally implemented the Touchpoints model in its mother/baby nursing unit, training 17 nurses in the program. The hospital eventually plans to train all 450 nurses who work in its center for obstetrical, perinatal and neonatal care.

Smith held a training session for nurses and child care professionals in June, teaching not only nurses from Harris, but also nurses from Cook Children's Health Care System of Fort Worth. For two days at a church recreation building in nearby Arlington, Smith walked her class of 30 to 40 students through the 13 Touchpoint milestones designated in Brazelton's course. In addition to videos, lectures and question-and-answer sessions, the attendees also enjoyed personal visits from parents and their children for live demonstrations.

Twenty-month-old Julian arrived apprehensively in the play area of the center, overwhelmed by the sight of so many strangers around him. They watched Julian interact with his father and a Touchpoints program coordinator before slowly enthralling himself with books, balls and stuffed animals. The students noted his diminishing shyness, though still needing to stay within a zone of comfort near his father.

"We point out the little things the child is doing, and why," Smith said. "And we not only look at the development of the child, but the development of the parent."

Improving the relationship between parents and children is the base goal of Touchpoints, but the first step in achieving that goal is improving the relationship between the nurse or doctor and the parents. Nurses said Touchpoints teaches them how to defer to parents, who sometimes feel excluded or powerless in deciding the direction of care for their child.

"It makes really good sense in building relationships with people you're caring for," Smith said. "These people are going to come back for more appointments, be more satisfied with their care [and] they're going to tune in to their babies more."

Kathleen Stuckly, RN, a neonatal nurse for Harris Methodist trained in Touchpoints, said parents are understandably reticent to interfere with a health care provider's treatment of their children, but sometimes that caution ushers in a guarded, psychological barrier especially evident with premature and sick babies.

"A baby might be in the NICU from four weeks to four to six months," Stuckly said. "They're usually scared and afraid to make a bond, thinking 'What if something happens?' "

Stuckly said her application of Touchpoints tools made an immediate difference for some of these parents. Stuckly showed parents how their underdeveloped premature babies still respond to parents' voices. She advised them to look for visual clues, like the ones she picked up from her experiences with her own baby born earlier this year.

"I've noticed my baby likes it better to be bathed in the evening, so I'll tell them to look for specific behaviors [like that]," Stuckly said. "But we let [the parents] guide themselves."

Power to the parents

Parental empowerment is the most important lesson most nurses feel they learn from Touchpoints training. Michelle Lansford, RN, a neonatal nurse educator at Cook Children's in Fort Worth, noticed the dramatic improvement in parents of sick children maintaining critical follow-up visits through Touchpoints education.

"Many times, our children are going to have a lifelong battle with health issues," Lansford said. "So if we can build a good relationship with the family as their real first step into the health care realm, maybe they'll be more trusting and be able to build relationships along the way, instead of avoiding it and having that 'doctor fear' and that 'nurse fear.' "

The improvement of parental involvement in child care was evidenced in a study in Napa County. Kristie Brandt, ND, MSN, CNM, chief of public health for the Napa County Health and Human Services, said patients with Touchpoints-trained providers have one-fourth more well-child visits and follow-ups, while emergency room and sick-child visits to health care facilities were drastically cut in half. "That was phenomenal," Brandt said.

Smith said Harris Methodist will conduct surveys to contrast pre- and post-training attitudes of participating nurses, and introduce Touchpoints-related questions and comments to employee evaluation forms. Ultimately, the hospital would like to incorporate Touchpoints checklists into daily reports filled out by nurses, Smith said.

For Los, the Napa PHN, she didn't need the results of a study to see what Touchpoints does for her revolving caseload of 50 clients-a majority of whom have a distrust of social service agents such as Los. Instead of anger and apathy, many of the troubled parents opened up to her through the Touchpoints discussions. They kept appointments, followed through with meetings and promises, and in some cases sought her out for questions and advice about their children, Los said.

The 16-year-old girl in the teen home, who, at one point, had no inkling of her motherly instinct, became one of Los' most successful cases. She kept her regular visits with Los throughout the following year, and even returned to finish school to fight for a better future for herself and her baby.

"It was powerful," Los said. "By building [their] trust with you and building a relationship, you can all work together."

Contact Glen Fest at glenf@nurseweek.com