Sibling Rivalry

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Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

Here is another question posed to me by a number of parents recently: How do you deal with sibling competition and aggression?

This problem is common and has a simple answer. That does not mean it is easy to “fix”; it just means that it is easy to understand. The answer has three parts: (1) create a comfortable and relatively stress-free family environment; (2) create routines that teach children skills in sharing, turn taking, and negotiating; (3) separate siblings who cannot be together without fighting and then create short, parent-facilitated times together that have maximum probability of successful outcome, and practice them.

I am going to start by answering #2, then #3, and leave #1 – perhaps the most complicated one – for the last.

(2) This answer is a mixture of two of my favorite recommendations for parents – routines and family values. The routines function to put into place and practice the family values of sharing, turn taking, and negotiation. Remember that the power of “family values” is that you can’t argue with them. That is, you could try to argue, but the answer is always unarguable – “That’s just the way we do things in this family.” For example, if one child calls the other child a name or makes an insulting remark that the parents consider unacceptable, the response is, “In our family, we don’t use names like that or say insulting things like that.” That cuts through the child’s argument that another kid said the same thing – even if the other kid was in the same family. Or, if one child insists that he always sit in a preferred seat in the car, the response is, “In our family, we share.” Then the routine that practices the family value is something like – on the way to school X gets to sit in that seat, and on the way home from school, Y gets to sit there, or something like that. Another common conflict between siblings is fighting over the same toy. In that case, the family value of sharing is implemented by a negotiating process that is taught beautifully by the teachers in the Cambridge Ellis School. The child who wants the toy is helped to ask the child holding the toy, “Are you finished with the toy?” If the child holding the toy says no, then the other child is helped to ask, “How many more minutes do you need before I can have a turn – 1, 2, or 3?” (For older children, the time period is usually longer.) This scaffolds both children’s agency in the situation and supports the child who ultimately has to give the toy up.

(3) The third answer is similar to what I have recommended for play dates. Although parents certainly need relief, play dates are not primarily intended to serve that purpose but instead are meant to provide the child with opportunities to learn how to have fun playing with other children and learn to get along with them, among other things. The same can be said for the time siblings spend together, although sibling relationships are of course much more meaningful and intense than peer relationships. If siblings are going through a period of not getting along (this can happen for many reasons, including one sibling in particular having a hard time and taking it out on his or her brother or sister) then the time they spend alone together should be minimized (I realize this is often difficult) and they should be given short periods of structured play time together with parents facilitating the interaction. For example, the parent might say, “Since you guys have been having a hard time getting along recently, then X is going on errands with me while Y stays home to do homework with Dad, and then later this afternoon we will all go to the park together. It is important for the siblings to have enough good times together for them to want to spend time together in the future, which will motivate them to behave well with each other. While they are together in the relatively short enjoyable times the parent is playing the role of the teacher (above), scaffolding the development of sharing and good negotiating skills, as well as the respect for family values.

(1) Create a comfortable, relatively stress-free family environment. Of course this is not at all easy to implement. The reason I include it as #1 is because it is so important and because parents often forget that a major source of sibling conflict is preexisting tension within the family. Sometimes the original source of tension is in the marriage or between separated parents. Sometimes the tension is related to problems with extended family members, or to financial worries or job dissatisfaction. Other times tension is generated by conflict between one particular child and a parent, and the parent holds the tension within him or herself in between actual times of conflict. Then, when a demand has to be made on that child, the parent anticipates noncompliance and approaches the request in a negative frame of mind. Sometimes this tension is communicated by the parent’s facial expression, tone of voice and abrupt gestures, and aggressive choice of words.
Regardless of the origin of the tension, the children in the family pick up the stress, and often they will express the stress they feel by fighting with each other. Partly, this fighting response emerges from the irritability the family stress causes in the children. Also, the children unconsciously may be distracting the parents from the original source of their tension by calling attention to the problem they are causing in the moment. Interestingly, that can make everyone feel “better” because at least they know what the problem is – “fighting kids” – instead of living in a situation in which the cause of the unhappiness is hidden or unacknowledged. The answer to this problem of tension in the family is to refocus attention on the parents’ need for support. Remember the old directive of what to do with the oxygen mask in the airplane. First put it on yourself and then put it on the child sitting next to you. That is because the child will need you to be alert and strong in order to take care of him or her. In some cases, this need for support means getting more help from extended family and friends, or hiring someone to help take care of the house or the children. In other cases, the parents need professional help to manage the trouble in their lives.

Read this blog in Spanish.

Avoiding Meltdowns

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Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

Yesterday two excellent parents came to talk to me about their 8-yo daughter, “Hannah”. They suffer from her temper tantrums, and they know she suffers too. When we tried to sort out what was causing her to meltdown, we were able to identify three major sources of the tantrums. I am going to write three blog postings, one for each of the vulnerable times for this child and her parents. The first was our old friend or enemy, transitions. The second is sibling relationships. The third is complying with parental authority. As you may have guessed, these three trigger points are not completely distinguishable, since sibling conflict often arises at times of transition, and the same could be said of compliance with parental demands. Let’s start with transitions.

This beautiful and intelligent child happens to have a tricky cognitive profile, something I have talked about before. She is extraordinarily bright in some areas of cognitive capacity and only average or even below average in others. This makes life harder for her. It is harder for her to make realistic expectations for herself since she can perform excellently in some tasks and struggles much more than her peers in others. In addition, just the unevenness in the domains of her cognition can be subjectively experienced as disorganizing. It is harder for her to make flexible and adaptive meanings of her experience in the world. You can see how this would add to the usual difficulty people have with transitions.

Let’s start with the first transition of the day – waking up in the morning and getting ready for school. Many of us have difficulty with this transition. Lou Sander, the “grandfather of infant research”, has said that day-night organization is the first organization facing the newborn human organism. In this case, Hannah often wakes up “in a bad mood”. The anticipation of this possibility makes Hannah’s mother anxious, which increases the stress of the situation for both of them. I suggested talking to Hannah about how she feels in the morning – maybe they could create a scale, for example, “grumpy”, “a little grumpy”, “good”, maybe even including “very grumpy” and “great”. The benefits of doing this together is that while you are in the process of coming up with “strategies” for dealing with Hannah’s moods, you are also helping her learn about her various affect states – their subjective “feel”, what causes them, and what to do about them. This will take some time, and you certainly don’t want to pop this idea on her when she is just waking up, especially in a grumpy mood. But you can begin with a gentle observation that she doesn’t seem to be feeling very good, coupled with an idea about how to make things better. Would it help to take a little longer waking up? Would it help to have Mom bring a small glass of juice or water to her bedside? Would it help to have some music? The idea for Mom is that there is some legitimacy to Hannah’s grumpiness (a struggle making the transition – physiological, motoric, symbolic – to get up in the morning) and that she, Mom, can come up with ideas about how to make it better. Mom doesn’t need to feel helpless nor does than Hannah. (Mom’s feelings of helplessness in this situation can contribute to her lack of flexibility in responding to Hannah’s needs.)

The getting dressed part can also be a big challenge. Sometimes Hannah can’t decide what she wants to wear to school. Sometimes she knows what she wants and she can’t find it, or it is in the dirty clothes. There is a simple (though not always easy) solution to this problem. Institute a routine of picking out her clothes the night before.

Bedtime is another big transition. The key to a comfortable bedtime is a good bedtime routine. (As I have mentioned many times, “a routine is a parent’s best friend”; that is true of the morning transition, too, of course!) That means the same preparatory activities practiced every evening the same way at the same time in the same order, except under unusual circumstances. Usually these activities include a bath or washing, tooth brushing, toilet, bedtime story or song, and bed. Typically, only one parent is in charge of the bedtime routine for one child, and if there are two children or more, the parents take turns. Important things to remember are (1) no excitatory activities such as roughhousing or video watching right before bed; (2) no overly long bedtime story time – settle on 1-2 stories and stick to it; (3) if there are two siblings, it is better if each sibling stays out of the bedroom area where the other child is being put to bed. Sometimes that is very hard when there is one parent putting to bed two children, but it usually works better that way.

I will pick up the subject of siblings in the next blog post.

Read this blog in Spanish.

Teenage Trouble

girl friendsImportant Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels. 

Teenage Trouble

Mother: “Jamie asked for a special privilege to extend his curfew from 11:00 to 1:00 tonight, but it is the third time this week he has asked for this. My husband thinks it is good that he is asking us instead of just disobeying the curfew. I just said, “So what are you going to do with Jack and BJ until 1:00?” Jamie stormed out of the room and went to talk to his father. His father said, “Sure, OK, have fun and be careful.” “Be careful!” If we trusted that he would be careful, we wouldn’t be in this situation. He has done dangerous things. Those kids he has been hanging around with are big trouble. I think one of them is dealing for sure. But he won’t speak to me now – only to his father. His father says, “Let me deal with it!” But what does that mean? I guess it means set no limits at all. He is afraid to say no to him. That makes him the good guy and me the bad guy. I am always the bad guy. He acts as if he hates me. I feel as though I have lost my son.”

Father: “She is so negative and judgmental that I can’t blame Jamie for avoiding her. I hear them downstairs getting into it and I want to shut the door and pretend it isn’t going on, but I am afraid for him. She gets Jamie so upset; I don’t know what he will do. So I try to go down and intervene. That only makes her enraged at me, and he just leaves. Don’t get me wrong. She has been a good mother in many ways. I know she loves him. But I don’t know why she can’t leave him alone. She really doesn’t listen to me when I tell her to give him space, to let me handle it. She just has to control the situation.”

Son: “I really can’t stand her. I feel bad about it, but just being around her is too much for me. She doesn’t understand me at all. She wants me to be someone that isn’t me, like some of the kids of her friends. She is always thinking the worst about me. She won’t let me have any freedom, won’t let me be with my friends – and she criticizes my friends – says really bad things about them. She thinks they are criminals or something. All my friends think she is crazy. They don’t want to come to my house. I just have to stay away. Sometimes I think I will run away. Just to get away from her.

How do we understand this situation? This mother and father have such different points of view. As a matter of fact, you could describe their points of view as “polarized” – extreme, without any elaboration in between. Would you be surprised to hear that both mother and father have the capacity to be reasonable human beings, have friends, function well in society? I would not. Something has disrupted their relationship and has disrupted the functioning of the family. Nothing tears parents apart more than feeling helpless when their child is in danger. Remember John Bowlby’s “Attachment Theory”? He thought that the primary motivating factor in human behavior was the desire for safety, security. His theory takes the perspective of the child.

But it is not that one-sided. In real life, Bowlby’s theory is just as valid for the parent as for the child. I would say that the primary motivating factor in parenting behavior is keeping their child safe. When children are very young, parents are highly stressed when their child has a medical illness or steps into the street in front of a car. Some parents of teenagers tell me with tears in their eyes about a childhood illness when their child reached out to them and they were able to comfort him. That felt so good, so right. How they wish they could “make it better” in the same way now. But in the case of an adolescent, the situation is much more difficult. The teenager wants to “do it myself’ even more than when he was 2-yo, so the parent can’t just swoop in and take over and make things better. Yet, some teenagers are just as unable to “do it myself” as they were when they were 2, and the consequences of letting them do it themselves are much more dire.

One reason for teenager’s poor judgment – among many – is the pruning of the brain that takes place in adolescence. The prefrontal cortex, the area of the brain that controls judgment (an over simplification as are all such attributive statements about the brain), is undergoing disorganization for the sake of adaptive change. Before the adaptive change is organized, the brain’s functioning is disrupted. That’s why many – but not all – teenagers take crazy risks that they never would have taken before. Jamie’s parents are afraid that he is in danger, and indeed he is. But what can they do to keep him safe? Their options are many fewer than when he was small.

There are many other reasons that families fall apart when teenagers have problems. Sometimes the parents begin to behave in problematic ways that make the teenager feel like a failure, a bad kid, or unrecognized for who he is. In fact, some parents have always had tendencies to have unrealistic expectations for their child or lacked a degree of empathy for their child’s inner life, but these vulnerabilities didn’t have the same impact as they did when the child tried to come into his own in adolescence. Another reason is that the parents have always had deep fault lines in their marriage, and when their beloved child started to suffer, these marital weaknesses were amplified in response to the pull to polarize that is generated by threat. In fact, this polarization is often – maybe even usually – a family pattern from early on, one parent (usually the mother) taking the role of the bad guy and the other parent (usually the father) taking the opposite role. In addition, beginning independence is such a watershed in one’s life that one’s own experience (the “way I did it”) is often stirred up

Jamie’s Mind: Jamie thinks that BJ is cool because he is on his own, living with other guys, making his own money – so what if he is dealing? Is it his fault more than the kids who buy the drugs? He doesn’t have to listen to his mother. She doesn’t bug him about school because he doesn’t have to listen to her. Ever since she moved in with her boyfriend, BJ has been on his own. Sometimes he comes to school and sometimes he doesn’t.

Jamie has struggled in school since about third grade, when the curriculum became more challenging and he started to get real homework. His mother helped him then. She checked his school bag to make sure she knew what his homework was and that he had all his books. She went over all his assignments with him. Sometimes when he got too discouraged or too tired she did some of it for him. She said the main point was that he learns the material, not that he torture himself. It did feel like torture. As the schoolwork got harder, things got worse. He left some of his assignments at school just so that he wouldn’t have to look at them. He convinced himself that he didn’t have any homework some nights even though it wasn’t true. He started to sleep when he got home from school. He was tired from texting his friends late at night, but he also wanted to escape from his life.

Where can we start to help this family? There are many “ports of entry”, but here I would like to talk about Jamie’s parents. Both Jamie’s parents love him and desperately want to help him. Yet, they can’t seem to break out of this destructive pattern of polarization. As a psychoanalyst I am aware of the value of understanding unconscious processes and the importance of one’s own parenting experiences on one’s behavior as a parent. Exploring one’s past experiences as a child is key. On the other hand, I also believe that things are not going to change fast enough with this approach. The way to change is to break the pattern that is keeping the destructive cycle going. I also like to talk in terms of “breaking” the pattern because it connotes aggression, and it takes aggression to make this change. Let’s look at some ways this can happen.

I am going to refer to the “original bad guy parent” as “OBG” and the “original good guy parent” as “OGG”. In order to break the pattern, the OBG has to immediately stop the BG behavior and the OGG has to step into the limit setting position, setting him or her up to be the BG. On the surface this seems simple; it is anything but simple. There will be huge resistance from both parents to this change. The resistance is driven by anxiety.

One way of beginning is for the parents to make a temporary plan about how to handle a hot button issue, such as curfew. The plan should be temporary to make it easier to agree. It is something that is going to be tried out. For example, “we are going to allow two extensions of curfew per week”. Then when the teenager presents the challenge, the OBG has to disappear and allow the OGG to take over. After the OGG negotiates something with the teenager, the two parents should not communicate about what happened for a period of time to allow both of them to manage their emotions. If possible, it is better to wait until the next day. When they talk about it, they should try very hard to avoid criticizing each other. If one slips and criticizes the other, the other should just remind him or her once of their agreement not to criticize. They should give the “temporary plan” about one week if possible. Then they should review the plan and decide if they want to change it. This process will take multiple iterations in order for it to work, but it can work.

What about getting professional help? It is a good idea to get professional help, but it is hard for professionals to deal with this situation. That is because the professionals tend to get pulled into the polarization and see one parent as the bad guy and the other as the good guy. They know they should not succumb to this temptation, but they often cannot avoid it. The parents can help by looking out for this tendency on the part of the professional and both of them objecting to it. If only, the OBG, points it out, it just strengthens the bad pattern.

How Can Teachers Respond Optimally to a Child’s Temperament?

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How Can Teachers Respond Optimally to a Child’s Temperament?

Teachers’ concerns typically focus on young HR children’s withdrawn or constrained behavior – their preference to watch other children play rather than to join them; their hesitancy in physical games on the playground; their clinging to a parent at drop off; their reluctance to enjoy messy sensory stimulating activities; and their general reluctance to take risks, especially in unfamiliar situations. Often, teachers organize their observations in functional categories such as “separation”, or “peer relationships”. Of course, there can be many reasons why children cling to their parents at drop off or why they do not play with their peers (see below).

In order to identify a HR child, you must listen carefully to the parents. The first clue parents will tell you is that “I was very shy myself.” The second clue is “She is completely different at home – outgoing, active, playful.” The first clue is important, because as we noted in the first posting of this sequence, temperament has an important genetic component. The second is important because HR temperament is primarily about an excitable limbic system. That means that the child is more sensitive to the perception of threat, and the new, the novel, the unpredictable, are threatening. Home is usually familiar and unthreatening. Because of this important factor, I have begun to do home visits when I consult to teachers and parents of children whose teachers have these concerns.

One such child was a 4-yo girl I will call “Jessica”. Her parents described her as loving, sweet, empathic, and smart. She was also “really shy”, and they worried that she was “not comfortable in her skin”. At home, she was confident, free, and creative, but at school she didn’t show these traits. She preferred to play with the teachers instead of the other children. When she went to birthday parties, she retreated into her shell, hiding under her mother’s sweater. Her preschool teachers suggested the consultation because of their concern that she was not engaging with her peers.

“Melinda”, another child, was 3-yo when her teachers expressed concern to her parents that she did not play with her classmates but sat quietly doing activities on her own. Although she looked content, they could not really tell how she was feeling and what she was thinking. On the playground, she liked to swing on one particular swing and got quite upset if that swing happened to be taken by another child.

4-yo “Benjamin” was a quiet, pleasant child whose teachers had to place limits on the time he spent with a girl classmate, Hannah, since she began to look uncomfortable with the degree of physical contact between them, as he insisted on holding her hand and sitting so close to her that he was always touching her. Benjamin explained that he loved Hannah and wanted to marry her, but Hannah complained that she wanted to play with some other friends in addition to Benjamin. In response to the teachers’ limits, Benjamin slowly began to play with other children and has now made a number of friends. Even so, he was often found sitting quietly alone at a table, busy with an activity put out for the children that day.

In the case of each of these children, the teachers balanced their encouragement to take risks in the classroom against their acceptance of the children’s need to “take their time”. As time passed, each child became more comfortable in the classroom. Jessica became animated and playful with the other children. Melinda began to play with her peers and ceded her favorite swing to other children. Benjamin even began to assert himself when another child started to boss him around. It is unclear what precipitated the transformation in each child’s behavior, what allowed these children to be more comfortable in school. In one case the birth of a sibling seemed to introduce possibilities of greater competencies and higher status. In another case my home visit may have been reassuring to the parents. In the third case, the teachers’ more active coaching in social situations combined with acceptance to private school may have been instrumental. Most likely, a combination of these factors played a role. However, the easing of pressure of some sort plus the introduction of new positive possibilities for the future must have figured in all the changes. In any case, we will never know for sure.

Other Reasons for Children to Withdraw:

One important acknowledgement is that there is a large overlap between temperament and sensory processing. Most children with HR temperament have some sensory sensitivities. It is also that children may withdraw if they are sad or depressed. Finally, children with other processing difficulties – for example, auditory processing in which case they have difficulty making sense of verbal communications – may withdraw. In older children, learning disabilities may cause them to “give up”.

How Can Parents Respond Optimally to a Child’s Temperament?

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There is evidence that infant reactivity is related to the predisposition to have an excitable limbic system. There is also evidence that there is influence in uterine environment that can affect temperament. But biology is not destiny. There are ways that parents and teachers can help HR children moderate the effects of their high sensitivity.

The balance between protecting and promoting is a challenge for all parents to achieve, but it is an even greater challenge for parents of HR children. By protecting, I mean softening the bumps in the road of life – allowing the child to stay home from a birthday party or speaking for the child when he greeted by an unfamiliar person. By promoting, I mean insisting that the child take the risks that he needs to take to build a strong body and acquire necessary skills, such as eat healthy foods and engage in physical activity. Often the parents of HR children tone down their expectations of their child, either because they fear the child will fall apart when required to take the risk, or because they “know their child’s limits” and have rationalized a permissive parenting style. Other times, parents of HR children push the child beyond her limits and cause her to withdraw further or “give up”. Even good parents can err in either direction. Sometimes one parent takes one position and the second parent takes the other. This is particularly problematic because the polarization that results increases the stress on the whole family and erodes parental collaboration.

How can parents find this balance? First of all, there is not one balance to achieve. Each family must experiment until they find the “right” balance for their family – and since families and especially children are always changing – the trial and error efforts never really end. Snidman reported that researchers who did extensive home visits on 4 families – half HR and half LR babies – found that in the HR cases the mothers who set firmer limits on their children’s behavior helped their children feel more comfortable taking risks. In the case of the LR children, the mothers’ behavior made little difference. Of course, this is a study with a very small n despite the extensive observational data, but it is consistent with my clinical experience. By setting limits on their HR children’s behavior, parents communicate to their children their comfort with their children’s initiative. It is also true that setting limits can slip into a struggle pattern, and that is a problem to be avoided if at all possible. In my experience, it is easier to get into struggles with a HR child then with a LR child. That is because stress causes everybody to expend energy in order to manage it, and that drains energy, pulling everybody in the direction of simpler, more reactive behaviors. Struggles definitely involve simple, reactive behaviors. The HR child is always under more stress than the LR child, and this is especially true when faced with a challenge. Those of you with HR children will recognize the dread provoked by adding an additional demand to the morning routine.

The ideal to work towards is one in which you “choose your battles” and support a child in taking health-promoting risks up a point, then protecting him if he shows that it is too much for him. These caregiving behaviors are always evolving and frequently include corrections or “repairs”. Corrections and repairs are not something to be afraid of. They are what we learn from.

I will discuss the ways teachers can respond to a HR child in the next posting.

Why is Temperament Important to Parents and Teachers?

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Roughly 10-20% Caucasian children are shy and hesitant in unfamiliar situations. Another 10-20% are sociable and intrepid in response to novelty. The underlying features of these predispositions usually referred to as “temperament”, remain remarkably consistent over time. It has also been found that the caregiving environment in the early years can significantly influence the behaviors characteristic of these temperaments. That makes the study of temperament particularly relevant to this blog.

Nancy Snidman, a colleague of the pioneer researcher in temperament, defines temperament as a “predisposition to respond to the environment in certain ways” (lecture to UMB IPMHPCP, March 6, 2016). The baby comes into the world with certain temperamental qualities. These temperamental qualities may be due to genetics or epigenetics – influences from the environment in the womb. Children’s temperament influences the way they react to their environment – physical, social, and emotional. For example, a child’s temperament affects the way they react to novelty, sensory stimulation, or transitions. How does temperament at infancy translate to temperamental characteristics such as shyness in a preschool child? What does the “shy” infant look like as an older child or adult? Snidman and Kagan did a series of longitudinal studies to try to answer these questions.

Kagan and Snidman studied 400, 4-month old babies and classified them as high reactive (HR) and low reactive (LR) on the basis of their response to auditory, visual, and olfactory stimuli. They observed the babies’ responses in the form of heart rate increase, motor arousal (such as limb flexion and extension, motor tension, and back arch) and fretting or crying. They looked for the extremes of HR and LR babies and started to follow them.

They postulated that the HR children had inherited a low threshold of excitability in the amygdala; a part of the mid-brain called the limbic system, and the related limbic areas. The amygdala sends signals to the autonomic nervous system, communicating a sense of threat in the environment.

They studied the babies’ physiology and behavior in response to a number of laboratory procedures, from 9 months to 15 years. Some of these procedures were mild, such as puppets or tasting sweet and sour liquids, and some were more challenging, such as a toy robot and a stranger approaching wearing a lab coat and a gas mask. The two extreme styles of temperament, HR or LR, or behaviorally inhibited (BI) – shy, wary of novelty, slow to approach, or behaviorally uninhibited (BU) – sociable, comfortable with novelty, were remarkably consistent over the years.

Interestingly, the researchers found that as the kids got older the physiological markers were more important than the behavioral ones. This was because the children were taught to be polite. It was less the general behavior to strangers that distinguished the HR from the LR kids, and more the smiles and spontaneous comments. When children are presented with the same stimuli in repeated exposures, for example when they are shown invalid pictures (a horse head on a fish body), they usually habituate to the stimulus. That means their reaction becomes smaller with repeated exposures. In the case of HR kids, however, there is no habituation! That means that although they look more and more like their LR peers in terms of social behavior, their heart rate, pupillary dilatation, muscle tension, and stress hormones remain more reactive.

This is very interesting to me in my work with children and families. For more than two decades, Attachment Theory has dominated research in child psychology. This way of understanding child development minimizes the contribution of temperament. Yet, I have found temperament a very useful way of making sense of some of the problems that parents bring to me regarding their children’s behavior. It is also helpful to me when I consult to preschool teachers. In the next blog posting I will describe how I use ideas of temperament to help parents and teachers understand the children in their care.

Readings

Schwartz C, Snidman N, Kagan J (1999). Adolescent social anxiety as an outcome of inhibited temperament in childhood, JAACAP 38(8):1008-1015.

Kagan J (1997) Temperament and the reactions to unfamiliarity, Child Development 68(1):139-143.

Kagan J (1989). Temperamental contributions to social behavior, American Psychologist 44(4):668-674.

Family Fights: Changing “Bad Habits”

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The mother of a family in my practice recently complained to me about her 11-yo son’s meltdowns. She told me that he provokes his siblings by criticizing them, getting into their space, or insulting them in some way or another. He is very reactive, and it takes very little to provoke him into a rage. He doesn’t seem to hold himself accountable for any of his actions. For example, the night before, he kicked her under the dinner table, and when she told him to stop, he said that he hadn’t done anything. This denial of responsibility is typical. She said she knows I say that if anyone in a family has a problem, then the whole family has a problem, but she can’t figure out what she and the boy’s father are doing to contribute to his meltdowns.
I told her that it is common for families to develop bad habits. I call this bad habit the “struggle pattern”. Usually, it is one child who generates the negative feelings that motivate the interactions that become organized into a family “habit”. In these habits, each family member plays a particular role, even though they don’t recognize that they are doing so. Typically, the “problem” child (PC) will provoke and the parent will respond with a prohibition. The PC will then up the ante with further provocation, and the parent will continue to prohibit. Often, the actions on both the parent’s and child’s parts will escalate until everyone feels distraught and out of control.
It is interesting to consider what starts everything off. Sometimes the PC has had a hard day and doesn’t have the resources to reflect on that experience and talk to the parents about it in order to be comforted. Often the PC has the capacity to reflect on his inner experience when he is calm and comfortable, but has difficulty with stress regulation and loses this important self-reflective capacity when he is stressed. This is also true of parents, and sometimes it is the parent who has had a hard day and unconsciously provokes the child (such as by making a slightly unreasonable demand at a time when the child might be expected to be vulnerable.) In either case, the spark of the provocation ignites a fight that gives everyone a chance to express their frustration and aggression, but in a highly maladaptive way. No one feels good after this kind of fight, and to make it worse, it just strengthens the struggle pattern within the family and inside each of the family members’ brains. Sometimes the resolution of the fight is a tearful reconciliation with professions of love. This is not the best resolution, because it usually does not unpack the interaction to allow for positive change and even adds a reward to trick everyone into thinking everything is all right.
What I suggested to this mother and to other parents to try to avoid these bad habits is 3 things:
1. Identify the turning point. Experiment with identifying the moment when the interaction could begin to escalate and ask the child to take some time out, or the parent can leave if that is more convenient. The main idea is for the parent to make some distance between them.
2. Change up the process. Do not respond to any provocation. If the child denies his action, ignore it. Do not try to reason with the child. Instead, say something about starting over or “press the reset button” or something like that. If that doesn’t work, move to item 4 below. When everyone is calm, then discuss what just happened without assigning blame. The focus should be on learning how to do things better in the future.
3. Practice the new way of doing things again and again. Families move like molasses in January. They change very slowly. That means that you have to practice new and better ways of interacting over and over again. Another good cliché is “neurons that fire together, wire together”, meaning that when you practice non-struggle patterns over and over, you are building new neural circuits in everyone in the family’s brains and they will gradually erode the neural circuits governing the struggle pattern.
What to do after the struggle has started,
4. Get space. Sometimes it only takes walking to the next room. Taking a deep breath and counting to 10 help too. Listening to music can help. Anything you can do to regulate yourself is good.
5. Take time. Time is also important to reestablish a calm regulatory state.
6. Reflect. When you are calm, you can reflect on what just happened and identify what you did to contribute to the old struggle pattern. When you rejoin your child to discuss the matter, do not over-apologize. That muddies the water. Take responsibility for your part, but not for the part played by your child. Once you separate out your part, his part should be easier for him to manage, if not this time, then after more practice.

A Message for the Holidays: Finding a Way to Say I Love You

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A mother I know has a 12-yo daughter who goes to school away from home. This girl, whom I will call “Mona”, can sometimes seem unresponsive to her parents. For example, when her parents come to pick her up at school, she may at first appear to ignore them instead of running to greet them with the enthusiasm the other girls show their parents. Mona also struggles in school and requires academic support. Her development has been atypical; neuropsychological testing suggests that using language to make sense of her world is a particular challenge. Even making sense of her bodily sensations may escape her so that she neglects to put on her coat when it is cold outside. It also seems that picking up cues about others’ feelings and from her own emotional state is difficult for her. This does not mean that Mona is without feelings or insensitive. She in fact feels things deeply and can be very sensitive to others. It is just that it sometimes takes her more time or more energy to achieve a state of responsiveness. She needs to “put it together” instead of it smoothly coming into place the way it does for people with typical development. Because her internal world is often confused or poorly integrated, she can be hard to “read”. She is not an easy child to parent.

One time, on the way to pick Mona up at school, her mother was reflecting on some of the frustration and disappointment she and Mona’s father felt in their relationship with her. She decided that she would have to search for a better way of expressing her love for her daughter, one that Mona could “hear” better than conventional ways. She was particularly conscious of Mona’s embarrassment at expressing feelings for her parents in front of the other girls. When they met, she said, “You know, Mona. I was thinking on the way here that I always say, “I love you, I love you,” but that doesn’t really capture the depth of the feeling I have for you. We have to think up our own words for it.” The next day, a thought occurred to her. She spoke to Mona again. She said, “I thought of it, Mona. ‘I glove you’. Mona’s mother was thinking of surrounding her daughter with her love, the way a glove surrounds her hand. It may also be that she was thinking of her wish to protect her daughter from the cold in a way that Mona herself sometimes seemed unable to do. Finally and perhaps most important, in her suggestion that they “think up our own words for it”, her mother was showing Mona that together they could be creative in the ways they communicate their feelings to each other. They did not have to restrict themselves to conventional language. The next day when they said goodbye to each other, her mother held up her hand. Mona smiled and raised her hand.

Mona’s birthday is close to Christmas. This year her mother wanted to make something special for her. Instead of typical Christmas decorations on their tree, her mother decorated it with different colored gloves. While the tree is very attractive, it also has special meaning for Mona and her mother. It is a way to say, “I love you” without words. It captures new possibilities for mutual understanding and for ways of growing their relationship. Maybe it is a way of saying “Happy New Year” for next year and for the future. As I always say, parenting is a creative enterprise.

Day 2 of Joy Osofsky at IPMH

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The following day Joy Osofsky talked about trauma. She outlined ways in which children can be traumatized by adverse childhood experiences as noted in the “ACE” study, in the 1990’s, . She talked about how trauma affects children’s cognition, behaviors, emotions, and brain architecture. Finally, she described several ways traumatic sequelae can be healed. I would like to think of these issues in terms of a spectrum from normative stress, which can be positive, to trauma, with “tolerable” and “toxic stress” in the middle. I will explain more about this spectrum later on, but I want to introduce the idea of a spectrum of stress at this point, because I believe that much of what Joy was talking about in terms of trauma can also be true in situations of high stress – especially when it is prolonged – that do not reach the level of actual trauma.

Children are traumatized by child maltreatment; exposure to community violence in their neighborhoods and in their schools; exposure to domestic violence in their homes; exposure to or hearing about unusual traumatic events such as accidents, terrorist attacks, or hurricanes; military children when their parents are deployed; and exposure to violence in media (usually the effects of an earlier trauma will be exacerbated by subsequent exposure to media).

Joy and her husband were leaders in the psychological response to Katrina in New Orleans. She notes that the psychosocial impact of natural disasters can be similar to that of trauma. The impact is related to the disruption of family structures, changes in the ways people and communities relate to each other, and the taxing effect on the individual, family, school, and community infrastructure. The psychological referral rate for students was very high after Katrina and then declined, but subsequent smaller spikes seem to reflect retraumatization from other hurricanes, oil spills, etc. A child in my hospital clinic began waking up with nightmares after hearing Donald Trump on television saying that all Mexican immigrants should be deported, because she feared that she would lose her parents.

Interestingly, in New Orleans, the children who were integrated into East Baton Rouge schools had higher depression rates than the children who were able to return to their New Orleans schools. This seems to relate to the importance of a “sense of place”. Another window into trauma is the child welfare system, where children have experienced family violence, substance abuse, sexual abuse, removal from primary caregiver, subsequent placement in foster care, and physical abuse.

Trauma alters the developmental trajectory of the child. Joy referred to the children’s book, The Little Engine That Could. She said that trauma pushes the train off the track, and our job as mental health professionals is to help put the little train back on the track. Joy noted the continuum from stress to trauma, starting with normative, developmentally appropriate stress, then emotionally costly stress, sometimes called “toxic stress”, and finally trauma. Positive stress is necessary to healthy development. It occurs in the context of stable, supportive relationships and results in brief increases in heart rate and mild changes in stress hormone levels. Tolerable stress includes stress responses that could disrupt brain architecture but are buffered by supportive relationships that make it possible for the brain to heal. Toxic stress involves a strong, prolonged activation of the body’s stress response system in the absence of the buffering protection of adult support. Toxic stress can damage the developing brain architecture and create a short fuse for the body’s stress response systems, leading to lifelong problems in learning, behavior, and both physical and mental health.

IPMH Joy Osofsky Weekend

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I am catching up on my infant parent postings by writing about a wonderful weekend with Joy Osofsky last month. In her first day of her teaching Joy began by introducing us to three evidence based interventions for very young children – Attachment and Bio-behavioral Catch-up (ABC),  Parent Child Interaction Therapy (PCIT), and Child-Parent Psychotherapy (CPP),  Although not exclusively used for this purpose, these interventions were designed to treat traumatized young children and their parents.

ABC is an intervention for parents of young children who have experienced adversity that helps parents recognize their children’s problematic coping strategies and recognize their own problematic parenting behaviors, so that they can create a caregiving environment that promotes their children’s bio-behavioral regulation. The intervention takes place in 10 sessions that target key issues for traumatized children and is manualized, though the relationship between the clinician and the parent is crucial to the success of the treatment. This intervention is particularly useful for foster parents of infants of toddlers 1-3-years old, high risk birth parents of infants and toddlers, and parents adopting internationally.

Two main emphases of ABC intervention are that (1) some children reject their caregivers even though they need nurturance, and (2) parents can sometimes behave in ways that frighten children, often without realizing it. When traumatized children behave in rejecting ways, their parents must learn to re-interpret their signals so that they can respond to them with effective nurturance. Also, parents who have been traumatized or frightened as young children will sometimes display an angry or frightened face to their child or even “tune out” (“dissociate”) in a way that may frighten a child. Parents with troubled past histories may also misinterpret their children’s expressions of distress and fail to respond in a comforting way. This intervention teaches parents to recognize patterns such as these in their own behavior and in that of their children so that they can learn optimal patterns of parenting behavior. These optimal behaviors include following the child’s lead with delight, attending to the child’s signals, supporting the child’s agency, and the importance of touch.

An interesting feature of this intervention is that of encouraging the parent to provide nurturance even if it doesn’t come naturally – “fake it until you make it”, as I say. We know that practicing a behavior can build new neural circuits in the brain, and ABC attempts to override the parents’ own problematic tendencies by building good nurturing behaviors that are practiced and reinforced in the relationship with the clinician. In this intervention, the parent’s problematic past is directly addressed as it is currently represented in the parent’s behavior towards her child.

PCIT is an intervention in which the clinician behind a two-way mirror coaches the parent through a bug in the parent’s ear. This is a strictly behavioral approach that incudes elements of family systems theory, learning theory, and traditional play therapy. The emphasis is on restructuring parent-child patterns, rather than modifying target behaviors. PCIT is designed to be most effective in treating disruptive behaviors. In this intervention, parents are not blamed but are given responsibility for improving their child’s behavior.

Decisions about family preservation, reunification, or permanency need to be made prior to beginning a course of PCIT, which takes place in 14-21 weekly sessions. Some of the limitations of PCIT are that it focuses on the child’s behavioral problems and parent skills but not on domestic violence, substance abuse, or parent psychopathology.

The third intervention, CPP, focuses on current stress and trauma as well as “ghosts from the nursery” in the past of the parents. This phrase is the title of a famous paper by Selma Fraiberg, a pioneer of parent-infant mental health and refers to traumatic experiences in the parents’ past that haunt them when they become parents themselves (Fraiberg, Adelson, & Shapiro, 1987). This intervention is also manualized and multi-theoretical.
The intervention uses play, physical contact, and language to further the child’s development. Symbolic play is used to create a “trauma narrative”. Games are used to help with emotional and physical regulation – such as blowing, patting, and breathing games. Mazes and other games are used to help a child gain a sense of his body in space, and touch is used to restore trust in physical contact. Another way of describing this intervention is that it is a combination of play and “unstructured developmental guidance”. Important feature of this guidance are to help the parent understand appropriate developmental expectations of their young child and to help both parent and child name and cope with strong feelings. In addition to modeling good parenting behaviors and offering concrete assistance, such as with safe housing, the clinician makes interpretations linking present to past and distant past, “ghosts in the nursery”. These interpretations create the “trauma narrative”.

An interesting and I think important study of the factors disrupting and facilitating emotion regulation is being conducted by a group in New York and Geneva. They suggest that the child’s helplessness, fear, and rage can elicit traumatic memory traces in the mother with PTSD (“ghosts in the nursery”) and propose to help the mother change her behavior in a similar way to the ABC protocol but with videotape feedback. Since I am familiar with videotape feedback and a big believer in its effectiveness, I am awaiting the results of this study with anticipation (Schachter and Rusconi Serpa, 2014).
Fraiberg, S., Adelson, E., & Shapiro, V. (1987). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant– mother relationships. In S. Fraiberg (Ed.), Selected writings of Selma Fraiberg (pp. 101–136). Columbus: Ohio State University Press.

Schechter D, Rusconi Serpa S (2014). Understanding how traumatized mothers process their toddlers’ affective communication under stress: towards preventive intervention for families at high risk for intergenerational violence, in R Emde and M Leuzinger-Bohleber, Eds., Early Parenting and Prevention of Disorder, Karnac Press, pp. 90-117.