Stress Regulation: From Theory to Practice

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Stress Regulation: “From Theory to Practice”

Perry’s ideas about stress regulation are particularly important to me in my clinical work. In contrast to the negative cascade stress can cause in a sensitized child, helping a child grow his stress regulation system may initiate a healthy “cascade” effect.

In my practice, if a child gets better at calming herself, she can pay more attention to my ideas about the motivations for some of her problem behavior and consider trying more adaptive ways of behaving. For example, if a child is poorly regulated, she will not be receptive to my observations that when she starts out with “loser feelings” she cannot bear to play competitive games with her peers. She is more likely to use psychological defenses such as denial and avoidance to protect herself from the stress of acknowledging her painful feelings. If, however, we begin by my giving her a “handicap” that makes it easier for her to win, and then emphasize the rhythmic, repetitive turn taking patterns of the game with my actions and with my voice, she may be able to establish and maintain a receptive, alert position in relation to my communications and even allow me to scaffold some self reflection. In play sessions with one child, I would ask her at the beginning of the session whether it was a “bad guys in” or “bad guys out” day for her before we settled into a game of Candyland. If it had been a hard day for her, we would take all the cards that send you backwards out of the pile. If it had been a good day, we would leave them in. This small ritual allowed us to play the game together, while also helping her begin to reflect on and identify her feelings, and eventually appreciate the link between her temper tantrums and her sense of herself as a “bad girl”.

In psychology and psychoanalysis we refer to “respecting the child’s defenses”, something that Anna Freud talked about. That means not overwhelming a child, usually by avoiding confronting him with information he is not ready to receive. Perry’s idea of “dosing” and “spacing” adds a new dimension to the concept of “defense”. It brings the body into the equation in an important way. Thinking in these terms helps us organize our interactions with a child in time and space. It helps us put the music and dance into our clinical work. Because I study videotapes of my work with children, I see the nonverbal communication, what I call the “music and dance” of psychotherapy, both in a standard time frame and in a microprocess, second by second, time frame. In the microprocess, you can see this dosing and spacing even better than in real time. For example, in one session with a 4-yo boy, you see me introduce an idea about something scary to him; I deliver my communication in short (2 sec) vocal turns defined by short internal pauses (“dosing”) and then, right after I finish, I sit back and fold my arms across my chest. This is “spacing”. When you look at the film in slow motion, you can infer my (out of my awareness) intention of giving him space, giving him a turn.

“Dosing” adds the factor of measurement, of size, which I think is very useful to keep in mind. I remember playing with a little boy who felt the need to exert extreme control over me in the session. In order to help him grow, move him towards reciprocity, I had to stress him by interrupting him sometimes, declining to jump to comply with an order, or by adding a detail of my own to the narrative that he was spinning, any of which could make him mad. Sometimes I “dosed” my contributions by adding humor, sometimes I made them very short, and other times I acted a little confused. Slowly, using dosing in that way, he began to give me a turn now and then.

Spacing is another very helpful perspective. “Spacing” is even closer to the theory of psychological defenses than “dosing”. I was observing the need for “spacing” when I sat back and folded my arms across my chest in the previous example. Another example is my work with a child who lost a parent. When he saw me in the preschool classroom, he would “pretend” reject me by playfully pushing me away or telling me in a loud voice to go away. I would play along, sometimes moving back a few inches, but not going away until it was time for me to say goodbye. When you think about it, there is a lot of communication in our behavior. He is telling me he needs to know if his behavior can cause me to disappear forever, and I am telling him that his behavior is unrelated to when I come and go. My leaving the classroom was a dosing experience for this child. One day after many months of this daily play (“spacing”), I stood to leave, and the boy approached me sideways, without giving me a direct gaze, and leaned against me. I stroked his hair and he didn’t move.

In addition to dosing and spacing, Perry’s thoughts about “distributed caregiving” have also been helpful to me. Actually, what has happened is that my own clinical experience has been moving me further and further from thinking in terms of categorical diagnoses and “clinical” interventions. Instead, I think about children’s problems more often in dimensional terms and tend to move to support the child’s caregiving environment before immediately beginning an individual psychotherapy. Supporting the child’s caregiving environment means working with the child’s parents and teachers. One of my favorite ways of intervening is to work in the preschool. Then, I not only have a chance to offer the very capable teachers an insight now and then about a particular child. I also have the chance to “be there” for certain children when and how they need me. This is what Perry means by “distributed caregiving” – allowing a child to initiate a particular kind of interaction with each caregiver in a group available to him. This kind of thinking moves away from formulations about pathology and towards developmental goals. For example, Perry talks about how after the Waco disaster, the traumatized children seemed to identify particular caregivers for specific needs of the child – one for help with schoolwork, another for rough housing, another for snuggling. I have seen the same kind of distributed caregiving activity in the preschool classroom with healthy children.

I realize that psychotherapists and even psychoanalysts like me sometimes consult to teachers in schools by sitting down with them and listening to them talk about the children and answering their questions, and even by entering the classroom to observe certain children pointed out by the teachers. What I prefer to do is “live” in the classroom so that I can see the children in action and sometimes engage directly with them, while at the same time trying from time to time to identify what the teachers can do even better. For example, I might see a little boy who seems more fearful than average and begins tentatively to play with a toy car. I might suggest to the teacher that she encourage some gentle crashing games if the child initiates them.

In closing, I would like to emphasize the importance of rhythmic patterned activity that is repeated over and over again in helping people grow. This is very different from what I learned in psychiatric and psychoanalytic training. It is not that I have not engaged in that kind of activity in my clinical work; I have. On the other hand, now that I have integrated it into my theory, I do it more, and I do it better.

Stress Regulation: Bruce Perry

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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. 

Every time I hear Bruce Perry speak, I hear something new, and I take a step forward in making sense of my experience with children and families. On September 16, Bruce talked to our IPMH course about his “theory of change” – Change is created by an intentional act that is repeated in a way that will influence the system in the brain relating to the function you are engaging in the action.

As always, he grounds his remarks in the science of the brain – although he is careful to remind us that all “models” of the brain are gross oversimplifications and only useful in so far as they help us understand how the brain works. That is because the brain is unbelievably complex. There are approximately 86 billion neurons in the human brain and many more glial cells. The brain is hierarchically organized both in terms of architecture and function. The most “primitive” part of the brain – the part that is most like the brain of primitive animals – is at the base of the brain. This part, including the brainstem and cerebellum, maintains bodily equilibrium – body temperature, heart rate, blood pressure, and respiration. Above that is the diencephalon that regulates functions such as appetite and sleep. Then there is the limbic system that deals with basic emotions such as anger, fear, and happiness, and also affiliation, and reward. Finally, there is the most uniquely human part of the brain, the cerebral cortex, that produces abstract though and the more complex emotions of guilt and shame. Yet, every time we introduce a model of the brain we oversimplify; these anatomical parts of the brain do not relate precisely to the functions described; it is complicated.

In addition to “intrinsic neurons” that make primarily local connections, there are neural systems in the brain that have wide distribution throughout the nervous system. These systems, such as the ones of the neurotransmitters norepinephrine, serotonin, and dopamine, are crucially important in managing stress. The stress response systems connect the lower parts of the brain with the cortex and also connect the brain to the autonomic nervous system and to the endocrine system, the immune system, the musculoskeletal system, and the internal organs.

As we have noted in other blog postings, the lower part of the brain forms earliest in intrauterine life when the brain is growing most rapidly and is most subject to influences from the environment. Although “neuroplasticity”, or brain growth, occurs throughout life, the most rapid and profound changes occur in the first few years. That is why students of development stress the importance of a good early caregiving environment. An adequately responsive, consistent, and predictable caregiving relationship can modulate the effect of adverse experiences on the developing brain.

When an infant experiences an adverse event – such as exposure to toxins in utero – there can be a “cascade” of effects. The lower part of the brain may be primarily affected, but because the child then becomes compromised in his ability to regulate stress, subsequent development of all the interrelated parts of the brain and body may be affected. That is the reason why children born into homes that suffer chronic poverty, domestic violence, and substance abuse, for example, are more likely to have problems with their emotions, their relationships, and learning.

The neural networks of the stress response system are in dynamic equilibrium. Too high a level of stress-inducing novelty will activate the system in order to lower the stress. Too low a level of novelty will cause the system to increase stimulation to restore alertness. When a child experiences repetitive, unpredictable, stressful events, her stress regulation system will be sensitized, lowering her set point and causing her to be more vulnerable to similar stresses in the future and to react with a more extreme response. A child may be sensitized by a chaotic or violent home environment. He may also be sensitized by vulnerability caused by inherited developmental vulnerabilities or serious childhood illnesses. For example, a child who inherits genes associated with “autistic spectrum disorder” (I put this in quotes since I consider this a highly problematic diagnostic category.) may be highly stressed by making eye contact with another person. A child with this inherited vulnerability is sensitized early in life and will inevitably have multiple repetitive adverse experiences while living in what for another child might be a comfortable home life.

In order to change the regulatory set point of a stress response system in a healthy direction, it is necessary to activate the same system with small repetitive stressors that are organized in an appropriate pattern of dose and space. The last time I wrote about Bruce Perry, I introduced his idea of “dosing”, one that I find very important in my therapeutic work. This time Dr. Perry introduced another important concept, that of “spacing”. Dosing means that you apply a stressor but not in a dose that is beyond the capacity of the child to manage; you do not overwhelm him. Spacing means that you time the doses so that the child is prepared for another challenge. For example, if I am working with a child who becomes easily dysregulated by negative affect states, I am likely to accept her protestations that she really loves her little brother for some time before gently questioning them.

I will continue the discussion of how I use Bruce Perry’s ideas in my work with young children in my next blog, “Stress Regulation: From Theory to Practice”.

Bruce Perry, Lecture, U Mass Boston Infant Parent Mental Health Course, September 16, 2016

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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. 

Aggression in Early Childhood

Aggression is a good thing. It motivates initiatives – including learning, athletic effort, and healthy competition. Yet, good outcomes depend on the capacity to regulate aggression, and that is always a challenge. Self-regulation, as we have said many times in this blog, is a developmental competency that we keep working on throughout our lives. Self-regulation is a special challenge in early childhood, when it is just getting established, but it is a challenge at any age when we are under stress.

How do young children express aggression? They express it by running joyfully with their friends through the playground, by throwing a basketball or riding a tricycle fast, by shouting out the words of a song when cued, by laughing at a clown or shrieking with excitement at a magician. They also express it by pushing another child, by screaming, biting, or hitting, or by grabbing a toy away from a friend. What is the difference between these two ways of being aggressive? The difference is that the first way is adequately regulated; the aggression is under control. The second way is poorly regulated and out of control.

If children do not have adequate self-regulatory capacity to manage their aggression, they may express it with aggressive outbursts such as noted, but they also may express it by holding themselves tight – holding their bodies tight and holding on tightly to their emotions. That frightened, too-tight holding-on is intended to guard against an unwanted aggressive outburst and can manifest as excessive shyness or fear of speaking, or even as bodily problems such food pickiness or constipation. The reason that children fear the loss of control of aggression so much is that they are afraid of the destructive force of their aggression. Even if it is completely unrealistic that a small child could hurt an adult with an aggressive attack, children (out of their awareness) fear that this could happen. That can lead to nightmares of bad things happening to them or to their parents, whom they love and depend on. I want to stress that it is not the aggression that is bad, but it is the fear of losing control of it and harming someone that is bad for the child.

Why do some children have more difficulty managing aggression than others? Some children are temperamentally more sensitive, more active, or more intense. Some children have developmental difficulties that make it hard for them to “get it altogether” – from the point of view of regulation in various domains – motor, emotional, cognitive. Imagine how hard it would be to feel relaxed and confident if your body “didn’t listen to your mind”- that is what I sometimes say to impulsive children. Other children come from high conflict families in which overt or covert aggression presents a chronic threat. Still other children have histories of trauma – either directed at them or at a parent or even grandparent. Finally, some children have more than one of these reasons to have difficulty with aggression.

How can we help children develop the crucial competency? We can help them in three ways. First, we can create a safe situation in which both child and caregiver are not afraid. That usually means adequate and predictable adult supervision, predictable routines, and secure boundaries. Second, we can communicate tolerance of aggression and model constructive forms of aggression. For example, teachers who play basketball or tag with the children are helping the child experience the high arousal state of aggressive activity without the fear of losing control. At home, a parent’s skillful rough housing with a child can offer the same experience. Third, we can make it possible for children to practice aggressive activities without getting hurt or hurting others. Children cutting play dough with a wooden knife, crashing small cars into magnet tile constructions, and engaging in active playground activities are just a few ways I observed today at the preschool.

Our society has a strange and highly ambivalent relationship to aggression. Some parents in our culture prohibit pretend play with toy guns and soldiers, while others teach their children to shoot real guns. American television, video games, and movies are full of aggression. That puts parents in a difficult position, having to negotiate a reasonable balance between under and over controlling both their children’s aggressive behavior and the aggressive displays they are exposed to. There is no simple solution, but the guidelines as mentioned above are – demonstrate to your children a healthy attitude towards aggression; offer them a safe opportunity to take risks with their aggression and to practice using it; and give extra support to children with special sensitivities and needs so that they too can try out their emotions and test their bodies with exuberance.

Read this blog in Spanish.

Back to School Jitters

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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. 

It is back to school time again. Returning to school after summer vacation is a major transition. We have talked about transitions and what a challenge they are for everybody, especially for young children and vulnerable children of any age. Here are some ideas about how to make back to school time easier for everyone.

Try to Be Calm and Relaxed

Parents’ communication of anxiety to their child plays a significant role in the anxiety experienced by the child. Evidence for this influence is presented in a recent review of 15 studies addressing the question of the extent to which fear-relevant features of parental verbal communications affected the child (Percy et al, 2016). However, scientific studies are not necessary to convince teachers of this fact. Observations in a typical classroom offer support for this important dynamic. For example, I observed a father dropping off his 4-year old daughter, giving her a hug, and asking her, “Will you be all right, now?” She said, “Yes, Daddy.” The father responded, “Are you sure?”

In fact, much of this communication occurs nonverbally in parents’ behavior – such as lingering in the classroom, returning to the child after the initial good bye to add some information or give some advice. After the child is in the hands of the teacher, it is almost never a good idea for the parent to return if the child complains or even cries.

Positive Communication 

For young child, the most effective way parents can support him or her at drop off is to communicate positive feelings about the experience, to “hand off” the child to a teacher, and to leave. For example, a parent might find a teacher and in the child’s presence tell the teacher something about the ride to school or the child’s excitement about the class activity planned for the day, reassure the child about who is picking up the child and when, give the child a hug, and say good bye.

Child’s anxiety 

All children have some anxiety about returning to school – usually to a new classroom, a new teacher, and new classmates. Children express their anxiety in different ways. Most young children express their anxiety verbally and by clinging to a parent. Other children express it by running from one activity to another in a dysregulated manner. And others become more constrained, holding themselves in, sitting quietly and avoiding taking risks.

Some children are particularly vulnerable to separations and transitions and need extra support. Some need to bring a comforting object from home to help with the transition (although that object must usually be put away after the class begins). A goodbye ritual is helpful to all children. The parent can help the child hang up her coat, check the schedule for the day, wash her hands, etc. In some of the classrooms of the preschool where I work there is a “goodbye window” where parents can say another goodbye after they have exited the school building.

Listening to Your Child 

Communicating positive expectations to the child does not mean that the parent – or teacher – refuses to listen to the child’s concerns. No matter how unrealistic the child’s fears might be, the adult must take them seriously as fears – not as reality – and validate them. For example, the child may say, “You won’t come to pick me up!” The parent must respond with some kind of acknowledgement of the child’s fear that he will be abandoned in this scary place, while also reassuring him that his fears are unjustified. For example, she might say, “That is such a scary thought, that I wouldn’t pick you up. I know you are scared. But you know that I really will pick you up at lunchtime and that Ms. Smith (the teacher) will take good care of you until then. You are going to have a cooking activity today. You know how much you love that!”

Familiarity with the School 

Familiarity with the school helps too. Most schools have visiting days, but some children need time to familiarize themselves with the school without the noise and activity of many other children and parents. Other ways to help the child feel comfortable include coming to the school when it is not in session and playing on the playground (if that is permitted) or walking around the building and pointing out where the child’s classroom is located, where the parent will bring the child and pick her up.

Get to School On Time

Getting to school on time is important for many reasons. At the beginning of the school day the teachers have more availability to greet the child and parent than when groups of children and parents descend on the classroom. The classroom is less noisy and has less physical activity – sensory challenges that are particularly hard for some children. Being rushed does not lend itself to a positive good bye. Also, teachers usually plan “free play” time at the beginning of the day, and if children come to class late, they miss that important and enjoyable time.

Percy R, Creswell C, Garner M, O’Brien D, Murray L (2016). Parents’ verbal communication and childhood anxiety: a systematic review. Clinical Child and Family Psychology Review, 19(1):55-75.

Read this blog in Spanish.

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.