Monthly Archives: April 2013

Helping a Child Manage Violent Events

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As promised, I have given more thought to the question of what to tell children about the recent tragic events in Boston. I have talked to teachers and other clinicians and listened to children and read information on the Internet and in published material. One of the good things I read was the American Academy of Child and Adolescent Psychiatry guidelines on talking to children about terrorism and war. http://www.aacap.org/cs/root/facts_for_families/talking_to_children_about_terrorism_and_war. Another is an excellent link provided by Dr. Heidi Ellis from Boston Children’s Hospital –
http://www.nctsn.org/content/pfa-mobile

In general, sensible guidelines for helping children through these troubled times include talking to children about the events, communicating comfort with emotions about the events (both child’s emotions and parents’ emotions), and emphasizing safety.

First, the talking: Talking can be very helpful, but only in the child’s own “language” and time frame. Too much talking can be at best confusing to children and at worst can be alarming. It is of course essential to speak in words the child can understand. Discussing frightening events is best done at the initiation of the child, usually in response to his questions. The rule of thumb I usually use is to answer the child’s question briefly and without elaboration, then stop. If the child wants to know more, she will ask. Moving back and forth in this turn taking rhythm gives the child the chance to feel adaptively in control of the information gathering, to find the answers he or she needs and to avoid unnecessarily alarming or confusing information. A 9-year old boy, hunched over a video game told me in response to my simple question about his experience of the attack, “When bad things happen, I just don’t pay attention and wait for them to go away.” When I did not challenge him, he later told me about how some kids in his class were scared and talked a lot about the attack and its aftermath.

It is also important to remember that you do not have to answer all your child’s questions. Repetitive questions can often indicate the child’s wish for reassurance about safety more than his desire for specific answers. Instead of responding concretely to a question about the type of weapon used, for example, the parent may instead say something like, “What I do know is that the policemen are working hard to find out the information they need to protect us.” (Now some parents will insist that their child will “not let them get away with” an indirect answer like that. What I would say about this is that the child is trying to find reassurance in what seems like an out of control world through controlling the parent with his questioning, and in the long run a calm parent who declines to answer the questions he thinks inappropriate will make the child feel safer.)

Children also give other cues besides questions to communicate their concerns. For example, a young child may tell a parent that he had a scary dream, or an older child may say that she feels like staying home from school that day. In these cases, the parent may choose to ask about the dream or the child’s wish to stay home from school without bringing up the event specifically. Or, the parent may say something about the dream or the wish to stay home reminding them of the scary event. “Your scary dream reminded me of the scary things that happened in Boston yesterday,” or “Your not wanting to go to school reminds me of how I don’t want to go to work today after all the frightening things that have been going on!” In both cases, the parent isn’t pressuring the child to “take on” the frightening thoughts but joining the child in her concerns. It is important to hang around, to be available to talk. Tell the truth because child will know if you are being dishonest. Be prepared to answer questions multiple times in different ways, since children put together information in bits and pieces depending on the context and on their mood and state of concentration. This is different from the perseverative questioning I mentioned before.

Second, communicating comfort about emotions: All children – young and older –respond not only to the frightening event but also to the emotions of the people around them. Remember that a picture is worth a thousand words, so that the image of a parent’s anguished face will tell a child more than her reassuring words. It is important for parents to take care of their own emotions first in order to prepare themselves to be available to their child, just as the flight crew tells you to put the oxygen mask on your own face first and then on the child’s, in case of an emergency on an airplane. When your own feelings are under control, acknowledge them – fear, anger, sadness.

Children may tend to revert to earlier behaviors in response to frightening events, just as they do after other stresses. For example, when I went into a classroom yesterday morning, one 3-year old boy that I know well greeted me with baby talk. Of course, his affectation may not have been directly related to the crisis. Still, given the context of current events, it occurred to me that his baby talk might have been a response to fears about those events, and that awareness alerted me to the state of his mind on that day. In another classroom, two 5-year old boys at the lunch leaned in towards me when a third boy brought up the subject of the bombings. All children need and deserve extra tolerance and comfort in times of crisis.

Children will respond differently to frightening events, depending on their unique circumstances and personalities. Kids whose parents are separating, children who have had a recent move or other transition, or children who have lost a relative or friend, would be expected to react more strongly to danger in their environment.

Finally, emphasizing safety. Parents can stress safety by containing the stimulation of television, radio, and adult conversations. Remember that when children are anxious they listen more carefully to communication that is intended to be for adults alone. Limit the amount of television in the home at these times, and if you turn on the t.v., watch it with your children so that you can help them make sense of what is being broadcast.

They can support a feeling of security by maintaining comforting routines at home and in school. After Katrina, one of the first acts taken by Joy and Howard Osofsky in their rescue efforts was to create a school for the displaced children (Joy Osofsky, Personal Communication, 2010).

Parents can also help their child feel secure by scaffolding the child’s own efforts to create a feeling of safety. Some children will want to play firefighters or choose rescue vehicles instead of the usual racing cars or trucks. In a 3-year old classroom today, the children were playing with rescue vehicles, making them so strong and magical that they could fly through the air to rescue people. No explicit mention was made of the bombing, but the children could in their play experience an enhanced sense of their own strength and master that will protect them against some of the adverse effects of traumatic events. Older children may want to make some kind of restitutive action such as writing letters or giving gifts to the first responders. Regardless of how unrealistic the child’s ideas might be, parents should treat them with respect. One 5-year old boy told me Monday that he had a plan to throw blueberries at the bad guys, and I just nodded with interest.

 

 

 

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How to Help Children Make Sense of the Bombing

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I am in Dallas, having a good time with new friends and colleagues. I have been – as we all have been – gripped by the shock and tragedy of this whole episode. For a while, I was strangely comforted by the thought of the unknown perpetrators as evil. Now, with the reports from people who knew the two young men, especially the younger one, I am rattled again by the confusion and complexity of humans. If there were pure evil we could maintain the illusion of isolating it and protecting ourselves. If evil comes from sweet-faced young men who are called good dependable friends and who volunteer to be the designated driver (what I heard about the younger brother), then how can we ever protect ourselves? How can we give an acceptable explanation of the events to our children, when we cannot explain them to ourselves?

There is good, sensible advice on the internet and given in interviews on the radio and t.v. Schools send out thoughtful reminders about limiting children’s access to media coverage, monitoring adult conversations about the events so that they are not overheard, and talking to children about all the help being given to the victims so that they will be aware of the constructive activity and not perceive the adults in their lives as helpless and passive. I will read and listen to as many of these pieces of advice as I can over the next few days and report on what I think might be useful.

Right now, though, I want to send a word of caution to parents of young children – maybe especially those with children with developmental quirkiness – but really to parents of all children. Do not feel that you must answer all the concrete questions about these tragic and frightening events that your children ask you. Questions about the details of the bombings or of the injuries sustained, should not be avoided, but should be respectfully declined. Instead, parents will do well to find their own particular way of communicating these general ideas: (1) We will not leave you; (2) We as your parents will work hard to keep you safe and sound; (3) All the grownups in the city will find out new information from what happened so that we can learn new ways to protect children.

 

 

 

My Thoughts on Video Games

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Recently, a child in my practice has become a minecraft afficianado. This child is very smart but has processing problems and struggles in school. He is adept at the game, which wins him admiration from his siblings and peers, with whom he plays the game both at home and in free periods at school. When he brought the game in to show me, on his mother’s iphone, I was impressed by his proficiency and also noted the fact that he talked to me more – about the game – and in a more coherent fashion, than I can remember his having done before. I was pleased. However, I was also suspicious, because I have had a rather negative view of videogames and their effect on my child patients for quite a while. Was this game going to change my mind?

I had always thought that videogames were attractive to children with regulatory problems – for example, kids with learning disabilities, processing problems, or tricky moods – because in playing the game the child experiences strong affect and intense physiological arousal that is highly pleasurable and that is otherwise unavailable to the child without the negative consequence of his falling apart. That is because the game is doing the regulating for him and the child is the passive recipient of the structure and rhythm provided from outside.

The problem with this is twofold. First, the child needs all the practice in self-regulation he can get, and he isn’t getting any playing the game. Second, it is very unpleasant to discontinue this experience – a real downer, and that leads to a set of other problems. Children with regulatory problems often have particularly difficult times with transitions, and a parent’s demand that the child leave such an attractive activity can often generate a struggle or provoke a fight. In addition, parents of these children typically have a hard time setting limits on their children’s behavior due in large part to the child’s neuro-cognitive challenges, and old struggle patterns can be triggered by these demands for compliance, in effect “practicing” these problem patterns and making them worse.

Then by coincidence, a colleague, Dr. Tim Davis, brought up the game of minecraft in a clinical discussion we were having about another child. Tim supported my original opinion of the game. Tim said that the game presents the player with small tasks and an immediate reward, in that way offering gratification to the player who has organizational or processing problems. This may contribute to a tendency for children to prefer this game and avoid more difficult but more growth enhancing activities, or for these reasons may even lead to an addictive behavior. Yet, Tim and I are of the same opinion about setting limits on videogames like this. We both think that it is better not to prohibit the game completely, especially since the game is often popular with the child’s peer group, and these children often need all the support they can get “fitting in”. However, this puts a large strain on parents, because it means that you are setting limits all the time on a child who responds poorly to limit setting. On the other hand, it gives parents and children the chance to practice very challenging negotiations so that they can build their competencies. Each family has to set their own rules, but generally I recommend that children not play videogames until their homework is done and done well (not dashed through to get to the game). On weekends, parents may also wish to insist on another kind of play with peers or physical exercise before the videogames. The time children are allowed to play videogames – or the time allowed for any “screen time” varies from family to family.

Later, I contacted another colleague who knows a lot about videogames, Dr. Peter Chubinsky. He wrote me back, “After a break from serious gamers in my practice, I find myself doing psychotherapy with some older adolescents with great passion and skills for these video games. They now realize as their parents had years before that being the greatest wizard on a 200,000 person server, or having the most kills and earning the respect of soldiers playing online with you are not the best answer to the question on their college application, ‘What accomplishment in high school are you most proud of?’ Even more compelling to my patients and the motivation to modify their gaming is realizing how poorly the games have prepared them for finding a girlfriend!”

Read this blog in Spanish.

Childhood Sexual Abuse (continued)

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The psychological and behavioral reactions described in the last posting are based on how the child’s brain developed. In addition, the child tries to make sense of what happened and creates a narrative (what I have called a “story of pain”) based on how he or she perceives the world, which is in great part based on the messages, overt or covert, received from adults responsible for his safety (or lack thereof). The story might go something like, “I am bad, I am guilty, responsible for provoking what adults did to me. I am alone. I deserve nothing except punishment. I am not worthy of protecting myself, and I do not know how to do so. I am too afraid to show my anger, etc. I would like to end with a story about how this narrative can be rewritten. It is about an institution that created a “healing place” for children who had been sexually abused. The abuse was perpetrated by one of the highest authorities in the institution, a father figure. This is of course not uncommon, as is witnessed by the story of the The Horace Mann School, the story of Jerry Sandusky, and many stories about the Catholic Church.

In this story, the second person in authority, a mother figure in the institution, was determined to create healing out of harm. Even though this woman had also been betrayed by the perpetrator in a painful way, she did not turn away, but engaged the situation with great courage. She brought the children – a group of girls from about 9 to 15 – together, to talk about what had happened. She told them that what they had experienced was not their fault, that it was terrible they should have been abused in this way, that they had been let down by the adults, and that she would ensure their safety from then on. She told the girls that there would no secrets kept from them, that it was important for them to be able to speak freely about what had happened. I was present during the meeting to give her support, and after her speech, I waited anxiously to see if the girls could speak. After a moment of silence, one girl spoke, then another. As they sat in the circle, some of the girls sat leaning against one another, one girl fixed another’s hair. They seemed remarkable relaxed and comfortable. By the end of the meeting, all the girls had spoken. They had spoken about their confusion about the perpetrator’s motives, about their anger, about their fear that he would return and their curiosity about what would happen to him. One girl said that she thought the devil had entered his heart. In the end, the “mother” had helped these girls to tell a different story about the hurt, pain, and betrayal they had experienced at the hands of a “father”. Their “mother” had helped them heal.

Read this blog in Spanish.

 

Childhood Sexual Abuse

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Dealing with Sexual Abuse in Children

Sexual abuse is most common in dysfunctional families, but it occurs in all socio-economic groups. It is common in institutions for children. Why? One reason is because children in institutions come from families that could not nurture or protect them, for whatever reason. Sometimes these reasons include abuse and neglect in the home. Another reason is because institutionalized children may be vulnerable and easily exploited. Why do caregivers sometimes sexually abuse the children in their care? In families, this is called incest. One reason is because sometimes they carry childhood histories of abuse by their own caregivers into their adult lives. Often, child abusers have two sides to their minds – one “the rescuer” and one “the abuser”. “The abuser” exploits the child for the adult’s own needs. Often the adult convinces himself that he is acting for the good of the child (“She wants it.”) or normalizes it (“It is natural.”). In addition, the adult often has unhappiness in his present life that tips the balance from “the rescuer” to “the abuser”. Why is the abuse so destructive? Because it is exploitative, because it involves a crucial breach of trust, because it can be transmitted from one person to the next, and finally, because it can affect the developing brain of the abused child.

In relation to that last important point, let’s look at some of the major features of childhood sexual abuse, provided by the expert in child trauma, child psychiatrist, Maria Sauzier, (Maria Sauzier, Personal Communication, 2013).

Major Things to Know about Sexual Abuse

  1. Children must learn to cope with their own aggressive and sexual urges; that is part of normal development.
  2. The vicarious expression of this part of mental and physical life can be found in fairy tales and stories throughout history and across all cultures.
  3. Contact with the “cruelty of nature” is part of everyday life, especially in traditional and rural societies (animal slaughter, etc.).
  4. Most children witness adults arguing, are punished, and see others punished. This punishment is physical in some cultures.
  5. Some children live in unsafe neighborhoods where they have early contact with the cruelty of human beings.
  6. Children may witness violence in their own homes – towards a parent or a sibling.
  7. Children may be treated with violence, in their home or their school, as punishment.
  8. Some children’s bodies are treated with violent or sexual acts for the sadistic or sexual gratification of adults.

It is important to realize that the ascending curve of these various levels of contact with aggression and sex has no matching curve of distress, or of internal (depression, anxiety) or external (acting out behaviors) response. Instead, the reactions of children to violence and sexuality or sexual stimulation do not follow any predictable pattern.

The whole of the child’s brain does not grow uniformly; various parts of the child’s brain grow at a faster pace at any given time. Stress reactions will influence the part of the brain that happens to be in a fast-growth mode the most severely.

Children are also born with a variety of levels of reactivity to being stressed. Some babies startle in response to benign new experiences, while others will take even unpleasant experiences in stride. Their brains are wired differently, and the level of stress that will provoke the neurochemical cascade of stress reactivity varies widely.

Once the cascade of neurochemical hormones is activated, it follows the same pattern in humans as in animals in the response to perceived danger: the production of adrenaline prepares the body to react to the danger either with fight or with flight. These are normal reactions that have ensured the survival of the species. A third reaction is not helpful: freezing, going blank, without a coherent strategy is maladaptive in all cases.

Once the danger is over, the high adrenaline and cortisol levels circulating through the body and the brain need to be metabolized, deactivated, because the effects of high levels are not healthy. If this does not happen, the consequences may be high blood pressure, rapid respiration or heart rate, the diversion of blood supply from the gut and other internal organs to the muscles, or mental alertness to the point of oversensitivity to any sign of threat.

If this cascade is triggered frequently in the course of a child’s growing up, the child may stay on constant alert. The child’s brain is bathed in neurochemicals that will change his or her growth pattern and may lead to subtle or not so subtle changes that may take one of three major paths:

(1) Fast and indiscriminate reactivity; expecting danger where there is none and fleeing from it; feeling that you are on your own without support; no capacity to trust, being less capable of using higher levels of brain functioning that allow planning and flexibility, an inability to have a quiet, receptive brain in order to learn or even listen, need for constant stimulation expressed in risk-taking behavior. (2) Fast and indiscriminate reactivity; expecting danger where there is none and fleeing from it; feeling that you are on your own without support; no capacity to trust, being less capable of using higher levels of brain functioning that allow planning and flexibility, an inability to have a quiet, receptive brain in order to learn or even listen, risk-averse behaviors, sometimes to the point of paralysis. (3) Generalized helplessness, no mechanism for self-protection, no self-care, emotional and mental paralysis, giving up.

The children in the first group have serious behavior problems, as they are easily triggered and overreact to adult demands, to any change in plans, to anything they perceive as leading to a lack of control, losing face, to any “dissing” by a peer. They may invite danger with risky behaviors, provoke adults to punish and abuse them, get stimulated by repeating their abuse at the expense of others. I will continue with my Dr. Sauzier and my thoughts about child sexual abuse in the next posting.

 

Read this blog in Spanish.

 

“A Healing Place”: Part VI

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Rewards and Consequences

It is important for each caregiving system to decide ahead of time about the rewards and consequences that are given in response to particular behaviors. It is true that the rewards and consequences must change over time to be consistent with the child’s developing capacities and needs, and that they must be adjusted to fit the individual child, but having a list of rewards and consequences written down somewhere where all can see is a decided advantage. This clarity of expectations minimizes threat in that child and caregiver both know what reward or consequence follows from what behavior, so that the child anticipates the result of his behavior and the caregiver does not have to think something up on the spot, and also the caregiver gains support in facing the child’s anger and aggression through being able to refer to an established set of rules.

When choosing consequences, it is also important to remember that small consequences are often as effective as large ones, and they leave more room in which to make a subsequent response. If you move quickly to the “nuclear alternative” and the child does not comply, you have nowhere to go from there.

Another consideration is acts of reparation. Some children get stuck with their caregivers in a painful negative pattern of mutual self-punishment. No matter how awful the consequence, they can’t seem to back down. Children (and caregivers) rarely learn anything good from this experience. It is sometimes better in these cases to help the child repair the rupture in the relationship caused by the “bad” behavior through some small act of recognition or kindness towards the injured party. It might be a note, a picture, or a small helpful task. These reparative acts are also particularly good in cases of two children in conflict with each other. They can restore a child’s self esteem and help him or her feel like a “good person” again.

Supporting the Caregivers

Finally, it is always important to support the caregivers. Helping children behave is hard. Resolving conflict is stressful. Dealing with anger and aggression takes a lot out of you. You cannot anticipate everything. What is the solution? Communicate with one another. Try to understand each other. Give a hand in comfort to each other.

Read this blog in Spanish.

“A Healing Place”: Part V

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Be Predictable:

Generally speaking, predictability is helpful in dealing with problem behavior. This is because if the child knows what to expect, he is not confused about what he is supposed to do. Predictability also diminishes the stress in the caregiver because the caregiver does not have to think of what to do on the spot. On the other hand, there is one situation in which predictability is a problem, and that is when caregiver continues to use a strategy that does not work.

This happens more than you would imagine. It doesn’t make any sense to continue to do something that fails to achieve the desired goal, but people do it all the time. Caregivers may have in mind what the child needs to do in order to allow the household routine to proceed in a necessary way, or in order to become adequately independent, and though the caregiver may continue to insist that the child comply with her demands, failure results every time.

If It Is Not Working, Stop.

The solution to this problem is simple to propose, but hard to implement. It is, when a strategy is not working, stop it and try something else. Remember that repetition builds brain structure, and you do not want to build a stronger and stronger struggle pattern in the brain.

I like to explain the situation to caregivers using the metaphor of a landscape (Granic & Patterson, 2006). A caregiving system is like a landscape with multiple population centers. Some are highly adaptive such as ones characterized by collaboration, compliance, and respect. Others are less adaptive and are characterized by struggles and coercion. The more a particular city is occupied (the more times a pattern of collaboration or of coercion is repeated) the stronger the infrastructure of that city becomes. One cannot abruptly dismantle a problem city. Instead, the plan should be to build up the infrastructure of the positive cities by repetition of the adaptive patterns, so that over time they become the easiest to get to and to live in, and the infrastructure of the problem cities fall into disrepair, eventually turning them into ghost towns. The more often the caregiver-child dyad negotiates a common agenda, avoids a struggle, achieves mutual understanding through discussion, the stronger the “good” cities become and the weaker the problem ones become.

Granic, I & Patterson, G (2006). Toward a comprehensive model of antisocial development: A dynamic systems approach, Psychological Review 13 (1), 101-131.

Resolving Conflict

Successful resolution of conflict between caregiver and child or between two children requires an initial assessment of the state or intensity or physiological arousal of the child or children. This is important because a child who is functioning at a high level of intensity will have different – and fewer – capacities available to him than a calm child. It is common sense, but it is easy to forget to look at the child to see where he is in his ladder of arousal – high or low.

Next, the caregiver must look at, and listen to, what the two children are doing together. If the conflict is between the child and caregiver, it is helpful to have a second caregiver give his or her perspective about what is going on. If this is not possible, the caregiver must do his or her best to step back from the interaction and observe it as objectively as possible. It is not only the physiological arousal state of the individual child that must be assessed, but the intensity of the conflict between the two people. If the conflict is low intensity, the caregiver can try to negotiate a common agenda. For example, if the child wants to play a game instead of get ready for school, the caregiver may negotiate a way for the child to get ready for school quickly and then play the game. Or, if both children want to play with the same toy, the caregiver may negotiate a turn-taking in which each child gets a turn with the toy. If the conflict is high intensity, on the other hand, it is usually necessary to separate the two fighting children, or for the caregiver to try to disengage from the conflict with the child. Disengagement does not necessarily mean leaving the scene, though that can sometimes be effective with an older child. Instead, it means the caregiver’s taking her attention and emotions out of the interaction. She communicates to the child without words that she is perfectly happy to discuss the situation with the child in a civilized manner, but that she is not interested in arguing or being shouted at. I have realized through talking to many parents, and through being a parent myself, that disengagement is not easy. Parents often experience a strong inner pull to be right, or to win the battle. Often they rationalize this intention as the need to show the child that they are in charge. In high intensity conflict, this rarely works. I have also noticed that sometimes this kind of conflict generates in the parent a wistful feeling about losing the child if the child does not comply. Again, this is irrational.

After everyone calms down following a high intensity conflict, it is important to “de-brief”, that is, to discuss what happened. What were the intentions, the agendas, of the conflicting parties? What made it impossible for them to negotiate? What could they do differently next time?

Read this blog in Spanish.

“A Healing Place”: Part IV

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Anticipate Problems

It is always important to anticipate problems. That means, for example, anticipating stressful events, the effect of a high conflict relationship, and transitions.

Stressful events may include a visit home from the orphanage, a birthday or other special occasion, a test at school. High conflict relationships can cause stress at home with a caregiver or sibling, or at school with a teacher or a classmate. Any observer on the playground during free play at school will witness many problematic exchanges; sometimes these exchanges are repeated in the same relationship day after day, and those patterns can be anticipated.

Transitions are difficult for all children, indeed, for people of all ages. Children with developmental problems – and as I have said, that includes all children with significant histories of neglect and maltreatment – have even greater difficulty with transitions than others. This is because ideal developmental outcome is evidenced by the smooth integration of experience and function at different levels and in different domains in a continuous flow. In this case, a transition – which necessitates the taking apart of the organization that was functioning in the previous state and creating a new organization to deal with the new one – is manageable. For example, when a “healthy” person wakes from sleep, the complex physiological, emotional, and motoric transitions that are required to move from bed to upright and to preparing for the day are no big deal. If, however, the person suffers from a mood disorder or has a fever or has a developmental problem related to autism or trauma or cerebral palsy, for example, this transition can seem or even be actually impossible. The same is true for the transition from home to school or to work or even from one classroom activity to another or one work situation to another. One must never underestimate transitions, because transitions are challenges to organizational capacities, and these capacities are the first to be affected when development follows a problematic pathway.

Prepare for Transitions

Preparing for transitions can be done in many different ways according to the needs and capacities of the individual child. It is often helpful to make a schedule of predictable events and display it in some central place in the child’s bedroom or in the home. Some children respond better to visual cues. For example, a teacher in the preschool where I work has created a beautiful laminated strip of photographs of classroom events (children engaged in these activities) in the order in which they occur to use as a visual reminder for a child with a developmental problem. This child also has a laminated strip with the steps in hand washing (turning on the tap, taking soap from the dispenser, rubbing hands together, rinsing hands, drying hands with paper towels, throwing towels in the trash). This has proved to be extremely helpful and has turned an often oppositional struggle into a calmer series of redirections to keep on task.

It is also helpful to give friendly warnings to prepare for transitions. Although this seems routine, caregivers often forget. If the caregiver anticipates the need for the warnings, they can be given without the annoyance generated by noncompliance. First, the caregiver can give a 5 minute warning, then a 2 minute warning, and finally a 1 minute warning, for example. If a schedule similar to this is given routinely, a ritual is established. The child knows what to expect, and the caregiver is not stressed to think of how to respond.

Read this blog in Spanish.

“A Healing Place”: Part III

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Realistic Expectations:

As we all know, to help a child grow we must make it possible for him or her to experience success. It is therefore important to set expectations for children that they can realistically achieve. This of course requires attention to what we just talked about in terms of “knowing the child”. It also means that at times of stress, the caregiver must lower the bar. What a child is capable of in times of stress is different from what he or she is capable of when calm and comfortable. None of these points are unfamiliar, but caregivers often lose track of them when dealing with children.

Caregivers must also be prepared to help the child over the rough spots and to support the child’s initiative. This is more complicated than it seems at first glance. That is because when to help and when to encourage the child to try it on his or her own is not always clear. Complicating the matter is the fact that caregivers fall into patterns with children, patterns that are shaped in part by (usually out of awareness) the caregiver’s needs or by other demands of the environment. Examples include when the caregiver’s need to get ready to go to work in the morning makes it easier to dress the child than to help him dress himself. Or, the caregiver’s desire to hold the child close as she did when he was a baby in order to preserve a sense of intimacy that is no longer appropriate.

Another pattern is that of insisting a child “do it himself”, when the child actually needs some support in carrying through on the task. Examples of this situation are when the child has problems organizing the complex motor activities required in getting dressed, or when the child has problems maintaining his focus of attention. Even when the caregiver has repeated a pattern with a child frequently without success, it is hard for him or her to recognize that this way of doing things is not effective. This is especially true if the child is “hard to read”, or has a complicated mix of competencies so that he or she is very good at some things and surprisingly not good at others, such as is the case of children with uneven development. (Remember that traumatized children almost always have some degree of unevenness in development.) In these cases, it is excellent to have other caregivers offer their perspectives on the capabilities of the child. These alternative perspectives, whether offered by other caregivers in the home or by teachers, are valuable and should always be taken into account.

Finally, it is important to listen to the child. By “listen” I mean observe as well as listen to what he tells you. If the child continues to struggle, it is time to ask him what he needs to accomplish the task. Does he need your help? What kind of help? If he claims that he needs your help but that claim is at odds with your observation, you might continue the discussion – “Help me understand how you need my help to do X when I see you do it so well yourself at Y other times.” Or, “Let me watch you try it so that we can see where things go off track.” Or, “Would you have the same comforting feeling if you did this yourself and afterwards I gave you a hug?” Discussions such as these not only help the child with the task, but they also support the child’s initiative in that they encourage the child to look within and assess his own capabilities, which is a competence in itself. It also demonstrates to the child that the caregiver has an open mind, is willing to be wrong, can talk about these conflicts with the hope of resolution.

Read this blog in Spanish.

“A Healing Place”: Part II

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I continued with the workshop, referring to Bruce Perry (as I so often do) as I addressed what Rachel had described to me as the caregivers’ discouragement. I told them that the parts of the brain that influence this problem behavior “have been shaped over many years with hundreds and thousands of repetitions”, and that traditional therapies that typically take place in 45 or 50 minute sessions at a frequency of once a week cannot be expected to reverse years and years of traumatizing experiences (Perry & Hambrick, 2008, p. 39). I wanted to talk about changing the brain in healthy directions and how that improves behavior, but mindful of the role of consultant and the necessity of staying close to the caregivers’ stated concerns, I addressed the need to respond to problem behavior “right now”.

Changing Behavior Right Now: Think Ahead

(1) Know the child. (2) Make realistic expectations. (3) Anticipate problems. (4) Prepare for transitions. (5) Be predictable, but not too predictable. (6) If something is not working, stop and try something else. (7) Resolve conflict. (8) Give rewards and consequences.

I will go into detail in the first point in this posting and continue with the subsequent ones in the following postings.

Know the child:

It is important to keep in mind the child’s strengths and weaknesses, and also to remember the child’s story of pain. The role of the child’s traumatic background is easy to forget when you are dealing with his problem behavior, but it is important to bring it to mind now and then, because it can help you with how to respond. First of all, remembering the child’s story of pain can refresh your empathy for the child. Second, it can help you identify “triggers” or special challenges for this individual child. For example, a child who has been sexually abused will often be triggered (have a traumatic reaction) to certain kinds of touch or to intrusive behavior (someone putting his or her face too close to the child’s face, or looming over him or her). Remember what I said about children on the autistic spectrum. Often these children will also react violently to someone coming in too close.

Again, channeling Bruce Perry, I emphasized the importance of special relationships – For traumatized children, “The relational environment of the child is the mediator of therapeutic experiences.” (Perry & Hambrick, 2008, p. 43) In fact, in the fortunate case that there are multiple good caregivers available, such as is true at Love and Hope, the child may choose one person who can help him feel calm, another whom the child can rely on to be firm, and another who can help him have active, rough housing kind of fun. This is not so different from what happens in families, especially big families.

We know that it is also important for the relationships that partners make with each other – such as adult partners or even close friends at any time in life – to include a mix of these functions. That is, we would not choose a partner or close friend for whom we could not rely on both for fun and also for comfort. Yet these children may require time to put it altogether, and a “family” environment in which these relationship functions are offered by different people is often a first step.

Reclaiming children and youth www.reclaiming.com

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