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Infant Parent Mental Health Weekend: Bruce Perry

Bruce Perry came to speak to the Infant Parent Mental Health course last weekend. As usual, I was impressed by his discussion, and I agreed with him that his thinking has changed and grown more sophisticated and complex even from when I first met and was inspired by him a decade ago.

This time I was especially gripped by the notion of “dosing” the interventions that are aimed at growing the brain. I put that idea together with two other primary principles of Perry’s Neurosequential Model of Development – changing the environment to meet the developmental needs of the child, and repetitive, rhythmic patterned activity – to create the mnemonic, “RED”. Here is a summary of my thoughts after the weekend. These thoughts are directly relevant to the subjects of ADHD and Executive Function Disorder.

R: Perry frequently talks about the regulating function of repetitive rhythmic patterned behavior. This makes sense, since the body has many rhythms that are repeated over and over again mostly out of our awareness, creating micro patterns that then coordinate to create macro patterns, that help to organize and integrate our human body and mind. For example, we don’t usually pay attention to our heart rate or respiratory rate unless something is going wrong, such as the rapid heart rate associated with anxiety or panic. But our sense of well being emerges from among other things the signals these rhythms send us. An example of the coordination of these rhythms is the coordination of respiratory rate with walking. If walking at a comfortable pace, many people tend to take two strides for one inhalation and between two and three strides for one exhalation. Perry refers explicitly to walking as a regulatory activity, as well as dancing and drumming, and many other repetitive rhythmic patterned activities. In fact, music and dance often provide refined regulatory procedures that make one feel good – calm (“music soothes the savage beast”) or invigorated.

A child develops regulatory capacity through a process of mutual regulation with a caregiver (Cohn & Tronick, 1988, Tronick, 2005). This helps to explain why regulatory activities done with another person are often even more effective than done alone, for example, taking walk with another person. Even having a conversation with another person involves rich processes of turn taking that creates coordinated rhythms between the two people and also simultaneously within each individual (Beebe et al, 1992).

E: One of Perry’s key points is the importance of changing the environment to accommodate the child’s developmental needs for both regulation and for engagement.

From the point of view of regulation, that means more than adding regulatory activities to the child’s schedule. It also means evaluating the child’s capacity for processing sensory input to make sure that the noise, the visual stimulation, and the touch occurring in the child’s daily life is not overwhelming to the child. A crowded classroom or a disorganized routine can be modified to make life easier for a child with sensory sensitivities and that makes life easier for everyone in the family. Sometimes this is called a “sensory diet”.

From the point of view of engagement, this means that the child’s vulnerabilities must be engaged. As Perry says, “You can’t change any neural network unless you activate that neural network.” (Perry, 2015). Not surprisingly, children resist activities that require them to exercise functions that are hard for them, especially if their development is uneven and they do other things quite well. In that case they will tend to stick to what they do well and avoid what is hard. To help them grow, their caregivers must support them in attempting the difficult or uncomfortable task. For some children who are socially skilled but have a learning disability, this means practicing academic tasks that are difficult for them. For other children who have academic strengths but are stressed by interacting with other people, it means drawing them into social interactions, usually in play.

D: But how does one engage a child who is highly stressed by, for example, social interaction, such as very shy children or children on the autistic spectrum? Perry’s idea, which I find very useful, is that of dosing. By paying attention to the child’s cues, you can “read” the child’s intentions to “do something with you” or not. In the rather extreme case of an ASD child, you can’t just let him remain in a withdrawn position without attempting to make a connection; you often have to take the initiative yourself. I recommend small gestures that take place in short time intervals and are over quickly, and also that are of low to medium level of intensity (in noise, visual stimulation, affective tone, and arousal). After you have taken the initiative, you watch for the response. If the child seems not to respond you might try one more time. If the child pulls back further, you might wait. If the child looks a little interested, you might repeat the gesture.

The beauty of this notion of dosing is that it is coordinating intention with the child, and dosing is repetitive and has a rhythm to it. Together with the child you are creating patterns of ways of being together. So you are putting together regulation-enhancing activities with growth-stimulating activities. Another good thing about dosing is that it takes the emphasis off success or failure and places it on creating a balance. If the child indicates, “no”, then you don’t feel, “Oh, I lost him.” Instead, you think, “OK, that was a “no”; I will wait and try again. The “no” is part of what we are doing together. It is part of the back and forth.” And, of course, back and forth is a rhythm too.

How is this discussion related to ADHD and EFD? Both ADHD and EFD can be thought of as regulatory disorders (or difficulties on a dimension, if we use my preferred terminology). I will discuss this further in another blog posting.

References:

Beebe, B., Jaffe, J. & Lachmann, F. (1992). A dyadic systems view of communication. In N. Skolnick & S. Warshaw (Eds.), Relational perspectives in psychoanalysis (pp. 61-81). Hillsdale, NJ: Analytic Press.
Cohn, J., & Tronick, E. (1988). Mother-infant face-to-face interaction: Influence is bi-directional and unrelated to periodic cycles in either partner’s behavior. Developmental Psychology, 24, 386-392.
Perry B (2006). The neurosequential model of therapeutics: Applying principles of neuroscience to clinical work with traumatized and maltreated children, In: Working with Traumatized Youth in child Welfare (N Webb, Ed). The Guilford Press, New York, pp. 27-52.
Perry B (2015). Presentation to the Infant Mental Health PGC Program, U Mass Boston, Feb. 25-26.
The Child Trauma Academy (2015). Overview of the neurosequential model of therapeutics, www.ChildTrauma.org
Tonick E (2007). The neurobehavioral and social-emotional development of infants and children, New York, WW Norton.

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More About ADHD

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I promised you that I would write more about ADHD, including the neurodevelopmental findings.

Different types of studies demonstrate the heterogeneity of ADHD. One is to look for latent class trajectories through a method called growth mixture modeling. That means the researchers are using mathematical models to see whether ADHD children sort out into different groupings over time. Many studies have shown that there are two “symptom clusters” in ADHD – inattentiveness (In) and hyperactivity and impulsivity (H/I). One recent study (Arnold et al, 2014) followed 684 children over 3 years. Although these children were originally chosen to study a mood disorder, a large percentage of them (526) of them met the criteria for ADHD. In the group of ADHD children, the researchers were able to show that the children did sort out into several groups that followed different paths in the severity of their symptoms during the course of the 3-year follow-up. There was a high overlap in severity of the In and H/I symptoms over time, confirming that there is a link between these two symptom clusters. Yet, it also seemed clear that the hyperactivity/impulsivity symptoms waned over time, whereas the inattentiveness did not. This finding is consistent with other studies and with clinical experience that suggests that children with HA/I and Inattentiveness become less hyperactive and impulsive as they grow older, but they may continue to be inattentive and distractible.

A study approaching ADHD from the point of view of specificity of current diagnostic criteria looked at the effect of increasing the age of onset listed in the diagnostic criteria for ADHD in the old – DSM-IV – diagnostic manual to see if there was something specific to the children diagnosed by 7-yo (Vande Voort et al, 2014). In fact, the researchers found that if you extend the age of onset for diagnosing a child with ADHD from 7-yo to 12-yo, you get a condition that is indistinguishable from what you get if you use 7-yo as a cut off. Interestingly, the later onset group tended to come from lower income and ethnic minority populations, suggesting that these children had less access to clinical evaluation (or perhaps a different cultural bias against evaluation) and that was the reason they received the diagnosis later. Again this study challenges the specificity of the ADHD diagnosis and suggests that there are many other variables involved in making the diagnosis than valid diagnostic guidelines.

Another approach to “capturing the heterogeneity” of ADHD is to see whether some children with ADHD symptoms also have another kind of problem, whereas other ADHD children do not. One group of researchers did a recent study in which they tried to determine whether emotional reactivity and regulation could distinguish different groups of ADHD children (Musser et al, 2013). In other words, they were testing qualities of the children’s stress regulatory system. They found that ADHD is not only heterogeneous clinically, but it is also heterogeneous with respect to these traits. One ADHD group showed atypically elevated parasympathetic reactivity (associated with emotional dysregulation) along with increased sympathetic activity (associated with elevated arousal) when the child was stressed in the laboratory situation. By contrast, another group had reduced parasympathetic reactivity and reduced sympathetic activity (low emotional arousal). This second group was also more clinically symptomatic, having more conduct problems, peer problems, and more total difficulties, than the first group. In sum, the study showed that both groups of ADHD children had altered autonomic nervous system functioning, but of different types.

A recent prospective study demonstrating the fact that there is not just “one ADHD” is that by (Ramos Olazogasti et al, 2013). This study is unusual in that it is a 33-year prospective study of a large number, 135, boys with ADHD in childhood. Some of the boys also had conduct disorders, and some did not. The researchers wondered about the link between ADHD and adverse life events in the future, such as accidents related to risky behavior associated with impulsivity or even medical illness. What they found was the group that had both ADHD and conduct disorders had more risky behavior in adult life and a significantly greater incidence of problems related to that risky behavior such as admissions to the emergency department, head injury, and sexually transmitted diseases. Interestingly, they did not report a greater number of medical illnesses. This study also found that psychostimulant medication did not predict for cardiac illness.

Finally, many genes in pathways involved in dopamine/norepinephrine and serotonin neurotransmission, and also genes involved in neuritic outgrowth, are implicated in the etiology of ADHD but thought to have a small effect at the individual level (“small effect size”). One study used multivariable analysis to combine the effect of single genetic variants thought to play a role in ADHD (Bralten et al, 2013). When they summed the genetic effects of these genes they found a significant association with H/I symptoms but not with inattention symptoms! This offers yet more evidence that ADHD is not a discrete disorder but a “final common pathway” of many genetic and structural factors, all of them contributing in some way to the development of the nervous system. Whether these neurodevelopment end points are appropriately called “disorders” or are instead extremes in a spectrum of neurodevelopmental positions is yet to be determined.

References (See Post for Aug 31, 2014 )

Bralten J, Franke B, Waldman I, Rommelse N, Hartman C, Asherson P, Banaschewski T, Ebstein R, Gill M, Miranda A et al (2013). Candidate genetic pathways for Attention-Deficit/Hyperactivity Disorder (ADHD) show association to Hyperactive/Impulsive symptoms in children with ADHD, JAACAP, 52(11):1204-1212.

Photograph by Ginger Gregory

More About Orchids

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I am interrupting my blog progression again to talk about a recent infant parent mental health weekend, while it is still on my mind. We heard two terrific lectures last month about temperament and attachment, both subjects of particular interest to me.

The lecture on temperament was again given by Nancy Snidman, the temperament researcher. Nancy defines temperament as “predisposition to respond to the environment in certain ways”. There are many terms to describe temperamental characteristics – for example, introversion and extraversion, fearfulness, sociability, rhythmicity, thrill and adventure seeking, thoughtfulness or empathy, and many more.

One of the most important dialectics is the relationship between temperament and environment. In this case, temperament refers to inherited characteristics and the environment refers to experiences with family, friends, school, and life events. Nancy pointed out that there has been a long history of ways of thinking about temperament. In classical times, the Greeks and Romans thought of temperament in terms of the “humors”. In the 18th century, John Locke deemphasized temperament in favor of the influence of the environment, but then in the 19th century, Darwin focused on the importance of heritable factors in his evolutionary theory. The post World War II period again attributed the most powerful influence to the environment, for example in Freudian theory that gained widespread popularity. However, current research, such as in genetics and neuroimaging, has brought us back to a focus on temperament. Luckily, contemporary theories generally maintain a complex perspective by also including the important influence of the environment.

Some of the variables used by Nancy in studies of temperament deriving from Rothbart infant behavior questionnaire include approach, sadness, activity, perceptual sensitivity, fear, soothability. For example, does the baby get excited when given a new toy (approach), or how sad does the baby get when the caregiver goes away, is the baby easily soothed, does the baby enjoy cuddling?
Nancy reported on a longitudinal study of two styles of temperament – behaviorally inhibited (shy, wary of novelty, slow to approach), and behaviorally uninhibited (sociable, comfortable with novelty). They measured the time it took 31-month old children to accommodate to various novel situations, such as the time it took for them to enter a toy cloth tunnel, the time it took them to approach a robot. Some children behaved in relatively “inhibited” ways, and others were significantly less inhibited. The researchers wondered where this “shy” and “outgoing” behavior was coming from.
Starting with the hypothesis that people have different thresholds of excitability in the amygdala that create different sympathetic nervous system responses, resulting in different kinds of behavioral reaction to uncertainty, Nancy’s research team designed various kinds of auditory, visual, and olfactory stimuli to activate their amygdalas and test their hypothesis. In the lecture, Nancy showed films of 4-month old babies in the experimental situation. The babies were seated in a baby seat, and first one mobile figure was waved in front of him and then another, and then three at once. The first baby sat, attentively watching the moving figures, moving his fingers slightly, calm. The second baby started to fuss as the level of stimulation increased until he arched his back and began to scream. The experimenters studied the frequency and direction of every arm and leg movement, negative vocalization, arched back, etc. The babies sorted themselves out into high reactive babies with “high motor/high cry” and low reactive babies with “low motor/low cry”. Then they studied a group of children from 9-months to 15 years, to see what happened to them.
They were thinking of reactivity in terms of biology. If the amygdala fires, there is sympathetic nervous system activity – arousal, heart rate, respiratory rate. They believe that the biology of the children has a direct effect on their behaviors. If the amygdala is firing and the sympathetic nervous system is “Go!” it will produce behavioral responses. The hypothesis was that the babies who at 4 months were high reactive (high motor/high cry) by 2 ½ years became shy children, and that was because they had inherited a temperament associated with a low threshold of reactivity in the amygdala. These children were what I have referred to previously in the blog as “orchids”.
Across the years, they measured the children’s behavioral and physiological responses – at home at school, and in the lab – to situations that challenged them with different types of novelty or uncertainty. They found that the children moved from simple high reactivity in the youngest babies to a mixture of reactivity and shyness, or inhibition, in the older babies. This shift from high motor activity and high vocalization, to inhibition in the older infants reflects what we know about adults. In some high reactive older infants, when the experimenter changed the tone of her voice from pleasant to harsh as she invited the child to touch a toy, the child withdrew. Over the years, the researchers found remarkable consistency in the reactive style of the children. Some of the high reactive children became less shy, but the uninhibited children did not change. Interestingly, when the high reactive children became comfortable in their environments, they did OK. It was the transitions that are the problem. The high reactive children had more trouble with transitions.
The researchers concluded that there is “strong evidence that infant reactivity is related to a predisposition to have an excitable limbic system” and that this kind of reactivity is a “stable quality over time and situation” (Snidman, 2014). In addition, the research suggests that though these biological factors do not determine anything about the child’s future, and that environment can have an important influence on the child’s behavior and personality characteristics, these biological constraints remain as part of the child’s inherited predisposition.
From my point of view as a clinician, I would stress the value in helping parents understand their children, and teachers understand their pupils, so that they can take the children’s temperament into account when they make expectations of them. Children of all temperaments may be able to achieve the same accomplishments, but they may require different degrees and different types of support in order to achieve them. Earlier blog postings include information related to this subject.

photograph by Ginger Gregory

Snidman, Nancy, “Temperament: Importance, Influence, Impact”, Lecture given at Infant-Parent Mental Health Program, U Mass Boston, Sept. 19, 2014.

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Transition to Preschool

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September is a turbulent time of year for young children. Recently, a mother of a preschool boy contacted me to ask me what to do. She asked me about a problem with her son’s sleep and also with an exacerbation of temper tantrums. I will call him Andrew. Three-year old Andrew has always had trouble with sleep, but just before the start of school he began waking up at night and insisting on sleeping in his parents’ room. The temper outbursts seemed random and were shocking to the adults present. For example, recently when his beloved grandmother came for a visit, he ran up to her and punched her. Then he refused to apologize. Andrew’s worried parents were exhausted by his frequent waking during the night and felt helpless to deal with his temper outbursts. Time outs had never really worked for Andrew. His mother asked me for suggestions.

Before giving her mother any suggestions, I visited Andrew at school. This was Andrew’s second year at school, and he was in a different classroom with a larger number of children and more activities. In the classroom, Andrew’s behavior showed that he was excited and proud to be such a big boy. There was a little swagger in his walk as he rushed over to meet his returning classmates with a friendly and confident greeting. However, Andrew’s confident behavior was an over reach. On several occasions his old friends, who were having their own difficulties accommodating to the beginning of school, were unable to reciprocate his exuberant greeting and clung to their parents or held back in preoccupied silence. When this happened, Andrew’s confidence instantly melted. His face fell, his shoulders sagged, and he slouched away from the other child. It was easy to imagine his inner picture of being Big Man on Campus and how catastrophically it collapsed when the reality of his friends being only 3-yo (as of course so was he) interfered with their ability to play their role in his grandiose fantasy.

Andrew had a similar reaction to a mild correction by a teacher. He had readily and apparently magnanimously given up a toy car to another child who requested a turn, but as it turned out, he hadn’t really had a chance to think it through. He had been playing a wonderful game of collecting pebbles and sticks from the playground for one of his new teachers. His enthusiasm had recruited another classmate in the activity, and they had been happily wheeling around the playground. After a while, his attention strayed and he left the car, which was then claimed by the second child. At this point, Andrew looked around at the other child whizzing off in the car, and his disappointment was obvious. “Now what can I do?” he muttered under his breath. After grumpily refusing multiple alternatives from another teacher, he settled on a smaller vehicle and began pushing it across the playground surface. His friend from the previous activity joined him in this fast-paced game, and his good mood seemed recovered. Then, suddenly a third teacher announced – in a perfectly friendly manner – that children must sit on the seat; pushing the vehicle was not allowed. Again, Andrew’s face and body were transformed into a thundercloud. This time he fell to the ground and hid his face in his hands.

You can see how exhausting a morning it was for Andrew, and it was only 9:30! Insight into the mind of a child like Andrew can guide his parents in their decisions about to handle his sleep problems and his tantrums. After considering what is in Andrew’s mind, his parents might tell him, “You are working so hard to be a big boy, and we are so proud of you. But sometimes you get tired out and can’t act like a big boy any more.” They might then comfort him and assure him that they believed he could “be a big boy again tomorrow”.

They decided to let him sleep in their room for a couple of weeks while he managed the transition to school, with a planned, graded, return to his own bed facilitated by rewards. This approach had the advantage of offering him the support he currently needed with an additional built-in transition-practicing exercise. (By this I mean that the planned return to his bed was another chance to practice making transitions.) In addition, a procedure like this reinforces the link between his inner experience (distress about transitions) and his behavior.

With regard to the assault on his grandmother, they concluded that an apology was too much to expect at the moment. If another such incident occurred, they agreed that they would take his hand and apologize to his grandmother for him (after giving him a chance first) and explain to the grandmother that he was having a hard time recently with starting school, and sometimes his body just bursts out with a mad behavior like the punching (another chance to link the inner experience with the behavior, modeling for him self reflection) and you know he is very sorry about it even if he can’t say it right now. Then, later, they would give him the chance to do something nice for her in reparation.

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ADHD – What is it and What can we do about it? I

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Why write about ADHD?

I was recently asked to write a paper to contribute to a volume addressing changing trends in child psychiatry. I chose to write about ADHD. I made this choice for many reasons. One reason is that more parents bring their children to me with ADHD as one of their stated concerns than any other problem. Another reason is the evolution of thinking about ADHD has grown to appreciate the complexity of the problem (though back in 1992, Leon Eisenberg warned about the rush to medicate) (Eisenberg, 1992). That makes it interesting. And yet, despite the greater complexity of what is currently known about ADHD, many clinicians still behave as if it were a simple disease entity with a single etiology, and consider medication the first and often the only treatment option. Finally, I think the young child psychiatrists I teach and the parents and teachers I consult to should have access to contemporary knowledge on the subject.

Executive function

I know I promised to blog more about executive function. I intend to do that. However, my reading about ADHD interrupted my agenda for a good reason. There is a large overlap between ADHD and EFD. That is due in part because there is no clear definition of executive function in the literature. Basically, executive functions refer to the internal processes an individual uses to organize the knowledge he has in the service of accomplishing goals. Problems with executive functioning include difficulty organizing oneself in time and space; initiating and formulating a plan of action to accomplish a goal; maintaining motivation during a goal oriented activity; avoiding distractions while working; and following through to a satisfactory result. You can see the similarities between dysfunction of these processes and ADHD.

I am going to write several installments on the subject of ADHD. They will be somewhat academic and may try the patience of readers who want a quick explanation and a “how to” section, but unfortunately (or fortunately) life isn’t that way. Our children are complicated, and in order to understand them we have to be patient and learn all we can learn about what makes them tick. Here is the beginning.

What is ADHD?

Among many stated claims that are unclear about ADHD, there are three facts are clear.

The first is that the number of children diagnosed with ADHD is growing. Between 2003 and 2011, 2 million more children in the U.S. aged 4 to 17 were diagnosed with ADHD (Visser et al, 2014, p. 34).
The second is that there is a central nervous system basis for ADHD symptoms. This fact is supported by many candidate gene studies that show associations between ADHD and dopamine transporter and dopamine receptor genes (Lou et al, 2004; Bralten et al, 2013), and also by neuroimaging studies that identify functional connectivity abnormalities in particular neural networks in the brain (Konrad et al, 2010; Liston et al, 2011; Levitt et al, 2013).
The third is that a multi-dimensional assessment and treatment approach is far preferable to a rush to medication.

ADHD is characterized by inattentiveness, distractibility, impulsivity, and overactivity. It is certainly not a disease. Many attest to the heterogeneity of ADHD (Jensen, 2000; Musser, 2013; Arnold, 2014). Some even question whether it is a disorder rather than an extreme of temperamental variation (Jensen, 2000, p. 195). This consideration is based on the observation that a significant group of children with ADHD seem to “grow out of” ADHD (Hechtman, 1992), as well as studies that demonstrate the influence of social and school environment on the diagnosis of ADHD (Schneider & Eisenberg, 2006). It does seem likely that the demands our current culture places on children to sit still and pay attention, to manage frequent transitions, and to multi-task, may not be as easy for some “normal” children to accommodate as for others. This kind of consideration has led some to argue for a “dimensional” rather than a “categorical” diagnosis of ADHD (Vande Voort, 2014).

In the next installment I will write about some of the neurodevelopmental findings on ADHD.

References

Arnold L, Ganocy S, Mount K, Youngstrom E, Frazier T, Fristad M, Horwitz S, Birmaher B, Findling R, Kowatch R, Demeter C, Axelson D, Gill M, Marsh L (2014). Three year latent class trajectories of attention-deficit hyperactivity disorder (ADHD) symptoms in a clinical sample not selected for ADHD, JAACAP 53(7):745-760.

Bralten J, Franke B, Waldman I, Rommelse N, Hartman C, Asherson P, Banaschewski T, Ebstein R, Gill M, Miranda A, Oades R, Roeyers H, Rothenberger A, Sergeant J, OOsterlann , Sonuga-Barke E, Steinhausen H , Faraone S, Buitelaar J, Arias-Vasquez A (2013), Candidate genetic pathways for Attention-Deficit/Hyperactivity Disorder (ADHD) show association to hyperactive symptoms in children with ADHD, JAACAP, 52(11):1204–1212.

Eisenberg L (1972). The clinical use of stimulant drugs in children, Pediatrics 49:709-715.

Hechtman L (1992). Long-term outcome in attention deficit hyperactivity disorder. Child Adolesc Psychiatr Clin North Am 1:553-565.

Jensen PS. Commentary: The NIH ADHD consensus statement: win, lose, ordraw? J Am Acad Child Adolesc Psychiatry 2000; 39: 194-197.

Konrad K, Eickhoff SB. Is the ADHD brain wired differently? A review on structural and functional connectivity in attention deficit hyperactivity disorder. Hum Brain Mapp. 2010;31:904-916.

Lawrence K, Levitt J, Loo S, Ly R, Yee V, O’Neill, Alger J, Narr K (2013). White matter microstructure in subjects with Attention Deficit Hyperactivity disorder and their siblings, JAACAP, 52(4):431-440.

Lou, H. C., Rosa, P., Pryds, O., Karrebaek, H., Lunding, J., Cumming, P., & Gjedde, A. (2004). ADHD: increased dopamine receptor availability linked to attention deficit and low neonatal cerebral blood flow. Developmental Medicine & Child Neurology, 46, 179–83.

Liston C, Malter Cohen M, Teslovich T, Levenson D, Casey BJ. Atypical prefrontal connectivity in attention-deficit/hyperactivity disorder: pathway to disease or pathological end point? Biol Psychiatry. 2011;69:1168-1177.

Musser E, Galloway-Long H, Frick P, Nigg J (2013). Emotion regulation and heterogeneity in Attention-Deficit Hyperactivity Disorder, JAACAP, 52(2):163-171.

Vande Voort J, He J-P, Jameson N, Merikangas K (2014) Impact of the DSM-5 Attention-Deficit Hyperactivity Disorder age-of-onset criterion in the US adolescent population, JAACAP, 53(7):736-744.

Visser S, Danielson M, Bitsko R, Holbrook J, Kogan M, Ghandour R, Perou R, Blumberg S (2014). Trends in the parent-report of health of health care provider-diagnosed and medicated Attention Deficit/Hyperactivity Disorder: United States, 2003-2011, JAACAP, 53(1):34–46.

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El Salvador: Executive Functioning Part II

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School Observations:

We visited the three private schools attended by the children in the home. Whereas they all bore the stamp of Salvadoran educational philosophy, they were very different. The most strikingly different was the Laura Lehtinen school recently started in San Salvador. This school for children with learning disabilities was remarkable for the high teacher/student ratio and the skill of the teacher we observed. The child we were observing, “Tomas”, had demonstrated slow development from infancy and had always struggled in school. In his last school, he was very unhappy. In this new school, his contentment was obvious.

Tomas’ classroom had 8 children, though only 4 were present during the lesson we observed, the others apparently in an adjacent room with another teacher. The teacher in Tomas’ room worked individually with a student for about 10 minutes, then moved her chair and began work with another. As she attended to each student, she periodically turned to redirect another student who had strayed from his or her academic agenda or who needed immediate attention. She had great patience and tolerance for Tomas’ behavior – which included frequent departures from his seat and making little dancing or hopping movements – and she gave him many affirmations for correct answers.

An important focus of my school observations is the playground. In Tomas’ school, both teachers were present for the entire playground activity – an unusual and welcome observation, since so much can be learned on the playground, and opportunities to support that learning are so frequently missed. The atmosphere on the playground was relaxed and pleasant. Tomas needed to be redirected once when he strayed into territory outside the bounds, but otherwise he enjoyed himself watching some of the older boys and playing with a girl classmate. Although Tomas’ difficulty following through with an agenda was apparent in his playground games as well as in the classroom, his ease in making social connections and his friendly manner seemed to mitigate his many abrupt departures from the game.

The other two schools were also good schools with dedicated teachers and lively playground activities. One was more academically rigorous than the other and had smaller classes. In this school, the teachers were able to engage their students in the material they were teaching to an impressive degree. We focused on several children from the home in this school. One, a handsome boy of 13, was often distracted by the attentions of the girls sitting near him. Another, a 10-yo girl, seemed focused on filling in the answers in her workbook instead of listening to the teacher. Liz and I took careful notes and returned to the home to discuss our impressions.

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El Salvador – Testing for Executive Functioning

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A few weeks ago I returned from El Salvador. It was a wonderful trip because we got a lot done and we also enjoyed the time we had with our friends there. (The names of the caregivers and the children in the orphanage will be changed to protect their confidentiality.) I usually over-prepare for the workshop before my arrival. I am rewarded for all that hard work by discovering that the caregivers are really focused on another subject, and I must do the presentation all over again. This time I decided I would be smarter and wait to prepare the power point until the day before. My traveling companion and colleague for this trip was Elizabeth Tedesco, a talented preschool teacher at the Cambridge Ellis School in Cambridge. I came to discover that she was a pleasant and comfortable companion, a hard worker, a great observer, and an all around terrific collaborator.

Our general plan was to assess the children for executive function – in an informal way, since neither Liz nor I are psychologists. I had been doing some thinking after my India trip – and also considering my skypes with Rachel – I decided that school problems were the most important focus for us right now. The commonest problem facing the children in both places seemed to be executive function problems (EFD) – organization, initiation, follow through. It made sense to me that this would be the case, because in addition to all the reasons my middle class child patients have EFD, children in the low SES population of developing countries may have the additional risk factors of malnutrition, poor health care, neglect, and trauma. That means, according to Perry’s developmental model of the brain (Perry & Dobson, 2008, the infrastructure is weak and regardless of how intelligent the child’s thinking brain is, he or she will not be able to assimilate and integrate information and produce good schoolwork.

A colleague told me about Betsy Kammerer’s work to develop an assessment tool in Africa, and I called her (Kammerer, Isquith, & Lundy, 2013). Betsy is working mostly with very young children, but she agreed with me that assessing for EFD would be most cost effective, given the likelihood that the children in our population would have this problem, and also given that there are strategies designed to help them. She also wondered whether the children in our population might be culturally unprepared to take a test themselves and thought that it might be better to give questionnaires to caregivers. She recommended the BRIEF assessment tool as an easy to do questionnaire for parents and teachers. She cautioned me about the importance of a good translation. When I looked up the BRIEF, it said that a Spanish translation was coming out soon, but I couldn’t wait, so I asked Liz and “Mona” (the education director at the children’s home) to take a try. Liz translated the parent questionnaire and Mona got a native Salvadoran friend to do the teacher questionnaire. Then Liz checked her parent questionnaire against the Salvadoran one, since the items are almost all the same in the two questionnaires. Liz and I were excited to get to work.

This time we flew through Atlanta. In Atlanta, the scene changed from middle class white American travelers, including business people, no upgrades available to first class, to the San Salvador gate. There the culture already is different. People are traveling mostly in families. First class has empty seats. The trip was pleasant and uneventful. When we arrived in San Salvador and entered the arrival lounge and immigration, the tropical air swallowed us in a hot humid blanket. Birds squawked in the palm trees. We had arrived. The director of child care (“Sarah”) met us outside immigration. We drove in the red pick up truck to the orphanage to see it in its new location, and then we headed to our first school observation.

Kammerer B, Isquith P, Lundy S (2013). Approaches to assessment of very young children in Africa in the context of HIV, in M Boivin & Giordani (eds), Specialty Topic in Pediatric Neuropsychology, Neuropsychology of Children in Africa, Perspectives on Risk and Resilience, Springer.

Perry B, Hambrick E (2008), The neurosequential model of therapeutics, www.reclaiming.com, Vol. 17, No. 3, pp 39-43.

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“Los Momentos Magicos”: A poster at WAIMH

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This is one of the two posters I presented at WAIMH (World Association of Infant Mental Health) this past week in Edinburgh.

“Los Momentos Magicos”: A Practical Model for Child Mental Health Professionals to Volunteer by Supporting Caregivers in Institutions in Developing Countries.

“Los momentos magicos” refers to small interactions between caregiver and child that when repeated multiple times can have a lasting positive effect. This hopeful perspective is important for caregivers of children in institutions in developing countries, many of whom carry the scars of early neglect and abuse. Through her experiences in visits to orphanages in Central America and India, Dr. Harrison has developed a model for mental health professionals in developed countries to volunteer their consultation services to caregivers (CG) of children in care in developing countries in the context of a long term relationship with episodic visits and regular skype and video contact.

Weekly Skypes:

Example of Notes from Skype Sessions with Director of Caregivers (DCG) – In a meeting with the teachers, DCG felt frustrated when the teachers implied that the children were neglected. The teacher said the children do well in school but do not bring in their homework. The teacher was concerned that they were hanging out with kids at school who were a negative influence. DCG has told them that they can be friends with these kids, but when they see them involved in problem behavior they should walk away. I suggest – because this has been successful in the past – the possibility of a community meeting in which the other children at the home are invited to brainstorm how to stay out of trouble and how to deal with other kids who are getting into trouble at school. DCG says that is a good idea. She will try it and let me know how it went. We talk about how much responsibility to expect from a 10-yo with his homework. A CG is leaving, and we talk about how to prepare the children for this loss – which children will be most affected, how they might express their distress, how to say good bye.

El Salvador Workshops:

Workshops take place in the orphanage during a weekday, when the children are in school. They begin with coffee and pastry, and there is a break for lunch, sponsored by the workshop leaders. The format is a power point presentation with accompanying video. Following a consultation model, the workshops focus on the caregivers’ chief concerns, underscored by the consistent message of the importance of the relationship. Videotapes of caregivers engaging in interaction with children are used to illustrate successful caregiving techniques, while also demonstrating how the caregiver’s ability to imagine the mind of the child is crucial. Discussion is encouraged throughout the presentation. After the first workshop, examples of the caregivers’ evaluations included, “It is good what you said, but now you should tell the children to do what we tell them to do.” Examples of evaluations after subsequent workshops included, “ I learned that it’s important to get down to a child’s level and listen to him, before I set a limit.” And “How to have a better relationship with a child and how to understand his situation.”

North India Workshop

Workshop to 80 nursing students at mission hospital in No India. Subject: Supporting the First Relationship.

Using Nugent’s book, Your Baby is Speaking to You ( 2011), Harrison and Gregory emphasized three points: (1) Babies are speaking to their mothers; (2) Mothers can listen to their babies; and (3) Nurses can help mothers listen to their babies in a way that can influence the future health and well being of the children. We stressed the importance of making the mother feel competent to understand the communications of her own baby. To illustrate these points, Ginger played the role of the mother, and I played the role of the nurse. As usual, eliciting the help of the translator added another dimension of cultural richness and respect to the consultation process.

South India Consultation to Teachers at School

Again followed consultative model focusing on teachers’ questions about students. Using data from teacher and child interview to answer the questions. For example, (1) Why does he not attend school regularly? (2) How can we make school more interesting to him and motivate his learning?

Child was observed in the classroom and child and teacher were interviewed. Data from observation and interviews were used to answer the questions:

(1) There is the feeling in the family that he will be the brother who stays home and keeps the farm. He is also afraid of family discord and wants to protect family from fighting. He does not see the practical reason for studying. He also has some learning problems – working memory, auditory processing, executive functioning. (Include explanations of executive functioning, working memory, auditory processing).

(2) Story problems about farming (math) – buying selling, ratios of the fields, making calculations on the spot to determine prices and make sure venders are not cheating.

Auditory processing support – when possible, give him important factual information parsed in chunks separated by few seconds pause, with repetition of information afterwards.

Building working memory – tasks that require remembering longer and longer bits of information over time (addresses, phone numbers, “telephone games” of hearing information from one person who repeats it to the next person, etc., drills, repetition, and rote memorization for basic facts, making up his own acronyms for information that is hard to retain.

Strengthening executive functioning –practicing organization of homework, building predictable routines, checking homework lists to make sure everything is done and in its place, going over tests and assignments afterwards to identify errors and to understand how to avoid those errors in the future.

Read this blog in Spanish.

Addition to “Disruptive Behavior”

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Ed Tronick added this important comment:
“I think the thing left out of the account – which is great – is that the child is trying, struggling to make meanings, of which there are many – “What do I need to do? What are they thinking? What happened yesterday? What will they do to me?” – of himself in relation to others, and he is failing. This leads to anxiety and disruption – non-conformity. Yes, there may be sensory issues, but sensory can be empty of meaning. Meaning making is a regulatory process and sensory input can be meaningless and arousing, which further disrupts meaning making. The teacher and others, I think, need to see the struggle the child is burdened with.”

I think what I value most about Ed’s insight is the idea that sensory input can be “empty of meaning”, by which I think Ed means, “apprehensible meaning”. For example, sensory input that is over stimulating can “burden” the child with experience that he cannot act on effectively, that he cannot transform into something that makes sense to him, in Bion’s language, that he cannot metabolize. In this chaotic state, his perception of himself as an agent in the world is undermined.

Disruptive Behavior or Something Else?

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One of the problems teachers and parents face every day is disruptive or inattentive behavior. Often this behavior is interpreted as noncompliant in some way – “not listening”, “not minding or obeying”, or “oppositional”. The more I learned from the OT’s I have worked with, the more I began to see some of this behavior as an attempt to do the very things that the teacher or parent wanted the child to do – listen, obey, comply – but it wasn’t working. In addition to these behaviors being ineffective, they also presented an even bigger problem. The behaviors became immersed in a social system with the parent, teacher, and also with peers, such that they accrued a negative meaning. This is what we worried would happen with Ben. In other words, the child is thinking, “If the teacher (or parent) looks disapproving or angry at me, I must be (doing something) bad.” I put the “doing something” in parentheses because young children usually think in concrete action terms, and so “doing something bad” easily becomes “bad” (a bad child) in their minds. The implicit social pattern persists, and everyone is miserable.

If, on the other hand, the parent or teacher could recognize the child who is squiggling or jittering as having the intention of staying alert and engaged, he or she might have a much more positive response and try to find some support for the child. Maybe the child could take a little break, maybe hold something or use some other sensory calming or organizing method.

I heard one of my favorite neuroscientists, Steve Porges, lecture in an excellent recent trauma conference. He talked about how immobilization in response to threat was risky, even life threatening sometimes (slowing heart rate and respiration). I thought about some of the children I knew who ran and flapped their hands and jumped. I knew that these behaviors were an implicit attempt at sensory organization, stimulation for the sake of organization, and this idea added another dimension. Of course it is hard to sit still if somewhere inside your brain (and not in the thinking part) you are starting to feel an increasing disorganization of your human system. That could make you feel – in the worst case – the threat of impending chaos. And worse yet, you would not be able to explain what was happening, even to yourself.

The bottom line is that we who work with young children must always take into consideration the original reason for his or her “disruptive” or “noncompliant” behavior and try to extend support to the child instead of disapproval.

Read this blog in Spanish.