Tag Archives: Regulation

Stress Regulation: From Theory to Practice

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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. 

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

Link

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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.

Avoiding Struggles: Breaking “Bad Habits”

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

Helping Your Child Learn Self Regulation: The “3 R’s”

IMG_boysinarow What is regulation? Regulation refers to the integration of the various functions of the body and mind in order to achieve a sense of wellbeing. Regulatory processes are organized into rhythms. 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. Walking is a self-regulating 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, beginning in infancy (Tronick, 2007). 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 (or a dog). Even having a conversation with another person involves rich processes of turn taking that create coordinated rhythms between the two people and also within each individual. The capacities for mutual regulation are developed over time, and some children develop them more easily and earlier than others. That is because some children are born with better functioning capacities for self-regulation and coordinating with others than other children, and because some caregiving environments are better “regulators” for children than others. Mutual regulation is intimately tied to self-regulation, so that if someone is not good at mutual regulation, he is also not so good at self-regulation.

In order to better understand regulatory processes, it is important to understand something about brain development. No one describes the connection between brain development and stress regulation than Bruce Perry. Perry explains, 1. The brain develops sequentially from the brainstem to the cortex; in the first year of life, the cerebral cortex is not yet “on line”, and the lower and mid brain are what the infant makes use of to make sense of his world. 2. The brain is use dependent – “use it or lose it”, “Neurons that fire together, wire together.” 3. The stress response systems originate in the lower parts of the brain and help regulate and organize higher parts of the brain – or if poorly organized or poorly regulated themselves, they dysregulate or disorganize higher parts of the brain.

Interventions that support regulation can target various parts of the brain. Thinking through a challenge (“Use your words!”) targets the cerebral cortex that is involved in functions of language and thinking. Thinking things through or “understanding” is highly regulating. However, if an individual is stressed, or if certain of his thinking functions are not well developed due to an inherited learning challenge or immaturity, intervening at these higher-level brain functions will be insufficient.

In fact, all of us from time to time need more basic regulatory means than “thinking things through”, at least to settle ourselves enough to actually do the thinking. We benefit from building up our stress regulatory system in the lower part of our brain. How do you do that? We do that through – Rhythmic, repetitive, patterned activity.  3 R’s – rhythm, repetition, relaxation. Walking; dancing; meditation; rhythmic music; drumming.  Although dancing and making or listening to rhythmic music is highly regulating, most of us do not have the habit of doing this regularly. However, taking a walk is easy to do. It may have the added advantage of taking you physically away from a stressful situation.

There is another set of 3 R’s – routine, ritual, rendering (articulating). Daily routines and rituals (the parents’ best friends); rendering means articulating transitions – creating multiple steps to organize the transitional space (first we get out of bed, then we go to the bathroom, then we brush out teeth, then we wash our face, then ….). For more information on routines, follow the tag “routines” on the blog.

 

Tronick E (2007). The Neurobehavioral and Social-Emotional Development of Infants and Children, Norton.

Infant Parent Mental Health Weekend: Bruce Perry

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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.

 

 

 

Managing Transitions Part I

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This blog posting is a continuation of my writing on helping children make transitions – of all kinds. I am writing this with the awareness that very young children are much easier to help in this way even though it may not seem so at the time. In fact, it is possible that helping very young children to manage transitions could make this challenge easier for them later in childhood or even in adulthood, but this is not certain. It is always our wish that we could prevent future problems by addressing them early on, but that is not always the case. For that reason, I will also focus on helping older children and adolescents manage transitions. Since I am approaching these tasks as collaborative activities between child and caregiver, I will use a short cut and refer to C-CG as a unit.

As I write this I am also aware that the whole subject of making transitions cuts across many categories of concern for parents and other caregivers, as I mentioned in my previous posting. That is, for example, issues of regulation, compliance, motivation, learning, organization, emotion and mood, sensory, and probably many more. Here is an illustration of what I mean. In order to make the transition from home to school in the morning, the C-CG must manage the transition from sleep to wake (involving the organization of state and the regulatory challenges involved in the shifting from one physiological state to another), then the C-CG must organize the sequence of small tasks involved in preparing for the day – bathroom tasks, dressing, eating breakfast, etc. I use the word “organizing” consciously because putting all the small actions together is part of the challenge. I remember reading an article somewhere about a study in which subjects were tracked as they went through their day in a restricted space to demonstrate all the redundant movements and retraced steps they took (back to the refrigerator to get the milk after you had just gotten the butter out). The task of getting dressed – finding and choosing what you are going to wear, and putting on the clothing – may be complicated by varying degrees of discomfort if sensory hypersensitivity is a problem. Eating breakfast may be complicated by lack of appetite or (again) sensory sensitivities. Leaving the house is affected by feelings about leaving home and family and anxieties about what one will face in the challenging world of school.

All of these aspects of transition can be facilitated by three aids – 1) attention to regulation; 2) knowledge of specific strengths and vulnerabilities of the particular C-CG pair; and 3) routines and rituals. Each of these aids must be accompanied by the girl scout (it is probably in the boy scouts, too) motto of “Be Prepared”! Let’s go over them one by one.

1) Attention to regulation is extremely important for both members of the C-CG pair (in fact for the whole family or group). That means thinking ahead (Be Prepared) so that, for example, in managing the morning transitions, you can assure as much as possible that the C-CG is well rested. It means (Be Prepared) that adequate time, or even extra time, has been allocated for the task at hand. It also means that (again Be Prepared) that complications (someone else in the bathroom, another child interrupting with their own demands) are anticipated. It might mean that the CG has already had his/her cup of coffee. It might also mean that the CG is thinking about (has in mind) talking with his/her partner or a friend for support later in the morning.

2) Knowledge of the specific strengths and vulnerabilities of the particular C-CG pair is also crucial. The best way to illustrate this point is through examples. In fact, I have decided to try something new and to publish one example at a time, inviting my readers to post comments on the subject. What I would like you, as readers, to consider are the specific strengths and vulnerabilities of the C-CG pair I am writing about. Here is the first C-CG pair, of course, embedded in family and community environment:
a. Morning Transition:
Jamie is a smart, engaging Caucasian 3-year old boy who lives with his mother and father and his 1-year old sister in a large apartment downtown. His father has a job that requires him to travel and be away from home on average several days a month, and he often comes home from work late at night after Jamie is in bed and leaves for work again before Jamie wakes up. His mother left her professional job when her second child was born and they moved to Boston for a promotion in her husband’s company; she considers her primary role to be a mother. It was difficult for her when she perceived her first precious child as irritable and difficult to soothe, because she worried that she was doing something wrong and reading his cues incorrectly, but the pediatrician assured her that Jamie would grow out of it.
Transitions were a particular problem for the family. Bedtime was complicated because often Jamie would stay awake late in order to spend even a little time with his father after he came home from the office. Then when he would fuss about going to bed his father was reluctant to allow a negative exchange to spoil the good time they had together, so two goodnight books would turn into three, and three into four. The next morning it was very hard for his mother to get Jamie up to go to the preschool he attended in the mornings.

The worst problem for his mother is getting him up and ready in the morning – even when he has no school, but especially if there is a time constraint such as getting to school on time. His mother, fearful that the teacher would judge her for bringing him to school late, would focus all her attention on getting him out of the house and into the classroom. She would brush his teeth (usually not without a fight), dress him, and bring an energy bar with them for him to eat as breakfast in the car. Sometimes she even stopped and bought him a doughnut on the way, to sweeten the ride. She was often reduced to screaming at him when he stubbornly refused to cooperate with the simplest task, such as let her put his arm through the sleeve of his jacket. He would scream back at her. When this happened, she would glance with guilt at the 1-year old in the car seat and wonder what bad effect these screaming matches would have on her.

Leaving Jamie at school was also a challenge, since he would often cling and cry when it was time for her to leave. At first she would stay and try to help him get settled into play, but sometimes her daughter would start to fuss, and she concluded that the length of time she stayed didn’t seem to affect Jamie’s distress at her leaving. She felt awful leaving him there, crying. After that, his mother had barely finished the food shopping and other errands before it was time to pick up Jamie at school. She occasionally talked on the phone to her best friend, who lived in another city, but as the problems with Jamie grew, she started to avoid the other mothers at drop off and pick up time.

Please comment by suggesting ideas for what the particular strengths and weakness of the dyad of Jamie and his mother.

The Challenge of Making Transitions

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Just before I left on vacation, a mother of a child in my practice asked me why it was so hard for her 6-yo son to make transitions. I was rushing to get ready to leave, so I sent her a quick email promising to respond more fully when I had a chance to think about it. I have had her question in the back of my mind and was especially struck by it when I arrived in Europe and experienced jet lag. It occurred to me that jet lag was a good metaphor for the kind of transition the mother was asking about.

First of all, her child is one of those highly sensitive children I refer to as “race horses”, of others in the literature have called “orchids”. He is extremely intelligent but sometimes retreats to infantile behavior patterns, and he often reacts with extreme distress in the context of transitions – even simple daily transitions such as getting up and getting ready for school in the morning or leaving play to go somewhere or do something else. This problem is interesting because it gets mixed up with all sorts of other categories of problems – such as problems with compliance (behavior problems) or sensory over-responsivity problems (SOR) (Ben-Sasson et al, 2010).

I think there are reasons for this confusion.As writers on “orchid” children point out, it is easier for children with certain temperamental characteristics to readjust to changes in their environment. (I chose the above photo of young Indian dancers because I imagined – though I do not know these children – that the girl on the left has an easier temperament than the girl on the right.) These delicate children are often much harder to parent than children with easier or more resilient temperaments (“dandelions”), and parents and child often initiate problematic interaction patterns early on that can influence the child’s developmental trajectory in an unfortunate direction. It then becomes the job of the child therapist to help the family (child and parents) correct this misdirection.

The kinds of problematic patterns that are characteristic of this situation typically involve mutual over-control. That is, children who feel highly stressed by demands for change (in other words, transitions) often try to exert a counterbalancing force by controlling their environment (their parents, included). Parents may respond either by engaging in a control struggle with the controlling child or by giving in, or by both (Granic, 2006). When these patterns are repeated, they become more firmly rooted in family behavior. I refer to this as building stronger infrastructure for the problem cities (metaphor for problematic relational patterns such as struggles in families) so that it is easier to get there and stay there. Of course, it is better for all involved to build strong infrastructure for the cities that represent more adaptive behavior patterns such as collaboration, but when people are stressed, they often choose the behavior that takes less energy (from the point of view of managing emotions and using reflective capacity) in the short run and more energy in the long run (having to repair the ruptures that struggles and fights cause in the family).

The job for child therapists is to work with child and family to “break the habits” of the problem behaviors and substitute more adaptive patterns. This is done by a variety of techniques including gaining insight into the meanings underlying the behavioral reactions of child and parents and supporting the emotional regulation of all concerned, and then … practicing the new more adaptive patterns again and again and again. I will write more about this important aspect of the topic in a future posting, but I will limit myself here to the mother’s question of “why?”

Let me return to the metaphor of jet lag. My intention is not only to respond to “why” a child has trouble with transitions, but also to offer a way of empathizing with the irritable child. (Often, a parent empathizing with the child allows her or him to better imagine the child’s mind and this can facilitate the parent’s choice of response to the child’s demanding or oppositional behavior). I found a good article on jet lag that describes it in terms of whole organism dysregulation (Vosko et al, 2010). Circadian rhythm – sleeping longer at night and less during the day – is one of the first organizations to emerge in the developing newborn (Sander, 2008). It is achieved through a series of oscillatory networks that include a master oscillatory network in the suprachiasmatic nucleus (SCN) in the brain and also sensitivity to environmental light cues (Vosko, p. 187). During jet lag, the paper continues, abrupt changes in the environmental light-dark cycle desynchronize the SCN from downstream oscillatory networks from each other, disrupting sleep and wakefulness and disturbing function (ibid, 187). This kind of “circadian misalignment” can lead to a series of symptoms, including major metabolic, cardiovascular, psychiatric, and neurological impairments (ibid, 187).  During this trip, as usual, my jet lag “took over”. Although I intended to stay awake and enjoy the company of my friends and the new landscape, I was compromised in my ability to do so. The feeling of dysphoria came in waves; sometimes I felt my old self again and other times I felt tired, irritable, and even sick.

The benefit of this metaphor is that it emphasizes the notion of whole human being “organization”. Many problematic behaviors result from a disorganization of adaptive patterns of functioning. The human organism is constantly working to keep itself on track and to accommodate small bumps and disruptions. It is when the reorganization does not happen smoothly, when things fall apart, that a “symptom” appears. The symptom can be physiologic as well as emotional, just as in jet lag. Children who have delicate temperaments or other developmental reasons for high sensitivity (such as children with ASD, uneven development, trauma, or SOR) are particularly vulnerable to this problematic disorganization.

Consider all the demands for reorganization that a child has to respond to on a daily basis: She has to wake up, changing from a sleep state to an alert state. She has to get up and get ready for school, requiring many transitions from the multiple small tasks involved in washing and dressing. She has to eat breakfast, even if she is not hungry at the time. She has to say goodbye to home and parents and make a big shift from a relatively dependent position to a more autonomous position in terms of initiative and compliance. When she gets home from school she has to deal with other important transitions. Don’t think for a moment that greeting a beloved parent is necessarily going to be a pleasant experience; the transition from a holding-it-together-at a higher-level-of-organization-state at school to a more relaxed and dependent one at home is often bumpy! In addition, often parents of sensitive children give them aids to help them keep organized in the transition, such as video games. As I have mentioned in another posting, these games work very well to keep a child organized because they provide an effective external regulator. When this external source of regulation is taken away abruptly, it can be expected to cause great distress. Even a book, a much more adaptive regulating activity, can cause distress when discontinued.

What is the answer to these problems? I will respond in a subsequent posting!

 

Read this blog in Spanish.

References

Ben-Sasson A, Carter AS, Briggs-Gowan MJ (2010). The development of sensory over-responsivity from infancy to elementary school, J Abnorm Child Psychol, DOI 10.1007/s10802-010-9435-9.

Granic I (2006). Towards a comprehensive model of antisocial development: A dynamic systems approach, Psychological Review, Vol.113, No. 1, 101-131.

Sander, L. (2008). Living Systems, Evolving Consciousness, and the Emerging Person, New York: The Analytic Press.

Vosko AM, Colwell CS, Avidan AY (2010). Jet lag syndrome: circadian organization,  pathophysiology, and management strategies, Nature and Science of Sleep, http://www.dovepress.com/jet-lag-syndrome-circadian-organization-pathophysiology-and-management-peer-reviewed-article-NSS.J

Supporting the Caregiver in Creating a Connection with a Hard to Reach Child

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I had the pleasure of observing a preschool teacher, Lisa, with an almost 4-year old boy with autistic spectrum disorder, Max, in the classroom last week.  What became clear is that what is necessary with children like Max is a shift in perspective to the essentials of learning. Instead of a focus on teaching him academic and concrete skills, one could instead emphasize above all social relationships and the communication of emotions. (This is not new; Stanley Greenspan and his DIR followers to a refined degree have developed these ideas in the technique of “Floor Time”.) In the list of priorities after social relationships and the communication of emotions, is regulation – because regulation is critical but it can’t be supported outside an affectively attuned relationship. Next, it is important to place Max’s initiative in the center of the relationship; helping him make decisions, feel like an active agent in the world. Finally, you want to help Max make links between his internal states (emotional and physiological arousal states, such as calm or revved up) and his behavior. You also would like to help him make these links between other people’s feelings and their behaviors. 

So, let me address my observations. I want to mention up front that these thoughts consist of my elaborations of the consultation I had with Debbie Bausch, my friend and colleague who is a DIR (“Floor Time”) O.T. and sensory perceptual specialist. 

First of all, I was very appreciative that the school had gotten a swing. Regulatory breaks are so important and the swing can be a resource for many children. In the swing, Max can experience calm. Once he is calm, he can make use of person-to-person interaction, with the aim of creating reciprocity. One can ask him, “Max, shall we go faster or slower?” He can be part of the decision about how to swing – back and forth, fast and slow. That is scaffolding his initiative. When I saw him in the swing, he was calm, and he looked at me and smiled, demonstrating that he was ready for an interaction. That is a good swing for him. 

The swing break was called to a close by the entrance of other children. Lisa was gentle and patient with Max in helping him make the transition out of the swing. The slow pace she used consistently during her time with Max was perfect for him. Slowing things down makes them easier to understand. That is especially true for a child with processing problems, as most children with developmental disabilities have. When Lisa and Max were putting away the swing, Max was trying hard to hold himself together. There was a lot going on for him – the stimulation of the other kids coming in and the challenge of going through the motoric, physiological, sensori-perceptual, and affective transition from the swing to standing upright and leaving the room to return to class. He used his hands in his mouth as a self-regulating behavior here and at other times during the morning. Debbie mentioned that a special hard plastic bracelet could be used for this kind of oral stimulation. 

If Max were calm enough, this would be a good time to give him some more information, such as, “Max, look! The other children are coming in! We have to get out of the swing because the other children have activity time!” In general, it is good to narrate all these small, ordinary events, because first of all it is not clear that he perceives them (due to processing and attentional problems) and also because it gives you a chance, using your adult competencies, to scaffold his meaning making of the world. Of course, you always have to “read” his state to see if he is well regulated enough to take in that information. Also of course, you can never be right all the time about this. It is a messy, sloppy, business – reading someone else’s state. Yet I would bet that most preschool teachers are particularly good at reading non-verbal cues, and you will get to know Max’s cues, such as putting his hands in his mouth, squiggling around in his seat, etc., better and better. 

In general, once he is calm enough to communicate, it is good to direct him into a back and forth communication. “What should we do, should we swing faster or slower?” with the swing, or, “Shall we walk or hop?” when you are walking down the hall. This could be described as a “sensory-emotional break” (Debbie Bausch). 

After that, it is time to prepare him for what is coming next. What will be expected of him in the next period of time? It is good to think ahead and help him get ready. Lisa repeatedly talked to Max about what they were going to do. She bent down to his level and spoke slowly to him about going back to his classroom. She asked him what he would like to do and when he did not answer she suggested the block corner. If Max had been in a state of better regulation, he might have been able to participate in the decision that Lisa tried to engage him in, but the stress of making the transition may have gotten in the way.  Debbie suggested giving him a whistle to blow to exercise his oral senses, and some heavy beanbags to throw, or to carry when he walks down the hall as an aid to regulation. Sometimes maneuvering so that you are in his line of vision (not intruding into his “space bubble”, but right there if he looks up) can help engage him in exercising his initiative. Experiment a little; it may take him longer to look at a face. Other times, slowing things down even further can help. Another thought is to back up and talk to him when he is still in the swing, calm and attentive, before moving down the noisy hall.  If he is still sitting in the swing when you are talking to him about what is going to happen next, you can have ready some alternative ways of communicating to him about the next step. For example, you can have cards with pictures of the activities, in case he doesn’t respond to the words. 

The main point here is that Max’s teachers will need to learn to imagine what is going on in Max’s mind. All these things going on around him during the day do not connect for him; the world is chaotic. Even inside of him it is often chaotic.  His teachers will have to find answers for the question of when is he at his best, and how can they make school easier for him.  

Walking into the classroom, Lisa saw that the blocks corner was occupied. She was right on target when she explained to Max that there were already “four friends” in the block corner, so that they would have to make another choice. She helped him choose a book. This was my favorite part of the observation. In the book corner, Lisa found many opportunities to teach Max about himself and his world while he was calm and regulated. As they were sitting down, Max picked up a wooden board on the bookshelf, and remarked, “Art Activity!” Lisa responded positively to his communication. I thought this demonstrated a real strength on Max’s part. I would like to think that I would have been able to join him there and say something like, “Oh, Max, yes! Art Activity! I remember when you made X or did Y in Art Activity!” But I do not know for sure if I would think of it. That is why it takes practice to “imagine Max’s mind”. Once you get better at it, you more naturally think of joining him in those moments and expanding a little on what he has started. In those cases you are helping him make more sense of his world than he could do by himself, using your adult competencies to scaffold his meaning making, and simultaneously supporting his agency by recognizing what he has done and taking it a step further.

Then, Janie came over, holding a book. This might be an opportunity for teaching about relationships and about the rest of the world in that context. For example, “Oh, look! Janie is coming over!  Look what she has! Shall we ask her if she wants to read a book with us?” Or one could do it an even easier way for Max: “Janie, Max and I are going to read a book. I am going to ask Max if he would like you to read a book with us. Max, would you like Janie to read a book with us?” The difference is that by addressing Max first you are taking the social pressure off him and also previewing the central point of the social communication – does he want another child to join. It is also a good example of the way I work with Gil Kliman’s “Reflective Network Therapy”, making use of the classroom to help Max make sense of his experience of himself with a peer. 

Another thought is that when Max is asked to choose a book, the choice may overwhelm him. That is when you can make it easier for him by taking two books out and asking him to choose between the two. By limiting the choices but emphasizing his choosing, you scaffold the processing task he needs to use his initiative. 

When Max reads the book, he is calm and totally engrossed. He has chosen a book with pictures of his class. He recognizes each classmate by name and points to him or her. This, again, is a significant strength. One of the hallmarks of his disorder though, his lack of looking at Lisa’s eyes, interferes with his taking in other crucial information. He looks only at the book. That is a less challenging way for him to take in information than by looking at the constantly changing facial expression of a person. It would be good to gently but persistently try to get him to look at your eyes. There is a wonderful point in the book reading when Max points to the eyes of the child in the book and then at the eyes on the figure on his shirt, and Lisa says, “Does Max have eyes?” pointing to Max’s eyes, and then, “Does Lisa have eyes?” At that moment, probably the best moment in the observation, he looks directly into her eyes and sees her smiling at him. This of course is what he misses when he doesn’t look at the other person’s face. That was truly what I call a magic moment. One would like to repeat that magic moment. One way you could do it is by pausing now and then and making a big expression with face and voice say, “Oh, yes! That’s Jacob! I remember you playing ball with Jacob!” or something like that. If you look at his face, you will see lots of little facial expressions that you can comment on, again enhancing his awareness of his own inner feelings, such as, “Oh, Max. I can see that you like that picture!” or “Max, I think you do not like that picture!” In the observation, Lisa uses Max’s pointing to pace their activity, a great way to support his initiative. 

Then little Janie barges in and sits in between them. Interestingly, Max does not seem to notice that she is there for quite a while. Is this because he cannot attend to these two things at once? Is it because he cannot easily scan the periphery and return his gaze to the page of the book? I don’t know, but one could help him take in the information with words: “Max, Janie is coming to sit with us. Is it OK that she sits in between Max and Lisa?” When Max notices Janie, he gives her a direct gaze and a smile; then, he leans over against her, and she squeals in annoyance. It appears that Max really desires a connection with Janie but doesn’t know how to do it. This is the time, Debbie says, when the teacher could put a little weighted lap pad or pillow on his lap to give him some of the sensory input that he seems to need to regulate himself. One could also talk to him about it, “Oh, Max. You want to sit next to Janie! It makes you excited to sit next to Janie! Let’s use your pillow to help you keep calm while you sit next to Janie.” In fact, Lisa does recognize what is going on and gives him information about what he might do – “You could say, ‘Hi’.” She also gives him some pressure with her hand to help him regulate himself. Then Lisa directs Max back to the book, and in a nice attention shift, he joins her. 

The next step might be to engage Janie in reading the same book. You can say, “Oh, Janie, Max knows the names of all the kids!” or “Max, Janie is wearing the same necklace in the book that she is wearing now. Look at her necklace!” then point back to the book. Not only is that working on his relationships and using the neuro-typical peer as a co-teacher, but it is also working on his ability to flexibly move his body and his attention from one point to another. 

During the rest of the observation, Lisa was able to get Max to use his matching board, though he clearly was having a hard time staying regulated, and even to get him to help her pick up the cards that he dumped behind the bench (in an expression of protest). I was left thinking that this was a child with real potential growth and a teacher with real talent. On the other hand, I was also left with the clear imperative to give the teachers the recognition and support that they deserve and need with this wonderful but very challenging little boy.

 

Read this blog in Spanish.

 

 

 

 

April Trip to El Salvador

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Day 1 and 2:

As has become the custom, this trip was organized around a workshop. The workshop was designed to respond to the evaluations from the last workshop that requested (1) Discussion of adolescent issues, particularly adolescent sexuality; (2) More discussion, especially including those who had not talked in previous workshops; (3) Discussion of work with families.  Because of our past experience, I decided to wait until I arrived to gather the data for the workshop on site, and I planned to first visit a new orphanage for HIV-AIDS children, discuss two worrisome children with the home psychologist and social worker, then accompany Rachel on her meetings with families to pick up children visiting the children’s home for the weekend, and finally capture video of teenagers in the home, all before the workshop on Saturday morning.

On Thursday afternoon, Rachel picked me up at the airport, and we headed off to visit the Reina Sofia orphanage, run by the Mensajeros de la Paz, located between the airport and Suchitoto, a medieval city I had visited years before. The director who greeted us was hospitable and knowledgeable about the home, and the venue was appealing – clean and airy and attractive. The children that we saw were friendly and seemed happy and well attended. On the wall was a schedule listing their routines, with medication times interspersed between the other daily activities. There was something comforting about the matter of fact way the medical care was handled, as well as the sense of security provided by the availability of a doctor and nurse.  The only disturbing feature was the number of children in the home – 14. About half of the children had recently been “reunited” with their biological families in compliance with the law, Lepina. The director explained that many of the families of the children lived in the countryside, some far from bus lines, and she was worried that the families would not be able to manage the complicated medical regimens the children needed to keep them healthy.

The next day, I was picked up early to meet with Love and Hope’s psychologist and social worker. We discussed two boys whose behavior problems have been an ongoing issue. I of course knew these boys, one since he was 1-year old and the other since he was 2. They were now 8 and 9-years old. We began with the 8-year old.

The social worker prepared a report on “M”: He is anxious and playful. In the last 7 months he has had uncontrollable tantrums, bucking authority, aggressiveness, and impulsivity. He has a defiant personality that mainly emerges during academic activities. One time he said to the psychologist, “I don’t know what is wrong with me. I feel I turn into another person. I can’t control myself.” The social worker and psychologist are working to connect him to other kids and his brothers and sister (also in the home) through games. They have made out a conduct system of smiley faces and “walking towards the sun” in which there is a calendar with each day offering options of a cloud or a sun, depending on M’s behavior. They are trying to reward good behavior and give consequences for bad behavior, and the results have been sporadic. At times M says he doesn’t care about prizes or punishment. During play therapy they work on improving his sense of the limits of good behavior. They have gotten his mother involved, asking her to support their efforts by calling once a week. His relationships with his mother and his siblings have improved. His tia (the caregiver in the home assigned to M) had a meeting with his teacher. When you speak to him after he has a tantrum, he can say exactly what happened and knows what he should have done differently. They decided to get a psychiatric consultation. The psychiatrist suspects a genetic factor and prescribed blood tests. M seems to be bothered by everything. At school he fights with other children and shows lack of respect for the teachers. He doesn’t seem to have any friends. Kelly, one of the directors of Love and Hope, says that her relationship with M changed dramatically for the good since she began to invite him to her house, outside the children’s home. He took care of the handicapped child she is hoping to adopt, and he took pride in cleaning and helping around the house. In this setting, he behaved very well.  I asked the psychologist and social worker what questions they had about M that we should consider. They asked,

  1. Are the blood tests necessary?

I looked at the list of the blood tests and responded that they should get a second opinion from their new pediatrician, because I was not qualified to give a medical consultation in El Salvador. I strongly recommended that the team bring the problem to the pediatrician, because they have recently made a connection with an experienced and well-reputed pediatrician in the community who has expressed interest in seeing the children from the home. I pointed out that good medical care requires one primary clinician who knows the child and caregivers and can help make decisions about specialty consultations. My memory of M was that he had a problem eating when he was much younger, and trouble falling asleep at his desk in kindergarten, so that his nutrition should be evaluated, despite the fact that he was eating better, his growth seemed to have caught up, and he looked physically healthy.

  1. Is it OK to show him that they are angry, because sometimes the only way to get him to settle down is to talk to him in a firm and angry manner?

Here, I underscored the distinction between “angry” and “firm” and suggested that whereas “firm” was good, “angry” – though completely understandable at times – was not as good.  The ideal, which no one can attain all the time, is firm and clear, but not highly reactive (which one usually is when angry). I then pointed out that in order to answer the first two questions well, we really needed to ask a third.

  1. What is the cause of the tantrums?

I said that we would try to answer this question in the workshop the next morning, when I had a chance to review all the data. I planned to try to film M later in the day to see if I could identify any important relational patterns. (Then the sw and psych asked a fourth.)

  1. What are other forms of discipline besides “consequences” (that involve taking things away)?

I said that consequences are important, because it is good to follow through with the established rules and the results of breaking them. Another form of “discipline”, though, is reparation. That means giving M a task to do that will benefit the community – cleaning or making something, doing a job. Although this can also be perceived as a punishment, it does not primarily involve taking something away. Instead, it involves a “giving back”, and it can be received with positive recognition and thanks.

 We talked about how though M and the other boy we were planning to discuss were quite different in some ways and of course distinct individuals, they seemed to share similar behavior problems, and both acted sad and disconnected. I also responded that even at this point, knowing the boys as well as I did, I would suggest that each boy have individual therapy once a week and an individualized educational plan. I mentioned these two interventions because each boy seemed lonely and seemed to have trouble making and keeping friends, and also because despite the fact that I knew both boys to be intelligent, they were not succeeding in school and resisted doing their homework.

 Rachel said that she worried if the boys were given individual time every week that they would develop “the kind of bond” in which they would want “to do everything with you”. I explained that though this kind of attention may elicit longing for “more”, it was necessary to build the kind of relationship the boys needed, and there were boundaries to the relationship that played a therapeutic role. That is, the beginning and end of the therapy session would come to represent the limits to what one could reasonably expect to receive compared to what one wished for (everything), and the therapist (or caregiver) could help the child manage the distress provoked by maintaining the boundaries. The therapy sessions should take priority over other tasks of the social worker and psychologist, since some of the tasks they have been doing could be done by other non-psychologically trained personnel, and these boys needed a special relationship very badly. I said that I could help support the therapists and Rachel in this process.

We then talked about a “two part approach” in which we considered how to manage the meltdowns, and then tried to build their self-esteem, another problem that the sw and psych brought up.

1.     Managing the meltdowns or aggressive behavior could be dealt with by establishing appropriate (reasonable expectations for this particular child) rules and consequences ahead of time, something which the home has done very well. Then, I suggested not even trying to reason or even talk to them much when they are “off line”, in other words, when they are so stressed (and physiologically aroused) that they cannot think. Just do your best to help them calm down. Depending on the child this will mean sitting quietly with him, or getting someone to help calm them with you. After the child is calm, then you give him the consequence and talk to him about what happened. This may take some time, since if you come in too soon with this challenge, you may provoke another escalation.

2.     Building self-esteem occurs in relationships and with mastery. That is why an individualized educational plan, even if it is only in the home and not in the school (which may be impossible), is important. Positive relationship experience can occur in therapy and through the support of peer and sibling relationships, which has already begun.

 We then spoke a little about a big problem increasingly being faced by the home as they shift their focus of support to include the families in addition to the children. When the psychologist or social worker tries to meet with demanding, provocative parents, it is very stressful. It is often hard to keep in mind that these parents frequently are themselves victims of trauma, abuse, and neglect and have developed these antisocial coping strategies as means of survival in their bleak lives. Instead, when they use their children as pawns in their manipulative behavior, one is confronted by their cruelty and by one’s own helplessness. An example is a parent who refused to allow her child to return to the home for the weekend, though the child desperately wanted to come, unless the psychologist gave her money that was not in the agreement. I suggested that these professionals seek out a colleague when they felt helpless in this situation and that the team have a second weekly meeting to talk about their emotional experiences.

After this discussion, I noticed out of the corner of my eye that M was having a conflict with one of the staff, and I went to get my camera to try to capture the interaction. The results of this and of my interview with the three adolescent girls in the home will appear in my next post, describing the workshop.