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,
- 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.
- 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.
- 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.)
- 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.