Tag Archives: sensory over-reactivity

The Episode of the Raincoat on the Playground: An Effort to Make Transitions Easier for a 2-yo

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“Ben” was born after a difficult pregnancy and had “the worst colic (their experienced pediatrician) ever saw”, crying for 10-15 hours per day until he was 4 months old. Because of gastric reflux, he was put on numerous medications and a gluten free diet. Ben is also over reactive to sensory stimuli stressed by sounds and sunlight, and particularly by touch – , making bathing, diaper changing, and wearing clothes aversive! His parents describe him as always preferring to be in motion. He has seen many specialists and has received OT and speech therapy.

At age 2, he entered preschool. Ben’s classroom has a calm but playful atmosphere, a predictable routine, a small number of children, and three skilled teachers. In this environment, Ben began to make strides in his development. Although his teachers delighted in his sense of humor and in the rapid progress he was making, his parents continued to struggle with meltdowns at home. They described him as a 24/7 occupation. They were worried about having a second child. How could they manage another when they were so busy with Ben?

In particular, Ben’s parents noted his difficulty making transitions. Although he loves school, he often refuses to go downstairs in the morning in order to get ready. He may have a tantrum about getting into the car to go to school. In addition, not surprisingly, he makes a fuss about going to bed at night.

One day, I encountered Ben on the playground. He was crying softly and burying his head in his teacher’s chest. There was a light rain that morning, and raindrops were making dark spots on Ben’s shirt and sweat pants, and even glistening on his hair and forehead. His teacher was holding a raincoat in her hand and attempting to persuade Ben to put it on. She explained to me that Ben did not like to get wet, but he didn’t want to put on the raincoat. She asked Ben why he didn’t want to wear it, and he just shook his head and continued to cry, explaining only, “I sad.” Acknowledging that maybe Ben himself did not know what was making him so sad, his teacher and I continued to imagine why he was crying. Maybe he did not want to wear a different raincoat, since his own raincoat had been left at home and this raincoat was from the lost and found. Maybe he didn’t like the feeling of a coat on his body anyway. Also, he didn’t like to get wet! Maybe he was crying because of all of these things.

Eager to draw from the teacher’s experience, I asked her what she had tried and what she was going to do. She explained that they had a rule that children must wear raincoats if they wanted to play in the rain, and that otherwise they had to go inside. Ben cheerfully said he wanted to go in. His teacher said that he could go in, but she also knew he wanted to play with his friends, and he couldn’t play with his friends if he went inside. Ben looked confused and unhappy. The teacher consulted her watch. She told me that there were only a few minutes left of their outside time, and that she was inclined to let him stay outside and change into dry clothes after all the children returned to the classroom. This was the “choose your battles” approach. I asked her what she would do if the circumstances were different. She said that if it were pouring rain, she would insist on his putting on his coat if he chose to stay outside in the rain and refused to go in, even if she had to physically help him put it on. Often parents and teachers are reluctant to take the concrete initiative to help a child put on his coat. However, I have found that sometimes doing so has a good result; once the initiative has been taken, a momentum is established that makes it easier for the child to collaborate. Of course, one wishes to support the child in taking his own initiative, so encouraging him to do so is the way to begin. Only if that fails would I take the lead. It is always important to have many strategies available.

What was most impressive about the whole situation is that when I called Ben’s mother afterwards to follow up, she told me that Ben had explained the whole experience to her after he came home from school. He told her about not wanting to put on the raincoat, that it wasn’t his raincoat, that he was getting wet and that made him sad, but that he had wanted to play with his friends. I reflected on the remarkable learning experience this had been for Ben. In Ben’s presence, his teacher and I had discussed slowly and thoughtfully the meaning we made of Ben’s dilemma and some possible solutions. We noted that Ben didn’t like any of the solutions we suggested. We came up with others. He didn’t like these either. There was a way in which Ben’s rejection of our suggestions enhanced the learning experience by drawing out the reflective process, by allowing him to consider more and more possibilities, by helping him see that there was a bigger territory in between all or nothing than he had realized, even if he could not bring himself to choose one of those options. Finally, in telling the story to his mother, he engaged in the active process of creating new meaning of his own of his experience. In remembering, in choosing the words to fit the memory images, in making himself known to his trusted and beloved parent, he took a small step into a mind of his own.

I believe that through a repetition of small growth experiences like this Ben will learn how to make transitions more smoothly, because he will be making them in an expanded repertoire of choices.

Photos by Ginger Gregory

 

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!

 

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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