Monthly Archives: April 2012

The Workshop: Magic Moments

Day II: The Workshop

A good group gathered for the workshop, including representatives of four orphanages. I began the workshop with a description of brain development. I used Dan Siegel’s ingenious model of the brain in which the thumb represents the brain stem and midbrain, and the fingers curled around this core represent the cortex. The thumb, the evolutionarily primitive brain maintains essential functions such as heart and respiratory rate, sleep, appetite, and reaction to threat of danger (objective or subjective), but also reward, regulation, and mood (Bruce Perry). The fingers are the “thinking brain”. The thumb develops first in life, and the fingers don’t “come online” until around 1-year old. You can see where I am going with this, because M entered the home at age 1, and therefore he moved into an enriched environment after most of this development took place. The circumstances of his earlier life were known to be depriving and neglectful. I also reminded the participants that development was unpredictable and that boys were generally more vulnerable than girls. It has been observed that in the home the girls tend to do better than the boys, both from the point of behavior and also achievement.

Then I reminded the participants of the notion of “magic moments”, those moments in the interaction between caregiver and child when the pair confronts a choice between (1) taking the risk of trying something new (and more energy-demanding in the short run) or (2) slipping down the slippery slope into a problem pattern such as a struggle, and instead of following the old problem pattern they find their way to a better path. I showed them two clips of children at the home that demonstrated magic moments, pointing out that these magic moments prepared the way, or increased the probability, for future magic moments; in other words, the more of these you practice, the easier it is to slip into a good path in the future. Both clips illustrated child and adult working side by side. In one, a boy was grating carrots with an adult, and in another a girl was being helped to cut cucumbers with a big knife. In both, the side-by-side aspect of the activity was emphasized. My message (despite the fact that some cynics in the group thought that some of the behavior was influenced by the presence of a camera) was that when children practice tasks at the side of an approving adult, the task becomes more doable by the child independently in the future.

Then I began the Presentation of “M”:

M entered the home at age 1-year old. I invited the participants, now that they knew about brain development in the first year of life, to consider what neurodevelopmental vulnerabilities M might have brought with him into the home. In fact, early on, Rachel identified him as having delayed speech. He was described as sweet, warmly attached to familiar adults, but unusually timid and fearful, crying a lot. Still, many foundational skills seemed in place – in one observation Sarah Measures did when he was 2-years old, he was able to engage in reciprocal play and had gestural language, his motor sequencing seemed OK, his language comprehension was good, his reading of social cues seemed fine, and he showed no signs of extreme sensory sensitivities. He was observed hanging around the other boys, on the edge of the rough and tumble play. Still, he eventually joined in and remained engaged for 30 minutes.

I showed a video clip of M at 1-year old. He was a sweet-looking boy in a high chair, with a pleasant expression, playing with a toy on the tray of the high chair. When he dropped it, he patiently waited for the caregiver to replace it, which she did. He did not, however, give her a direct gaze, nor did he initiate a gesture to recover the toy himself. Yet, he was clearly interested in the child sitting next to him and to what was going on with her.

In kindergarten, M’s teacher complained that he fell asleep in school. Sarah and I observed him, and he did have his head on the desk most of the time. His teachers seemed to not know what to do with this behavior. At this time, Rachel also had concerns about his not eating and having stomachaches, though the doctor could find nothing wrong. He continued to have crying spells and to spend more time sitting alone than the other children, sitting on the steps eating mangos. At other times, though, he would join in the fun. I reminded the group of the physiological regulation problems that can be associated with problems in neurodevelopment in the first year of life.

M Today: Video of M’s Noncompliance: Rupture and Repair

Step 1. I described the interactions I captured on film the day before. The first step was M’s refusal to change out of his school uniform, an expectation at the home. Tia (“Auntie”, caregiver) Ani and Jessica (the psychologist) tried to help him comply. Instead, he lay on the floor. Gentle persuasion got nowhere. In the clip, M’s foot is seen on the floor of the bedroom, where he is lying and talking in a whimpering, defiant voice. Ani’s voice is soft, and she leaves pauses that seem to say, “You can take over if you want.” She does not escalate the emotion. Later Ani explained that she was asking M what was wrong, and at first he said, “Everything is wrong!” He later explained that he spilled his yoghurt at school, and then further explained that the boys made fun of him for doing that. This information emerged bit by bit, allowed by Ani’s empathic approach. Still, M could not respond to the demand to change his uniform. In the clip he tentatively kicks the door in rebellion, but he is not “too far gone” yet.

Step 2. The next clip is of Tio Luis, who comes to help Ani. His style is to use affectionate physical support, holding M around the waist (M is standing now) and bending his body gently in the same arc as M’s. Still, M shows he is not ready to respond; he grabs hold of the gate to resist Luis’ pull. He may still escalate. I suggest taking a break (who knows if this was the “right” thing to do?) and Luis backs off gracefully. M retreated to the bedroom and lay on his bed, covering himself with a blanket. I went into the bedroom with him and sat quietly on another bed.

Step 3. There was music in the adjoining room, where Kirsten was playing the guitar with three littler boys. M got up and moved into that room, sitting on a chair on the outskirts of the action, watching. I moved to a position behind him; he turned once to look at me and then looked back. Kirsten made no fuss about his joining, nor did she make an explicit invitation for him to come closer. I was glad, because I thought M needed low-key responses.

Step 4. M got out of his chair and lay on the floor next to the other children, with his cheek on the floor and his bum in the air, in a caterpillar position. There was a potential conflict with an assertive little boy when they both reached for the same object, but it did not escalate.

Step 5. Kirsten gave the guitar to M to take a turn. M sat up and took the guitar and began to strum. She gave gentle instruction to M about how to do it and reminded the littler boy to get his hands off the guitar while M took his turn. Slowly, M stood up and strummed the guitar. After a while, he stood taller and assumed a little of a rock star posture. I thought, “This is how self esteem is redeemed.”

Steps 6 and 7. Later in the afternoon, I saw that M had changed the shirt of his uniform, leaving on the pants. Later still, before the birthday celebration, I saw that he had changed his pants as well. His twin brothers were celebrating their birthday, and he sat close to one of them, watching everything.

Because the evaluations from last time included the desire to hear more voices, I had decided to at this point divide into small groups for discussion. Here are some of the results of the discussion from these groups.

Discussion from the Small Groups-:

-Tia Ani did not raise her voice to M in the bedroom because we have raised our voices before, and it doesn’t work. When the child is stuck in a rut, raising your voice doesn’t work.

– It was a good idea for Luis to step in when he did, because collaboration between two caregivers is often helpful and can avoid a struggle.

– There was a discussion about “teaching a child to manipulate” and what is the message to the other children if the understood consequence for “bad” behavior is delayed or not applied. I suggested that there must be communication among the caregivers (CG) so that there is no “splitting” (the child playing one CG off the other) and so that if one person gets confused and is tending to bend the rules, the second person can set him straight. These actions work against manipulation.

– We also talked about how it is good to be flexible sometimes. Yet, “being flexible” can also be seen as a reflection on the CG’s job performance. In that case, it is good for the CG to explain her reasoning to her supervisor.

– We discussed the timing of giving consequences. If the child is in a highly reactive state, reminding him of the consequence for his “bad” behavior is likely to escalate his aggressive behavior. Certainly he will not be able to “learn” from a lecture in that state, when his cortex (thinking brain) is “offline”. It is a challenge to assess the “state” of the child and then to make a decision about the timing of the consequence. All CG’s struggle with this challenge. We all thought that M should get a consequence later, when he could handle it. In this case, after M had calmed down and Ani had responded to him empathically in a gentle, slow paced way, he received his consequence easily.

– All groups also thought that it was important to talk to M about what happened later. One participant suggested that if the child is unable or chooses not to talk, he may draw or write about what happened. I added that children may communicate “what happened” either in reality or in his unconscious fantasy in the form of symbolic play.

– What were the “magic moments” in this scenario? (1) The first may be Ani’s choice to empathically question M about his day instead of immediately setting the limit about changing his uniform. (2) The second may be Luis’ joining Ani so that she would not be alone and vulnerable to being drawn into an old struggle pattern. (3) The third may be Luis’ “letting go” and allowing M to withdraw in order to “get himself together”. (4) The fourth may be Kirsten’s low key and implicit welcome of M into the group without stressing him. (5) The fifth may have been Kirsten’s allowing M to “take the stage” and in that way reclaiming his self-esteem. (6) Finally, the staff’s allowing M to pace himself in his eventual compliance with the rule, even though he had to accept the consequence of refusing to comply when he was asked.

If you can imagine the child’s mind, you do not expect more than he can accomplish. You can empathize with his experience and help him feel less alone. You can in that way maximize the probability of his success.

In the next posting I will briefly address the issue of working with families and then talk about the adolescents.

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,

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.

March IPMH Meeting: Attachment Theory: Two Views

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In this posting I will summarize the presentations of Marjorie Beeghly and Ed Tronick on the subject of Attachment Theory (AT). Marjorie’s presentation explained and offered video demonstrations of the strange situation paradigm, and Ed’s presentation challenged some of the tenets of the theory. This is a long post, and I apologize, but I wanted to complete the description of the IPMH weekend.

Marjorie Beeghly:

Although we don’t know much about how attachment mechanisms get transmitted from one generation to the next, attachment research is a burgeoning field. The research has generated lots of controversy – sort of like religion or politics. The main idea underlying Attachment Theory is that if the baby learns to trust the mother to comfort him when he is in trouble, he begins to learn that he can trust other people later in life.

It used to be that the mother-child relationship was not thought of very much. Harry Harlow, in the late ‘50’s and early ‘60’s, designed a study with a monkey fed on a wire mother. In spite of the fact that the nourishment derived from the wire mother, the baby spent most of his time on the cloth mother. The tactile comfort of the cloth mother dominated.

WWII – war orphanages. Renee Spitz. The description of infants deprived of their mother for 5 months is haunting. It sounds like Autistic Spectrum Disorder except for the motor retardation. It also look like pictures of children from Romanian orphanages – face vacuous, stereotypic finger movements, etc.

Attachment is bio-behavioral, wired in. when you separate infants from the caregiver, especially in the second half of second year of life – the baby responds with anger, and then sadness. Attachment is only activated under conditions of uncertainty, threat, danger, fatigue, or illness. There are other competing biobehavioral systems, such as exploration and affiliation.

Bowlby’s 4 attachment phases

1. Pre-attachment (birth) – mother’s sensitivity; people are drawn to want to take care of babies .

2. Attachment in the making – 2-6 mo. Lot of brain development, infants start having differential behaviors (crying) to different caregivers, social smile, etc.

3. Clear cut attachment – 6-12 mo. Separation anxiety, motility.

4. Goal corrected part (reciprocal relation) 2 plus years. Bob Marvin researched this stage. Internal working models, felt security gets internalized. Erikson also talked about this idea.

Mary Ainsworth did not design the Strange Situation to measure attachment but instead to study how the three biobehavioral systems interchanged (attachment, affiliation, exploration). She did research in Uganda, and her Uganda findings confirmed in the Strange Situation. It is true that the n of her studies were very small.

Often, adherents of Attachment Theory are critical of Freudian theory. Although S Freud’s theory of infancy did have a “virtual infant” in that it derived from reconstructions of the childhoods of his adult patients, Freud was also an acute observer of children – such as his grandson who threw a spool out of his crib and pulled it back and then repeated it, saying “Fort. Da.” (Gone. There.) – when his mother had left the room, thinking that the infant was representing and attempting to master the separation (Freud, S, Beyond the pleasure principle, The Standard Edition,1920). Also his coaching of the analysis of 5-yo Little Hans (Analysis of the phobia of a five year old boy, The Standard Edition) in 1909 demonstrated sensitivity to children in that he told the father to follow Little Hans’ lead in the conversation (it wasn’t really play), he emphasized tolerance and affirmation in father’s responses, and he was keenly aware of the body-centered focus of children’s inner representational life. Also, Anna Freud with her friend Dorothy Burlingham observed in the war nurseries and were marvelous observers. In one paper that is not well known today they describe the powerful bonds developed by children kept in the same children’s home that lasted years later after they had been separated and adopted (Alpert, A (1945). Infants without families: By Anna Freud and Dorothy T. Burlingham, The Psychoanalytic Quarterly, 14:236-238).

Mary Main described “Disorganized Attachment” (Hesse, E, & Main, M (2000) J Amer Psychoanal Assoc, 48:1097-1127). This is a heterogeneous category, characterized by the lack of a coherent strategy to help the child cope with the stress of separation. It is hypothesized that in this case the source of a secure base is also the source of fear. This attachment category is associated with trauma in mother’s history and also with maternal psychopathology.

In Attachment Theory, you have to have special training to score kids.

In videos of the strange situation, the key is that the child is comforted by the mother after the separation and then able to “explore”, reengage with the toys in the mother’s presence. In avoidant behavior, when the mother returns, the child avoids her, a snub. Some babies ignore the mother. The last clip, from a study of cocaine exposure, was hard to score. The child can’t maintain the calming, plus there is a weird resistant behavior. In high risk populations, the relationship between attachment status and outcome is not so clear; there are so many other factors at play.

Is maternal sensitivity the best or the sole predictor of adjustment in life? DeWolfe and van Ijzendoorn conducted a meta-analysis of 65 studies. Their results confirm that maternal sensitivity is the best predictor but the effect size is small. Temperament: Jerry Kagan.and Nathan Fox, etc. suggest that attachment style is predicted by temperament. Most studies indicate that temperament affects attachment behavior but does not predict attachment status. Temperament can alter the type of subcategory.

Grazyna Kochanska studies MRO (mutually responsive orientation), a dyadic factor. She looked at fearfulness and looked at whether MRO predicted attachment status. Kochanska found that secure children showed less fear at 33 mos and were more joyful. Ambivalent kids were the most fearful and least joyful. Avoidant kids showed increasing negative emotions (counter to temperament). The kids who were angriest later were the kids who were classified as D at one year.

Ed Tronick:

Instead of using AT to characterize infant-caregiver relationships, Ed proposes the following ideas, following a non-linear systems meta-theory (Tronick, E. (2007) The Neurobehavioral and Social-Emotional Development of Infants and Children, New York and London: WW Norton Press):

(1. Infant and adult are active. (2. Infant and adult are intentional. (3. Process of reparation is messy. (4. Form of reparation is unpredictable. (5. Process is co-creative. (6. Specific fittedness – must fit to intentions of infant and adult.

Dynamic systems include engagement with others and with oneself. DST (dynamic systems theory) includes an experiential component for us as humans (Tronick, 2009). When you are successfully gaining information you have an experience of pleasure, expansion, and you seek connection. It is in the co-creation of meaning that this happens. You are flexible and dyadic. When you fail, you have anxiety, withdraw, and are unhappy. Meaning making is a fundamental way of regulating ourselves. It can be in words and also in the body. When it goes wrong, things get disorganized and move towards entropy. To preserve ourselves, we become rigid, defensive, aggressive and hostile, use projection, etc. Kids who are compulsively one way or another are staving off disorganization. They are holding on for dear life (the Spitz kids) and staving off disorganization. Kids with behavior problems are also rigidly organized – they go from one state to another and the pattern in which they go from here to there is unvarying. Bullying, for example, is a rigid pattern; kids who bully gain coherence and a defense against anxiety. Homeostasis – there is a dynamic homeostasis over time, but real homeostatic systems are rigid and not dynamic systems. There are some states that must stay pretty much the same, but we bring to bear a lot of other systems to keep them stable, such as body temperature.

Normal development involves change. Normal disorganization is regulated by the parent-infant system. The infant goes from crawling to walking and disorganizes the crawling system to the walking system; this involves anxiety and takes energy. Change is costly and this is true in part because it is unpredictable, and because you are taking apart the old organization, which is anxiety provoking. The clinician’s work is to maintain the organization while the patient allows for the disorganization of the previous organization and takes the risk of trying something new.

The Jim Coan did a study with the MRI and holding hands. Being alone per se is stressful. You could take Coan’s study as a model of the need to be in the presence of another. In this study, the MRI demonstrated that pain can be mediated by holding the hand of a person with whom the subject was in a relationship better than by holding the hand of a stranger (Coan, J. A., Schaefer, H. S. & Davidson, R. J. (2006). Lending a hand: Social regulation of the neural response to threat. Psychological Science, 17, 1032-1039). ?

Getting attached has to do with forming a relationship and creating a new way of being together, a feeling of “connection”. Bowlby focused on a process going on over time that was related to emotions and making a connection in relationships. We have since somewhat lost focus on the process of Bowlby’s theory, through our attention to the categories. The process of meaning making leads to a different take on attachment relationships. When new meanings are co created they generate a variety of emotions and qualities. This may sound like attachment but we confuse ourselves with this overly broad use of the term. Attachments are primarily about safety, feelings of security and the reduction of fear. We have gone on from these ideas to what may be an unrealistic expansion of the theory. In fact, relationships involve lots of ways of being together. Attachment security and the myriad qualities of relationships can be dissociated. Moreover, relationships contain contradictory emotions. For example, intimate relationships may or may not be secure. An abused child may love the abuser but may not feel secure with him. You don’t only have positive feelings towards someone. In fact, to the extent that you have positive feelings about someone, you also have negative feelings such as the fear of loss of that person. What therapists sometimes have to do is to provide the hope or scaffolding to allow for change. For an individual to hold in mind these contradictory possibilities – love and hate – in the service of something you do not know will happen for sure, threatens organization. To the extent you can simplify it, you resolve many issues, so you protect yourself from having to hold it all at the same time.

A problem with Attachment Theory is that it is often used reductively. For example, just because someone is depressed does not mean that they are disorganized. There are also probably borderline personalities that have secure attachments. Which information would be more valuable to have – an assessment that this child has an insecure attachment or the information that from the time he was 5-yo he was in 9 different foster homes? We have elevated Attachment status to a level that carries too much meaning. People will give a patient a disorganized Attachment status and then go on to mention all the other traumatic features of their lives. In AT models, the Attachment status and clinical diagnosis can be reversed, such that instead of beginning with insecure attachment that leads to depression, you could start with depression and end up with an assessment of insecure attachment. These are all correlation studies. When predictions are made, it suggests causality, but in this case the issue of causality is not at all clear. Take for example, the development of the capacity to reach for an object. All infants at about 15 mos of age, end up reaching for an object, yet every infant gets there through a unique process. We have some understanding of what goes into that process – including gravity – but you can’t predict the particular path an individual child will take to get there (Thelan and Smith, 2001)). You you can predict the outcome but not how the process by which the outcome is reached.

A more variegated process is needed to account for the varieties of normal and abnormal, and Ed proposes the process is meaning making. Meanings come in infinite and multi-leveled forms, all of which are aimed at increasing complexity or coherence (according to the meta-theory of dynamic systems theory). When successful, relationships can take on infinite forms and qualities, intensities and rhythms, and ways of being together in emotional, sexual, and body domains because each of these domains is a domain of meaning making.

Most of the research in AT fails to test alternative hypotheses accounting for long-term stability. Take for example the AAI (Mary Main’s Adult Attachment Inventory). Suppose we consider the AAI to measures of self esteem, ego function, and sense of self. Self- esteem is a mid-level concept. You could think of self actualization, or of Erikson’s theories of development. If we compared Erikson’s theory of development and the AAI, which helps most? The basis for the legitimacy of the AAI is that it indicates the type of attachment but in fact it covers a whole lot of other things that are not discussed. Whereas the AAI proposes to reflect the coherence of thought in relation to the security of attachment, in fact it also reflects coherence of thought in other domains such as self-esteem. There have not been studies about this. Why is it not equally legitimate to state that if you have good self esteem, you are more securely attached? The AAI is really talking about a coherent narrative. Mary Main studied with Liz Bates, a linguist; she originally studied psycholinguistics. So the idea of coherent narrative came to her from this route. What if that one thing we call security picks up on many different things, but security is the only thing we are addressing? For example, when Marjorie talked about the child who had secure attachment, she pointed out shared attention and a lot of things and related them to secure attachment, but these behaviors were not in the coding scheme. It is similar to CBT studies in that if you do studies in CBT you study the manual but you do not study all the other things that are going on such as in the relationship. We do not have process research, but only outcome research. CBT may make you better, but we don’t know what it is about CBT that makes you better. When we take AT our of the laboratory and into the consulting room, we use the term AT as if it had the imprimatur of science, when actually we are only going from our observations about the relationship. We invoke a biologic scientific idea to explain what you should do in the clinical situation. It would be similar to using the strange situation paradigm to help guardian ad lidems make decisions about the child’s custody.

AT also forgets about what predictability means. Bowlby talked about process, but we have reified the status. We forget everything going on between one year and five years of age. If you are in a fairly stable environment, it is likely you will be in the same environment five years from then. What if you get an epigenetic change and it dissipates but then the environment comes in and says, let’s put that gum on the light switch again?

There is also the issue of problematic anchors – the end of the scale for sensitivity is not trauma and neglect. If you use scales, people often avoid using the first and last point. When Ed was taught scaling, he was taught to put down an anchor and scale from there. When people talk about attachment, there is a subtle movement from normal caregiving to neglect and abuse, and the neglect and abuse becomes the convincing anchor. It is the child with neglect and abuse that turns out to have problems at 5-yo. Ed bets that if you took a child with abuse and neglect, the abuse and neglect would be a better predictor of problems at 5, than attachment status. In other words, the “insensitive” parent is more likely to abuse or neglect. The sensitivity scale is problematic – sensitivity is a problematic way of talking about it. Also in most contexts if you are good enough to take care of a child’s fear, chances are that you take care of other things they need as well. We have taken one concept and cast a big net with it and end up with a score. Ed studied the Gusii tribe, who do not play with their infants and habitually do not respond empathically to the infant’s expression of emotion, and he guesses that there are lots of secure Gusii infants. The Gusii are sensitive about regulation but not about emotions.

With AT the marker is that the child is willing to stay with a person who can regulate them and make them feel comfortable, but not everyone has this opportunity. You first have to feel secure and physiologically stable in order to do anything. Lou Sander called these things pre-emptive. Although AT does describe illness or other biological sources of distress such as hunger as factors that may interfere with the development of secure attachment, the importance of these factors is frequently overlooked in the AT literature. One can be reduced to fighting and fleeing. Steve Porges said you first have to make the child feel secure, safe, physiologically well regulated. You can do that and you can stop, or having done that you can do a whole bunch of things – socialization, language, motor skills, etc. If you have been ill, all your resources are going into being not fearful, and you don’ want to be social.

Thelen E, Schoener G, Scheier C, Smith L (2001). the dynamics of embodiment: A field theory of infant perseverative reaching, Behavioral and Brain Sciences 24(1):1-34.

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March IPMH Meeting: Epigenetics II

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(Continuation of Barry Lester’s presentation with discussion)

What are some long-term prenatal stressors that affect placental genes? These risk factors may play a role in future problems but do not predict the future. What they can do is alter the HPA system set points and affect the way the newborn responds to stress. This in turn could influence the baby’s regulation. One could hypothesize that potentially this could lead to dis-inhibition, psychopathology, cognitive problems, and adolescent substance abuse. Of course, there are many steps along the way and many forks in the road. We are only talking about risk factors in a very complex set of processes. We don’t know what these pathways are that lead to problems down the road. We only see correlations.

Let’s look at cocaine using mothers. It becomes difficult to isolate a particular risk factor in the lives of these women. But the cocaine exposed babies showed higher reactivity to stress. What are the other stressors in the picture? In addition to cocaine use, there is also a relationship of the babies’ high reactivity to the number of caregiver changes. The important point is that you are looking at how the drug interacts with adversity in the postnatal environment, not just the effect of the drug itself.

Which epigenetic changes will be passed on? Ed (Tonick) says that nutritional studies show that it takes two more generations after the parent generation to clear out some of the nutritional effects in the generation of the grandparents. Do these pass through the mother’s line only? (There are also those who dispute the intergenerational transmission.) If the changes that are passed on represent a guess about the environment, then that is important. How stable are these epigenetic changes anyway? It is possible that they are short lived but that the environment reinstates them. Suppose you are a 2-yo and you are neglected and so you methylate your GR receptors (stress regulatory system). Then you get neglected again, so you methylate them again. There then may be changes in your hippocampus that in effect become a damaged part of your stress regulatory system. Is it causality or association? It seems unlikely that methylation of one gene is going to cause the changes we are talking about.

It is essential to keep in mind that the connections we are talking about do not represent the actual events of the real world. Ed says that “simple” and “sovereign” is always wrong. We tend to find a new paradigm, and the situation always becomes more complicated the more you look at it. We always find a new paradigm and it gets more complicated the more you look at it. If you look at the Dutch famine study, think about the mothers who were pregnant during a war in which the whole country was starving. The famine ends, but people have died, fetuses have been aborted, the babies who are born are smaller and more irritable. The women who mother them are traumatized. We talk about the famine but do not seriously take into consideration all the other horrible factors that were involved. These amplifying and reinforcing factors were still going on even after the war.

The magnitude of effects – the effect size of all these factors – is small. It is interesting that you get this variability in the relationship between methylation and behavior in healthy babies, and it makes you wonder what would happen if you look at “at risk” populations; in that case, do you magnify the effects? Within the normal range you can find the same relationship between birth rate and behavior in a study done by Ed Tronick and Barry Lester. You need to consider the whole range – babies who weigh 8 pounds and those who weigh 6 pounds – will the bigger babies have a little better organized behavior?

There is a new NICU at Brown with single rooms. The changes taking place include more breast feeding, more kangaroo care, etc. An Italian colleague of Ed’s, Rosario, did a study in which he looked at the quality of care in 24 different NICU’s in Italy. He categorized them and gave them assessments, and the babies in the better NICU’s had better scores than those in the least good ones. You are then discharging a baby who is medically in better shape and also neurobehaviorally in better shape. Also, the higher the level of neurodevelopmental care, the lower the incidence of depression in the mothers. All of these NICU’s ascribe to a particular care policy, but in fact they vary. Some of the things that are done in developmental care are thought of as “neuro-protective”. Ideas of developmental care have shifted.

Schizophrenia – what is the epigenetic issue? There are people who are studying epigenetic changes related to schizophrenia and autism. There is not a lot published yet, but it seems there are prenatal effects that are related to schizophrenia. We also need to look at the relationship between epigenetic changes and genotype.

Steve Suomi has done cross fostering studies of rhesus monkeys. He took inhibited and uninhibited babies and cross fostered them, and found that there was evidence of temperament coming through in addition to the environment. Barry Lester thinks of temperament as a protective factor. Nancy Snidman asked about individual differences in the pups – not all the pups get licked, do they? Everyone agreed that there are probably individual differences among the pups that influence how much they get licked. Ed pointed out that just because these models have to do with stress, it doesn’t mean that stress is all bad. We don’t know what appropriate levels of stress are. What about the stress and temperament interaction – is it possible that stress for a highly reactive kid can lead to a blow out, whereas stress for a low reactor can be facilitating? Yes, but it also depends on what you mean by stress. These kids have different thresholds for reactivity. Some people get a rush that is positive, and others feel a negative reaction immediately.

If you have an acute stressful event and it finishes and is done, and yet you ruminate about it, that self-amplifies the stress. This is where a psychodynamic factor plays an important role. In the case that the individual makes a harmful, self-critical meaning of the stress, then when stress happens, things deteriorate. Stress reactivity by itself, the cortisol effect, is a nonspecific model that could go many different ways. The Kagan model is more specific – it is reaction to novelty – across the lifespan. Stress reactivity and care is a different model. There are many paths that fussiness in a baby can take. Nancy and Kagan were looking at reaction to novelty, and they wanted to get the system aroused to see the physiological systems respond. There were a lot of things they could not include that have to do with caretaking. The amygdala approach-withdrawal reaction – is specific in its relation to novelty. They started with older children. How could they bring that reaction down to infancy and what was going on in the brain? They do see SES differences. Nancy reminds us that most kids are a mix of the temperamental features they are talking about. They were studying mainly the extremes.

This kind of research is also constrained by the use of checklists. Remember that it is not only parental translation to what these words like “seldom” and “often” mean; it is also what we mean. In the checklist we have to interpret the answers, and what was “trouble” when the checklist was developed and what it is now sometimes has changed. The reason you use CBCL is that the parent has a thick relationship with the child and you may not see all these things for 15 min in the lab. It is also true that the more extreme anything is, the greater effect you will see from it. So that you will see a greater effect the more abnormal the caretaking is. In the case of the relationship between temperament and training in dogs, it is harder to train certain breeds to be aggressive than others, but you can do it. You could probably override most traits.

In the discussion, one fellow talked about a home placement program in which a child who has not been able to develop certain skills is put into a supportive foster home. Then, when he is better, he is sent back into the home, and they cannot manage. It is typical for kids to do well in structured environments but do poorly at home, and the school says. There is a tendency to dismiss the fact that the child does better in one context because of the regulatory support context.

In the next blog, I will report on the presentation about Attachment Theory.

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March Infant Parent Mental Health Meeting: Epigenetics I

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Barry Lester taught us about epigenetics. He started with reviewing the background of “fetal origins” and the concept of “fetal programming”. Can the study of genes and environment at the cellular level inform us about molecular influences on behavior? The hypothesis states that susceptibility in cardiovascular disease, non-insulin-dependent diabetes mellitus, and the insulin resistancy syndrome, is programmed in utero as a response to fetal malnutrition. This dates to the German starving of Dutch mothers during World War II. There was a relationship between low birth weight and hypertension, 40 years later. The general concept is that reduced fetal growth leads to altered structure and function in the fetus, leading to increased risk for adult disease. During the famine, the fetuses were starving and they wanted to prepare themselves to survive in a famine environment. Instead, the famine ended and the babies were born into adequately nourishing environments. They had adapted their systems to slowed-down metabolism and couldn’t adapt.

Developmental plasticity enables the organism to change, reprogram structure and function in response to environmental cues. The adaptive significance is that plasticity enables a range of phenotypes. Many studies have replicated this finding. The idea is that your risk of disease depends on the extent to which you are prepared for, or match with, the external environment. Can these effects be produced by environmental insults other than malnutrition? What might be the underlying mechanisms? Could epigenetics provide the molecular basis for fetal programming? What might be the applicability of this model beyond chronic disease to behavior?

There is evidence that the fetal origins theory relates to the etiology of neurobehavioral problems and mental illness. Low birth weight is related to schizophrenia, depression, and psychological distress. What is the molecular basis?

Epigenetics has to do with the heritable and stable control of gene expression beyond DNA sequence. It is heritable – can be passed on to successive cells – yet does not alter the genetic sequence, and inter-generational. It is stable and cannot be altered. It is environmentally sensitive. There are critical periods (a lot of this happens in periods of rapid development) and reversible. Epigenetics controls gene expression and transcription, turning off and on the gene. The gene stays the same, but what the gene makes happen is changed. Conrad Waddington (Professor Genetics, Univ. Edinburgh, 1905-1975) described epigenetics as “cross talk” between the gene and the environment.

Epigenetic changes happen all the time. The field started in cancer. Epigenetic research has since expanded into behavior. Barry’s “favorite example” is that in which the mother is a drug addict and is loaded with addiction genes. If you could turn them off, the baby will inherit the same DNA but will not inherit the addiction. This is pure fantasy but possible. Epigenetics refers to the changes in gene activity, expression, without changing the gene. It can be silenced, enhanced, and change can be transferred to the next generation some of these changes can be reversed.

The most common mechanism in which environmental influences can produce stable alterations is DNA methylation. (Histone is another one. The outer layer of the package of DNA is histone.) The metaphor is gum on a light switch. Epigenetic changes occur when genes are being replicated. The DNA is transcribing to RNA and that is producing proteins. The amino acids guanine and cytosine hang out at the gene transcription sites – CPG islands. A protein puts little methyl tags on the gene. That is like gum on a light switch; it turns off the gene.

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March Infant Parent Mental Health Weekend: Temperament

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We began the weekend with Dr.Nancy Snidman, a colleague of Dr. Jerome Kagan who talked to us about temperament. She defined temperament as “what a child brings to the interaction with the environment to create personality”, pointing out that nowadays we tend to talk about “individual differences” instead of temperament, but that individual differences tends to be a “blend of temperament and environment”. Nancy talked to us about the differences in reactivity of children related to different thresholds of reactivity in the amydala. In their study of the amydala output effects, such as sympathetic responses, output to the larynx (crying), and output to the skeletal motor system, the research group identified a group of “timid” children who had inherited a low threshold of reactivity of the amydala.

It turns out that if you look at the sensory integration scale and the temperament scale, you find a lot of overlap, and some people think they are not so different. Nancy said that if part of your definition of sensory integration disorder is that there is an overwhelming response to sensory information that the child is born with, you could call it temperament.

Nancy showed us videos of two 4-month old infants responding to a mobile. One baby was highly reactive to the stimulus, and the other was not. The research group chose babies who were high reactive and low reactive in terms of motor behavior and crying modes of reactivity and they followed them over time. Starting at 21 months the researchers saw a lot of consistency.

The high reactive girls at 21 months started to look shy, a trait that diminished later on. As the children grew older, the best behavioral indicator of their status was spontaneous smiles and comments. The cognitive style related to high reactivity is associated with high levels of response inhibition and over control. The most cohesive group was low reactive boys.

Socialization differences did have an impact. Interestingly, the low reactive boys tended to seek out risky behavior, whereas the (more “timid”) high reactive boys were often encouraged by their parents to get into sports, against their initial inclination. When these high reactive boys were older they would often end up in individual sports such as swimming, which is a team sport but may avoid some of the rough and tumble aggression characterizing the others. As the kids got older, it was novelty that would trigger the threat. In preschool, when they became familiar with the school, they were fine. There were some high reactive boys who were doing very well in high school but couldn’t manage the transition (the novelty) to college.

Nancy sees temperament as underlying all that gets created in the interaction between the individual and the environment. What is the environment that the child finds him or herself in? If you were counseling parents, you might think – in the case of a high reactive child – to suggest that the parent take more time with transitions. In the case of a low reactive boy, you might try to protect the child against a tendency towards risky behavior.

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Ten Ways to Help Your Child with Nonverbal Learning Disabilities at Home

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Here are the second, five ideas about helping your child with NLD at home. I have included some examples of my own, with the hope that some of you who are parents with an NLD child send me some more examples.

6. Practice:

Whatever strategy you find helpful for your child will lose its efficacy if it does not become a part of the child’s sense of himself and what he can do. That means practice. The strategy must become almost automatic, like a habit. Previewing or rehearsing new activities or places, can become a habit. Reviewing the calendar to remind you of the events of the coming day can become a habit. Discussing “what the story is about”, the “forest” rather than the trees, can become a habit. Taking regulatory breaks can become a habit, and slowing down can become a habit.

Example: Susan’s mother was so stressed when she got home from work that the last thing she wanted to do was engage in a series of what seemed like chores, with Susan. She just wanted to relax and enjoy her time with her. However, she found that if she made a list of the things to do with Susan – go through her back pack, go over the calendar, talk about the theme of the story – and followed the list every night, it actually didn’t take much time and she and Susan had a better time together. The more she did her list, the less bothersome it became. She found that after a while she began to rely on the security of the structure as much as Susan did. She found that Susan could sit at the table better if she jumped on the trampoline or took a walk before supper. She began to look forward to what she would find in Susan’s backpack. She felt reassured by reminding herself of the upcoming events on the calendar. She even found ways of talking about the theme of the story that made it more fun for both of them, for example, whether this was a story of a child (or animal) who did something he was not supposed to do and got into trouble, or a story of a child who used her imagination to have an adventure. Susan’s mother kept having to remind herself to slow down, but even that made her feel calmer after a while.

7. Organize:

Here is another idea for the child with this cognitive profile, which almost always includes disorganization and “executive function disorder”. Start early in the child’s life building a routine for organizing the child’s room and the extensions of his room (back pack, lunch box). It is often hard for busy families to do this, but if parents think of it as a powerful learning experience for their child and not just keeping the house neat, sometimes it helps them keep it up. It is best to keep up whatever organizational schema you create religiously. Some important features of any plan should be a clean and orderly workspace (child’s desk or table) with only the essentials on it, a routine of going through the backpack (parent and child together) every afternoon after school and every morning before school, and a regular place to keep coat, gloves, hat, and boots. Parents should not hesitate to work together with the child to keep this order in the child’s life. Requiring the child to do it alone only invites struggles, which are to be avoided at almost any cost.

8. Network with teachers, babysitters, parents, peers:

Your child’s teachers, babysitters, other parents, and peers are valuable resources. Talking with them can help fill in the gaps of your child’s life that he cannot do himself. Babysitters will have an important perspective on your child that can complement your experience. Frequent discussions with the teacher can help you keep track of comings and goings in the classroom that may have an impact on your child without his being aware of it. Now, many schools have activities and schedule changes on a website, but in the past notes from the school would get left in the cubby or dropped in the playground. Other parents will have information about the complexities of school social life that your child may completely miss. Other children in the class will also pick up information that may go unnoticed by your child. Sometimes parents of a child with NLD have so many painful experiences – such as hearing about their child’s disruptive, noncompliant, or atypical behavior – that they withdraw from these essential connections. In these cases, it takes a great deal of energy to stay involved with the community. Identifying a couple of trustworthy people you can talk to without fear of being shamed or hurt can make it possible to avoid isolation.

Example:

Jason’s mother had received so many telephone calls from the school complaining about Jason’s behavior or notifying her that he had missed the deadline for some important event that she shuddered every time the phone rang. She began to avoid the gaze of the other parents in the hallways and rush to get Jason out of the school and into the car as soon as possible. One day after a particularly painful telephone call, she forced herself to make an appointment to meet with Jason’s school team. She found that they were more sympathetic to her than she had imagined and that they really liked Jason, even though he was difficult. She made a plan with them to check in with the assistant teacher, with whom she felt the most comfortable, every Monday and Friday afternoon. The teacher’s friendly greeting made her feel welcome and as if she belonged in the school.

9. Process afterwards:

Talking about an event after it happens is as important as previewing it before it happens. When you do this you are helping your child make sense of a situation that he may be completely unable to understand. This is particularly important when your child has an upsetting experience. However, it also can be very helpful when things go well; in that case talking about it afterwards can maximize the possibility of the positive experience happening well again.

Example:

Matt’s younger brother begged him to “not tell” the secret joke he wanted to play on their babysitter, but as soon as his babysitter came in the door, Matt rushed up to her and told her the joke. His brother broke into tears and his mother was furious. Couldn’t he let his brother have that one satisfaction, or did he have to grab the attention every time? She tried to talk about it with Matt, but he got angry and ran out of the room. That evening, when they were sitting down to read a story, she told Matt that before they read the story she was going to talk to him about what happened that afternoon. (Note that she did not ask him if she could talk to him about it; she told him that she was going to do it. Often parents cede their authority to their children in a way that is not helpful to them nor to the child.) Matt looked unhappy, but he wanted the story, and he listened. His mother explained that his brother had been so excited about showing the babysitter the joke, and that though she knew how hard it was for Matt to share that kind of attention with his brother, he should not have spoiled his brother’s fun. Matt quietly agreed. Then they talked about what they could do the next time his brother wanted attention and Matt felt jealous. His mother knew that this situation would happen again, but she also knew that with practice Matt would get better at restraining himself, and even more important, that he would get better at imagining how his brother would feel if he stole his thunder.

10. Play dates:

Play dates are not only enjoyable; they are valuable learning experiences. However, play dates can be particularly challenging for the NLD child and her parents. They take more work and planning than with typical children. The most important goal is to make the play date fun for your child and her playmate. That means that you tailor the experience to minimize the challenges and maximize the probability of success. If your child is more comfortable at home, you have the play date at your house. If your child gets territorial about his possessions, you have the play date on the playground. If your child takes a while to warm up and get going, you try to make the play date longer. If your child can’t hold it together for more than a couple of hours, you make the play date shorter. Don’t try to invite more than one other child at a time; your child will have a hard enough time with one playmate. Don’t expect to be able to chat with the other parent while your children play; you may be called into action suddenly to negotiate a conflict.

I am looking forward to your comments. In the next posting I will begin a summary of our infant parent mental health course weekend in March.

April 23, 2012

Here is a very helpful comment offered by my friend and valued colleague, Dr. Anne Berenberg:

I think it would be helpfu to say more about understanding what is usually involve in an NLVD, with a stress on the difficulties reading and interpreting nonverbal cues such as facial expression, tone of voice, body language; the difficulties in giving off appropriate cues so that others can “read” the child; and the difficulty in interpreting his own emotions before they becoming overwhelming. Then there’s the difficulty in processing and integrating novel information, so that every new situation is hard–the child kind of starts over each time. The child is overly reliant on learned “rules,” tends to be rigid, and has trouble adapting to slight changes flexibly. In addition, the nonverbal concepts of spatial relationships and of time are difficult for many children with NLVD. Understanding how pervasively these deficits affect every day life is a first but very challenging step for parents in understanding how to help their children. Often, walking through the child’s day, thinking about how her particular deficits would make everyday tasks difficult, confusing, and therefore exhausting, is an eye-opener. The mother you quoted tried doing that with one incident in her child’s day, which was great. In order to do that, she had to first have some idea of the difficulties her child faces in dealing with her world–the ways in which her child is likely to misperceive and misinterpret cues that other children pick up without coaching.

I find that many parents don’t have a good frame of reference for seeing the world through their child’s eyes and it really helps to walk them through the meaning of “nonverbal” cues and the trouble these kids have in reading them in others and in giving them off to others. Also there is the fact that these children can’t read their own internal affective cues until their reactions become so strong that they have an overly strong emotional response to something others would see as minor. It helps parents to underscore the problem these kids have with anything new–it helps parents to understand why the children tend to be rigid and rule bound. That’s the basis for a number of your recommendations, and again can be really important as an opening framework for parents to understand their children. You’re weaving a narrative for the parent or caregiver of a child who is doing the very best he can to operate in a world which is much more challenging for him than it is for others, but for which parents are helping to provide roadmaps and signposts.