Monthly Archives: June 2014

“Los Momentos Magicos”: A poster at WAIMH

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

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

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

Weekly Skypes:

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

El Salvador Workshops:

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

North India Workshop

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

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

South India Consultation to Teachers at School

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

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

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

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

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

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

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

Read this blog in Spanish.

Addition to “Disruptive Behavior”

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

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

Disruptive Behavior or Something Else?

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

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

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

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

Read this blog in Spanish.

Another Moment in the Classroom with Ben

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Ben had been having some rough times in school. There were several episodes of his pushing or pulling the hair of some of his classroom friends. The children who were pushed or whose hair was pulled were often his favorite playmates. Though they were upset at the time, they forgave Ben, and afterwards the teachers helped Ben apologize and make a repair, for example, by asking the child what he could do to make her feel better. However, his teachers worried that the behavior continued, the children would become afraid of him and begin to avoid Ben.

These episodes were unpredictable, and even in retrospect the sophisticated and sensitive teachers could not identify the precipitant of the aggressive outbursts. They happened when he seemed tired and when he was well rested, when he was frustrated or when he was having a calm, good time. It occurred to me that these outbursts were most likely as surprising to Ben as they were to those around him. I wondered if they were an impulsive response to environmental stimuli that was perceived as a threat or that suddenly stirred a strong negative affect – such as a noise, or an object intruding into his “space bubble”, or an otherwise imperceptible misattunement by a teacher or another child. If such a stimulus triggered an impulsive aggressive move, Ben might be oblivious to the whole process until it happened and he witnessed the stricken face of the other child. This sight would certainly generate feelings of shame and guilt in Ben. We definitely wanted to break this cycle.

Ben’s teachers had many good ideas about how to introduce a counterbalancing calming stimulus, such as something to squeeze. I wondered if there could be a way to make the link between the feeling and the action more explicit. During the weekend I attended a talk by a sensorimotor therapist, Pat Ogden. She showed a film of a child who threw objects in a similar impulsive gesture. The session was videotaped, which was helpful in identifying several moments when her father – present in the interview – shifted his attention to the therapist at just the time the girl was asking him to look at something she was doing. This was acknowledged. Then the therapist asked the child to make the gesture without the throw – extending her arm in an abrupt movement – and to talk about the feelings she had when she did that. The child was able to talk about her “impulses” and gain insight into them through pairing the pattern of body movement to her new awareness of the feelings. This was effective in changing the problem behavior.

I wondered if we could do something like this with Ben. In another tape in Pat’s talk, the therapist coached the patient to do the movement associated with a problematic affective position and then “slow it down”. I recalled how Bruce Perry has talked about slowing down a movement and then talking about what is going on. This then allows the cortex (thinking part of the brain) to engage with the motor experience of the body into make some kind of integrated meaning of the experience and give the individual more control over his body as well as insight into his feelings. I wanted to try something like this out on Ben. I will let you know how it works out.

Read this blog in Spanish.

A Little Followup on Ben and Transitions

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Ben has continued to grow in his capacity for language and friendship. He is a happy child who loves his parents, his teachers, and his friends. He also seems to love school and the activities in the classroom and the playground.

In a brainstorming session in the classroom earlier in the year, his parents and teachers and I tried to come up with a plan that would make it easier for Ben to make the transition from bed to school. Although as I noted he loves school, he had a hard time making the transition from bed to getting ready for school in the morning. The teachers wondered if his parents could give him a job to do in the morning, since Ben delights in the jobs (meeting assistant, snack helper, etc.) he has at school. His parents followed through, and sure enough the job solution seemed to help the morning transition. The last time we spoke, his mother said that helping his father make breakfast or even do the laundry (which everyone agreed was a less desirable job) facilitated the move from sleep state and cozy bed and mommy, to school.

It is important to add at this point that there is nothing magical in this kind of “strategy” and nothing that ensures that this particular good idea will help another child in another place and time. Yet, the idea emerged from a sharing of observations and impressions of Ben among important people in his life, and this collective effort to understand Ben is valuable in itself. The idea of a “job” was specific to one little individual, Ben, but I would guess that whenever teachers and parents engage in this kind of constructive process with or without someone like me, a similarly useful idea will result.

Another related thought is that “strategies” (parents and teachers frequently request them) are sort of Wizard of Oz phenomena. That is, their power may derive as much from the caregiver’s subjective response to them as to their inherent value. (I often think the same about medicine; perhaps some of the placebo effect is related to this.) If the caregiver asking for a strategy trusts in the wisdom of the authority – whether a person or a book – then the strategy has the potential of being helpful. The strategy and the authority behind it confer a sense of security or hope that works against the original helplessness experienced by the caregiver, and those positive feelings are communicated to the child.

And one more thought I have on the subject is that these strategies are placeholders in the child’s development. They can help children avoid getting stuck in their developmental paths and maintain their momentum so that they can continue to grow until the solution to a problem specific to one point in time is no longer needed.

Read this blog in Spanish.