Monthly Archives: September 2016

Stress Regulation: From Theory to Practice

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Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels.

Stress Regulation: “From Theory to Practice”

Perry’s ideas about stress regulation are particularly important to me in my clinical work. In contrast to the negative cascade stress can cause in a sensitized child, helping a child grow his stress regulation system may initiate a healthy “cascade” effect.

In my practice, if a child gets better at calming herself, she can pay more attention to my ideas about the motivations for some of her problem behavior and consider trying more adaptive ways of behaving. For example, if a child is poorly regulated, she will not be receptive to my observations that when she starts out with “loser feelings” she cannot bear to play competitive games with her peers. She is more likely to use psychological defenses such as denial and avoidance to protect herself from the stress of acknowledging her painful feelings. If, however, we begin by my giving her a “handicap” that makes it easier for her to win, and then emphasize the rhythmic, repetitive turn taking patterns of the game with my actions and with my voice, she may be able to establish and maintain a receptive, alert position in relation to my communications and even allow me to scaffold some self reflection. In play sessions with one child, I would ask her at the beginning of the session whether it was a “bad guys in” or “bad guys out” day for her before we settled into a game of Candyland. If it had been a hard day for her, we would take all the cards that send you backwards out of the pile. If it had been a good day, we would leave them in. This small ritual allowed us to play the game together, while also helping her begin to reflect on and identify her feelings, and eventually appreciate the link between her temper tantrums and her sense of herself as a “bad girl”.

In psychology and psychoanalysis we refer to “respecting the child’s defenses”, something that Anna Freud talked about. That means not overwhelming a child, usually by avoiding confronting him with information he is not ready to receive. Perry’s idea of “dosing” and “spacing” adds a new dimension to the concept of “defense”. It brings the body into the equation in an important way. Thinking in these terms helps us organize our interactions with a child in time and space. It helps us put the music and dance into our clinical work. Because I study videotapes of my work with children, I see the nonverbal communication, what I call the “music and dance” of psychotherapy, both in a standard time frame and in a microprocess, second by second, time frame. In the microprocess, you can see this dosing and spacing even better than in real time. For example, in one session with a 4-yo boy, you see me introduce an idea about something scary to him; I deliver my communication in short (2 sec) vocal turns defined by short internal pauses (“dosing”) and then, right after I finish, I sit back and fold my arms across my chest. This is “spacing”. When you look at the film in slow motion, you can infer my (out of my awareness) intention of giving him space, giving him a turn.

“Dosing” adds the factor of measurement, of size, which I think is very useful to keep in mind. I remember playing with a little boy who felt the need to exert extreme control over me in the session. In order to help him grow, move him towards reciprocity, I had to stress him by interrupting him sometimes, declining to jump to comply with an order, or by adding a detail of my own to the narrative that he was spinning, any of which could make him mad. Sometimes I “dosed” my contributions by adding humor, sometimes I made them very short, and other times I acted a little confused. Slowly, using dosing in that way, he began to give me a turn now and then.

Spacing is another very helpful perspective. “Spacing” is even closer to the theory of psychological defenses than “dosing”. I was observing the need for “spacing” when I sat back and folded my arms across my chest in the previous example. Another example is my work with a child who lost a parent. When he saw me in the preschool classroom, he would “pretend” reject me by playfully pushing me away or telling me in a loud voice to go away. I would play along, sometimes moving back a few inches, but not going away until it was time for me to say goodbye. When you think about it, there is a lot of communication in our behavior. He is telling me he needs to know if his behavior can cause me to disappear forever, and I am telling him that his behavior is unrelated to when I come and go. My leaving the classroom was a dosing experience for this child. One day after many months of this daily play (“spacing”), I stood to leave, and the boy approached me sideways, without giving me a direct gaze, and leaned against me. I stroked his hair and he didn’t move.

In addition to dosing and spacing, Perry’s thoughts about “distributed caregiving” have also been helpful to me. Actually, what has happened is that my own clinical experience has been moving me further and further from thinking in terms of categorical diagnoses and “clinical” interventions. Instead, I think about children’s problems more often in dimensional terms and tend to move to support the child’s caregiving environment before immediately beginning an individual psychotherapy. Supporting the child’s caregiving environment means working with the child’s parents and teachers. One of my favorite ways of intervening is to work in the preschool. Then, I not only have a chance to offer the very capable teachers an insight now and then about a particular child. I also have the chance to “be there” for certain children when and how they need me. This is what Perry means by “distributed caregiving” – allowing a child to initiate a particular kind of interaction with each caregiver in a group available to him. This kind of thinking moves away from formulations about pathology and towards developmental goals. For example, Perry talks about how after the Waco disaster, the traumatized children seemed to identify particular caregivers for specific needs of the child – one for help with schoolwork, another for rough housing, another for snuggling. I have seen the same kind of distributed caregiving activity in the preschool classroom with healthy children.

I realize that psychotherapists and even psychoanalysts like me sometimes consult to teachers in schools by sitting down with them and listening to them talk about the children and answering their questions, and even by entering the classroom to observe certain children pointed out by the teachers. What I prefer to do is “live” in the classroom so that I can see the children in action and sometimes engage directly with them, while at the same time trying from time to time to identify what the teachers can do even better. For example, I might see a little boy who seems more fearful than average and begins tentatively to play with a toy car. I might suggest to the teacher that she encourage some gentle crashing games if the child initiates them.

In closing, I would like to emphasize the importance of rhythmic patterned activity that is repeated over and over again in helping people grow. This is very different from what I learned in psychiatric and psychoanalytic training. It is not that I have not engaged in that kind of activity in my clinical work; I have. On the other hand, now that I have integrated it into my theory, I do it more, and I do it better.

Stress Regulation: Bruce Perry

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Every time I hear Bruce Perry speak, I hear something new, and I take a step forward in making sense of my experience with children and families. On September 16, Bruce talked to our IPMH course about his “theory of change” – Change is created by an intentional act that is repeated in a way that will influence the system in the brain relating to the function you are engaging in the action.

As always, he grounds his remarks in the science of the brain – although he is careful to remind us that all “models” of the brain are gross oversimplifications and only useful in so far as they help us understand how the brain works. That is because the brain is unbelievably complex. There are approximately 86 billion neurons in the human brain and many more glial cells. The brain is hierarchically organized both in terms of architecture and function. The most “primitive” part of the brain – the part that is most like the brain of primitive animals – is at the base of the brain. This part, including the brainstem and cerebellum, maintains bodily equilibrium – body temperature, heart rate, blood pressure, and respiration. Above that is the diencephalon that regulates functions such as appetite and sleep. Then there is the limbic system that deals with basic emotions such as anger, fear, and happiness, and also affiliation, and reward. Finally, there is the most uniquely human part of the brain, the cerebral cortex, that produces abstract though and the more complex emotions of guilt and shame. Yet, every time we introduce a model of the brain we oversimplify; these anatomical parts of the brain do not relate precisely to the functions described; it is complicated.

In addition to “intrinsic neurons” that make primarily local connections, there are neural systems in the brain that have wide distribution throughout the nervous system. These systems, such as the ones of the neurotransmitters norepinephrine, serotonin, and dopamine, are crucially important in managing stress. The stress response systems connect the lower parts of the brain with the cortex and also connect the brain to the autonomic nervous system and to the endocrine system, the immune system, the musculoskeletal system, and the internal organs.

As we have noted in other blog postings, the lower part of the brain forms earliest in intrauterine life when the brain is growing most rapidly and is most subject to influences from the environment. Although “neuroplasticity”, or brain growth, occurs throughout life, the most rapid and profound changes occur in the first few years. That is why students of development stress the importance of a good early caregiving environment. An adequately responsive, consistent, and predictable caregiving relationship can modulate the effect of adverse experiences on the developing brain.

When an infant experiences an adverse event – such as exposure to toxins in utero – there can be a “cascade” of effects. The lower part of the brain may be primarily affected, but because the child then becomes compromised in his ability to regulate stress, subsequent development of all the interrelated parts of the brain and body may be affected. That is the reason why children born into homes that suffer chronic poverty, domestic violence, and substance abuse, for example, are more likely to have problems with their emotions, their relationships, and learning.

The neural networks of the stress response system are in dynamic equilibrium. Too high a level of stress-inducing novelty will activate the system in order to lower the stress. Too low a level of novelty will cause the system to increase stimulation to restore alertness. When a child experiences repetitive, unpredictable, stressful events, her stress regulation system will be sensitized, lowering her set point and causing her to be more vulnerable to similar stresses in the future and to react with a more extreme response. A child may be sensitized by a chaotic or violent home environment. He may also be sensitized by vulnerability caused by inherited developmental vulnerabilities or serious childhood illnesses. For example, a child who inherits genes associated with “autistic spectrum disorder” (I put this in quotes since I consider this a highly problematic diagnostic category.) may be highly stressed by making eye contact with another person. A child with this inherited vulnerability is sensitized early in life and will inevitably have multiple repetitive adverse experiences while living in what for another child might be a comfortable home life.

In order to change the regulatory set point of a stress response system in a healthy direction, it is necessary to activate the same system with small repetitive stressors that are organized in an appropriate pattern of dose and space. The last time I wrote about Bruce Perry, I introduced his idea of “dosing”, one that I find very important in my therapeutic work. This time Dr. Perry introduced another important concept, that of “spacing”. Dosing means that you apply a stressor but not in a dose that is beyond the capacity of the child to manage; you do not overwhelm him. Spacing means that you time the doses so that the child is prepared for another challenge. For example, if I am working with a child who becomes easily dysregulated by negative affect states, I am likely to accept her protestations that she really loves her little brother for some time before gently questioning them.

I will continue the discussion of how I use Bruce Perry’s ideas in my work with young children in my next blog, “Stress Regulation: From Theory to Practice”.

Bruce Perry, Lecture, U Mass Boston Infant Parent Mental Health Course, September 16, 2016

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Aggression in Early Childhood

Aggression is a good thing. It motivates initiatives – including learning, athletic effort, and healthy competition. Yet, good outcomes depend on the capacity to regulate aggression, and that is always a challenge. Self-regulation, as we have said many times in this blog, is a developmental competency that we keep working on throughout our lives. Self-regulation is a special challenge in early childhood, when it is just getting established, but it is a challenge at any age when we are under stress.

How do young children express aggression? They express it by running joyfully with their friends through the playground, by throwing a basketball or riding a tricycle fast, by shouting out the words of a song when cued, by laughing at a clown or shrieking with excitement at a magician. They also express it by pushing another child, by screaming, biting, or hitting, or by grabbing a toy away from a friend. What is the difference between these two ways of being aggressive? The difference is that the first way is adequately regulated; the aggression is under control. The second way is poorly regulated and out of control.

If children do not have adequate self-regulatory capacity to manage their aggression, they may express it with aggressive outbursts such as noted, but they also may express it by holding themselves tight – holding their bodies tight and holding on tightly to their emotions. That frightened, too-tight holding-on is intended to guard against an unwanted aggressive outburst and can manifest as excessive shyness or fear of speaking, or even as bodily problems such food pickiness or constipation. The reason that children fear the loss of control of aggression so much is that they are afraid of the destructive force of their aggression. Even if it is completely unrealistic that a small child could hurt an adult with an aggressive attack, children (out of their awareness) fear that this could happen. That can lead to nightmares of bad things happening to them or to their parents, whom they love and depend on. I want to stress that it is not the aggression that is bad, but it is the fear of losing control of it and harming someone that is bad for the child.

Why do some children have more difficulty managing aggression than others? Some children are temperamentally more sensitive, more active, or more intense. Some children have developmental difficulties that make it hard for them to “get it altogether” – from the point of view of regulation in various domains – motor, emotional, cognitive. Imagine how hard it would be to feel relaxed and confident if your body “didn’t listen to your mind”- that is what I sometimes say to impulsive children. Other children come from high conflict families in which overt or covert aggression presents a chronic threat. Still other children have histories of trauma – either directed at them or at a parent or even grandparent. Finally, some children have more than one of these reasons to have difficulty with aggression.

How can we help children develop the crucial competency? We can help them in three ways. First, we can create a safe situation in which both child and caregiver are not afraid. That usually means adequate and predictable adult supervision, predictable routines, and secure boundaries. Second, we can communicate tolerance of aggression and model constructive forms of aggression. For example, teachers who play basketball or tag with the children are helping the child experience the high arousal state of aggressive activity without the fear of losing control. At home, a parent’s skillful rough housing with a child can offer the same experience. Third, we can make it possible for children to practice aggressive activities without getting hurt or hurting others. Children cutting play dough with a wooden knife, crashing small cars into magnet tile constructions, and engaging in active playground activities are just a few ways I observed today at the preschool.

Our society has a strange and highly ambivalent relationship to aggression. Some parents in our culture prohibit pretend play with toy guns and soldiers, while others teach their children to shoot real guns. American television, video games, and movies are full of aggression. That puts parents in a difficult position, having to negotiate a reasonable balance between under and over controlling both their children’s aggressive behavior and the aggressive displays they are exposed to. There is no simple solution, but the guidelines as mentioned above are – demonstrate to your children a healthy attitude towards aggression; offer them a safe opportunity to take risks with their aggression and to practice using it; and give extra support to children with special sensitivities and needs so that they too can try out their emotions and test their bodies with exuberance.

Read this blog in Spanish.

Back to School Jitters

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It is back to school time again. Returning to school after summer vacation is a major transition. We have talked about transitions and what a challenge they are for everybody, especially for young children and vulnerable children of any age. Here are some ideas about how to make back to school time easier for everyone.

Try to Be Calm and Relaxed

Parents’ communication of anxiety to their child plays a significant role in the anxiety experienced by the child. Evidence for this influence is presented in a recent review of 15 studies addressing the question of the extent to which fear-relevant features of parental verbal communications affected the child (Percy et al, 2016). However, scientific studies are not necessary to convince teachers of this fact. Observations in a typical classroom offer support for this important dynamic. For example, I observed a father dropping off his 4-year old daughter, giving her a hug, and asking her, “Will you be all right, now?” She said, “Yes, Daddy.” The father responded, “Are you sure?”

In fact, much of this communication occurs nonverbally in parents’ behavior – such as lingering in the classroom, returning to the child after the initial good bye to add some information or give some advice. After the child is in the hands of the teacher, it is almost never a good idea for the parent to return if the child complains or even cries.

Positive Communication

For young child, the most effective way parents can support him or her at drop off is to communicate positive feelings about the experience, to “hand off” the child to a teacher, and to leave. For example, a parent might find a teacher and in the child’s presence tell the teacher something about the ride to school or the child’s excitement about the class activity planned for the day, reassure the child about who is picking up the child and when, give the child a hug, and say good bye.

Child’s anxiety

All children have some anxiety about returning to school – usually to a new classroom, a new teacher, and new classmates. Children express their anxiety in different ways. Most young children express their anxiety verbally and by clinging to a parent. Other children express it by running from one activity to another in a dysregulated manner. And others become more constrained, holding themselves in, sitting quietly and avoiding taking risks.

Some children are particularly vulnerable to separations and transitions and need extra support. Some need to bring a comforting object from home to help with the transition (although that object must usually be put away after the class begins). A goodbye ritual is helpful to all children. The parent can help the child hang up her coat, check the schedule for the day, wash her hands, etc. In some of the classrooms of the preschool where I work there is a “goodbye window” where parents can say another goodbye after they have exited the school building.

Listening to Your Child

Communicating positive expectations to the child does not mean that the parent – or teacher – refuses to listen to the child’s concerns. No matter how unrealistic the child’s fears might be, the adult must take them seriously as fears – not as reality – and validate them. For example, the child may say, “You won’t come to pick me up!” The parent must respond with some kind of acknowledgement of the child’s fear that he will be abandoned in this scary place, while also reassuring him that his fears are unjustified. For example, she might say, “That is such a scary thought, that I wouldn’t pick you up. I know you are scared. But you know that I really will pick you up at lunchtime and that Ms. Smith (the teacher) will take good care of you until then. You are going to have a cooking activity today. You know how much you love that!”

Familiarity with the School

Familiarity with the school helps too. Most schools have visiting days, but some children need time to familiarize themselves with the school without the noise and activity of many other children and parents. Other ways to help the child feel comfortable include coming to the school when it is not in session and playing on the playground (if that is permitted) or walking around the building and pointing out where the child’s classroom is located, where the parent will bring the child and pick her up.

Get to School On Time

Getting to school on time is important for many reasons. At the beginning of the school day the teachers have more availability to greet the child and parent than when groups of children and parents descend on the classroom. The classroom is less noisy and has less physical activity – sensory challenges that are particularly hard for some children. Being rushed does not lend itself to a positive good bye. Also, teachers usually plan “free play” time at the beginning of the day, and if children come to class late, they miss that important and enjoyable time.

Percy R, Creswell C, Garner M, O’Brien D, Murray L (2016). Parents’ verbal communication and childhood anxiety: a systematic review. Clinical Child and Family Psychology Review, 19(1):55-75.

Read this blog in Spanish.