Monthly Archives: June 2017

Interventions in Infancy

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.

Now we are ready to look at infancy. As a matter of a fact, this topic may be relevant to parents of preschool children, since these parents are often having second or third children when their first is in preschool. What we are talking about is showing parents what they can do to help their babies feel secure. If babies feel secure and safe in the infant-parent relationship, they are creating the expectation that reunion with their parent will bring comfort and safety. That expectation is correlated with a “secure attachment strategy”. When the baby is upset and cannot manage to comfort himself, he anticipates that his mother (or other primary caregiver) will comfort him, so when his mother approaches, he already begins to calm down.

The infant mental health mini-course that the nonprofit organization, Supporting Child Caregivers (SCC), teaches emphasizes the three tasks of parents – to protect, nurture, and enjoy their children. We believe that parents deserve the support of the community in raising their children. That support begins with ensuring the physical and emotional support of the pregnant mother and continuing to support the parents of the growing child. The more parents can be protected from stress, or the more they can be helped to deal with the stress in their lives, the more they can help their babies feel secure. Of course, stress can come in different packages. Most of the work SCC does is in developing countries, where there is a high incidence of chronic poverty, domestic violence, and serious illness.

However, my work in the U.S. has taught me that the stress on parents of infants even in affluent communities can be great. One important source of stress is isolation. In contrast with collectivist societies, our society does not offer new mothers easy access to alternative caregivers such as family members or neighbors. In the Indian villages I visit, mothers congregate around the village square. In the U.S., new mothers often do not have a natural way of connecting with other mothers with whom to share their worries and complaints and to gain useful information. I want to emphasize that I am not suggesting it is easier to bring up an infant in a poor country, but only that in addition to similar stresses, there are also different ones.

For example, parents of newborns in the U.S. are often burdened by the cultural demand to “multi-task”. In order to feel productive and organized they believe they must be getting many things done. It is hard to do that when you have a newborn. In order to be available to respond to the baby, it is necessary to let go of most other agendas. This can be stressful to some parents. Also, in the age of technology, parents are often “plugged in”. It is painful to observe mothers pushing their babies in strollers while they talk on their mobile phones to some distant friend, and to imagine what their sense their babies are making of the relationship.

Another big stress in Western culture is the responsibility given to parents to produce a perfect child. The expectation that good parenting produces a good child is a relatively recent one in the history of humankind. The corollary can lead to relentless self criticism- if your child has problems, then you are not a good parent. Let me clarify an important point. Whereas I have been emphasizing sensitive and responsive caregiving as a building block of healthy development, I do not mean to say that good caregiving ensures a healthy child. This is part of what I was referring to in the previous post as “uniqueness” of the child and the family.

Children are different. Infants are different. Ask any parent of more than one child whether this is true. One of my criticisms of Attachment Theory is that it does not account for the uniqueness of infants and the active role they have in making meanings about safety in the infant-parent relationship. Do we doubt that a premature infant makes the same meanings about comfort and safety as a full term baby, or that a baby with high reactive temperament can be made to feel secure as easily as a baby with an easy temperament?

Let me talk about interventions in the next posting.

Other Alternatives to the “Little Girl with a Curl” Problem

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The second option is consultation to the parents, for example, video feedback. This can be a very effective way of showing parents in visual form the nonverbal communication they might be unconsciously giving their child. The therapy takes the form of the therapist’s analyzing videotapes taken in the therapist’s office, or sometimes in the family’s home, and then looking at them together with the parents. For example, in one family video of mine, the father was stretched out across the floor in a supplicating position, trying to get his son to comply with my request that they play together. (Remember that effective limit setting contributes in important ways to the child’s sense of security.)

Feedback like this is usually followed by an invitation for parents to talk about what they might have been feeling that motivated the behavior they saw on videotape. Often, the self-reflection initiated by the video images helps the parents identify inner conflicts that interfere with their conscious intention of setting limits on their child’s behavior. For example, in this case, the father might recall the way he felt controlled by his mother when he was a small boy. This unconscious identification with his son might be influencing his difficulty collaborating with his wife in setting limits on the boy’s behavior. The main drawback in using this excellent technique is expertise. It is very difficult to analyze videotape and relatively few clinicians are trained in it.

The third option is dyadic or family therapy. This option is a good choice in that it can help both parent and child (or the whole family) become more aware of the way they actually behave in relation to one another in contrast with the way they imagine they behave. With reference to Attachment Theory, the therapist might be seen as a new source of security, creating a sense of safety experienced by both parent and child, and allowing both to take risks at trying new approaches that might have seemed too difficult at home.

There are many schools of family therapy. For example, there is “structural family therapy” in which the therapist focuses on identifying dysfunctional patterns of relationships within the family and disrupting them in the service of creating more adaptive ones. By contrast, a psychodynamic family therapy might focus primarily on the symbolic themes presented by the family in a play session. For example, in one family meeting, the “problem child” instructed his parents to “help (him) herd the animals into the barn because a big storm is coming!” Despite the parents’ conscious intention to support their son’s agenda, the play ended without getting the animals into the barn. The therapist thought that the family was showing her their problem – they were showing her how helpless they all felt to contain the impulsive aggressive outbursts of this little boy (“the storm”).

The final option is individual psychotherapy – play therapy – for the child, plus parent meetings. Play therapy requires a therapist who is trained in psychodynamic psychotherapy. That means that the therapist has learned to make sense of the symbolic representation in play of the child’s inner world. For example, if the child anxiously fingers a broken toy and then moves to play with something else, the therapist might imagine that he is afraid of his own or someone else’s aggression and its destructive potential, and the therapist will attempt to explore the child’s more elaborated fantasies. In this case, the fantasies might be about the child’s fear that his aggressive behavior towards his mother will hurt her and destroy their relationship, making him a bad boy and causing him to be abandoned. The therapist might then slowly support the child’s capacity to reflect on these fantasies, gaining insight into what thoughts and feelings motivate the aggression – for example, that the mother loves his sister better than him – and helping him discover a more complex landscape of meanings than the polarized all bad and all good ones the child started with. The work with the parents will focus at least in part on helping the parents understand their child better, gain empathy for him, and learn new approaches to setting limits. For example, in this case, the mother might find ways to help her son make a repair after hurting her, instead of punishing him with a lengthy time out.

It is hard to describe these complicated processes in such an abbreviated way, but I have tried to offer you some ideas about what to do to try to make the “Little Girl with a Curl” problem better. Returning to Attachment, you can see that problems with roots in infancy can be approached in various ways later on; there are many ports of entry. Each individual is unique and will make different meanings of themselves and their family relationships. I will talk more about this uniqueness and its relationship to Attachment Theory in my posting on interventions in infancy.

Growing the Attachment Strategies of Preschool Children

The Problem of “The Little Girl with a Curl”

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A particular problem has come to my attention over the years consulting to a preschool – children behaving in controlling and sometimes aggressive ways to parents at school transitions. Teachers report that the child behaves badly with his or her parents at drop off and pick up. Often the teachers express amazement that the children who seems well behaved in school, can change dramatically when they are with their parents – boss them around, even push or hit them. Another behavior characteristic of this problem is the child running away from the parent or refusing to come with them at pick up time. It is difficult for even the most empathic teacher to avoid the suspicion that the parents are somehow allowing their child to mistreat them by not setting adequate limits for the child. Supportive evidence is sometimes found in parents restraining from disciplining their children in the school.

This situation reminds me of a Mother Goose rhyme that my parents read me when I was a young child about a “little girl with a curl”. The rhyme goes, “There was a little girl who had a little curl, right in the middle of her forehead. When she was good, she was very, very good. But when she was bad, she was horrid.” I always secretly worried that I might be that girl.

Perhaps partly for that reason, I have given this problem a good deal of thought. My conclusion is that the answer to the mystery of the “little girl with a curl” mystery is rather complicated. The reason I say this is that when I talk to the parents of these children, I get a wide variety of answers about their child’s behavior in different settings. Some children are relatively well behaved in most settings and become suddenly noncompliant and belligerent at pick up time. Other children are compliant when they are involved in activities but become disorganized and unhappy during unstructured time at home and in school. Some children are usually cooperative but have difficulty with all significant transitions – bedtime, getting up time, leaving an activity, etc. Other children are always a handful.

What ties together all the children who fuss at pick up time and behave defiantly with their parents but not necessarily with their teachers? All these children are expressing difficulty with finding a positive strategy for reuniting with their parent. The subject of reunion strategies falls into the domain of a theory that informs much current developmental research and that has now also become popular in the vernacular – Attachment Theory. I have talked about Attachment Theory in other blog postings, because of its importance in research. The essential feature of Attachment Theory is that it presents the infant’s essential motivation as staying close to the parent in order to feel safe and secure. If the infant achieves the capacity to feel secure in his relationship to his mother, then he is free to explore the world, knowing that he can easily return to the safety of that connection.

We know that an important but primitive response to threat is running away or aggression. Remember that the “fight or flight” response of the sympathetic nervous system is one of the main “bottom up” as opposed to “top down” responses of the stress regulation system. That means that we must feel confident in our capacity to achieve security in order to use our thinking brain to tell us what we should do in a threatening situation. Transitions are inherently threatening, even small ones, because they require us to disorganize ourselves on the way to a new organization. That is, we have to stop playing in the sandbox in order to join Mother, get into the car, stay still in the car seat, etc. Playing in the sandbox is a complex organization involving a cognitive plan (building a castle), a motor rhythm (dig, pour, pat; dig, pour, pat), an affective and physiological state (contented, calm); and maybe even a compelling interpersonal experience (collaboration or competition with a peer). That is a lot to take apart in order to get into the car. And the hardest part is the disorganization in between the sandbox play and the car seat, between one organized state and the other. How do children manage that transition? It starts in infancy with the regulatory aid of the parent.

These interpersonal regulatory patterns that start in infancy gain power and stability as parent and child repeat them over and over again during the course of daily life. One pattern, that Attachment Theory would call “secure”, is demonstrated by the parent-child dyad who are able to support the child in managing all these disorganizing (and therefore threatening) experiences of – letting go his plan of building the castle, discontinuing the motor rhythm, interrupting the calm and contentment, and giving up the competition or collaboration – and maintaining adequate regulation and sense of security until the new car seat organization is established. I say “parent-child dyad” because I do not see this activity of facilitation transition as emanating exclusively from the parent. Although sophisticated advocates of Attachment Theory would probably agree with me, Attachment Theory largely tends to place the responsibility squarely on the mother, who carries attachment patterns within her even before her child is born, according to the AAI.

I will tell you how I use these thoughts about Attachment Theory in my search for answers to the “girl with a curl” problem in my next posting.