How Can Teachers Respond Optimally to a Child’s Temperament?

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How Can Teachers Respond Optimally to a Child’s Temperament?

Teachers’ concerns typically focus on young high reactive(HR) children’s withdrawn or constrained behavior – their preference to watch other children play rather than to join them; their hesitancy in physical games on the playground; their clinging to a parent at drop off; their reluctance to enjoy messy sensory stimulating activities; and their general reluctance to take risks, especially in unfamiliar situations. Often, teachers organize their observations in functional categories such as “separation”, or “peer relationships”. Of course, there can be many reasons why children cling to their parents at drop off or why they do not play with their peers (see below).

In order to identify a HR child, you must listen carefully to the parents. The first clue parents will tell you is that “I was very shy myself.” The second clue is “She is completely different at home – outgoing, active, playful.” The first clue is important, because as we noted in the first posting of this sequence, temperament has an important genetic component. The second is important because HR temperament is primarily about an excitable limbic system. That means that the child is more sensitive to the perception of threat, and the new, the novel, the unpredictable, are threatening. Home is usually familiar and unthreatening. Because of this important factor, I have begun to do home visits when I consult to teachers and parents of children whose teachers have these concerns.

One such child was a 4-yo girl I will call “Jessica”. Her parents described her as loving, sweet, empathic, and smart. She was also “really shy”, and they worried that she was “not comfortable in her skin”. At home, she was confident, free, and creative, but at school she didn’t show these traits. She preferred to play with the teachers instead of the other children. When she went to birthday parties, she retreated into her shell, hiding under her mother’s sweater. Her preschool teachers suggested the consultation because of their concern that she was not engaging with her peers.

“Melinda”, another child, was 3-yo when her teachers expressed concern to her parents that she did not play with her classmates but sat quietly doing activities on her own. Although she looked content, they could not really tell how she was feeling and what she was thinking. On the playground, she liked to swing on one particular swing and got quite upset if that swing happened to be taken by another child.

4-yo “Benjamin” was a quiet, pleasant child whose teachers had to place limits on the time he spent with a girl classmate, Hannah, since she began to look uncomfortable with the degree of physical contact between them, as he insisted on holding her hand and sitting so close to her that he was always touching her. Benjamin explained that he loved Hannah and wanted to marry her, but Hannah complained that she wanted to play with some other friends in addition to Benjamin. In response to the teachers’ limits, Benjamin slowly began to play with other children and has now made a number of friends. Even so, he was often found sitting quietly alone at a table, busy with an activity put out for the children that day.

In the case of each of these children, the teachers balanced their encouragement to take risks in the classroom against their acceptance of the children’s need to “take their time”. As time passed, each child became more comfortable in the classroom. Jessica became animated and playful with the other children. Melinda began to play with her peers and ceded her favorite swing to other children. Benjamin even began to assert himself when another child started to boss him around. It is unclear what precipitated the transformation in each child’s behavior, what allowed these children to be more comfortable in school. In one case the birth of a sibling seemed to introduce possibilities of greater competencies and higher status. In another case my home visit may have been reassuring to the parents. In the third case, the teachers’ more active coaching in social situations combined with acceptance to private school may have been instrumental. Most likely, a combination of these factors played a role. However, the easing of pressure of some sort plus the introduction of new positive possibilities for the future must have figured in all the changes. In any case, we will never know for sure.

Other Reasons for Children to Withdraw:

One important acknowledgement is that there is a large overlap between temperament and sensory processing. Most children with HR temperament have some sensory sensitivities. It is also that children may withdraw if they are sad or depressed. Finally, children with other processing difficulties – for example, auditory processing in which case they have difficulty making sense of verbal communications – may withdraw. In older children, learning disabilities may cause them to “give up”.

How Can Parents Respond Optimally to a Child’s Temperament?

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There is evidence that infant reactivity is related to the predisposition to have an excitable limbic system. There is also evidence that there is influence in uterine environment that can affect temperament. But biology is not destiny. There are ways that parents and teachers can help HR children moderate the effects of their high sensitivity.

The balance between protecting and promoting is a challenge for all parents to achieve, but it is an even greater challenge for parents of HR children. By protecting, I mean softening the bumps in the road of life – allowing the child to stay home from a birthday party or speaking for the child when he greeted by an unfamiliar person. By promoting, I mean insisting that the child take the risks that he needs to take to build a strong body and acquire necessary skills, such as eat healthy foods and engage in physical activity. Often the parents of HR children tone down their expectations of their child, either because they fear the child will fall apart when required to take the risk, or because they “know their child’s limits” and have rationalized a permissive parenting style. Other times, parents of HR children push the child beyond her limits and cause her to withdraw further or “give up”. Even good parents can err in either direction. Sometimes one parent takes one position and the second parent takes the other. This is particularly problematic because the polarization that results increases the stress on the whole family and erodes parental collaboration.

How can parents find this balance? First of all, there is not one balance to achieve. Each family must experiment until they find the “right” balance for their family – and since families and especially children are always changing – the trial and error efforts never really end. Snidman reported that researchers who did extensive home visits on 4 families – half HR and half LR babies – found that in the HR cases the mothers who set firmer limits on their children’s behavior helped their children feel more comfortable taking risks. In the case of the LR children, the mothers’ behavior made little difference. Of course, this is a study with a very small n despite the extensive observational data, but it is consistent with my clinical experience. By setting limits on their HR children’s behavior, parents communicate to their children their comfort with their children’s initiative. It is also true that setting limits can slip into a struggle pattern, and that is a problem to be avoided if at all possible. In my experience, it is easier to get into struggles with a HR child then with a LR child. That is because stress causes everybody to expend energy in order to manage it, and that drains energy, pulling everybody in the direction of simpler, more reactive behaviors. Struggles definitely involve simple, reactive behaviors. The HR child is always under more stress than the LR child, and this is especially true when faced with a challenge. Those of you with HR children will recognize the dread provoked by adding an additional demand to the morning routine.

The ideal to work towards is one in which you “choose your battles” and support a child in taking health-promoting risks up a point, then protecting him if he shows that it is too much for him. These caregiving behaviors are always evolving and frequently include corrections or “repairs”. Corrections and repairs are not something to be afraid of. They are what we learn from.

I will discuss the ways teachers can respond to a HR child in the next posting.

Why is Temperament Important to Parents and Teachers?

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Roughly 10-20% Caucasian children are shy and hesitant in unfamiliar situations. Another 10-20% are sociable and intrepid in response to novelty. The underlying features of these predispositions usually referred to as “temperament”, remain remarkably consistent over time. It has also been found that the caregiving environment in the early years can significantly influence the behaviors characteristic of these temperaments. That makes the study of temperament particularly relevant to this blog.

Nancy Snidman, a colleague of the pioneer researcher in temperament, defines temperament as a “predisposition to respond to the environment in certain ways” (lecture to UMB IPMHPCP, March 6, 2016). The baby comes into the world with certain temperamental qualities. These temperamental qualities may be due to genetics or epigenetics – influences from the environment in the womb. Children’s temperament influences the way they react to their environment – physical, social, and emotional. For example, a child’s temperament affects the way they react to novelty, sensory stimulation, or transitions. How does temperament at infancy translate to temperamental characteristics such as shyness in a preschool child? What does the “shy” infant look like as an older child or adult? Snidman and Kagan did a series of longitudinal studies to try to answer these questions.

Kagan and Snidman studied 400, 4-month old babies and classified them as high reactive (HR) and low reactive (LR) on the basis of their response to auditory, visual, and olfactory stimuli. They observed the babies’ responses in the form of heart rate increase, motor arousal (such as limb flexion and extension, motor tension, and back arch) and fretting or crying. They looked for the extremes of HR and LR babies and started to follow them.

They postulated that the HR children had inherited a low threshold of excitability in the amygdala; a part of the mid-brain called the limbic system, and the related limbic areas. The amygdala sends signals to the autonomic nervous system, communicating a sense of threat in the environment.

They studied the babies’ physiology and behavior in response to a number of laboratory procedures, from 9 months to 15 years. Some of these procedures were mild, such as puppets or tasting sweet and sour liquids, and some were more challenging, such as a toy robot and a stranger approaching wearing a lab coat and a gas mask. The two extreme styles of temperament, HR or LR, or behaviorally inhibited (BI) – shy, wary of novelty, slow to approach, or behaviorally uninhibited (BU) – sociable, comfortable with novelty, were remarkably consistent over the years.

Interestingly, the researchers found that as the kids got older the physiological markers were more important than the behavioral ones. This was because the children were taught to be polite. It was less the general behavior to strangers that distinguished the HR from the LR kids, and more the smiles and spontaneous comments. When children are presented with the same stimuli in repeated exposures, for example when they are shown invalid pictures (a horse head on a fish body), they usually habituate to the stimulus. That means their reaction becomes smaller with repeated exposures. In the case of HR kids, however, there is no habituation! That means that although they look more and more like their LR peers in terms of social behavior, their heart rate, pupillary dilatation, muscle tension, and stress hormones remain more reactive.

This is very interesting to me in my work with children and families. For more than two decades, Attachment Theory has dominated research in child psychology. This way of understanding child development minimizes the contribution of temperament. Yet, I have found temperament a very useful way of making sense of some of the problems that parents bring to me regarding their children’s behavior. It is also helpful to me when I consult to preschool teachers. In the next blog posting I will describe how I use ideas of temperament to help parents and teachers understand the children in their care.

Readings

Schwartz C, Snidman N, Kagan J (1999). Adolescent social anxiety as an outcome of inhibited temperament in childhood, JAACAP 38(8):1008-1015.

Kagan J (1997) Temperament and the reactions to unfamiliarity, Child Development 68(1):139-143.

Kagan J (1989). Temperamental contributions to social behavior, American Psychologist 44(4):668-674.

Family Fights: Changing “Bad Habits”

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The mother of a family in my practice recently complained to me about her 11-yo son’s meltdowns. She told me that he provokes his siblings by criticizing them, getting into their space, or insulting them in some way or another. He is very reactive, and it takes very little to provoke him into a rage. He doesn’t seem to hold himself accountable for any of his actions. For example, the night before, he kicked her under the dinner table, and when she told him to stop, he said that he hadn’t done anything. This denial of responsibility is typical. She said she knows I say that if anyone in a family has a problem, then the whole family has a problem, but she can’t figure out what she and the boy’s father are doing to contribute to his meltdowns.
I told her that it is common for families to develop bad habits. I call this bad habit the “struggle pattern”. Usually, it is one child who generates the negative feelings that motivate the interactions that become organized into a family “habit”. In these habits, each family member plays a particular role, even though they don’t recognize that they are doing so. Typically, the “problem” child (PC) will provoke and the parent will respond with a prohibition. The PC will then up the ante with further provocation, and the parent will continue to prohibit. Often, the actions on both the parent’s and child’s parts will escalate until everyone feels distraught and out of control.
It is interesting to consider what starts everything off. Sometimes the PC has had a hard day and doesn’t have the resources to reflect on that experience and talk to the parents about it in order to be comforted. Often the PC has the capacity to reflect on his inner experience when he is calm and comfortable, but has difficulty with stress regulation and loses this important self-reflective capacity when he is stressed. This is also true of parents, and sometimes it is the parent who has had a hard day and unconsciously provokes the child (such as by making a slightly unreasonable demand at a time when the child might be expected to be vulnerable.) In either case, the spark of the provocation ignites a fight that gives everyone a chance to express their frustration and aggression, but in a highly maladaptive way. No one feels good after this kind of fight, and to make it worse, it just strengthens the struggle pattern within the family and inside each of the family members’ brains. Sometimes the resolution of the fight is a tearful reconciliation with professions of love. This is not the best resolution, because it usually does not unpack the interaction to allow for positive change and even adds a reward to trick everyone into thinking everything is all right.
What I suggested to this mother and to other parents to try to avoid these bad habits is 3 things:
1. Identify the turning point. Experiment with identifying the moment when the interaction could begin to escalate and ask the child to take some time out, or the parent can leave if that is more convenient. The main idea is for the parent to make some distance between them.
2. Change up the process. Do not respond to any provocation. If the child denies his action, ignore it. Do not try to reason with the child. Instead, say something about starting over or “press the reset button” or something like that. If that doesn’t work, move to item 4 below. When everyone is calm, then discuss what just happened without assigning blame. The focus should be on learning how to do things better in the future.
3. Practice the new way of doing things again and again. Families move like molasses in January. They change very slowly. That means that you have to practice new and better ways of interacting over and over again. Another good cliché is “neurons that fire together, wire together”, meaning that when you practice non-struggle patterns over and over, you are building new neural circuits in everyone in the family’s brains and they will gradually erode the neural circuits governing the struggle pattern.
What to do after the struggle has started,
4. Get space. Sometimes it only takes walking to the next room. Taking a deep breath and counting to 10 help too. Listening to music can help. Anything you can do to regulate yourself is good.
5. Take time. Time is also important to reestablish a calm regulatory state.
6. Reflect. When you are calm, you can reflect on what just happened and identify what you did to contribute to the old struggle pattern. When you rejoin your child to discuss the matter, do not over-apologize. That muddies the water. Take responsibility for your part, but not for the part played by your child. Once you separate out your part, his part should be easier for him to manage, if not this time, then after more practice.

A Message for the Holidays: Finding a Way to Say I Love You

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A mother I know has a 12-yo daughter who goes to school away from home. This girl, whom I will call “Mona”, can sometimes seem unresponsive to her parents. For example, when her parents come to pick her up at school, she may at first appear to ignore them instead of running to greet them with the enthusiasm the other girls show their parents. Mona also struggles in school and requires academic support. Her development has been atypical; neuropsychological testing suggests that using language to make sense of her world is a particular challenge. Even making sense of her bodily sensations may escape her so that she neglects to put on her coat when it is cold outside. It also seems that picking up cues about others’ feelings and from her own emotional state is difficult for her. This does not mean that Mona is without feelings or insensitive. She in fact feels things deeply and can be very sensitive to others. It is just that it sometimes takes her more time or more energy to achieve a state of responsiveness. She needs to “put it together” instead of it smoothly coming into place the way it does for people with typical development. Because her internal world is often confused or poorly integrated, she can be hard to “read”. She is not an easy child to parent.

One time, on the way to pick Mona up at school, her mother was reflecting on some of the frustration and disappointment she and Mona’s father felt in their relationship with her. She decided that she would have to search for a better way of expressing her love for her daughter, one that Mona could “hear” better than conventional ways. She was particularly conscious of Mona’s embarrassment at expressing feelings for her parents in front of the other girls. When they met, she said, “You know, Mona. I was thinking on the way here that I always say, “I love you, I love you,” but that doesn’t really capture the depth of the feeling I have for you. We have to think up our own words for it.” The next day, a thought occurred to her. She spoke to Mona again. She said, “I thought of it, Mona. ‘I glove you’. Mona’s mother was thinking of surrounding her daughter with her love, the way a glove surrounds her hand. It may also be that she was thinking of her wish to protect her daughter from the cold in a way that Mona herself sometimes seemed unable to do. Finally and perhaps most important, in her suggestion that they “think up our own words for it”, her mother was showing Mona that together they could be creative in the ways they communicate their feelings to each other. They did not have to restrict themselves to conventional language. The next day when they said goodbye to each other, her mother held up her hand. Mona smiled and raised her hand.

Mona’s birthday is close to Christmas. This year her mother wanted to make something special for her. Instead of typical Christmas decorations on their tree, her mother decorated it with different colored gloves. While the tree is very attractive, it also has special meaning for Mona and her mother. It is a way to say, “I love you” without words. It captures new possibilities for mutual understanding and for ways of growing their relationship. Maybe it is a way of saying “Happy New Year” for next year and for the future. As I always say, parenting is a creative enterprise.

Day 2 of Joy Osofsky at IPMH

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The following day Joy Osofsky talked about trauma. She outlined ways in which children can be traumatized by adverse childhood experiences as noted in the “ACE” study, in the 1990’s, . She talked about how trauma affects children’s cognition, behaviors, emotions, and brain architecture. Finally, she described several ways traumatic sequelae can be healed. I would like to think of these issues in terms of a spectrum from normative stress, which can be positive, to trauma, with “tolerable” and “toxic stress” in the middle. I will explain more about this spectrum later on, but I want to introduce the idea of a spectrum of stress at this point, because I believe that much of what Joy was talking about in terms of trauma can also be true in situations of high stress – especially when it is prolonged – that do not reach the level of actual trauma.

Children are traumatized by child maltreatment; exposure to community violence in their neighborhoods and in their schools; exposure to domestic violence in their homes; exposure to or hearing about unusual traumatic events such as accidents, terrorist attacks, or hurricanes; military children when their parents are deployed; and exposure to violence in media (usually the effects of an earlier trauma will be exacerbated by subsequent exposure to media).

Joy and her husband were leaders in the psychological response to Katrina in New Orleans. She notes that the psychosocial impact of natural disasters can be similar to that of trauma. The impact is related to the disruption of family structures, changes in the ways people and communities relate to each other, and the taxing effect on the individual, family, school, and community infrastructure. The psychological referral rate for students was very high after Katrina and then declined, but subsequent smaller spikes seem to reflect retraumatization from other hurricanes, oil spills, etc. A child in my hospital clinic began waking up with nightmares after hearing Donald Trump on television saying that all Mexican immigrants should be deported, because she feared that she would lose her parents.

Interestingly, in New Orleans, the children who were integrated into East Baton Rouge schools had higher depression rates than the children who were able to return to their New Orleans schools. This seems to relate to the importance of a “sense of place”. Another window into trauma is the child welfare system, where children have experienced family violence, substance abuse, sexual abuse, removal from primary caregiver, subsequent placement in foster care, and physical abuse.

Trauma alters the developmental trajectory of the child. Joy referred to the children’s book, The Little Engine That Could. She said that trauma pushes the train off the track, and our job as mental health professionals is to help put the little train back on the track. Joy noted the continuum from stress to trauma, starting with normative, developmentally appropriate stress, then emotionally costly stress, sometimes called “toxic stress”, and finally trauma. Positive stress is necessary to healthy development. It occurs in the context of stable, supportive relationships and results in brief increases in heart rate and mild changes in stress hormone levels. Tolerable stress includes stress responses that could disrupt brain architecture but are buffered by supportive relationships that make it possible for the brain to heal. Toxic stress involves a strong, prolonged activation of the body’s stress response system in the absence of the buffering protection of adult support. Toxic stress can damage the developing brain architecture and create a short fuse for the body’s stress response systems, leading to lifelong problems in learning, behavior, and both physical and mental health.

IPMH Joy Osofsky Weekend

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I am catching up on my infant parent postings by writing about a wonderful weekend with Joy Osofsky last month. In her first day of her teaching Joy began by introducing us to three evidence based interventions for very young children – Attachment and Bio-behavioral Catch-up (ABC),  Parent Child Interaction Therapy (PCIT), and Child-Parent Psychotherapy (CPP),  Although not exclusively used for this purpose, these interventions were designed to treat traumatized young children and their parents.

ABC is an intervention for parents of young children who have experienced adversity that helps parents recognize their children’s problematic coping strategies and recognize their own problematic parenting behaviors, so that they can create a caregiving environment that promotes their children’s bio-behavioral regulation. The intervention takes place in 10 sessions that target key issues for traumatized children and is manualized, though the relationship between the clinician and the parent is crucial to the success of the treatment. This intervention is particularly useful for foster parents of infants of toddlers 1-3-years old, high risk birth parents of infants and toddlers, and parents adopting internationally.

Two main emphases of ABC intervention are that (1) some children reject their caregivers even though they need nurturance, and (2) parents can sometimes behave in ways that frighten children, often without realizing it. When traumatized children behave in rejecting ways, their parents must learn to re-interpret their signals so that they can respond to them with effective nurturance. Also, parents who have been traumatized or frightened as young children will sometimes display an angry or frightened face to their child or even “tune out” (“dissociate”) in a way that may frighten a child. Parents with troubled past histories may also misinterpret their children’s expressions of distress and fail to respond in a comforting way. This intervention teaches parents to recognize patterns such as these in their own behavior and in that of their children so that they can learn optimal patterns of parenting behavior. These optimal behaviors include following the child’s lead with delight, attending to the child’s signals, supporting the child’s agency, and the importance of touch.

An interesting feature of this intervention is that of encouraging the parent to provide nurturance even if it doesn’t come naturally – “fake it until you make it”, as I say. We know that practicing a behavior can build new neural circuits in the brain, and ABC attempts to override the parents’ own problematic tendencies by building good nurturing behaviors that are practiced and reinforced in the relationship with the clinician. In this intervention, the parent’s problematic past is directly addressed as it is currently represented in the parent’s behavior towards her child.

PCIT is an intervention in which the clinician behind a two-way mirror coaches the parent through a bug in the parent’s ear. This is a strictly behavioral approach that incudes elements of family systems theory, learning theory, and traditional play therapy. The emphasis is on restructuring parent-child patterns, rather than modifying target behaviors. PCIT is designed to be most effective in treating disruptive behaviors. In this intervention, parents are not blamed but are given responsibility for improving their child’s behavior.

Decisions about family preservation, reunification, or permanency need to be made prior to beginning a course of PCIT, which takes place in 14-21 weekly sessions. Some of the limitations of PCIT are that it focuses on the child’s behavioral problems and parent skills but not on domestic violence, substance abuse, or parent psychopathology.

The third intervention, CPP, focuses on current stress and trauma as well as “ghosts from the nursery” in the past of the parents. This phrase is the title of a famous paper by Selma Fraiberg, a pioneer of parent-infant mental health and refers to traumatic experiences in the parents’ past that haunt them when they become parents themselves (Fraiberg, Adelson, & Shapiro, 1987). This intervention is also manualized and multi-theoretical.
The intervention uses play, physical contact, and language to further the child’s development. Symbolic play is used to create a “trauma narrative”. Games are used to help with emotional and physical regulation – such as blowing, patting, and breathing games. Mazes and other games are used to help a child gain a sense of his body in space, and touch is used to restore trust in physical contact. Another way of describing this intervention is that it is a combination of play and “unstructured developmental guidance”. Important feature of this guidance are to help the parent understand appropriate developmental expectations of their young child and to help both parent and child name and cope with strong feelings. In addition to modeling good parenting behaviors and offering concrete assistance, such as with safe housing, the clinician makes interpretations linking present to past and distant past, “ghosts in the nursery”. These interpretations create the “trauma narrative”.

An interesting and I think important study of the factors disrupting and facilitating emotion regulation is being conducted by a group in New York and Geneva. They suggest that the child’s helplessness, fear, and rage can elicit traumatic memory traces in the mother with PTSD (“ghosts in the nursery”) and propose to help the mother change her behavior in a similar way to the ABC protocol but with videotape feedback. Since I am familiar with videotape feedback and a big believer in its effectiveness, I am awaiting the results of this study with anticipation (Schachter and Rusconi Serpa, 2014).
Fraiberg, S., Adelson, E., & Shapiro, V. (1987). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant– mother relationships. In S. Fraiberg (Ed.), Selected writings of Selma Fraiberg (pp. 101–136). Columbus: Ohio State University Press.

Schechter D, Rusconi Serpa S (2014). Understanding how traumatized mothers process their toddlers’ affective communication under stress: towards preventive intervention for families at high risk for intergenerational violence, in R Emde and M Leuzinger-Bohleber, Eds., Early Parenting and Prevention of Disorder, Karnac Press, pp. 90-117.

 

Bathroom Problems I: Soiling or Encopresis

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Many of the children whose parents consult me suffer from a condition called encopresis, or soiling, a distressing problem that is diagnosed in children older than 4-years old.  Encopresis usually starts with constipation. If a child experiences pain when passing a hard or large stool, it is common for the child to tighten up and hold back in response to the urge to defecate.  This of course makes the constipation worse, and often soft stool from higher in the gut leaks around the hard mass in the colon, causing soiling.

The first step in dealing with this problem is to go to the pediatrician. Good medical care is essential to the treatment of these symptoms. If the constipation is not treated the withholding is likely to continue and may cause anatomical changes in the gut such as stretching of the muscular intestinal wall. Children who suffer from chronic constipation may also develop a disturbed coordination of muscle function in the anal sphincter. Medical treatment often involves stool softeners that draw water into the gut and soften the stool, making it easier and less painful to pass. There are other more vigorous and more intrusive interventions that can be used if necessary.

Pediatricians also often recommend behavioral plans. The most effective behavioral plan is for parents to gently but firmly insist that the child sit on the toilet after mealtimes – usually breakfast and supper – twice a day for 5-10 minutes. The natural movements of the intestines after meals aid in defecation. Sometimes small rewards or star charts help motivate children to follow through with this plan.

If this is a typical pediatric problem, why is it a concern for a child psychiatrist? The main reason is that there are three groups of children who might come to me for another reason who are also prone to having encopresis. The first is anxious children, the second is aggressive children, and the third is children with developmental problems such as attention deficit disorder (ADHD) or  autistic spectrum disorders (ASD).

When I describe anxious and aggressive children as belonging to different groups I am only referring to their outward behavior. Most anxious children are afraid of the destructive potential of their own aggression (even if their general behavior is timid and withdrawn). Similarly, children with aggressive behavior usually struggle with the fear that their aggression will get out of control and hurt someone – especially a family member or themselves.  What is a natural response to the fear of something dangerous getting of control? Control it! In other words, hold it in. Since children make meaning with and about their bodies even more than adults do, they “hold it in” concretely and physically. This psychological meaning almost always occurs simultaneously with the biological meaning of the threat of passing a hard stool. In my office practice, it is common for a child who allows himself to freely play an aggressive theme, such as dinosaurs biting each other, to interrupt the play and go into the bathroom to poop.

Children with developmental problems are even more interesting. In addition to all the other reasons mentioned above, they have difficulty picking up their body’s cues such as the urge to defecate. This is because they have trouble paying attention to their body’s signals and also because they sometimes cannot decipher them. Some children with ASD need to be told to put on a coat or mittens when it is cold outside since they don’t notice the cold feeling without help. (Readers may be surprised when I link the diagnoses ADHD and ASD in the general category of developmental problems, but I think that is the most sensible way to understand them.)

Helping children with their fears and helping them learn to pay attention to the signals their bodies send them is very important, but nothing can take the place of a regular bathroom routine of sitting on the toilet for 5-10 minutes after breakfast and supper. So why do parents find this so difficult to do? One reason is that the child who is afraid of passing a painful stool will object, and parents of fearful children often have trouble insisting that they face challenges that frighten them. Another reason is that the child with attentional problems or the child who has trouble reading body cues will often “tune out” while sitting on the toilet (sometimes get lost in a book). While “tuning out” will sometimes not prevent a bowel movement, the child who is not paying attention to his body will not learn how to respond to his body’s signals. That is why I do not recommend letting a child read or play with an iPad while sitting on the toilet. It is difficult, but it is a good exercise for both parent and child to help the child tolerate this routine.

Avoiding Struggles: Breaking “Bad Habits”

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The mother of a family in my practice recently complained to me about her 11-yo son’s meltdowns. She told me that he provokes his siblings by criticizing them, getting into their space, or insulting them in some way or another. He is very reactive, and it takes very little to provoke him into a rage. He doesn’t seem to hold himself accountable for any of his actions. For example, the night before, he kicked her under the dinner table, and when she told him to stop, he said that he hadn’t done anything. This denial of responsibility is typical. She said she knows I say that if anyone in a family has a problem, then the whole family has a problem, but she can’t figure out what she and the boy’s father are doing to contribute to his meltdowns.
I told her that it is common for families to develop bad habits. I call this bad habit the “struggle pattern”. Usually, it is one child who generates the negative feelings that motivate the interactions that become organized into a family “habit”. In these habits, each family member plays a particular role, even though they don’t recognize that they are doing so. Typically, the “problem” child will provoke and the parent will respond with a prohibition. The child will then up the ante with further provocation, and the parent will continue to prohibit. Often, the actions on both the parent’s and child’s parts will escalate until everyone feels distraught and out of control.
It is interesting to consider what starts everything off. Sometimes the child has had a hard day and doesn’t have the resources to reflect on that experience and talk to the parents about it in order to be comforted. Often the child has the capacity to reflect on his inner experience when he is calm and comfortable but has difficulty with stress regulation and loses this important self-reflective capacity when he is stressed. This is also true of parents, and sometimes it is the parent who has had a hard day and unconsciously provokes the child (such as by making a slightly unreasonable demand at a time when the child might be expected to be vulnerable.) In either case, the spark of the provocation ignites a fight that gives everyone a chance to express their frustration and aggression, but in a highly maladaptive way. No one feels good after this kind of fight, and to make it worse, it just strengthens the struggle pattern within the family and inside each of the family members’ brains. Sometimes the resolution of the fight is a tearful reconciliation with professions of love. This is not the best resolution, because it usually does not unpack the interaction to allow for positive change and even adds a reward to trick everyone into thinking everything is all right.
What I suggested to this mother and to other parents to try to avoid these bad habits is 3 things:
1. Identify the turning point. Experiment with identifying the moment when the interaction could begin to escalate and ask the child to take some time out, or the parent can leave if that is more convenient. The main idea is for the parent to make some distance between them.
2. Change up the process. Do not respond to any provocation. If the child denies his action, ignore it. Do not try to reason with the child. Instead, say something about starting over or “press the reset button” or something like that. If that doesn’t work, move to item 4. When everyone is calm, then discuss what just happened without assigning blame. The focus should be on learning how to do things better in the future.
3. Practice the new way of doing things again and again. Families move like molasses in January. They change very slowly. That means that you have to practice new and better ways of interacting over and over again. Another good cliché is “neurons that fire together, wire together”, meaning that when you practice non-struggle patterns over and over, you are building new neural circuits in everyone in the family’s brains and they will gradually erode the neural circuits governing the struggle pattern.
In terms of what to do after the struggle has started,
4. Get space. Sometimes it only takes walking to the next room. Taking a deep breath and counting to 10 help too. Listening to music can help. Anything you can do to regulate yourself is good.
5. Take time. Time is also important to reestablish a calm regulatory state.
6. Reflect. When you are calm, you can reflect on what just happened and identify what you did to contribute to the old struggle pattern. When you rejoin your child to discuss the matter, do not over-apologize. That muddies the water. Take responsibility for your part, but not for the part played by your child. Once you separate out your part, his part should be easier for him to manage, if not this time, then after more practice.

Psychoanalysis on the Front Lines

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Recently I have had an experience that validated my purpose in this blog of supporting child caregivers with my psychoanalytic understanding and experience. A gifted child caregiver, R, from an orphanage of about 80 children wrote me that she had been searching for a way of “helping me to know my kids more”. She began by inviting some of the older children to write a journal in which they could tell her about their personal thoughts and feelings, and which she would keep confidential. She and I discussed whether sharing these writings with me would conform to the promise she made to the children and after careful thought, we decided that since I did not know the children, it would.

The first child R discussed with me was E, 12-yo. R wrote, E “always writes that she is very happy and content. She has no worries. She mostly will not write how she spent the day. She rather writes how she felt the whole day and finishes off her daily notes in four lines or five! Most times it will be the same words repeating that she is very happy and content and has no worries. Her day was good and she was happy. The same notes repeat almost each day. Only one day I do remember her mentioning about feeling sad.”

I responded, “E seems to have created a self-protective strategy (against painful feelings) of avoidance and denial, pushing her distress away and even out of her conscious mind. That strategy has its advantages – it allows her to go on with her life and enter into activities, but it is very rigid and therefore fragile, because flexibility is necessary to move and flow with the currents of life and personal relationships. In this kind of situation, I usually do not advise challenging the child’s defenses. For example, I would not say, “Surely you must not be happy all the time! What about that recent disappointment?!” Instead, I might say something like, “Well, I had a bad day yesterday. I was very frustrated, because nothing seemed to be going right. But then I fixed one problem, and I started to feel better.” In other words, you are taking the responsibility for managing sad and angry feelings onto your own shoulders and not expecting her to acknowledge them. At the same time, you are quietly offering her an example, an alternative, to her rigid way of dealing with life. Somewhere in her mind she may think about what you have told her. It is what I call a “magic moment”, because those magic moments can add up, and sometimes if they happen enough and at the right times, they can help change take place.”

If I were to be responding now, I would add that perhaps even more important than what P says to E is the relationship she is offering her. Although it is very limited, it becomes the crucial context in which the helpful words gain meaning. The fact that P has such little time for each child has one advantage. It necessarily places boundaries around a relationship that if did not have clear boundaries could invite unrealistic wishes and provoke painful disappointments.

Here is R’s description of a second entry: “B, during initial days used to write about her family and one day had mentioned she was sad that day as she remembered her parents (until this point as far as I know, B had insisted that she did not remember anything about her family!) I inquired as to what she remembers of her parents. She replied back saying that she remembers them bringing cake on her birthday. I had then asked her about her siblings. She said she had none and also wrote that after her parents died no one loved her and cared for her. None of her relatives or anyone showed love. After that day she kept writing about her daily routines. Later one day she mentioned that another girl at home called her ‘parent-less’. I consoled her saying that all children at (the orphanage) matter a lot to me and it doesn’t really matter whether they have a parent or not.”

I responded: “It is impressive that B is able to remember her parents and talk about them. I wonder whether her parents really died, or if they abandoned her (sold her?) and therefore died emotionally to her. Perhaps she has created a fantasy of her parents dying because she cannot bear the fact that they gave her away for money. Or maybe they did die, but it would be interesting to know when and how, and which one died first, and how old she was when that happened. It is possible that if her parents died. her relatives did not want to take care of her. That is another abandonment. When she told you about that hurtful remark that she was ‘parent-less’, I expect that she was not only telling you about a concrete event (the other girl telling her that) but also trying to communicate to you her deep feelings of being a ‘have-not’, someone who is lacking. Your kind answer is a natural one to give, but it will most likely not reassure her. Sheis talking about something deeper and more private, a deep feeling of being unlovable for example – “no one loves me” – cannot easily be healed. One way of responding the next time is to acknowledge her feelings, “That must have been so painful when X called you ‘parent-less’. I know you suffer from that feeling.” (We also know that she stole some things at the time when other children were going home to their parents for a visit.) When you acknowledge her feelings and empathize with her, you are doing something more important than reassuring her of your caring. You are actually being with her in her sadness, not trying to take it away, but letting her know that you want to be with her even though she is sad and feels unlovable and defective. That is another magic moment. They accumulate. I don’t know if you could do this, but since she is such a talented dancer, I wonder if there are any traditional dances that have sad themes that she could learn. Then she could have the chance to transform her sadness through art.”