Tag Archives: AAI

The Problem of “The Little Girl with a Curl”

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.

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.

Peter Fonagy on Metallization

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Peter Fonagy and his colleagues have introduced and elaborated the concept of metallization. Metallization includes the developmental capacity to reflect on one’s inner life and to imagine the inner life of another person. It is central to important other capacities such as the capacity of empathy and self control. The relationship between empathy and metallization is easy to understand in that you have to be able to imagine what another person is thinking and feeling in order to empathize with him. Self control, on the other hand, takes more explanation. As the child develops the capacity to reflect on what is going on inside of himself, he begins to be able to make sense of the motivations for his actions and also for the consequences of his actions on others. He sees a playmate cry when he pushes him or when he grabs a toy away from her. With the help of an adult caregiver, he realizes that his action caused distress to the other child. Then he starts to make a connection between his inner desire to have the toy or his anger at the other child and his action of pushing or grabbing. He also realizes that if he wants to play with the other child, he will have to control his impulse to push or to grab. All of this cognitive and emotional activity is scaffolded by the caregiving relationship and grows into a competency for self reflection and also for self control. Fonagy and his group call this competency metallization.

All individuals, including adults, lose their capacity for mentalizing when they are highly stressed. The individual’s ability to mentalize therefore depends both on the robustness and flexibility of their developmental competency and also on the stress in their lives.

Metallization distinguishes humans from other apes. Animals are very poor at recognizing whether an act of a conspecific is due to serendipity or is rooted in intention, wish, belief, or desire. The capacity to recognize these intention, wishes, desires, and beliefs of the other person is sometimes called “metallization”. It has been argued to account for the major difference between humans and other apes.” (Fonagy, 2014). (Peter says that dogs can mentalize humans but not other dogs. That could explain a lot!)

We all depend on one another to know ourselves. A working definition of mentalization is that of a form of imaginative mental activity, perceiving and interpreting human behavior. Mentalizing is the capacity to see ourselves from the outside and to see others from the inside. It has to do with seeing oneself as an agent, as an intentional being and also seeing others as intentional beings. The capacity to mentalize allows us to create a narrative continuity over time. Mentalization is an integrative framework.

The Development of Mentalization: The newborn has a social brain. She detects and prefers social agents, gazing longer at faces with open eyes and to direct versus averted gaze, showing greater activation of the anterior temporal cortex to voices versus non-voices, and differential activation of the orbitofrontal cortex and insula to happy versus sad voices. The newborn is prepared for mimicry by the mirror neuron systems in the prefrontal and parietal regions, and oxytocin and vasopressin mediate mutuality in the infant-caregiver relationship. In fact, administering oxytocin in the nose makes adults better at reading the expression of others’ intentions.

The Reward Circuits Are More Active in Secure Mothers: The oxytocin levels of mothers whose AAI’s (Adult Attachment Inventory) were read as secure before the birth of their child, went up when they interacted with their children. By contrast, in the case of mothers with “insecure” AAI’s, the oxytocin levels went down. Later on, the pituitary, the part of the brain that generates oxytocin, released more oxytocin in secure mothers. Also, the mesocorticolimbic areas were more active for secure mothers when looking at their babies smiling. All this suggests that the reward circuits are more active in secure moms. Fonagy suggests that this is because when the baby is crying, secure moms have an elevation of activity in the Ventral Striatum, whereas insecure moms do not. Rather, insecure moms have activation in insula (negative memories). Looking at their baby when he is sad makes her sad. You could argue that the absence of oxytocin in insecure moms gives them difficulty mirroring their awareness that it is the baby’s sadness and not theirs. That would make it harder for the baby to manage his sad affect.

Provisional Model for the Developmental Roots of Mentalization : The “secure” mother generates increased oxytocin when interacting with her baby, in association with a more mentalizing (marked-contingent) maternal response to the baby’s distress. The baby perceives the mother’s empathy, while at the same time appreciating that she herself is OK and available to comfort him. This improves the baby’s regulatory state. The evolving capacity of the baby to perceive his mother as having a different mental state from his own is consistent with the development of mentalization and the infant’s resilience. On the other hand, if the mother herself is insecure and generates a reduced level of oxytocin, she makes a “non-mentalizing response” to her infant, reacting not only with her own distress but with an escalating distress response that communicates helplessness. This is not comforting to the infant and may increase his sense of helplessness and fear. He is at risk of not developing the capacity to discriminate between what is in his mind and what is in his partner’s mind, which makes him more vulnerable.

Fonagy referred to a paper in which the maternal oxytocin response predicts mother-infant gaze: in the case of the antenatally secure mother with high oxytocin, the mother looks longer at her infant, especially in the recovery phase of the still face experiment, and there is more imitation of the infant’s intention (Kim, Fonay & Strathearn in press). This is interpreted as the mother’s capacity to tolerate the infant’s distress and is therefore emotionally available to the infant.

Numerous studies reveal the development of an important group of social capacities related to reciprocity, the sharing of mental states, self-awareness, and identification. Joint attention is usually achieved at 9-12 mos. This capacity involves the medial prefrontal cortex and posterior temporal sulcus and is incredibly important. In order for humans to have culture, a shared sense of where they are, they have to develop the idea that when they are looking at the same thing as others in their culture, they are thinking the same thing.

Studies suggest early emergence of the capacities for empathy and mentalizing. In the Baby and Smurf test, the baby’s capacity to put himself in the place of the smurf who has lost its ball is tested. The baby’s sensitivity to the smurf’s situation (the baby saw where the ball went but the smurf did not) is measured in terms of looking time. The baby at 7 months is capable of considering what the smurf believes about the status of the ball (AM Kovacs et al, Science 2011; 330:1830-1834). At 9 months, babies have a sense of fairness, as they demonstrate in an experiment in which of two giraffes one giraffe gets two toys and the other gets only one. Interestingly, it is relative deprivation, not absolute deprivation that predicts outcome. How well we are doing in relation to others around us has a profound influence on outcome.

The Romanian orphanage (orphanages in which the children were essentially deprived of a responsive caregiving relationship) studies show that the age beyond which the influences of deprivation cannot be repaired is between 6-18 mos. Children who were placed in these orphanages at birth and stayed for longer than 6-18 months demonstrated atypical development: signs of autism – reduced imitation, lessened response to name, lower social interest and social smiling, atypical eye contact. On the other hand, deprivation before 6 months (in cases in which the child was placed in a family at 6 months) has surprisingly little consequences.

A Safe Place

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Before I begin this posting, I would like to say a word about confidentiality. In my postings about children in the U.S., I avoid writing about specific children, preferring to create a composite of a number of children I have known that will best illustrate the point I am making. When I write about children in other countries I do the same. I have begun to visit a number of orphanages in El Salvador, and in order to protect the confidentiality of the children in these homes, I will avoid referring to specific homes and also disguise the children in other ways.

This posting is about my recent trip to El Salvador.

By the time I reach the gate of my flight to El Salvador – in Houston or Miami – I begin to feel that I am almost there. Spanish is the language most spoken at the gate. The passengers include many people of modest means preparing to return home or to visit relatives. Sometimes I imagine there is an appreciative attitude of the passengers on the plane, as if they feel lucky to be there, rather than hassled by yet another plane trip. After arrival at the San Salvador Airport, and after passing through immigration, the tropical air surrounds me with warmth and moisture, tropical birds squawk in the trees outside the airport, and I have the full sensory experience of really being there. A large crowd is always waiting to greet relatives. There is more emotional energy in the crowd – more intensity – than in the relatively restrained crowds waiting in U.S. and Western European airports.

This time taking my hotel’s shuttle into the city, I relax and enjoy the familiar images of the drive. Pick-up trucks with dozens of people sitting in the back or standing and hanging onto the sides, buses that light up at night when they stop to discharge or pick up passengers, illuminating a multitude of people wearing bright colors, traffic diversions with orange cones directing you in circuitous routes for no reason I can determine (sometimes they are for the police to check your papers but sometimes there is no one there at all). This time I arrived at night and the dark hills were spotted with the lights of civilization.

Whenever I come here, I have an idea that I want to communicate to the caregivers and a plan of how I want to do that. Every time I come, during the course of my visit I completely fracture my original plan and end up with something else. It is an exciting experience.

This time I came with the plan of helping both the staff and the children to tell their life stories. The idea was inspired by a young colleague of mine, Molly, who was going to spend some time at one of the homes and was interested in the theme of life stories and how they are related to learning and the desire to learn. I also had in mind the AAI and the research correlating the “coherence” of the narrative of adults about their early caregiving experiences to the security of their attachment style in adult life and to their behavior as parents (Main, 2000). Since the kind of psychotherapy available in Boston is not possible for the children in the children’s homes of El Salvador, and since I am not sure that it would make sense for them anyway (Perry, 2008) I wondered if helping them tell their stories might be a possible therapeutic alternative.

In all of the homes I visited, my young colleague and I gathered the caregiving staff and asked the caregivers to tell stories about their lives. We did this because we hypothesized that through telling their own stories they could learn the value of telling stories. That might result in their encouraging the children to do the same. We asked them to begin with an event that occurred to them at the age of one of the children in their care. The stories they told included several memories of being bullied or teased, or even beaten, and how that experience served to help them empathize with the children they cared for. They also reported memories of being left alone in childhood or expected to take on excessive responsibility. Many told stories of struggling in school. One story was about a teacher being the only one to notice her sadness, during the time her parents were getting divorced.

We then asked the caregivers to tell a story about their parents. That question elicited stories of abandonment – temporarily or permanently, literally or emotionally – by their mothers. Father figures were either absent or deeply flawed – either harsh and punitive or alcoholic. Many caregivers were brought up by their grandmothers, and their grandmothers were generally described as kind and loving. Some of them told stories about their family members – mothers, fathers, older siblings – leaving them to find jobs in the U.S. I was reminded of the families I see sometimes at the Cambridge Hospital who have emigrated from El Salvador, leaving family behind. They represent the counterpoint of the caregivers in our groups. Some of the families in Cambridge willingly take in the children of debilitated relatives in El Salvador. Others avoid them, attempting to escape the guilt of having left behind the poverty and despair of their home country. The escape, though, is only partial, because their children – whom they are bringing to the child psychiatry clinic – always carry some of the burden of their parents’ painful past.

So, we – Molly and I – were trying to find a way of helping the children tell their stories. The trouble was that every way we thought of seemed artificial and we knew would fall flat. Then in the home I have been visiting the longest, a child asked me if I had videos of him when he was little. I promised to look for them, and the next day I brought the videos I had found to the home. The children were mesmerized by the videos of my first visit to this home, in 2004. Laughing, they called out the names of people they recognized in the film. Occasionally, they would ask about people whom they did not recognize, or they would misidentify a person who had left as someone who was still present. I wondered if the fact of their departure posed a threat that needed to be denied.

Sometimes I would stop the video and ask the children what they thought the child on the video was thinking and feeling. They had a hard time doing that. In one video, a little boy dropped something on the floor and then became preoccupied with his “misdeed”, looking down and up with big expressive eyes, in a sweetly comical manner. The children laughed and responded that he was clowning. They could not recognize that he was anxious and ashamed about having “broken a rule”. In another film a child was refusing to eat when being fed by the caregivers and later clearly demonstrated her intention of feeding herself. The children were able to identify her oppositionalism but not her expression of agency. I thought that showing them videos such as these and pausing the video at moments when emotion was expressed – as I did – could be an excellent tool to help them grow a “theory of mind”. Rather than the more artificial scenarios Molly and I had discarded as potentially stressful to the children, this was spontaneous and initiated by the children themselves.

The single woman director of one of the homes noted ruefully that since the children had gotten older, she had not been able to maintain the same routines that had been so organizing and comforting to them when they were younger. For example, she had previously begun each meal with group prayers led by one child at a time. The patterned rhythmic movement included in the clapping and singing of the prayers – I had always thought – contributed to the children’s ability to sit together at mealtime and talk to each other. This routine, and similar ones, seemed to help in regulating the children and making them feel secure. Now that the children in the home included a group of teenagers, meals were more chaotic and unpleasant, with less conversation and positive engagement among the children and caregivers. Struggling to maintain order and discipline in general, and feeling burdened by having to assume the role of disciplinarian, the director was loath to engage in yet another struggle. Yet mealtimes had been an opportunity to pull the “family”, together in the past, and a chance to reconnect with the spiritual core of the community, in the blessing. There was a powerful meaning to that ritual.

Coincident with my visit to the homes was the arrival of “The Navy”, an exciting event in which the US Navy stationed in the city sent a group of young navy men to do activities with the children. The children loved these experiences and adored the kind, strong, young men who came to play games with them. As I talked to the director in anticipation of the visit of “The Navy”, it occurred to me that the military was expert at discipline and team building. Maybe they could help. The next day when the officer, a personable and clearly intelligent young man in charge of the Navy team, introduced himself to me, I told him about my idea. Would he consider designing an exercise for the children to do at the beginning of the meal to help them organize “body and soul” for the day? He said he thought they could do that. When I expressed regret that I would not be able to see the product of their efforts, he promised to make a video and send it to me. In the absence of the regulating ritual of prayer at the beginning of meals, I had been been searching for another predictable ritual that could introduce movement and rhythm into the lives of the children. I knew that such a ritual could enhance their regulatory capacity. Maybe this was an answer. My hope was that, in addition to mealtime, the Navy could generalize the routine to homework time. But, one step at a time.

In my next posting, I will continue the story of this visit.

Main M (2000). The organized categories of infant, child, and adult attachment: Flexible vs. inflexible attention under attachment related stress. Journal of the American Psychoanalytic Association, 48(4):1055-1097.

Perry B, Szalavitz M (2008). The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist’s Notebook, Basic Books.

Read this blog in Spanish.