Tag Archives: Bruce Perry

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

Helping Your Child Learn Self Regulation: The “3 R’s”

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What is regulation? Regulation refers to the integration of the various functions of the body and mind in order to achieve a sense of wellbeing. Regulatory processes are organized into rhythms. The body has many rhythms that are repeated over and over again mostly out of our awareness, creating micro patterns that then coordinate to create macro patterns, that help to organize and integrate our human body and mind. For example, we don’t usually pay attention to our heart rate or respiratory rate unless something is going wrong, such as the rapid heart rate associated with anxiety or panic. But our sense of well being emerges from among other things the signals these rhythms send us. An example of the coordination of these rhythms is the coordination of respiratory rate with walking. If walking at a comfortable pace, many people tend to take two strides for one inhalation and between two and three strides for one exhalation. Walking is a self-regulating activity, as well as dancing and drumming, and many other repetitive rhythmic patterned activities. In fact, music and dance often provide refined regulatory procedures that make one feel good – calm (“music soothes the savage beast”) or invigorated.

A child develops regulatory capacity through a process of mutual regulation with a caregiver, beginning in infancy (Tronick, 2007). This helps to explain why regulatory activities done with another person are often even more effective than done alone, for example, taking walk with another person (or a dog). Even having a conversation with another person involves rich processes of turn taking that create coordinated rhythms between the two people and also within each individual. The capacities for mutual regulation are developed over time, and some children develop them more easily and earlier than others. That is because some children are born with better functioning capacities for self-regulation and coordinating with others than other children, and because some caregiving environments are better “regulators” for children than others. Mutual regulation is intimately tied to self-regulation, so that if someone is not good at mutual regulation, he is also not so good at self-regulation.

In order to better understand regulatory processes, it is important to understand something about brain development. No one describes the connection between brain development and stress regulation than Bruce Perry. Perry explains, 1. The brain develops sequentially from the brainstem to the cortex; in the first year of life, the cerebral cortex is not yet “on line”, and the lower and mid brain are what the infant makes use of to make sense of his world. 2. The brain is use dependent – “use it or lose it”, “Neurons that fire together, wire together.” 3. The stress response systems originate in the lower parts of the brain and help regulate and organize higher parts of the brain – or if poorly organized or poorly regulated themselves, they dysregulate or disorganize higher parts of the brain.

Interventions that support regulation can target various parts of the brain. Thinking through a challenge (“Use your words!”) targets the cerebral cortex that is involved in functions of language and thinking. Thinking things through or “understanding” is highly regulating. However, if an individual is stressed, or if certain of his thinking functions are not well developed due to an inherited learning challenge or immaturity, intervening at these higher-level brain functions will be insufficient.

In fact, all of us from time to time need more basic regulatory means than “thinking things through”, at least to settle ourselves enough to actually do the thinking. We benefit from building up our stress regulatory system in the lower part of our brain. How do you do that? We do that through – Rhythmic, repetitive, patterned activity. 3 R’s – rhythm, repetition, relaxation. Walking; dancing; meditation; rhythmic music; drumming. Although dancing and making or listening to rhythmic music is highly regulating, most of us do not have the habit of doing this regularly. However, taking a walk is easy to do. It may have the added advantage of taking you physically away from a stressful situation.

There is another set of 3 R’s – routine, ritual, rendering (articulating). Daily routines and rituals (the parents’ best friends); rendering means articulating transitions – creating multiple steps to organize the transitional space (first we get out of bed, then we go to the bathroom, then we brush out teeth, then we wash our face, then ….). For more information on routines, follow the tag “routines” on the blog.

Tronick E (2007). The Neurobehavioral and Social-Emotional Development of Infants and Children, Norton.

Another Moment in the Classroom with Ben

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

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

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

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

Read this blog in Spanish.

A First Aid Kit

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Let me tell you about a child in another home. This 9-year old girl, “Miranda”, is by all accounts an intelligent child, who only just gets by in school. She is very distractible and misses a lot of what is said in class. In recess she is usually alone. When the students are asked to work in a group, she will hang back until the teacher assigns her a place in a group and then she will initially not participate. Only when she becomes comfortable with the other children will be begin to contribute. Recently, she began ask permission to go to the bathroom multiple times during the school day. The teacher, who is generally sympathetic and supportive of Ines, decided to limit her bathroom permissions to two per day. Since then, Miranda has complied with the limit.

At the home, her moods are up and down. There are two times when she presents a particular problem for the caregivers. The first is in waking up in the morning. Typically she will hide under the covers and refuse to get up when waked. Sometimes she will scream for the caregiver to go away. If the caregivers try to physically help her out of the bed and into the shower, she can escalate to an alarming degree. It is an excruciating ordeal for all involved. The second problem is that sometimes when she is in a bad mood she will be hypersensitive to touch and accuse a caregiver of “hurting” her. One time she accused a caregiver of grabbing her in her private parts, an act that the caregiver vigorously denied.

This is the story of the Miranda’s life. She entered the children’s home at 3-years old. While in the home of her biological family, she witnessed much domestic violence. A relative confided in the director that she suspected a male relative had sexually abused Ines, though this had not been confirmed. In my last visit to the home, Ines had been playing with a caregiver and another girl, creating something out of paper and a cardboard box. She would describe what she was making as she worked, saying that she needed band aids, medicine, etc. Another girl was helping her by meticulously covering the box with clean white paper, according to Ines’ instructions. When I asked what she was making, Ines explained that she was making a “botoquin”, a first aid kit. Miranda and her brother had just returned from a weekend “home” with her relatives. Her brother had told the caregivers that the adults in the home continued to be abusive. In her play about the botoquin, I thought Miranda was telling us that she felt “hurt” by the visit and that after returning to the home, she felt safe.

I was touched by Miranda’s botoquin play and thought of her during the time between my visits. I worried about the terrible tantrums she had in the morning and how it stressed the caregivers at the home, who were trying to help her get to school. She behaved as if they were torturing her. Actually, that is what gave me another idea. Maybe she was also telling us something in her morning meltdowns. Maybe, she was “triggered” by the act of being waked her up and physically pulled out of bed. Maybe, though it was not in her conscious mind – as Van der Kolk says, her “body keeps the score” – being taken out of bed when she was sleeping and sexually abused. Of course, we cannot know for sure, but her reaction at being wakened to go to school seems suggestive of that.

During this visit, I was looking forward to seeing more of her play. I thought of setting up a play interview, but what transpired was far better. On the way back from an activity, Miranda was in the back seat of the car with three other children. They were playing with barbie dolls – making them talk, negotiate friendships and disputes. This was the beginning of a doll play that lasted the rest of the day. When we returned home, she and the other girls moved the play into the girls’ bedroom. There they established themselves on the bottom bunk of one of the beds and continued the story of the several barbies and one ken. They played that the barbies belonged to families that were friends with each other. There were various events in their family lives, particularly birthdays that the families celebrated.

Each girl had her unique contribution to the play as well as collaborations. One little girl I will call “Daniela”, kept calling out for her mother. “Mommy!” she would call to the Barbie designated as the mother, “Come to my party!” They would plan for a birthday party, but for some reason – she was sick or busy – the mother Barbie would never come, and Daniela’s plaintive crying for her would continue.
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This play illustrates one of the ironies of LEPINA. The girls were playing about families, but I wondered what was the meaning of family in their minds? What was the meaning of the “Mommy” in Daniela’s play? The reality of Daniela’s life is that she had been given to the children’s home when she was a sick newborn and had been loved and nursed back to health by a caregiver in the orphanage, who continued to have a primary caregiving relationship with her until she was 6-years old. Her biological mother, a mentally fragile young woman with whom Daniela had a distant relationship, would visit from time to time and was content with Daniela’s staying at the home. When Daniela was 6-years old, LEPINA was implemented and Daniela was required to return to her biological family. The court deemed her mother ill equipped to care for her and gave her custody to her aunt, who had children of her own. Although she was well meaning, her aunt was moody and often lost her temper or was harsh with Daniela, behavior Daniela had not experienced from her gentle caregiver at the home. The biggest problem, though, was the separation from her functional “Mommy”. The disruption of the caregiving relationship caused grief to both Daniela and her caregiver. As is typically the case, once the courts made the recommendation, there was no real follow-up, no support for the aunt except for what the home tried to provide in terms of groceries or rides to school. When Daniela was allowed to spend the weekend at the home for a visit, it was bitter sweet, because both Daniela and her caregiver knew that their time together was limited and soon there would be another painful goodbye.

Anyway, back to Miranda. Miranda had her own unique contribution to the play. Before settling down with the doll play, she carefully prepared an enclosed space by fastening blankets and bedspreads under the mattress of the upper bunk so that the lower bunk was like a little tent. This was time-consuming, and she worked carefully at it, sometimes tucking in several layers of fabric. After a while, the other girls became disconnected from the game and either left or got involved in other aspects of the play. By contrast, Ines continued her work, opening drawers to get blankets, tucking them under the mattresses, making the enclosure more and more “secure”. As I watched her in fascination, I realized that she was playing another version of the botoquin game. She was trying to make a safe place. However, in contrast with the botoquin play, in which she was collaborating with another girl and chatting with cheerful, animated affect, in this case there was a lonely, compulsive quality to her activity. The play theme was not elaborated. She was exhibiting what is called post-traumatic play, as described by a major contributor to the literature on child trauma, Lenore Terr.

As I watched her play, I recalled two other incidents related to Miranda. The first was years ago, when Miranda was about 6-years old. I recall her hiding in the playhouse of another children’s home and peeking out the window, like a frightened little animal. The director of the home told me that when both Miranda and her brother were highly stressed, they would sometimes huddle up and hide under the bed or in a closet. I also remembered the director of the home telling me about times in which Miranda appeared to lose touch with what was going on around her, and even seemed to faint – lose consciousness – on several occasions. The director had taken her to the doctor, but after examining her, the doctor suggested that she was fine, and that her behavior was probably hysterical or manipulative. On the plane to San Salvador, I had been rereading Bruce Perry’s The Boy Who Was Raised as a Dog, and I realized that most likely what the director had been describing to me was the physiological response of lowered heart rate and dissociation to a traumatic trigger (Perry, Szalavitz, 2006, pp. 172, 191).

On the last day of my visit, I sat down with the caregivers to talk about Miranda and what we might do for her at the home, in school, and in relation to family visits. One of the first steps, we thought, might be to talk to her teacher about what we thought was interfering with Miranda’s paying attention in the classroom so that she would have an empathic understanding of Ines’ challenges, and then trying to implement regulatory breaks into her daily classroom routine. It seemed to me that this is what she had been asking for in her requests to go to the bathroom (although there may also have been symbolic meaning involved). Another crucial step was to try to change her morning routine so that she would not have repeated traumatic experiences in the mornings at home in the waking up process, and so that her caregivers would not be extremely stressed by her frantic oppositional (subjectively, her self-protective) behavior. I will follow up these steps and others in further blog postings. Two important issues to be addressed in further postings are Miranda’s “manipulative” behavior in other contexts, and her episodic accusations of abuse by the caregivers in the home. I will also talk more about the home visits and how they should be planned with the best interest of the child in mind.

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.

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.

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Emotional Regulation

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EMOTIONAL REGULATION (ER) –

I have a wonderful new mothers’ group, and when I asked them what topics they would like to discuss – and for me to research for them – this is the first one they picked.

Working Definition: “The automatic or intentional modification of a person’s emotional state that promotes adaptive or goal-directed behavior” (Mazefsky et al, 679).

The study of ER has recently gained more attention, in part because of developments in brain science and imaging techniques. The idea of emotional regulation was earlier considered as an aspect of temperament, which is a more inclusive concept and stresses biologically based individual differences of many kinds. (I often refer to children in my practice as having “artistic temperament”.) One of the pioneers of temperament research is Jerome Kagan, who identified high reactive infants in the womb and showed that their “temperamental” characteristics, while not necessarily hindering them in their future lives, did become part of their enduring personalities.

Why do we have emotions anyway? We would all agree that emotions contribute much of what we experience of the richness in life. They also serve the more primitive function of alerting us to danger and helping us size up situations rapidly (both from inside our bodies and from the environment). Your sudden recoil when you see a darting motion on the ground near your feet is an emotion-triggered response, that from the point of evolution probably allowed humans to avoid snakes. A similar reaction is the anxiety one experiences when one has an internal proprioceptive response to losing one’s balance. These emotions allow one to prepare subsequent action to the perceived threat, in order to maintain wellbeing.

However, each individual evaluates a stimulus differently from an emotional point of view in terms of strength – ie. intensity and speed – and this will affect the characteristic emotional response the individual has. This is referred to as “emotional reactivity”. Emotional response includes components of behavior, subjective experience, and physiology.

Many treatment modalities have been used to treat emotional dysregulation. They include psychodynamic and behavioral therapies, such as CBT (cognitive behavioral therapy) and DBT (dialectical behavioral therapy). Before I get into a discussion of the therapies, I would like to give you a sense of what is going on in the brain.

YOUR BRAIN
My favorite discussions of the brain, how it develops, and how its relationship to stress and emotion are given by Dan Siegel (Siegel, 2007, 2012) and Bruce Perry (Perry & Hambrick, 2008).

1. Brain is organized hierarchically in terms of function.
2. The “lower” parts of the brain – brain stem – mediate “simple” functions that keep the body alive such as respiration, heart rate, and body temperature. The brain stem processes sensory information such as sound, light, temperature. The drive to modulate sensory input to comfortable level in individuals with heightened sensitivity to environmental influences (sensory sensitivity, resistance to change) may also influence ER.
3. The mid brain, diencephalon, mediates among other things emotion (the famous amygdala).
4. The higher cortical parts mediate language and abstract thinking.
5. Neuronal networks communicate between and among the various parts of the brain. The prefrontal cortex (PFC) is a part of the brain governing judgment; PFC is important in perspective taking. PFC/amygdala connectivity deals with gaining perspective on emotional experiences.
6. Perspective – when focus or attention is diminished by anxiety or other means, result is interruption of access to important information that may decrease arousal, so a vicious cycle can result in distorted judgment of the environment, misattribution of negative intentions to others (“they are disapproving of me” can lead to anger, shame, which can cause further misattribution of negative intentions.
7. Classical lesion studies in rodent model systems have implicated the medial pre-optic area of the hypothalamus, the ventral part of the bed nucleus of the stria terminalis, and the lateral septum as regions pivotal for regulating pup-directed maternal behavior via a limited number of key genes and hormones – estrogen, prolactin, and oxytocin . Maternal responsiveness necessarily includes hypothalamic control of both approaching distressed offspring and inhibiting competing stress responses that would interfere with providing help. Approach motivation is increased via the nucleus accumbens-ventral pallidum circuit, and avoidance is reduced by interrupting threat signals from the amygdala to the peri-aqueductal grey. Both motivations are intimately tied to the regulation of the sympathetic response system (Swain et al, pp. 116-117). Continue reading →

“A Healing Place”: Part II

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I continued with the workshop, referring to Bruce Perry (as I so often do) as I addressed what Rachel had described to me as the caregivers’ discouragement. I told them that the parts of the brain that influence this problem behavior “have been shaped over many years with hundreds and thousands of repetitions”, and that traditional therapies that typically take place in 45 or 50 minute sessions at a frequency of once a week cannot be expected to reverse years and years of traumatizing experiences (Perry & Hambrick, 2008, p. 39). I wanted to talk about changing the brain in healthy directions and how that improves behavior, but mindful of the role of consultant and the necessity of staying close to the caregivers’ stated concerns, I addressed the need to respond to problem behavior “right now”.

Changing Behavior Right Now: Think Ahead

(1) Know the child. (2) Make realistic expectations. (3) Anticipate problems. (4) Prepare for transitions. (5) Be predictable, but not too predictable. (6) If something is not working, stop and try something else. (7) Resolve conflict. (8) Give rewards and consequences.

I will go into detail in the first point in this posting and continue with the subsequent ones in the following postings.

Know the child:

It is important to keep in mind the child’s strengths and weaknesses, and also to remember the child’s story of pain. The role of the child’s traumatic background is easy to forget when you are dealing with his problem behavior, but it is important to bring it to mind now and then, because it can help you with how to respond. First of all, remembering the child’s story of pain can refresh your empathy for the child. Second, it can help you identify “triggers” or special challenges for this individual child. For example, a child who has been sexually abused will often be triggered (have a traumatic reaction) to certain kinds of touch or to intrusive behavior (someone putting his or her face too close to the child’s face, or looming over him or her). Remember what I said about children on the autistic spectrum. Often these children will also react violently to someone coming in too close.

Again, channeling Bruce Perry, I emphasized the importance of special relationships – For traumatized children, “The relational environment of the child is the mediator of therapeutic experiences.” (Perry & Hambrick, 2008, p. 43) In fact, in the fortunate case that there are multiple good caregivers available, such as is true at Love and Hope, the child may choose one person who can help him feel calm, another whom the child can rely on to be firm, and another who can help him have active, rough housing kind of fun. This is not so different from what happens in families, especially big families.

We know that it is also important for the relationships that partners make with each other – such as adult partners or even close friends at any time in life – to include a mix of these functions. That is, we would not choose a partner or close friend for whom we could not rely on both for fun and also for comfort. Yet these children may require time to put it altogether, and a “family” environment in which these relationship functions are offered by different people is often a first step.

Reclaiming children and youth www.reclaiming.com

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Healing the Attachment System

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My observations in India – just as my much longer experience in El Salvador – have led me to question the idea that the way to heal attachment disorders is either by the establishment of a potentially secure attachment relationship through adoption or foster parenting, or through intensive and lengthy psychotherapy. That is not to say that I saw uniformly effective healing in either place, but just that I observed alternative healing methods that seemed to me to have promise.

In each children’s home, for example, there are multiple caregivers, at least one central parental figure, and (when all is going well) a secure environment. The secure environment is not only associated with the person of the caregiver but is also related to adequate food and shelter and freedom from threat. At Love and Hope, Rachel is the central parental figure, and the children also have important relationships with the tias and tios (female and male caregivers), the cook (as witnessed in the “papusa maker” video), and a social worker and psychologist on staff; the high caregiver-child ratio is one of the strengths of the home. At Deenabandhu, there are two central parental figures – Prajna and Prof. Jayadev – and the important continuity of one (the same) skilled and caring teacher throughout the early years of school. In addition to these strengths in each home there are the important relationships between and among the children – age mates and older-younger pairs. Perhaps the power of the peer relationships is enhanced by aspects of the culture; in El Salvador it is not uncommon to see a young boy carrying a baby on his hip. At any rate, the richness of the interpersonal environment offers many opportunities for finding security in a trusting relationship, contingent social interactions, and the subjective experience of caring and personal recognition.

It is important to recognize the apparently contradictory results of the Romanian orphanage studies that point to the dangers of early institutionalization and the need for a primary caregiving relationship such as through adoption or foster care (Zeanah et al, 2011, Fox et al, 2010). When viewing the films of the children in these orphanages, the caregivers appear to be surprisingly pleasant and sometimes engaging in friendly, even helpful, interactions with the children. The main problem, I guess, is the lack of contingency of caregiver responses, especially in infancy. That is, the children are fed without reference to their cues or initiatives, aggression in the free play situation is not responded to helpfully, and the caregivers do not play with the children. I guess I would suggest that the big difference I observed between what I saw in the films of the Romanian orphanages and what I saw at Love and Hope and Deenabandhu is greater personal involvement of the caregivers and the children so that relationships were encouraged, the children were known for who they were as little individuals, and there was a lot of interaction between caregivers and children – in play and in academic learning. This is related to the idea of “magic moments“, or “lost momentos magicos” of earlier posts.

I am reminded of Bruce Perry’s observations that traumatized children initially do better when allowed to seek out particular caregivers to fill specific personal needs – such as one caregiver to roughhouse with, another to provide food, another for comfort at times of emotional distress, another to help with homework. I am also reminded of Peter Fonagy’s therapeutic model of mentalization. That model avoids directly engaging the attachment system without simultaneously working on building reflective capacity that can guard against what one might call the “regressive pull” to intense destructive relationship patterns that were established in early childhood. Fonagy’s model was originally designed to treat adults with Borderline Personality Disorder, many of whom have experienced early trauma. However, it seems to me to be equally relevant to children – at least those with the cognitive capacity for mentalization – who cannot trust adult caregivers and cannot comfort or care for themselves. None of this means that developing a trusting and loving caregiving relationship with a single person is not healing. It is just to say that – at least now in my thinking – I am leaning towards the idea that there are multiple ways of healing the attachment system of children who have experienced trauma and severe neglect.

I hope my readers can make comments on this posting.

Bos K, Zeanah C, Fox N, Drury S, McLaughlin K, & Nelson C, Psychiatric outcomes in young children with a history of institutionalization, Harvard Review of Psychiatry, January/February, 2011, pp. 15-24; Fox S, Levitt P, & Nelson C, How the timing and quality of early experiences influences the development of brain architecture, Child Development, January/February, 2010, Vol. 81, Number 1, pp. 28-40).

Photograph by Ginger Gregory

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The School

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Ginger went to observe in the school with a group of other visitors the first day. When she returned, she had many positive things to say about the school and the teaching. Every classroom they visited had active engagement of almost all the children. The teachers were tolerant of children having conversations with each other while working on projects. There were no desks. The students moved freely from place to place during the classes, while still staying engaged in their work. The teachers maintained a calm, contained environment.

The teachers managed lack of participation and disruption – potential or actual – in an unusually skillful way. In one class on Social Studies, the students made paper lanterns and discussed a topic about profit and loss in an animated and involved way; the students who had trouble actively participating in the discussion, had something not disruptive to do with their hands in a self-regulating way, allowing them to listen and follow along. A little boy in the upper kindergarten who wanted to be part of a puzzle activity during a free choice time had difficulty collaborating with the puzzle doers. The teacher came up and put a hand on his shoulders and to calm him and support his efforts, and when that was not successful, guided him to another activity that had a more sensory basis, sorting seeds. He never sorted the seeds the way everybody else did but sat next to another child and kept scooping up the seeds and letting them fall through his fingers, his way of participating. He tried to take seeds from a little girl, but she set a clear boundary and he stopped.

The teachers consistently displayed a calm and receptive manner, quietly acknowledging individual children’s successes. In the upper kindergarten classroom, each child had to bring the teacher his or her journal when finished with each lesson, so that she could mark it. In that way no child was allowed to fall behind or drop out. The kids seemed to expect it to be a good day. Even at the end of the day, the children did not seem eager to leave.

After the school day was over, Ginger and I gathered in the Resource Room and gave a presentation about helping children learn. In addition to showing some videos of El Salvador that offered an example of adults facilitating learning in an infant, we concentrated on teaching about early developmental problems that can interfere with learning, introducing Dan Siegel’s model of the brain (Siegel, 2012) and Bruce Perry’s Neurosequential Model, and also offered some interventions designed for the “bottom up” healing of developmental problems that affect learning, such as breathing exercises, regulatory breaks of various types, and meditation (which is culturally syntonic here). The teachers were receptive and and stayed late to listen. At the end, Prajna suggested that we continue the next afternoon, so we did that.

After school, Prajna brought over tea and biscuits, and she reflected on how the school had changed over the years that she had known it. She discussed the project-based learning curriculum, a change from the original lecture-based curriculum. They eventually moved to what they called an activity-based instruction method in which they added structure to a project-based model. In that way they “grew” their own curriculum, adding structure to allow for more helpful classroom control. She explained that the teachers remain with their classes through the lower grades, providing a continuity of the caregiving role of the teacher. Prajna also mentioned her belief in the value of practice and structure in learning.

Then I did a little work of my own and later followed her to the dining room where the older children (“standards” 5-8) were doing homework. It was now 7:00, and the children would not eat until 9:00. There were thirty kids, both boys and girls, sitting in two circles on the floor, and Prajna was the only adult in the room besides me. Prajna was leading a lesson on English grammar, and of the twenty children sitting with her, all of them were actively engaged for more than 40 minutes, eagerly offering answers to her prompts. From time to time, a child from the other circle, where the children were working together in small informal groups doing math, would come to ask Prajna to review their work. She always interrupted to do this, and she gave a non-effusive but affirming response to each child. One thing I noticed is that Prajna immediately responded to each child who made a bid for her attention, even if it were for a few seconds; I remember being impressed with Rachel’s habit of doing this at Love and Hope.

Siegel, D. (2012) The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are (Second Edition). Guilford Press.

photograph by Ginger Gregory

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