Day II: The Workshop

A good group gathered for the workshop, including representatives of four orphanages. I began the workshop with a description of brain development. I used Dan Siegel’s ingenious model of the brain in which the thumb represents the brain stem and midbrain, and the fingers curled around this core represent the cortex. The thumb, the evolutionarily primitive brain maintains essential functions such as heart and respiratory rate, sleep, appetite, and reaction to threat of danger (objective or subjective), but also reward, regulation, and mood (Bruce Perry). The fingers are the “thinking brain”. The thumb develops first in life, and the fingers don’t “come online” until around 1-year old.  You can see where I am going with this, because M entered the home at age 1, and therefore he moved into an enriched environment after most of this development took place. The circumstances of his earlier life were known to be depriving and neglectful. I also reminded the participants that development was unpredictable and that boys were generally more vulnerable than girls. It has been observed that in the home the girls tend to do better than the boys, both from the point of behavior and also achievement. 

Then I reminded the participants of the notion of “magic moments”, those moments in the interaction between caregiver and child when the pair confronts a choice between (1) taking the risk of trying something new (and more energy-demanding in the short run) or (2) slipping down the slippery slope into a problem pattern such as a struggle, and instead of following the old problem pattern they find their way to a better path. I showed them two clips of children at the home that demonstrated magic moments, pointing out that these magic moments prepared the way, or increased the probability, for future magic moments; in other words, the more of these you practice, the easier it is to slip into a good path in the future. Both clips illustrated child and adult working side by side. In one, a boy was grating carrots with an adult, and in another a girl was being helped to cut cucumbers with a big knife. In both, the side-by-side aspect of the activity was emphasized. My message (despite the fact that some cynics in the group thought that some of the behavior was influenced by the presence of a camera) was that when children practice tasks at the side of an approving adult, the task becomes more doable by the child independently in the future. 

Then I began the Presentation of “M”:

 M entered the home at age 1-year old. I invited the participants, now that they knew about brain development in the first year of life, to consider what neurodevelopmental vulnerabilities M might have brought with him into the home. In fact, early on, Rachel identified him as having delayed speech. He was described as sweet, warmly attached to familiar adults, but unusually timid and fearful, crying a lot. Still, many foundational skills seemed in place – in one observation Sarah Measures did when he was 2-years old, he was able to engage in reciprocal play and had gestural language, his motor sequencing seemed OK, his language comprehension was good, his reading of social cues seemed fine, and he showed no signs of extreme sensory sensitivities. He was observed hanging around the other boys, on the edge of the rough and tumble play. Still, he eventually joined in and remained engaged for 30 minutes. 

I showed a video clip of M at 1-year old. He was a sweet-looking boy in a high chair, with a pleasant expression, playing with a toy on the tray of the high chair. When he dropped it, he patiently waited for the caregiver to replace it, which she did. He did not, however, give her a direct gaze, nor did he initiate a gesture to recover the toy himself. Yet, he was clearly interested in the child sitting next to him and to what was going on with her. 

In kindergarten, M’s teacher complained that he fell asleep in school. Sarah and I observed him, and he did have his head on the desk most of the time. His teachers seemed to not know what to do with this behavior. At this time, Rachel also had concerns about his not eating and having stomachaches, though the doctor could find nothing wrong. He continued to have crying spells and to spend more time sitting alone than the other children, sitting on the steps eating mangos. At other times, though, he would join in the fun.  I reminded the group of the physiological regulation problems that can be associated with problems in neurodevelopment in the first year of life. 

M Today: Video of M’s Noncompliance: Rupture and Repair

Step 1. I described the interactions I captured on film the day before. The first step was M’s refusal to change out of his school uniform, an expectation at the home. Tia (“Auntie”, caregiver) Ani and Jessica (the psychologist) tried to help him comply. Instead, he lay on the floor. Gentle persuasion got nowhere. In the clip, M’s foot is seen on the floor of the bedroom, where he is lying and talking in a whimpering, defiant voice. Ani’s voice is soft, and she leaves pauses that seem to say, “You can take over if you want.” She does not escalate the emotion. Later Ani explained that she was asking M what was wrong, and at first he said, “Everything is wrong!” He later explained that he spilled his yoghurt at school, and then further explained that the boys made fun of him for doing that. This information emerged bit by bit, allowed by Ani’s empathic approach. Still, M could not respond to the demand to change his uniform. In the clip he tentatively kicks the door in rebellion, but he is not “too far gone” yet. 

Step 2. The next clip is of Tio Luis, who comes to help Ani. His style is to use affectionate physical support, holding M around the waist (M is standing now) and bending his body gently in the same arc as M’s. Still, M shows he is not ready to respond; he grabs hold of the gate to resist Luis’ pull. He may still escalate. I suggest taking a break (who knows if this was the “right” thing to do?) and Luis backs off gracefully. M retreated to the bedroom and lay on his bed, covering himself with a blanket. I went into the bedroom with him and sat quietly on another bed. 

Step 3. There was music in the adjoining room, where Kirsten was playing the guitar with three littler boys. M got up and moved into that room, sitting on a chair on the outskirts of the action, watching. I moved to a position behind him; he turned once to look at me and then looked back. Kirsten made no fuss about his joining, nor did she make an explicit invitation for him to come closer. I was glad, because I thought M needed low-key responses. 

Step 4. M got out of his chair and lay on the floor next to the other children, with his cheek on the floor and his bum in the air, in a caterpillar position. There was a potential conflict with an assertive little boy when they both reached for the same object, but it did not escalate. 

Step 5. Kirsten gave the guitar to M to take a turn. M sat up and took the guitar and began to strum. She gave gentle instruction to M about how to do it and reminded the littler boy to get his hands off the guitar while M took his turn. Slowly, M stood up and strummed the guitar. After a while, he stood taller and assumed a little of a rock star posture. I thought, “This is how self esteem is redeemed.” 

Steps 6 and 7.  Later in the afternoon, I saw that M had changed the shirt of his uniform, leaving on the pants. Later still, before the birthday celebration, I saw that he had changed his pants as well. His twin brothers were celebrating their birthday, and he sat close to one of them, watching everything.

Because the evaluations from last time included the desire to hear more voices, I had decided to at this point divide into small groups for discussion. Here are some of the results of the discussion from these groups. 

Discussion from the Small Groups-:

-Tia Ani did not raise her voice to M in the bedroom because we have raised our voices before, and it doesn’t work. When the child is stuck in a rut, raising your voice doesn’t work. 

– It was a good idea for Luis to step in when he did, because collaboration between two caregivers is often helpful and can avoid a struggle. 

– There was a discussion about “teaching a child to manipulate” and what is the message to the other children if the understood consequence for “bad” behavior is delayed or not applied. I suggested that there must be communication among the caregivers (CG) so that there is no “splitting” (the child playing one CG off the other) and so that if one person gets confused and is tending to bend the rules, the second person can set him straight. These actions work against manipulation. 

– We also talked about how it is good to be flexible sometimes. Yet, “being flexible” can also be seen as a reflection on the CG’s job performance. In that case, it is good for the CG to explain her reasoning to her supervisor. 

– We discussed the timing of giving consequences. If the child is in a highly reactive state, reminding him of the consequence for his “bad” behavior is likely to escalate his aggressive behavior. Certainly he will not be able to “learn” from a lecture in that state, when his cortex (thinking brain) is “offline”. It is a challenge to assess the “state” of the child and then to make a decision about the timing of the consequence. All CG’s struggle with this challenge. We all thought that M should get a consequence later, when he could handle it. In this case, after M had calmed down and Ani had responded to him empathically in a gentle, slow paced way, he received his consequence easily. 

– All groups also thought that it was important to talk to M about what happened later. One participant suggested that if the child is unable or chooses not to talk, he may draw or write about what happened. I added that children may communicate “what happened” either in reality or in his unconscious fantasy in the form of symbolic play. 

– What were the “magic moments” in this scenario? (1) The first may be Ani’s choice to empathically question M about his day instead of immediately setting the limit about changing his uniform. (2) The second may be Luis’ joining Ani so that she would not be alone and vulnerable to being drawn into an old struggle pattern. (3) The third may be Luis’ “letting go” and allowing M to withdraw in order to “get himself together”. (4) The fourth may be Kirsten’s low key and implicit welcome of M into the group without stressing him. (5) The fifth may have been Kirsten’s allowing M to “take the stage” and in that way reclaiming his self-esteem. (6) Finally, the staff’s allowing M to pace himself in his eventual compliance with the rule, even though he had to accept the consequence of refusing to comply when he was asked. 

If you can imagine the child’s mind, you do not expect more than he can accomplish. You can empathize with his experience and help him feel less alone. You can in that way maximize the probability of his success. 

In the next posting I will briefly address the issue of working with families and then talk about the adolescents.

 

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