Tag Archives: culture

Interventions in Infancy

Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels.

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

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

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

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

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

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

Let me talk about interventions in the next posting.

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Aggression in Early Childhood

Aggression is a good thing. It motivates initiatives – including learning, athletic effort, and healthy competition. Yet, good outcomes depend on the capacity to regulate aggression, and that is always a challenge. Self-regulation, as we have said many times in this blog, is a developmental competency that we keep working on throughout our lives. Self-regulation is a special challenge in early childhood, when it is just getting established, but it is a challenge at any age when we are under stress.

How do young children express aggression? They express it by running joyfully with their friends through the playground, by throwing a basketball or riding a tricycle fast, by shouting out the words of a song when cued, by laughing at a clown or shrieking with excitement at a magician. They also express it by pushing another child, by screaming, biting, or hitting, or by grabbing a toy away from a friend. What is the difference between these two ways of being aggressive? The difference is that the first way is adequately regulated; the aggression is under control. The second way is poorly regulated and out of control.

If children do not have adequate self-regulatory capacity to manage their aggression, they may express it with aggressive outbursts such as noted, but they also may express it by holding themselves tight – holding their bodies tight and holding on tightly to their emotions. That frightened, too-tight holding-on is intended to guard against an unwanted aggressive outburst and can manifest as excessive shyness or fear of speaking, or even as bodily problems such food pickiness or constipation. The reason that children fear the loss of control of aggression so much is that they are afraid of the destructive force of their aggression. Even if it is completely unrealistic that a small child could hurt an adult with an aggressive attack, children (out of their awareness) fear that this could happen. That can lead to nightmares of bad things happening to them or to their parents, whom they love and depend on. I want to stress that it is not the aggression that is bad, but it is the fear of losing control of it and harming someone that is bad for the child.

Why do some children have more difficulty managing aggression than others? Some children are temperamentally more sensitive, more active, or more intense. Some children have developmental difficulties that make it hard for them to “get it altogether” – from the point of view of regulation in various domains – motor, emotional, cognitive. Imagine how hard it would be to feel relaxed and confident if your body “didn’t listen to your mind”- that is what I sometimes say to impulsive children. Other children come from high conflict families in which overt or covert aggression presents a chronic threat. Still other children have histories of trauma – either directed at them or at a parent or even grandparent. Finally, some children have more than one of these reasons to have difficulty with aggression.

How can we help children develop the crucial competency? We can help them in three ways. First, we can create a safe situation in which both child and caregiver are not afraid. That usually means adequate and predictable adult supervision, predictable routines, and secure boundaries. Second, we can communicate tolerance of aggression and model constructive forms of aggression. For example, teachers who play basketball or tag with the children are helping the child experience the high arousal state of aggressive activity without the fear of losing control. At home, a parent’s skillful rough housing with a child can offer the same experience. Third, we can make it possible for children to practice aggressive activities without getting hurt or hurting others. Children cutting play dough with a wooden knife, crashing small cars into magnet tile constructions, and engaging in active playground activities are just a few ways I observed today at the preschool.

Our society has a strange and highly ambivalent relationship to aggression. Some parents in our culture prohibit pretend play with toy guns and soldiers, while others teach their children to shoot real guns. American television, video games, and movies are full of aggression. That puts parents in a difficult position, having to negotiate a reasonable balance between under and over controlling both their children’s aggressive behavior and the aggressive displays they are exposed to. There is no simple solution, but the guidelines as mentioned above are – demonstrate to your children a healthy attitude towards aggression; offer them a safe opportunity to take risks with their aggression and to practice using it; and give extra support to children with special sensitivities and needs so that they too can try out their emotions and test their bodies with exuberance.

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Culture – What Can Caregivers in Our Culture Learn from Caregivers in Other Cultures?

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I am convinced that you can’t fight culture. Whereas we in the US have multiple subcultures, there is a general culture that values multi-tasking, technology use, and lack of downtime. The consequence seems to be a relative lack of tolerance for ambiguity and spontaneity, both of which are often associated with creativity. That is not to say that there are not creative individuals in our society nor that there is no creative activity, but it seems to me likely that one has to step out of the typical mind set and pattern of activity of contemporary American life to be truly creative. I accept the misconceptions that underlie idealization and the romanticization of other cultures, particularly those of developing cultures closer to their ethnic roots. However, I cannot be blind to the advantages I see here at the orphanage and school in South India and in the orphanage in El Salvador where I am a regular guest.

Two apparent advantages are – at least in the case of the younger children – plenty of down time, and few toys, especially tech toys. In the evening last night, the gentleness of the temperature matched the tempo of the activity of the courtyard of the boys’ residence. Boys of different ages were playing in two main groups. One group was playing with a volleyball. Two older boys, one of whom had just graduated college, were playing ball together with obvious enjoyment. About 6 much younger boys were trying to capture the ball, while also imitating the older boys’ athletic moves. Sometimes the older boys would allow them to take the ball, and there would be a playful skirmish between the younger and older boys that looked more like a soccer game than the original volleyball. Other times, the older boys continued to play together without much attention to their younger followers, who watched them closely, while also running around. How much learning was going on in that admiring observation, and how much healthy physical activity and enjoyment! There was no conflict among the boys that I could see.

The other group of boys was playing with stiff slender stems of a plant that they used as arrows. They fixed a small rubber band to the rough end of the stick and pulled it with their fingers while pointing the stick upwards. When they released the rubber band, the stick soared into the air. After a while they identified a tantalizing target – a huge jackfruit hanging low on a tree. As the arrows hit the target again and again a milky substance started to seep mysteriously from the fruit. Here also, there was no real conflict. No adults were constraining their activity, telling them what to do or what not to do. No one cared that the fruit of the tree was being injured – it wasn’t as if a precious garden tree or a piece of furniture in the family home was being harmed. The children were free to play unencumbered. How many of the limits we place on children are dictated by the environment in which we expect them to play?

The comfort of the boys in the courtyard was mirrored by the children in the kindergarten classroom. Thirty two children were sitting on small mats on the floor, overseen by one teacher. The teacher, a superb teacher I had known from earlier visits, was calling on the children one at a time to come to the front and create a story out of a picture with four panels of images. This is a rather sophisticated task, requiring them to create a coherent narrative out of the pictures, and the children were doing a good job. At least as impressive was the attentiveness of the other children while the narrating child was at work. Every once in a while one child would start to cause a minor disruption. The teacher did not call the child’s name from a distance. Without speaking at all at first, she moved to his or her side and put her hands gently on their shoulders, moving them back into position. Is there any way we can transport this into our culture?

How to Talk to Your Child About Complex Subjects

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At a gathering of family and close friends recently, a young couple asked me a question about their almost 3-year old son. I had observed the child and had found him to be intelligent, charming, and warmly connected to his parents. He also seemed sensitive, perhaps one of Kagan’s “inhibited” children (Kagan & Moss, 1983). The child, whom I will call “David” (not his real name), had been anxiously asking his parents about whether he might be put in jail, about whether he was a “bad guy”. He seemed to associate these fears to bible stories he was hearing in Sunday school, particularly the stories of Daniel and the Lion’s Den, and the story of Jesus being arrested. This was confusing to his parents, because in their understanding of these narratives, it was the “good guys” who were arrested. His parents told me that they constantly reassure him that he is a good boy, that they love him, and that he is safe. David’s parents further explained that he seems to ask these questions about being thrown in jail whenever a stranger is in the house, asking whether that person is going to throw him in jail. His parents decided to avoid stories about jail and to limit the bible stories since many of the concepts seemed too complex for him to process at this age. They asked me what I thought.

This question is fascinating from several points of view. First of all, it highlights the difference between the meanings an adult makes of certain narratives and those made by a preschool child. Second, it underscores the often discrepant levels of maturation of different developmental capacities in the same child. Third, it reveals aspects of a crucial cultural context that forms the way narratives transmit important beliefs and values in a society. Consideration of these factors may help parents in their efforts to talk to their children about complex subjects.

What about what Tronick calls the “age possible” meanings that two people of different developmental ages make of the same story (Tronick, 2007)? An example is offered by the 4-year old whose mother was trying to explain to her the generational relationship of people at a family reunion. The mother explained, “Your nana is your daddy’s mommy.” The little girl thought for a moment and then asked in wonder, “But how did she get him into the car seat?” I am also reminded of a little patient, a 3-year old who witnessed people jumping from the World Trade Towers on television and in a play session suggested to me that children could “jump big” in a playground because it is “softer” (Harrison & Tronick, 2007). I took her to be referring to a “soft landing”, though I knew that no number of soft mattresses at the foot of the WTT could have cushioned the fall of the jumpers. In David’s case, the meaning he derived from “being put in jail” was that you were a bad guy, period. He was not able to consider a nuanced meaning in which a good guy was unjustly jailed. It is clear that good guys and bad guys are on his mind these days. Remember the “terrible two’s”?. His age-typical anxiety about the result of noncompliance to parental demands (whether real acts of noncompliance or imagined ones) led him to fear that his “bad guy” feelings and thoughts would brand him as a bad guy and cause someone to throw him in jail. A “stranger” is a preferable enforcer of that terrible punishment, because a stranger can be seen as “all bad”. If it were one of his beloved parents who threatened him with jail, how could he manage the stress of fearing one that he also loved and depended on?

The second issue is that of discrepant developmental capacities. Human development is not a smooth, linear process. It occurs in a messy process of hits and misses, halts and bumps forward, and reiterative efforts to master. In many children, this messy process occurs at very different rates and in different ways in different domains of competency. For example, some children have precocious motor coordination but are slow to speak. Others speak sophisticated sentences early but struggle to do one rung of the monkey bars or are insecure about climbing and jumping. If you have significant discrepancies in your developmental capacities, you are left with a subjective sense of inner imbalance, sometimes even of incipient chaos, in the background. It does not always bother you, but when you experience a threat, it can emerge. This could be called “anxiety”, but that is a rather crude description of a complicated subjective experience. I do not know David well enough to guess about whether he has a discrepant developmental profile. The inheritance of “inhibited” genes is another possibility. However, I do know many children who fit this picture of uneven development.

Finally, there is the interesting factor of culture. In an earlier posting, I wrote about how another 3-year old sat through a 6-hour wedding dinner with a minimum of fuss. I described what I saw his French parents do in order to teach him to sit at the table for long stretches. In any culture many core beliefs are transmitted by narratives. Children hear these narratives repeated over and over from early on and learn the culturally shared meanings that their parents convey to them. However, the meaning is not transmitted by language alone. Peter Fonagy talks about this process. He says, “Human communication is specifically adapted to allow the transmission of cognitively opaque cultural knowledge, kind-generalizable generic knowledge, and shared cultural knowledge” (Fonagy, lecture IPMH, May, 2012). This knowledge is transmitted by what he calls “ostensive communication cues” such as eye contact, turn taking with contingent reactivity, and special vocal tones. In a study Fonagy cited, infants of 18 months old were asked by the researcher to pass an object, a doll. In the control group, the researcher gave no cues directed to the infant, but in the study group, the researcher first smiled and said hello to the infant. Then in both groups, the researcher smiled at one doll and made a disgust face at the other. At that point, another researcher came into the room and the baby was asked to give the second person a doll. Only in the group in which the experimenter had smiled and said hello, did the babies give the second person the doll the first experimenter had smiled at, the doll designated as desirable . In other words, the researcher had initiated a relationship with the baby and in that context, the baby attended to the “ostensive cues” (smiling or disgust face) she then gave him. The infant trusted the researcher who smiled and said hello and then judged the information she gave him to be reliable.

So, in response to my young friends’ question, I would say that I support their decision to protect David from anxiety provoking bible stories for the present. In avoiding certain bible stories they are acknowledging a dysynchrony between the dominant contemporary middle class U.S. culture and a culture in which bible stories are a primary means of transmitting beliefs. In the latter culture, bible stories would not just be read but from early on would be told as stories, with accompanying “ostensive cues”. In that culture, the parent would communicate – with eye contact, turn taking rhythms, and tone of voice – who the bad guys and who the good guys are in every story, over and over. In that way, David would learn the salient meanings – with associated values – of his culture. Of course, he might still have fears of being a bad guy, because of his age-typical struggles with his aggression and negativity. It is less likely, though, that his fears would focus on bible stories.

Harrison, Alexandra & Tronick, Ed (2007). Now we have a playground: Emerging new ideas of therapeutic action”, J Amer Psychoanal Assoc., 55/3: 853-874.

Kagan, Jerome & Moss, Howard A (1983) From Birth to Maturity: A Study in Psychological Development, Yale University Press.

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

photograph by Joshua Sparrow

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Some Thoughts About Culture

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Our IPMH group has been having an extensive and interesting discussion about culture on email. I have been traveling and it has been hard for me to follow all of it on my blackberry, but I thought I would offer some thoughts. It refers to caregivers in that we often forget to figure in culture to our caregiving practices and aspirations. Recent writings in the popular press about Chinese and French child rearing have made many American parents doubt themselves. Of course, every path chosen in life leaves another untaken, and every advantage that a particular culture offers also has a price.

I just returned from Normandy, where I attended the wedding of the son of my best childhood friend. It was like stepping out of my life and into a French movie and then back into my life again. I got the thrill that I often get when I am part inside and part outside a life that is not my own. One of the visual memories I have of this experience is that of looking across a room of 82 people, gathered around one big table and several smaller ones, talking. There was something in their animation that struck me, and in the fact that whereas the group included young intellectuals in academic and professional careers, middle-aged tradespeople, retired teachers, one nun, one very old grandmother in a wheel chair, and about a dozen children, I had the impression that they were all leaning forward in their chairs and talking happily. Of course, this was a lovely group of people, and it was a happy occasion, but they were also French, and the French love to talk. They love their language. I would say that is probably the anchor of their culture.

There were several other observations that I made about culture during those two days of the wedding celebrations. The first was about children. The children were quite noisy during the ceremony at the church. They talked and squawked, and no one seemed to care. But what was remarkable was how the children behaved during the dinner after the wedding. The dinner began at 8:00 pm., and there were many children at the dinner, including an infant and several preschoolers. A not quite 3-year old was sitting next to me. He maybe was the one exception to my previous description of people talking happily. At the beginning of the dinner I wondered how long he would last. I tried to make friends with him, but he shrank away from me. Later (just to underscore what I said about language) someone explained to me that his initial rejection of me was probably because of my accent. He was doing little provocative things like poking the straw from his drink into each piece of bread in the breadbasket on the table near him. His parents were all over him about it, correcting him, telling him to be good, but they didn’t seem very upset. They just kept telling him to behave over and over again, in a way that punctuated but didn’t seem to interrupt their conversation with their friends. Finally he just stopped doing little naughty things and started to amuse himself in various innocuous ways. By the end of the dinner at 1:30 am, he was sagging a little, but he was still awake. When people were saying good night, at the coaching of his parents, he even offered me his little fat cheeks to kiss goodbye. We were not necessarily friends, but not enemies.

The second observation I made was the next afternoon when we all came together again for lunch. I noticed that the first thing everyone said in greeting after hello was, “Did you sleep well?” (“T’as bien dormi?”) Now, that isn’t surprising, since we all had been up very late the night before. I noticed that it wasn’t just that people were speaking simply to me because they didn’t know the extent of my French, because they were asking one another the same question. It seemed that there was something facilitating, even comforting about the convention of asking this question, as if it were part of a song that we all knew. Again, language was key.

The last observation was about the goodbyes. Probably many Americans have remarked on “the French goodbye”. It seems to us as if it goes on forever. I guess it shouldn’t be a surprise that the French, who value their language so highly, should use it to soothe the pain of parting. As an American, you have to be prepared, you have to realize that when a French person first says goodbye, he doesn’t really mean goodbye. He means that he is beginning to say goodbye.

How do all these observations come together into a more general consideration about culture? I realize that my comments are coming from a naïve point of view and that many have surely studied this phenomenon and written about it more knowledgeably, but I would guess it has something to do with the place of language in French culture. And as we know, language development begins very early in a child’s life – not necessarily words and symbols, but the aspects of language I am talking about. That is, the tones, the rhythms, the “sense” of communicating and probably even the “sense of what is being communicated”, through the matching of affect and actions with the words. So that when the parents of the 2-year old persistently corrected him verbally without ever giving him the impression that his leaving was an option, they were teaching him how to stay at the table. I am not suggesting that his parents were teaching him patience; I do not necessarily consider patience to be a French virtue, but staying at the table is. I am also not suggesting that all French 2-year olds could stay at the table that long and that late, but since they have been immersed in that culture from birth or before, many can. To return to my original point about culture, I suppose that the advantage of being able to stay at the table carries a price too, but I can’t for the moment think of what it would be.

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Peter Fonagy Presentation II

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The Way Humans Learn About Their Culture

The way this kind of learning occurs helps us understand how the knowledge communicated between parent and child becomes “what is known” and “how it is done” in a large group of people, and then what about this gets passed down over generations. This does not occur through intentional, cognitive learning, but instead happens through the use of “ostensive communication cues”. These cues include such behaviors as eye contact, turn taking patterns, and specific tones of voice such as the falsetto voices mothers use to talk to their babies referred to as “motherese”. Fonagy explains that what establishes these ostensive cues most reliably is the same thing that generates secure attachment – sensitive, attuned behavior towards the baby, giving the baby the sense that the adult is trustworthy and therefore that the information is reliable. Fonagy stresses that all human life is built on social knowledge, and that if you deprive the child of “epistemic trust”, you deprive him of the possibility of benefiting from what he needs to succeed in the society into which he was born. Relationships are absolutely crucial to the transmission of cultural knowledge.

The Implications of Mentalization for Helping People Grow (in psychotherapy or other ways)

When you are with someone who is not mentalizing, it is impossible to have a rational discussion with him. That is because he has a rigid position that is heavily influenced by his own internal beliefs and he cannot bring an open mind to the conversation. For example, if he perceives himself as a victim, he will see everything that happens to him as victimization by a cruel world, and if you try to explore with him how he might have contributed to the outcome by some of his actions, he will not agree and will probably feel victimized by you. This is fairly characteristic of many adolescents, and actually occurs in all of us if we are stressed to an extreme enough degree. One of the ways I see “normal” people let go of their mentalizing is when that person is a parent who is desperately worried about his child. In that case, the internal perception of helplessness in an uncaring world (if people really cared, they would do something!) is so overwhelming that the parent cannot imagine a situation in which there is nothing to be done but wait. Another situation is in high conflict divorces in which each parent perceives him or herself as the victim of the other, and cannot empathize with the other at all.

Fonagy stressed the need to insist on a mentalizing process in therapeutic or other helping engagements. This means that if the person you are working with insists on taking a “non-mentalizing”, or irrational and highly personalized point of view, you must focus on bringing the conversation into a mentalizing one instead of just “hearing out” a lengthy non-mentalizing explanation from the other person. That is because the “hearing out” is deceptive in that it involves the person reestablishing his rigid point of view instead of presenting an opinon that is open to alternative perspectives. Fonagy points out that when your interactive partner is not mentalizing, you stop mentalizing!

Most of the patients Fonagy has studied from the point of mentalization have a diagnosis of Borderline Personality Disorder, but he makes the point that we are all vulnerable to lose our capacity to mentalize under extreme stress. This personality disorder (BPD), he thinks, is a developmental problem, in other words, the failure to develop a competency (mentalization) that it is possible to still develop. Twin studies suggest that it is heritable and it is also associated with early maternal separation and abuse (Belsky, Caspi, Arnseneault, Bleidorn, Fonagy et al, 2012, Dev. and Psychopathology). This suggests that children with a family history of mental illness (any kind) and early parental separation, neglect, or abuse, should be the primary focus of attention of mental health clinicians.

Fonagy reiterates the genetics and early environmental influences activating the attachment system and disrupting mentalization, giving way to a disorganized sense of self and three problematic activities:

1. Psychic equivalence – in which a person thinks that just because they are thinking something, it is automatically true. Flashbacks are an extreme example, and intolerance of alternative perspectives is a more ordinary one.

2. Pretend mode – the mental world is decoupled from external reality. For example, a woman can be completely convinced that a man in her office is infatuated with her even though he has never given her evidence of this.

3. Teleological mode – physical action is seen as the only way to modify someone else’s mental state. An example is when a person insists on concrete evidence of your caring for them – including extra sessions or telephone calls or physical touching.

Fonagy recommends certain techniques for helping your interactive partner (patient, client, etc) to mentalize:

1. Take a stance of active questioning and “not knowing”. That means that you do not presume to know what is going on until the other person explains it to you. While “not knowing”, you gently insist on alternative perspectives. (“Of course, I don’t know, but when I think about it, it occurs to me that X might be happening instead of Y.”)

2. Monitor your own mistakes. That means acknowledging your inability to really know what is in the other’s mind and apologize for your mistakes.

3. Empathy.

4. Curiosity about the other’s experience.

5. Staying in the present instead of moving to the past.

6. Lower arousal by bringing it back to you: “What have I said that bothered you?”

7. Quickly step back if the person seems to be losing control.

8. Highlight the experience of “feeling felt”.

9. Identify a break in mentalizing and “rewind” to the moment before.

10. The main idea is to “create a space” in which the rhythms of mentalizing can occur, a safe place where you collaborate in creating a more flexible and adaptive meaning about what is bothering the person.

Fonagy has a new book out about how to understand mentalizing and how to practice it:

Anthony W. Bateman and Peter Fonagy, Handbook of Mentalizing in Mental Health Practice, American Psychiatric Association, 2012.

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