Tag Archives: El Salvador

“Los Momentos Magicos”: A poster at WAIMH

This is one of the two posters I presented at WAIMH (World Association of Infant Mental Health) this past week in Edinburgh.

“Los Momentos Magicos”: A Practical Model for Child Mental Health Professionals to Volunteer by Supporting Caregivers in Institutions in Developing Countries.

“Los momentos magicos” refers to small interactions between caregiver and child that when repeated multiple times can have a lasting positive effect. This hopeful perspective is important for caregivers of children in institutions in developing countries, many of whom carry the scars of early neglect and abuse. Through her experiences in visits to orphanages in Central America and India, Dr. Harrison has developed a model for mental health professionals in developed countries to volunteer their consultation services to caregivers (CG) of children in care in developing countries in the context of a long term relationship with episodic visits and regular skype and video contact.

Weekly Skypes:

Example of Notes from Skype Sessions with Director of Caregivers (DCG) – In a meeting with the teachers, DCG felt frustrated when the teachers implied that the children were neglected. The teacher said the children do well in school but do not bring in their homework. The teacher was concerned that they were hanging out with kids at school who were a negative influence. DCG has told them that they can be friends with these kids, but when they see them involved in problem behavior they should walk away. I suggest – because this has been successful in the past – the possibility of a community meeting in which the other children at the home are invited to brainstorm how to stay out of trouble and how to deal with other kids who are getting into trouble at school. DCG says that is a good idea. She will try it and let me know how it went. We talk about how much responsibility to expect from a 10-yo with his homework. A CG is leaving, and we talk about how to prepare the children for this loss – which children will be most affected, how they might express their distress, how to say good bye.

El Salvador Workshops:

Workshops take place in the orphanage during a weekday, when the children are in school. They begin with coffee and pastry, and there is a break for lunch, sponsored by the workshop leaders. The format is a power point presentation with accompanying video. Following a consultation model, the workshops focus on the caregivers’ chief concerns, underscored by the consistent message of the importance of the relationship. Videotapes of caregivers engaging in interaction with children are used to illustrate successful caregiving techniques, while also demonstrating how the caregiver’s ability to imagine the mind of the child is crucial. Discussion is encouraged throughout the presentation. After the first workshop, examples of the caregivers’ evaluations included, “It is good what you said, but now you should tell the children to do what we tell them to do.” Examples of evaluations after subsequent workshops included, “ I learned that it’s important to get down to a child’s level and listen to him, before I set a limit.” And “How to have a better relationship with a child and how to understand his situation.”

North India Workshop

Workshop to 80 nursing students at mission hospital in No India. Subject: Supporting the First Relationship.

Using Nugent’s book, Your Baby is Speaking to You ( 2011), Harrison and Gregory emphasized three points: (1) Babies are speaking to their mothers; (2) Mothers can listen to their babies; and (3) Nurses can help mothers listen to their babies in a way that can influence the future health and well being of the children. We stressed the importance of making the mother feel competent to understand the communications of her own baby. To illustrate these points, Ginger played the role of the mother, and I played the role of the nurse. As usual, eliciting the help of the translator added another dimension of cultural richness and respect to the consultation process.

South India Consultation to Teachers at School

Again followed consultative model focusing on teachers’ questions about students. Using data from teacher and child interview to answer the questions. For example, (1) Why does he not attend school regularly? (2) How can we make school more interesting to him and motivate his learning?

Child was observed in the classroom and child and teacher were interviewed. Data from observation and interviews were used to answer the questions:

(1) There is the feeling in the family that he will be the brother who stays home and keeps the farm. He is also afraid of family discord and wants to protect family from fighting. He does not see the practical reason for studying. He also has some learning problems – working memory, auditory processing, executive functioning. (Include explanations of executive functioning, working memory, auditory processing).

(2) Story problems about farming (math) – buying selling, ratios of the fields, making calculations on the spot to determine prices and make sure venders are not cheating.

Auditory processing support – when possible, give him important factual information parsed in chunks separated by few seconds pause, with repetition of information afterwards.

Building working memory – tasks that require remembering longer and longer bits of information over time (addresses, phone numbers, “telephone games” of hearing information from one person who repeats it to the next person, etc., drills, repetition, and rote memorization for basic facts, making up his own acronyms for information that is hard to retain.

Strengthening executive functioning –practicing organization of homework, building predictable routines, checking homework lists to make sure everything is done and in its place, going over tests and assignments afterwards to identify errors and to understand how to avoid those errors in the future.

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.

Read this blog in Spanish.

“A Healing Place”: Part I

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I am in El Salvador and am reporting on a recent workshop I gave at the children’s home, Love and Hope, with my colleague and team member, Susana Fragano. Before my departure for El Salvador, I asked Rachel, in one of our regular skypes, what she and the tias and tios (caregivers) would like to have as the focus of the workshop. She said that what they really needed help with was how to manage severe behavior problems. She told me about some of the tantrums, insolence and noncompliance, and sexual behavior, of the children in the home. This behavior has gotten worse in the last year or so since LEPINA, the Salvadoran law that requires institutionalized children to be reunited with their biological families, has been implemented, causing most of the children in the home to be returned to their families in the community. These reunited children, when they return to the home at the request of their families – either for weekend visits or for longer stays – because the families declare themselves unable to care for them – demonstrate more problematic behavior than before the reunification. Whether the worsening in behavior is due to neglect and abuse the children report they have experienced during the time they were living with their families, whether it is a consequence of the disruption of a secure caregiving environment and the traumatic loss of the caring relationships they had enjoyed at the home, or whether it is simply due to their growing older, is not known.

In the next several blog postings I am going to report on my experiences at the home during this visit and the workshop we gave to the caregivers. For a reason that will become clear as I continue, I will call these postings, “A Healing Place”. I have awakened early to write, and as I open the curtains in the window of my favorite hotel in San Salvador, I look out on dark mountains in the near distance, palm trees and other tropical vegetation in the nearer distance, and the “Mister Donut” sign that protrudes above the rooftops and guides us home after a day’s work.

Pathway to Trouble

I introduced the workshop with a review of the sources of the problems that these troubled children now have. I reminded them of the important factors I have spoken to them about many times before: (1) Prenatal stress; (2) Early abuse and neglect; (3) A genetic contribution; (4) and the ongoing trouble caused by the effect of chronic stress on the developing brain. The more you repeat a problem behavior, the better your brain learns to repeat it. I would like to state at the beginning of this series of posts that many of the points I am making about traumatized children are equally valid in relation to children with serious developmental disturbances, such children on the autistic spectrum. That is because for these children ordinary life experiences with other people, even caring attention, can feel traumatizing.

Interrupting that Pathway to Trouble

This is what the stated goal of the children’s homes has always been. Put another way, it is “breaking the cycle” of the consequences of severe neglect and abuse. But this is very hard to do. It is also hard for caregivers to remember, to keep in mind, that the children they take care of have a story about pain and neglect in their brains. They carry it always, and it can emerge unpredictably in response to current experience. This story will not go away with good care. But it can become increasingly less potent, as a new story is created to take its place. The new story is about acceptance, trust, love, and hope. The new story is about healing.

A Healing Place

I then told them about an 8-year old girl I had observed the day before. Let’s call her “Angela”, not her real name. She entered the home at 3-years old as the victim of severe neglect and abuse, including sexual abuse. After 4 years in the home, she was “reunited” with her family. (It is important to remember that this ill-conceived law, LEPINA, was implemented abruptly, without adequate assessment of the families’ competence as caregivers, and without support for these families in the community.) When in Angela’s case the neglect and abuse began again, her family returned her to Love and Hope, with occasional weekend visits to her family. The day before yesterday, after a recent visit Angela made to her family, we observed her playing. She explained that she was making a “botiquin”. Neither Susana nor I understood the reference, so Susana asked her what a botiquin was. She explained that a botiquin was something that contained whatever you needed to make yourself better when you were hurt. With Rachel’s help, she carefully organized the contents she planned to put into the box when it was completed – band aids, tape, pretend thermometer, etc. Another girl in the home offered to help her with the project and was taping clean white paper onto the cardboard box with all the care of wrapping a present. As I watched this hurt child happily engaged in pretend play with the support of her primary caregiver and her friend, I thought to myself that she was representing in play the safety and comfort of Love and Hope. She was creating for herself a healing place.

Read this blog in Spanish.

April Trip to El Salvador

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Day 1 and 2:

As has become the custom, this trip was organized around a workshop. The workshop was designed to respond to the evaluations from the last workshop that requested (1) Discussion of adolescent issues, particularly adolescent sexuality; (2) More discussion, especially including those who had not talked in previous workshops; (3) Discussion of work with families. Because of our past experience, I decided to wait until I arrived to gather the data for the workshop on site, and I planned to first visit a new orphanage for HIV-AIDS children, discuss two worrisome children with the home psychologist and social worker, then accompany Rachel on her meetings with families to pick up children visiting the children’s home for the weekend, and finally capture video of teenagers in the home, all before the workshop on Saturday morning.

On Thursday afternoon, Rachel picked me up at the airport, and we headed off to visit the Reina Sofia orphanage, run by the Mensajeros de la Paz, located between the airport and Suchitoto, a medieval city I had visited years before. The director who greeted us was hospitable and knowledgeable about the home, and the venue was appealing – clean and airy and attractive. The children that we saw were friendly and seemed happy and well attended. On the wall was a schedule listing their routines, with medication times interspersed between the other daily activities. There was something comforting about the matter of fact way the medical care was handled, as well as the sense of security provided by the availability of a doctor and nurse. The only disturbing feature was the number of children in the home – 14. About half of the children had recently been “reunited” with their biological families in compliance with the law, Lepina. The director explained that many of the families of the children lived in the countryside, some far from bus lines, and she was worried that the families would not be able to manage the complicated medical regimens the children needed to keep them healthy.

The next day, I was picked up early to meet with Love and Hope’s psychologist and social worker. We discussed two boys whose behavior problems have been an ongoing issue. I of course knew these boys, one since he was 1-year old and the other since he was 2. They were now 8 and 9-years old. We began with the 8-year old.

The social worker prepared a report on “M”: He is anxious and playful. In the last 7 months he has had uncontrollable tantrums, bucking authority, aggressiveness, and impulsivity. He has a defiant personality that mainly emerges during academic activities. One time he said to the psychologist, “I don’t know what is wrong with me. I feel I turn into another person. I can’t control myself.” The social worker and psychologist are working to connect him to other kids and his brothers and sister (also in the home) through games. They have made out a conduct system of smiley faces and “walking towards the sun” in which there is a calendar with each day offering options of a cloud or a sun, depending on M’s behavior. They are trying to reward good behavior and give consequences for bad behavior, and the results have been sporadic. At times M says he doesn’t care about prizes or punishment. During play therapy they work on improving his sense of the limits of good behavior. They have gotten his mother involved, asking her to support their efforts by calling once a week. His relationships with his mother and his siblings have improved. His tia (the caregiver in the home assigned to M) had a meeting with his teacher. When you speak to him after he has a tantrum, he can say exactly what happened and knows what he should have done differently. They decided to get a psychiatric consultation. The psychiatrist suspects a genetic factor and prescribed blood tests. M seems to be bothered by everything. At school he fights with other children and shows lack of respect for the teachers. He doesn’t seem to have any friends. Kelly, one of the directors of Love and Hope, says that her relationship with M changed dramatically for the good since she began to invite him to her house, outside the children’s home. He took care of the handicapped child she is hoping to adopt, and he took pride in cleaning and helping around the house. In this setting, he behaved very well. I asked the psychologist and social worker what questions they had about M that we should consider. They asked,

Are the blood tests necessary?

I looked at the list of the blood tests and responded that they should get a second opinion from their new pediatrician, because I was not qualified to give a medical consultation in El Salvador. I strongly recommended that the team bring the problem to the pediatrician, because they have recently made a connection with an experienced and well-reputed pediatrician in the community who has expressed interest in seeing the children from the home. I pointed out that good medical care requires one primary clinician who knows the child and caregivers and can help make decisions about specialty consultations. My memory of M was that he had a problem eating when he was much younger, and trouble falling asleep at his desk in kindergarten, so that his nutrition should be evaluated, despite the fact that he was eating better, his growth seemed to have caught up, and he looked physically healthy.

Is it OK to show him that they are angry, because sometimes the only way to get him to settle down is to talk to him in a firm and angry manner?

Here, I underscored the distinction between “angry” and “firm” and suggested that whereas “firm” was good, “angry” – though completely understandable at times – was not as good. The ideal, which no one can attain all the time, is firm and clear, but not highly reactive (which one usually is when angry). I then pointed out that in order to answer the first two questions well, we really needed to ask a third.

What is the cause of the tantrums?

I said that we would try to answer this question in the workshop the next morning, when I had a chance to review all the data. I planned to try to film M later in the day to see if I could identify any important relational patterns. (Then the sw and psych asked a fourth.)

What are other forms of discipline besides “consequences” (that involve taking things away)?

I said that consequences are important, because it is good to follow through with the established rules and the results of breaking them. Another form of “discipline”, though, is reparation. That means giving M a task to do that will benefit the community – cleaning or making something, doing a job. Although this can also be perceived as a punishment, it does not primarily involve taking something away. Instead, it involves a “giving back”, and it can be received with positive recognition and thanks.

We talked about how though M and the other boy we were planning to discuss were quite different in some ways and of course distinct individuals, they seemed to share similar behavior problems, and both acted sad and disconnected. I also responded that even at this point, knowing the boys as well as I did, I would suggest that each boy have individual therapy once a week and an individualized educational plan. I mentioned these two interventions because each boy seemed lonely and seemed to have trouble making and keeping friends, and also because despite the fact that I knew both boys to be intelligent, they were not succeeding in school and resisted doing their homework.

Rachel said that she worried if the boys were given individual time every week that they would develop “the kind of bond” in which they would want “to do everything with you”. I explained that though this kind of attention may elicit longing for “more”, it was necessary to build the kind of relationship the boys needed, and there were boundaries to the relationship that played a therapeutic role. That is, the beginning and end of the therapy session would come to represent the limits to what one could reasonably expect to receive compared to what one wished for (everything), and the therapist (or caregiver) could help the child manage the distress provoked by maintaining the boundaries. The therapy sessions should take priority over other tasks of the social worker and psychologist, since some of the tasks they have been doing could be done by other non-psychologically trained personnel, and these boys needed a special relationship very badly. I said that I could help support the therapists and Rachel in this process.

We then talked about a “two part approach” in which we considered how to manage the meltdowns, and then tried to build their self-esteem, another problem that the sw and psych brought up.

1. Managing the meltdowns or aggressive behavior could be dealt with by establishing appropriate (reasonable expectations for this particular child) rules and consequences ahead of time, something which the home has done very well. Then, I suggested not even trying to reason or even talk to them much when they are “off line”, in other words, when they are so stressed (and physiologically aroused) that they cannot think. Just do your best to help them calm down. Depending on the child this will mean sitting quietly with him, or getting someone to help calm them with you. After the child is calm, then you give him the consequence and talk to him about what happened. This may take some time, since if you come in too soon with this challenge, you may provoke another escalation.

2. Building self-esteem occurs in relationships and with mastery. That is why an individualized educational plan, even if it is only in the home and not in the school (which may be impossible), is important. Positive relationship experience can occur in therapy and through the support of peer and sibling relationships, which has already begun.

We then spoke a little about a big problem increasingly being faced by the home as they shift their focus of support to include the families in addition to the children. When the psychologist or social worker tries to meet with demanding, provocative parents, it is very stressful. It is often hard to keep in mind that these parents frequently are themselves victims of trauma, abuse, and neglect and have developed these antisocial coping strategies as means of survival in their bleak lives. Instead, when they use their children as pawns in their manipulative behavior, one is confronted by their cruelty and by one’s own helplessness. An example is a parent who refused to allow her child to return to the home for the weekend, though the child desperately wanted to come, unless the psychologist gave her money that was not in the agreement. I suggested that these professionals seek out a colleague when they felt helpless in this situation and that the team have a second weekly meeting to talk about their emotional experiences.

After this discussion, I noticed out of the corner of my eye that M was having a conflict with one of the staff, and I went to get my camera to try to capture the interaction. The results of this and of my interview with the three adolescent girls in the home will appear in my next post, describing the workshop.