Tag Archives: Lenore Terr

A First Aid Kit


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.
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.

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