Tag Archives: Workshop

The Workshop: Magic Moments

Jandk

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.

 

Read this blog in Spanish.

 

 

 

 

April Trip to El Salvador

Ballgame_2

 

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,

  1. 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.

  1. 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.

  1. 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.)

  1. 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. 

 

Workshops for Caregivers

In order to learn about caregiving of children in care in developing countries, our team has been visiting the orphanage of Love and Hope.  As is typical in orphanages in CA, most of the children are not actually orphans but have families that are unable to care for them because of financial, mental health, or other reasons.  The children all have histories of severe neglect and maltreatment.

Caregivers

 Orphanage Caregivers attending Workshop 

In April, 2011, the team gave a second workshop to the caregivers in the orphanage.  Following a consultation model, the workshop focused the caregivers’ chief concern – discipline – but underscored by the message of the importance of the relationship.  Videotapes of caregivers setting limits in the orphanage were used to demonstrate successful limit setting techniques.  The caregiver’s ability to imagine the mind of the child was crucial to the success of the interactions.  Examples of the caregivers’ evaluations of the workshop included, “ I learned that it’s important to get at a child’s level, spend time with them, and connect with them first.” And “How to have a better relationship with a child and how to understand his situation.”

 

Read this blog in Spanish.