Category: Featured

 

In the 10 years I’ve been an Infant Mental Health clinician, picky eating habits in children top the list of things families come looking for support in. “My kid only eats mac and cheese” or “He won’t eat a vegetable” are common phrases heard at an initial intake appointment. I’ve often wondered:  What is picky eating? Is it behavioral/emotional, relational, medical, sensory or environmental? The answer I’ve discovered upon working with an Occupational Therapist (OT) for the past five years: All of the above. 

Research has shown that children with feeding challenges generally have more difficult temperaments, which leads to relationship conflicts and a lack of maternal confidence and competence in addressing these difficulties (Aviram et al., 2015). Through infant mental health services, a clinician can support children and families through navigating these difficult interactions, which can also address the children’s feeding challenges.  However, psychological support is just one of the many important pieces that goes into addressing this complex issue. 

In the field of mental health, we are well aware of the ‘anger iceberg,’ the idea that anger is an emotion that tends to be easy to see — the tip of the iceberg — but with many other emotions and experiences hidden below the surface. The field of occupational therapy has a similar metaphor around feeding.

For feeding therapy to be effective, the OT needs to take into consideration three overarching areas: the 1) psychological experiences with eating, 2) previous experiences with food/eating, and relationships with people around eating, and 3) oral motor skills and abilities to manage foods.  One or a combination of these can be the reason the child is having difficulties.  Due to the complexity of feeding, a team approach is required to have the highest level of success for overcoming challenges.

As Infant Mental Health clinicians, it is important to understand when it is problem feeding, not just picky eating.

As part of developmental guidance, and to be generally supportive, we may normalize picky eating, but we must also do our due diligence to help families discern when picky eating rounds the corner into problem feeding and when to refer to appropriate specialists.

So when would it be considered problem eating? It is not uncommon for toddlers to display preferences for specific foods or refuse to try new things that are introduced. By the age of three, children should have consumed at least 20 foods, with two to three items in each food group, on a consistent basis. Below are red flags for problem feeding; it is recommended that a child be referred to an OT, or other appropriate specialists, if at least two are present. 

• Restricted diet with little variety  
• Cries and falls apart when presented with new foods; complete refusal 
• Refuses entire categories of food textures or nutritional food groups 
• Almost always eats different foods at a meal than rest of the family; often doesn’t eat with the family 
• More than 25 steps of the 32 on the Steps to Eating Hierarchy** 
• Consistently reported by a parent as “picky eater” across multiple well child checkups. 
• Significant loss of previously eaten foods (as some loss can be considered typical)
• Signs of aspiration: wet sounding voice after and during eating, sweating, sneezing, coughing, excessive amounts of saliva, etc. If any of these are present, seek medical assistance from a physician.

If a child is exhibiting any of the above, as well as the signs/symptoms below, a referral to a speech-language pathologist or medical specialist is likely needed. 

• Ongoing poor weight gain 

• Ongoing choking, gagging, or coughing during meals 
• Problems with vomiting 
• History of traumatic choking incident 
• Inability to transition to baby food purees by 10 months of age 
• Inability to accept any table food solids by 12 months of age 
• Inability to transition from breast/bottle to a cup by 16 months 
• Has not weaned off baby foods by 16 months 
• An infant who cries and/or arches at most meals 
• Family is fighting about food and feeding (i.e. meals are battles)
• Parent reports repeatedly that the child is difficult for everyone to feed 
• Parental history of eating disorder, with a child not meeting weight goals 

We are focusing on occupational therapy interventions for the purpose of this article; however, it is also common for speech-language pathologists to address feeding concerns, specifically as it relates to swallowing/choking/aspirating behaviors. It is important to coordinate with the child’s pediatrician to make sure referrals are made to appropriate specialists. Choking, gagging, vomiting, food coming out their nose, and aspiration during and after eating are very serious concerns and the child may need a swallow study or other assessment to check for anomalies. 

The following case study highlights how Infant Mental Health and Occupational Therapy disciplines can work together to support the complex needs of infants and toddlers associated with picky and problem eating.  That relationships are the foundation for all successful interventions was apparent through our work together.

Building an Alliance and Settling In

Lindsey — Infant mental health clinician

My work with Chloe and her family began when she was 10 months old, but the family had been involved with my organization for many years before that. Chloe lived with her mother, Sarah; father, Michael, and older brother. Chloe’s brother had been involved in the parent-infant program as a toddler and at age 5 had been diagnosed with autism. Because of that, Sarah was anxious about Chloe’s development  and she was often very uncertain of her parenting skills. Sarah told me at our initial intake, “I don’t trust myself to know what is typical for kids anymore. How could I have missed the signs with her brother for so long?” The grief that comes with an autism diagnosis is often heavy and complex, and I often found myself supporting them during my four years of work with them.  This was not the child she dreamed of having, and I needed to create space to validate her grief and to talk about the guilt she was feeling before she could move forward with possible interventions with Chloe.

The first two years of work with the family focused a lot on developmental guidance. Sarah and Michael looked forward to the completion of Ages and Stages Questionnaires to monitor Chloe’s development. Sarah continued to be anxious about Chloe, often worried that she would also be diagnosed with autism. For much of the first year of our work together, Chloe’s development was on track. It was into the second year that I began to notice that her language skills were mildly delayed, and our interventions and parent-child focused activities became geared toward supporting her language skills. Sarah and Michael were always very open to learning new ways to support her and would eagerly try to continue the activities outside of our sessions. 

Along with developmental guidance, emotional support was a predominant core strategy used with Chloe’s parents to encourage their confidence and competence in raising their two children. During my weekly sessions, I would frequently observe the strengths they possessed as a family and notice them out loud. It was important to point out the moments of connection, as they were often difficult for Michael and Sarah to see. I wanted them to know how important they were to their children. Along with in-the-moment commenting, I would frequently use video in our sessions to observe strengths together and build upon them. 

Sarah especially enjoyed doing art projects with the kids, and we would often videotape these delightful moments. Both Sarah and Michael had good insights into their children’s challenges, but they often felt frustrated and sad over not being sure how to help them. I often noted out loud how much I appreciated their willingness to be vulnerable. Sarah was very playful with her children and loved going out into the community and offering them experiences she did not have growing up. Both of Chloe’s parents had complex trauma histories, and as we got into the second year of our work together, we were able to explore more of the impact those histories had on their relationship with their children, each other, and their home environment.

The home environment was often very chaotic with little structure. The children did not have a consistent meal and bedtime routine, and we frequently focused on that during our sessions in those first two years. From the time Chloe started becoming independent in her feeding/eating, she would sit in a highchair on the floor in front of the TV. Additionally, because of her mild speech delay and observance of her brother’s challenging behavior, she frequently screamed to get her needs met. Chloe did not have a consistent meal schedule, which resulted in grazing; her family would feed her whenever she screamed. The family also did not typically eat a wide variety of foods, which limited what Chloe was offered. 

Observation and Further Assessment

Lindsey

Around Chloe’s third birthday, Sarah and I started to become increasingly concerned about some of Chloe’s sensory processing issues and picky eating habits. It was something Sarah had brought to the attention of Chloe’s pediatrician on multiple occasions. Chloe frequently would scream when water was splashed in her face; she would not let her hair be brushed or washed so it was constantly matted, and she often refused to wear clothes. She had only 10 foods that she would eat, refusing to try anything new. Her food repertoire consisted of predominantly softer foods, with little variety. She would not eat foods of mixed textures (such as noodles with a meat sauce, instead the sauce had to be a plain marinara), she was very particular about meats (only cheeseburgers from McDonald’s, bologna and hot dogs), yogurt, one fruit and one vegetable. We would expect some pickiness or refusal to try some new items by the time a child is three, but we were not seeing Chloe eat many typical kid foods such as pizza, chicken nuggets, French fries, mac and cheese, etc. While she appeared to be a healthy weight (and trips to the pediatrician confirmed this), I was concerned that this would not be the case for much longer if her diet continued to be so limited. Mealtimes had consistently been a point of stress within the family at this point; Chloe frequently would have tantrums while Sarah would scream at the kids to just eat the food that was given to them. 

Around this same time, I had hired an OT through a grant, which allowed both an OT and IMH clinician to go on home visits to work together.

I understood many of the behavioral and relational interventions that would support Chloe’s picky eating, but I began to realize that her needs were outside of my scope of practice and that she needed more intensive intervention from a specialist.  

I referred Chloe and family to Deb for occupational therapy. 

I was able to be present during Deb’s initial evaluation, as well as subsequent sessions, which allowed me to gain further understanding on how treatment would look. My initial reaction while observing the evaluation was feeling almost surprised by how much Deb was aware of, and in tune with, Sarah and Chloe’s relationship. I was struck by Deb’s ability to wonder about the parent-child relationship dynamics as she explored what the family’s relationship with food itself was like. 

Through my work with Deb, I learned ways in which I could enhance what I already knew to support Chloe and her family. Deb and I quickly collaborated on how to support making mealtimes more enjoyable for Chloe and Sarah. Once again, we were able to successfully use videotaping to observe interactions and support these everyday routines. Deb helped me think about how the stress response system and appetite are directly linked together, which we were able to bring to Sarah and Michael during our sessions. The family was receptive to the information and the perspectives Deb and I brought them. Slowly, we began to see subtle improvements and more delight during meals. 

Collaboration and Occupational Therapy Intervention 

Deb

When I first met Chloe and Sarah, I noticed how Chloe was connected to and looked for her mother.  In addition, I noticed how she called for her help when Sarah left the room and not as often with her father.  During the evaluation, her mother was a strong participant and was encouraging to Chloe.  Sarah had insights into the challenges her daughter was having but did not know how to help her.  Their house had many activities and items that could support treatment, and Sarah was a willing participant in evaluation and subsequent treatment sessions. 

When working with Chloe, it became evident quickly that she had not fully integrated her nervous system.  This was evident by how she was still having difficulties engaging with activities and tasks of a variety of textures through her hands, without having negative reactions or atypical play with them.  For example, Chloe was able to play with water through her hands but could not tolerate it splashing on her face.  Also, she was slow to play with sand and paint.  Initially, she would engage with one or two fingers for a few seconds and then over time she would add more fingers and play for longer periods.  However, even between periods of play, she would wipe her hand or hands off.  Most children at the age of three would dive in with both hands to get messy.  They would not worry about cleaning their hands or be slow to touch either sand or paint textures.  This type of engagement and play that Chloe demonstrated through her hands indicated that they were not integrated from a sensory perspective, which also meant her head and face were not as well, since the nervous system develops from feet to head.  This meant we had to focus on integrating her nervous system before we were going to see change within the areas of grooming/hygiene, bathing, and feeding.  I also had to change the environment and how some of these activities were being performed to create a new pattern since the current patterns were creating a stress response and negative reactions.  This included changing the places activities occurred, who completed them, the tools used during the activity, and interactions/relationship between the parent and child.  It also took recognizing sensory cues and learning to accept when a therapeutic break was required to then allow the task to be completed instead of just pushing through it.

This model assists across all areas of activities of daily living.  A child will relax when you can create a secure and safe environment, which can then allow for growth and change.  In addition,

we needed to try and create routine and expectations, which also create security and safety during tasks that children perceive as scary or that create a sense/state of anxiety.

This was the model used for Chloe’s feeding therapy, which combined sensory integration, transcending the food hierarchy model (Steps to Eating Hierarchy) with a variety of foods, modeling, environmental modification, and parent-child interaction modification.  The sensory integration approach involved increasing exposure and tolerance to a variety of textures through her hands and slowly moving it up her arms toward her head and face, all while monitoring and respecting her interactions and need to clean up.  A play approach was used for adding foods to her very limited repertoire by first increasing tolerance for being in the environment, to breaking it up and playing with it with tools, toys, and hands, then allowing foods to progress up her body till we could get it to her mouth, and then possibly taking a bite and spitting it out.  These are activities we use to progress up the Steps to Eating Hierarchy.  It is a therapeutic approach that allows for exposure to foods at a level of tolerance that a child can manage while learning about the properties of foods without the pressure of eating while working and addressing the different properties of new foods.  It then progresses up to the mouth and eventually to eating a bit of a new food.  

The education process around feeding is multifaceted and has many layers to create overall changes in feeding, the relationship between food and the person, the person and the environment, and the person and others within the environment, as well as changing current patterns, behaviors, and routines. For this client and her family, there was education about presentation of new foods even at the level of tolerating them in the environment or on her plate, creating a new routine around mealtimes. We worked with the family on establishing consistent times of day for eating because grazing behaviors do not promote a sense of hunger. We also wanted to encourage that at least one meal a day take place as a family. I noticed Lindsey exploring barriers to these two routines with Sarah and Michael, wanting to make sure they were as successful as possible. I could see how understood they felt by her, which led to more success and confidence in their ability to make these changes. 

One of my top priorities was to move Chloe away from the TV, and instead to a table, in order to make food the most interesting thing happening at mealtimes.  By decreasing distractions, we were able to promote the increased speed of eating, plus being around other people eating allowed for modeling and socialization of mealtime and eating behaviors. It also gave her the opportunity to be around new foods even if they were not on her plate.  

There was a high degree of education, as well as emotional support provided by Lindsey and me, for Sarah to try and not worry during mealtimes. Often, Sarah was so concerned about what and how much Chloe was eating that Chloe’s stress rose during meals. Ultimately, we just needed her to eat.  Kids pick up their parent’s stress and when the stress response rises it decreases appetite.  This inadvertently creates a power struggle between the parent and child because the parent becomes focused on the child’s eating and then the child just exerts more control over the situation by not eating.

Lindsey’s knowledge of the family was integral in the development and implementation of all strategies and progress throughout the subsequent treatment sessions.  Her in-depth knowledge of the family allowed for more realistic goals to be determined and for me to gain all relevant client factors that could help and impact progress.  In addition, the relationship she had with both Chloe and Sarah created a sense of safety that allowed the client and her mother to be open to me and create progress within a very difficult area of feeding.  Feeding is so multifaceted that it took the combined skills of Lindsey and me to make a true difference.  I can impact the sensory processing, progress feeding, and create some environment and parent/child modifications, but Lindsey’s knowledge of the parent-child relationship was integral in changing those relationships to then allow the families to be available for my interventions.

“We don’t have to do it all alone. We were never meant to.” — Brene Brown

Lindsey

We wish we could say that all of Chloe’s feeding concerns were addressed by the time we finished working with this family, but just as parent-child relationship work takes time, so does occupational therapy and feeding treatment. Chloe made tremendous progress from a sensory integration standpoint, and she gained three new foods that she would consistently eat, and seven foods that she progressed up the Steps to Eating Hierarchy. Depending on when children ‘fall off’ the normal developmental feeding trajectory, it can take just as long to get back on track. Our work with this family highlighted the importance of professionals working together in collaboration and that we can’t do this work alone. Deb was able to support the family, and myself, in establishing new routines and attitudes around food, which created a building block, or planting of seeds, for us to take with us into our work long after she was gone. 

References and Resources: 

1. Aviram et al (2015) Mealtime Dynamics in Child Feeding Disorder: The Role of Child Temperament, Parental Sense of Competence and Paternal Involvement. Journal of Pediatric Psychology, 40(1). Pp. 45-54.
2. Growing hands-on kids. (n.d.). Retrieved from https://www.growinghandsonkids.com
3. Kranowitz, Carol Stock. The Out-of-Sync Child: Recognizing and Coping with Sensory Processing Disorder. New York: A Skylight Press Book/A Perigee Book, 2005.
4. STAR Institute (n.d.) Retrieved from https://www.spdstar.org/
5. Toomey, Kay & Ross, Erin. (2011). SOS approach to feeding. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 20. 82. 10.1044/sasd20.3.82.

**Steps to Feeding Hierarchy:   This hierarchy represents the 32 steps it can take a person to eat one bite of a new food.  It is a sequential desensitization approach created by Dr. Kay Toomey and is an evidenced-based approach to feeding therapy. It was established with a copy-write in 1995 (and updated in 2010).  A person moves through the steps with interventions that provide them a safe environment along with the addition of other treatment strategies and theories.  The major steps within the hierarchy are as follows: tolerates, interacts with, smells, touches, tastes, and eating. There are smaller steps within those larger steps, which progress upward from “tolerates” toward “eating,” and a person can start at any level for any food.  After eating a single bite of a food, it can take up to about 30 trials of that food to determine if you like or dislike that food. 

 

COVID-19 has dramatically shifted how we provide clinical and supervisory services to families and mental health practitioners.  Home- and office-based in-person meetings have been replaced with video and telephone calls.  Never before has the idea of “how we are is as important as what we do” in our clinical work been so important to remember (Pawl & St. John, 1995).

In this time of social distancing and subsequent provision of services via virtual formats, we are challenged to discover new ways of being present over a screen or the telephone.

We have been tasked with figuring out how to hold onto our core ways of being with others while at the same time to let go of ideas of operating under the premise of “business as usual.”  We have had to pull all of our resources for creativity, compassion, flexibility, and adaptability to the forefront of our work over the past several months and the unknowable future for many of us.  Meeting virtually no longer seems like a temporary arrangement to help families, but has become part of the fabric of how most of us are working for the foreseeable future.  A central challenge before us remains: How do we embody relational principles of “how we are” over a screen when meeting with families and supervisees so that they can experience feeling truly met with by us?

How We Are

Of course we should always strive to consciously embody how we are with others in our clinical work; however, working virtually demands that we be especially mindful of fully and authentically embodying our “how we are” to share with others over a computer screen or the telephone.  Our “how we are” includes being fully present, emotionally regulated, safe, reflective, and focused on the centrality of relationships (Pawl & St. John, 1995).  We must strive to be open and responsive to each individual’s experience of sheltering in place; tolerate and organize their feelings as they ride an unpredictable emotional roller-coaster; create a sense of safety in being together in whatever way might be available at any given time; continue to seek understanding of how behaviors, feelings, and thoughts shift in response to how things are in the home and the outside world, and keep in mind the critical importance of having a safe and trusted relationship in which to feel held, no matter the format in which it is experienced.

As we stretch to find new ways of maintaining a sense of connection during this time of extended social isolation, we must consider how to help others feel held in mind; to know that they are not alone as they navigate through this frightening time under such extreme stress, pressure, and vulnerability.  It is the felt experience of being held in another’s mind that is especially salient here.  An important aspect of being held in another’s mind includes being “spoken to over distance … tethered across space and out of mutual sight” (Pawl, 1995, p.5).  A sense of connection is created by being consistently held in another’s mind, which is by definition a way to sustain that sense of “not-alone” when physically apart from one another.  Current research suggests that irregular, brief, unscheduled contact with clients can strengthen the therapeutic relationship and lets them know that they are in your thoughts even when you are not meeting at a scheduled appointment time (Caldwell, 2020).  A quick text to check in with parents or supervisees may be important to consider during these unpredictable times.  Of course there are a host of valid clinical reasons to think this option through carefully in reflective supervision, and it may not be appropriate for every family, but from a relational perspective, it may be an important option to consider to help others feel held in mind during extended periods of quarantine and social isolation.

Therapeutic Presence

The concept of therapeutic presence is one that not only cuts across theoretical orientations as one of the most fundamental requirements for effective clinical work, but it can also cut across mediums in which therapeutic services are provided.  Therapeutic presence is defined “… as having one’s whole self in the encounter with a client by being completely in the moment on a multiplicity of levels — physically, emotionally, cognitively, spiritually, and relationally” (Geller & Greenberg, 2012, p.7).  Bringing our full presence to a virtual encounter with a family or supervisee is essential to creating and sustaining the sense of being together that we might otherwise take for granted when meeting in person.  By bringing our presence in an open and receptive state and then consciously focusing our sustained and sensitive attention on others, we are able to help them “feel felt with” by us (Furman, 1992; Siegel, 2010).

How do we access our presence and capacity to attune to others when working virtually?  We need to actively protect our ability to attend from any outside distractions — phone silenced, email and text notifications on the computer turned off — and to have a designated workspace from where we can sit comfortably.  It can be helpful to find a few quiet moments before a session to anchor your feet firmly on the ground and take a few deep breaths to clear your mind so that you can be in that open and receptive state from which you can then consciously turn your attention and attune to the people you are meeting with on the screen or on the phone.

In relationship-based work with families, we aim to bring our therapeutic presence and subsequent attunement to multiple relationships and the complex, interconnected experiences of the parent, child, and provider.  We strive to support parents in their relationships with their children and to help strengthen the attachment between them, and offering our presence is a necessary aspect of this process.  Siegel and Bryson (2020) emphasize the importance of presence in parenting, what they refer to as a parent’s capacity for “showing up,” and how parental presence is a foundation for developing a secure attachment relationship between parent and child.

By keeping in mind the centrality of presence in fostering healthy relationships and secure attachments, we can strive to provide this relational presence with the clients and supervisees with whom we meet.

Self-Care and Self-Reflection

We can only embody our “how we are” and offer our full attuned presence when we also prioritize our self-care.  We need to actively seek out the support we need in order to be truly and fully present in our work with others.  Being present for and with others is an active, emotional labor, and being present with others over screens can be even more emotionally labor-intensive.  When we are with others in person, we are able to make use of subtle, non-verbal cues that we are not even consciously aware of.  We can see the whole person in their whole environment, which allows a more relaxed presence to unfold.

Over a screen, we have to work harder to project our presence to be felt by others.  We may end up feeling depleted and exhausted by Telehealth sessions in ways that we didn’t anticipate.

For these reasons, we need to pay close attention to how we schedule our appointments, give ourselves breaks from looking at screens as needed, and be mindful of how we refuel ourselves when not working. In other words,  how do we practice self-care?

Self-care can look different for each of us — it can be about finding ways to connect with others or with nature, creating time to get lost in a book, moving our bodies, meditating, practicing yoga, talking with trusted colleagues, and/or meeting with our reflective supervisors and consultants.  “Self-care is any action you purposefully take to improve your physical, emotional or spiritual well-being.  By making time for self-care, you prepare yourself to be your best so you can share your gifts with the world” (Brownn, 2020).

We need to be mindful of how the change in the contextual frame in which we operate impacts ourselves and our clients and supervisees: how virtual ways of being together can initially feel uncomfortable or awkward, how the felt experience of being together might shift in both tangible and intangible ways, and how our relationships with others might be influenced over time.  I would suggest that it is only after we wrestle with and accept our own experience can we then invite supervisees and parents to join us in being curious about how these same shifts impact themselves, their children, and the relationships between them.  We need to appreciate what is being asked of all of us — supervisors, direct service providers, and families — to gently and compassionately “name it to tame it” (Siegel & Bryson, 2011) in order to help internally organize the experience for each of us during this unpredictable time in the world, so that all of us have the opportunity to feel held in the mind of another.

Summary

Some of our “what we do” needs to be adjusted and altered when working with families over video or telephone, but our “how we are” is a constant, no matter the format we use to meet with others.  We truly can offer these ways of how we are in relationships — our therapeutic presence — whether we are meeting with clients, supervisees, and/or students, and whether we are meeting them in their homes, in offices, or over computer screens or the telephone.  These ways of how we are with others are as important, if not more, than what we do, and thankfully are not defined by our physical proximity to each other, but by our embodied ways of being fully and therapeutically present when we meet with one another.

References

Brownn, E.  Retrieved May 4, 2020, from http://www.eleanorbrownn.com

Caldwell, B. (April 15, 2020). The Value of Between-Session Contact. Simple Practice. https://www.simplepractice.com/blog/contact-helps-therapeutic-relationship/?utm_medium=email&utm_source=sp-blog&utm_campaign=20200417-paid-trial-leads-blog-update-value-between-session-contact&utm_content=body-link-3-sp-blog-post

Furman, E. (1992). On feeling and being felt with. The Psychoanalytic Study of the Child, 47, 67-84.

Geller, S. M. & Greenberg, L. S. (2012). Therapeutic Presence. Washington, DC: American Psychological Association.

Pawl, J.H. (1995). The Therapeutic Relationship as Human Connectedness: Being held in another’s mind.  ZERO TO THREE, 15 (4), 1, 3-5.

Pawl, J. H. & St John, M. (1995). How You Are Is as Important as What You Do. Washington, DC: ZERO TO THREE.

Siegel, D. J. (2010).  The Mindful Therapist. New York, NY: W. W. Norton & Company.

Siegel, D.J. & Bryson, T. P. (2011). The Whole-Brain Child: 12 Revolutionary Strategies to Nurture Your Child’s Developing Mind.  New York, NY: Delacorte Press.

Siegel, D.J. & Bryson, T. P. (2020). The Power of Showing Up: How Parental Presence Shapes Who Our Kids Become and How Their Brains Get Wired. New York, NY: Penguin Random House LLC.

These articles, written by Ira Glovinsky, Ph.D., and Kelly Mahler, MS, OTR/L,  highlight their collaboration applying interoceptive work to infants and young children.

Understanding interoception, a person’s awareness of internal bodily signals, will have major implications for our work with dysregulated young children. Since the 1940s there has been a continued increase in the number of younger and younger children who are experiencing disruptive behavior disorders and pediatric mood disorders. This presents difficulties in the parent-child relationship both at home and in the child-care setting. Children in pre-K or child- care settings are expelled 3.6 times more frequently than children who are being expelled from grades K-12 altogether (Gilliam, 2005). A new diagnosis in the DSM-5, Disruptive Mood Dysregulation Disorder is now being used to differentiate these children from children who are diagnosed with pediatric bipolar disorder. These are children who are overwhelmed by their emotions in home and school contexts where adults have little or no knowledge how to deal with them. These are children who cannot decode the emotional signals from their bodies and who do not receive these signals until it is too late to do something about it. Becoming attuned and knowledgeable about our interoceptive circuitry as well as learning more about interoception will enable us to do preventive work from the cradle on.

Interoception: Opening Up a New Window to Understand Behavior

When I first met Eden, a four-year-old girl, I was immediately drawn to her by the bright gleam in her eyes, her exuberant smile, and her spontaneous, and animated relating ability. Margaret Mahler (1975) referred to this characteristic in her work with very young as “sending power.” This referred to the child’s ability to send non-verbal signals to another person that evokes a return response. Daniel Stern (2010), using different terminology, referred to “vitality affects” as the dynamic energy of a stimulus, “its movement, time, force, space, and intention/directionality” (p.4).

Eden did everything with forcefulness and energy.

In interacting with her one had the feeling of being in the presence of a “jazz dancer.” She would react quickly, hit her high point almost instantaneously and remain at her peak level of intensity for a longer period of time than most children or adults. She was spontaneous and animated in her gestures; her body craved excitement and high-level stimulation.

Eden’s parents, who were more reserved and low-keyed temperamentally, felt that her activity level and intensity were too high, and they were constantly telling her to “calm down!” Nothing they did seemed to work and her most predictable quality was her unpredictability. Her parents were told by family members, neighbors, and friends to work with her on breathing activities such as blowing bubbles or Itzy Bitzy Yoga (Garabedian, 2004) and Itzy Bitzy Yoga for Toddlers (Garabedian, 2008). However, calming activities made her more restless and irritable. Eden was filled with energy; pizzazz, was probably a better word, and she defined what Mahler (1975) described as a child’s “love affair with the world.”

My first clue to the origin of her behaviors came when Eden burst into my office, loud, irritable, and teary. She exclaimed, “My mommy tells me to calm down! My mommy’s always yelling, ‘Eden calm down, calm down!’. Daddy comes home from work and yells, ‘Eden, calm down! Dr. G., what’s calm mean?” Her uncharacteristic, genuinely confused facial expression, her upset state, and intense body movements struck me.  I took out the book No, David!  (Shannon, 1998) and we began to look at it together. Page by page, she watched David in all sorts of antics that caused his mother to scream at him. By the end of the book she was laughing and exclaimed, “That’s like me!” Looking at her and matching her energy level, I exclaimed “And…that’s…not…calm!” She laughed, but appeared to get the picture without my verbal explanation.

I began to ask Eden some questions about her awareness of some bodily states. I asked her how she knew she was hungry. She replied, “…don’t know!!” “How do you know when you’re sleepy?” “…don’t know!” When I saw Eden’s parents for a parent guidance session, I asked them about their experiences around eating and bedtime. Her mother responded, “If I didn’t tell Eden to eat, she would go the entire day without eating. Father chimed in and said that bedtime was always difficult because Eden “never got tired. She will just crash at some point!” If it was not for her general joyfulness, I thought that she would easily be a temperamentally “difficult child” (Thomas & Chess, 1968). But she wasn’t, she was fun to be around and very engaging!

Children like Eden are often seen in the pediatrician’s office, and often referred for “parental exhaustion” syndrome, i.e., the parent who is unable to keep up with the child’s energy level. They are often scooped up into parent-child psychotherapy, sometimes individual therapy, or parent guidance sessions to discuss behavioral management. Strategies that might work for the practitioner’s child are often discussed, books that might work for the author’s child are recommended, but these children really need to be addressed with personalized medicine, a plan that embraces their individual differences and doesn’t come under our current  one size fits all approach. Often, when nothing works, there is a push to medicate — even with a four-year-old — in the hope that the child will be responsive so the practitioner doesn’t have to acknowledge that he or she doesn’t have a clue what to do!

            We are just beginning to learn that there are some children like Eden who truly have no awareness of their inner body states. We give them suggestions about how to deal with anger or frustration although the child does not have any idea what anger and frustration are.

One young child told me that his therapist told him that anger was like a train that comes down the track. He said that he was told that he should think about anger like a train on an outside track and if you could see the train coming it would have a big light. “When you see the big light coming, take three deep breaths. That’s like anger. When you feel the angry feeling, take three deep breaths.”  The child then said to me, “That guy doesn’t get it!” “What doesn’t he get?” I replied. “I don’t feel anger coming down the track. I don’t feel my anger until the moment before I explode!” Giving such a child recommendations to breathe deeply does not work if the child does not experience the emotion until he is about to explode! Other children have an awareness of many feelings in their bodies but don’t know what they are. “I got lots of feelings!” one child exclaimed. “I don’t have a clue what they are!”

In working with these children and in a serendipitous experience with Kelly Mahler, a gifted occupational therapist I met for the first time at the STAR Institute- #5 Symposium in Atlanta, Ga.,  (2018) where we both presented on the same day, I became aware of “the eighth sensory system.” We are aware of the five sensory systems: vision, hearing, taste, touch, and smell. Some of us are even aware of the sixth system, proprioception (perception or awareness of the position and movement of the body), and the seventh sense, vestibular (sense of balance), but few of us have heard of the eighth sense, interoception.  Interoception allows us to notice and interpret our bodily signals such as heart rate, muscle tension, skin moisture, bladder distention and so forth.

Having now interviewed parents, worked with children and adolescents in therapy and seeing some major changes in children who have been seemingly resistant to treatment, focusing on the interoceptive system with families has underscored the importance of working with the body, noticing bodily sensations, linking these sensations to emotions, and then both to actions has enabled many children and adolescents to gain a higher level of control over themselves. The outcome of this work is linked to the foundation or development of reflective functioning. Being aware of what we are experiencing internally helps us form mental pictures and then to think about them, i.e., mentalization and reflection. Interoception is defined as, “the body-to-brain axis of signals originating from the internal body and visceral organs (such as gastrointestinal, respiratory, hormonal, and circulatory systems). It plays a unique role in ensuring homeostasis. Interoception therefore refers to the sensing of the state of the inner body and      its homeostatic needs, to the ever-fluctuating state of the body beneath its sensory (exteroceptive) and musculoskeletal sheath (De Preester & Tsakiris, 2019).

Children presenting with interoceptive challenges are often misdiagnosed and misunderstood by clinicians and teachers. With the publication of Mahler’s first book, Interoception: The Eighth Sensory System (Mahler, 2015)  her sequel The Interoceptive Curriculum: A Step-By-Step Framework for Developing Mindful Self-Regulation (Mahler, 2019), we now have a tool that specifically describes, explains, and offers a treatment paradigm to put behavioral and mood disturbances under a microscope and address them more systematically and in a way that is understandable to professionals as well as parents and children. Through lessons that focus on noticing sensations in specific parts of the body, then attaching those sensations to emotions and then to actions, parents are reporting changes in children’s understanding of how their bodies actually feel because they develop the ability to notice and describe a wide variety of body-emotion connections.

Connecting body sensations to emotions is a major milestone for children, adolescents, and adults. As adults, we frequently tell a child how he or she is feeling because we attend to facial expressions and body movements that evoke feelings in us. The problem is that the feelings that are evoked in us may have nothing to do with the feeling that the child is experiencing in the moment. In fact, our words can easily confuse a child who is feeling one emotion but being told by an adult that it is a different feeling. When we play with a child’s reality by giving the child a different reality, we are adding to their confusion about emotions. We are now beginning to understand that facial expressions may not reveal an individual’s emotions unless we totally understand the context. In the book How Emotions Are Made (Feldman-Barrett, 2018), there is a picture of a woman with her fists clenched and looking like she has been terrorized.  Most people looking at the picture would think that this woman is overwhelmed, negatively. But when the total context is then presented, it is revealed that the woman is Serena Williams expressing her elation at winning Wimbledon!

            Putting all of the pieces together, understanding interoception, and seeing how emotions are constructed in moment-to-moment experiences is opening up the door to meaningful and successful interventions.

The therapeutic work that has been done on the body has been done primarily with adults. However, this type of work is most applicable to children who have a smaller “language toolbox” and are just learning about emotions. Children express their emotions through their bodies and through their actions before they develop an emotional vocabulary. Starting with interoception, using a paradigm of body-emotions-actions (Mahler, 2019) promotes meaningful transactions between children, parents, and professionals. It facilitates attunement, synchrony, and contingency with very young children, enabling us to join them in their worlds and to develop a higher level of understanding into the behaviors that we see in front of us, but have difficulty interpreting.

References

Barrett, L.F. (2018) How Emotions Are Made, New York: Mariner Books.

Garabedian, H (2008) Itsy Bitsy Yoga for Toddlers. Cambridge, Mass.: Da Capo Press

Garabedian, H. (2004) Itsy Bitsy Yoga. New York: Atria Books

Mahler, K. (2015) Interoception: The Eighth Sensory System. Lenexa, Kansas: AAPC Publishing.

Mahler, K. (2019) The Interoception Curriculum. kelly-mahler.com

Mahler, M. (1975) The Psychological Birth of the Human Infant. New York: Basic Books

Shannon, D. (1998) No, David. New York:  Blue Sky Press.

Stern, D. (2010) Forms of Vitality: Exploring Dynamic Experience. Oxford, UK: Oxford University Press.

Thomas, A. & Chess, S. (1968) Temperament and Behavior Disorders in Children, New York: New York University Press.

The Michigan Association of Infant Mental Health sponsored this series of developmental articles to help us all reflect on the journey of parents and children from pregnancy through early childhood. This article explores the emerging preschooler and the wonderful, tumultuous transformation that the parent-child dyad experiences. On the shoulders of giants, this article attempts to build upon the writings on pregnancy, infancy, and toddlerhood presented over the past year by Michael Trout, Julie Ribaudo and Kathleen Baltman. Moving from the inner relationship in pregnancy through the beginnings of the attachment relationship and on through the emergence of the ME of toddlerhood, we are called to pause and remember the roots of our work, the space of the beginnings, the landscape of the children and families we serve.

Look at the world through the eyes of a preschooler — full of the delights of imagination, friendship, and stories. This is a time of transition for children and parents, centered on the balance of exploration and holding, independence and connection.

The primary caregiver continues to be vital in the preschool period, although the growing focus of social exploration can challenge this tenet.

As the preschooler tries on new roles, new relationships, and new opinions, there can be a misperception that the attachment figure is optional or secondary.

Marvin & Britner (2008) write about the need for attachment to remain “the holding environment to do the work of exploration and sociability” as the preschooler naturally feels drawn into the world beyond their front door. The parent-child relationship is the vital space of scaffolding, quiet attending, restoration, and repair in response to the brave trips into the big, exciting world. Shifting to more of a base camp mentality, the attachment relationship is vital for the child to recharge, share the stories of successes and failures, and be a laboratory for learning and developing more strategies needed for climbing up the mountain of the preschool classroom. Erna Furman, in her article Early Aspects of Mothering: Why it’s so hard to be left, writes of the role of this safe haven in preschool. “He (the preschooler) may need her (his mother’s) help with his own conflicted feelings and worries about his new venture, or he may need her assurance that she can tolerate his absence and can even share his enjoyment of new relationships and independent activities” (1982).

Attachment in the Preschool Period 

How the preschool child uses the attachment figure changes dramatically during this developmental period. While attachment “requires renegotiation at every developmental stage” (Moss et al., 2004), the milestones unique to this period exert a strong influence on how the interactions in the dyad are maintained and expanded. Preschoolers become increasingly aware of self and their own effect on others. Through experiments, the young preschooler begins to notice how he can affect their caregiver’s reactions, or even alter situations. In their foundational book, Touchpoints Three to Six, Drs. T. Berry Brazelton and Joshua Sparrow write about these “aha!” moments for young children. Like ripples in a pond, the child notices that their intentional (or unintentional!) expression of feelings, needs, and desires can change how the parent responds. At first accidental, these exciting and intense interactions teach a child that they have some control in their relationships and surroundings. Over time, and with practice, children learn to use various modes of communication to effect change.

John Bowlby explains these changes in the attachment relationship as the movement into a “goal-corrected partnership” (Bowlby, 1953).  Part of the child’s work of exploration is the realization of and curiosity about the fact that their parents have their own independent thoughts, feelings, desires and plans. Within a secure relationship, the young child is able to experience the discordance of differing agendas. With a good measure of increasing impulse control, coupled with an increase in empathy and a growing understanding of cause and effect, the preschooler begins engaging in negotiations with the primary caregiver, jointly creating strategies and new attachment schemas.  (Marvin, 1977).

Bowlby’s Internal Working Model (IWM) helps illuminate this crucial, early life transition. A blueprint for relationships, the child’s IWM is a compilation of their experience of deserving care, how efficacious they are in eliciting help, and the type of help that is available for them during times of distress. A child’s positive IWM, the memory of parental safety and care, is a source of internal strength when away from their attachment figure. During these moments, the preschooler uses her growing developmental skills of metallization, memory, and symbolism through her IWM to manage the challenges and stressors of exploration. Doug Davies, LMSW, PhD., in his book Child Development (2005), discusses this emerging representational competence, which he describes as the creation of mental schemas of interactions, feelings, thoughts, and sensory experiences. On the surface, preschoolers with “good enough” IWMs appear self-reliant, not needing their attachment figure for regulation. However, looking more deeply you will see that they are actually leaning on caregiving memories to modulate their emotions. Through a growing sense of time, the ability to use routine and rituals as time markers and, most important, these reliable IWM  schemas, preschoolers and older children reassure themselves that they are being “held in mind” by their caregiver who will return, and restore the child’s emotional balance.

Developing Friendships

While out in the world, the preschooler uses their IWM’s “implicit and explicit rules for social behavior and interaction” (Marvin & Britner, 2008) as a base to do the work of friendships, a key developmental milestone. Whether in the preschool classroom or in the community, preschoolers enter interactions with new caregivers or peers with the memories and expectations of their primary attachment relationship, and, when that relationship has been secure, view themselves as deserving of care, and capable of eliciting connection and support. In addition, they use the internalization of their family’s values and beliefs to guide how they treat others. The security of their IWM provides the foundation for their self-control and emotional regulation, which directly affects the ease in which they engage with others.

Awareness of peers, interest in their perspectives, and building friendships are central developmental goals for this period. A preschooler becomes curious and their attention shifts to being alongside and then with another child as they play. The increased ability to keep another’s perspective in mind, and the joy and success in meaningful peer relationships is self-motivating.

A preschooler and older child’s attachment styles affect their social competence, peer relationships, and future school success.

Language and play skills can especially affect a child’s success or challenges in peer relationships. An older preschooler begins to use language as a way to enter play or interaction with another child, negotiate play content, or work together to develop co-constructive plans. A less adept child who struggles with fluent, coherent language may have difficulty making and interacting with friends. Since same-aged children are less likely to work harder to understand the less capable preschooler, this difficulty in communication can lead to rejection by peers, creating an additive negative effect on language and subsequent social skills. Again, the attachment relationship has a central role in helping a preschooler integrate, understand, and problem solve new perspectives, interactions and activities.

Play

Play becomes an amazing tool in negotiating these new relationships and experiences, taking on an array of functions: a way of communicating, joining with others, expanding developmental skills and processing an expanding view of the universe. Believing that play can be a window into the child’s mind, Piaget urged all professionals to look more deeply into the meaning behind all levels of play in young children. Play can become a space for children to express, question, and understand an array of emotions and experiences. “Symbolism (in play) provides the child with the live, dynamic, individual language indispensable for the expression of his subjective feelings for which collective language alone is inadequate” (Piaget, 1999). The child can explore anxieties and confusion through bending reality through their highly creative fantasy life.

“In play, a child is always above his average age, above his daily behavior; in play, it is as though he were a head taller than himself” (Vygotsky, 1978).

From this area of strength, the child has the ability to face intense experiences and feelings. Doug Davies states that, “Play allows the child to comment on and try to understand reality through a make-believe medium that is under the child’s control and therefore more easily manipulated than the actual world” (2011).

Pretend play can become the safe framework for making difficult concepts more tolerable for the young fragile self.

While in a play episode, children can reenact trauma memories or reminders, which can sometimes be eerily close to reality, such as a foster child locking animals in jail. Other times, the metaphor of a play episode may be vague and obscured, requiring more repetition, elaboration, and time for full understanding.

Billy was a 4-year old whose father left the family without much notice when Billy was a toddler. His mother believed he was better off without him and was confident she was “enough” for him. Billy was highly emotional, had difficulty with peers, and resisted separation from his mother. In play, Billy quickly moved through various animals, people, and events, from story to story, at times without apparent cohesion. As his mother continued to witness his narrative in play, she began to see his theme: Billy was replaying times he had spent with his mother and father together. She discussed her surprise about his ability to recall these very early memories. As we allowed his play to continue, his mother was able (with the writer’s support) to begin voicing his memories, “I remember when we all did X…” As she retold the stories of the play themes, Billy’s play became more cohesive. Mother became braver and began speaking more directly of his father, her own denied sadness regarding his absence, and her wish that he was present. Billy’s story changed to a theme of loss, horses searching for a leader. With the writer’s encouragement, the mother became her own horse and took the lead. As the horses calmed in the story, Billy’s play changed to themes that are more typical, without repetitive trauma or intense meanings. He no longer repeated the themes of loss or aching nostalgia. Nearing the end of treatment the mother said to the writer, “From the beginning you wondered if he was missing his Dad and I thought for sure he wasn’t, being quite adamant about this subject. I did not believe he could remember him, let alone miss him. I see now he did.”

Many scholars have created theories for understanding how children use play in all developmental domains. In the area of social-emotional growth, Mildred Parten expanded on Jean Piaget’s foundational work recognizing the sophistication within the play of the very young child to create a model of social stages of play. Parten’s stages consist of solitary play — playing alone though around others; parallel play — playing alongside others; associative play — playing separately but where there is an exchange of items and interactions; and cooperative play — playing with others, involving negotiation and co-creation of play themes and metaphor. Her structure looks at how the child uses play to move gradually into direct relationship with others, especially peers. Awareness of these stages and theories, and how a child moves in and out of mastery of these concepts, can help adults understand many areas of development, and in turn learn how to support and encourage development. (For an overview of different play theories see Bulgarelli, D. & Bianquin, N. (2017).

The beauty of play is that it is very resilient and can communicate the inner world of the young child, but it too is susceptible to stress. Unfortunately, “(if) the play frame is not strong enough to contain frightening feelings and a child breaks off the play” (Davies, 2011), the child may regress to a lower level to developmental play. The child may lose the ability to use symbolic play, or pretend play, and fall back into sensorimotor type play — the use of objects in a functional, movement-focused manner.  With awareness and knowledge of play development, a sensitive adult can see this regression as a sign of dysregulation. Fortunately, with emotional scaffolding from a responsive, attuned caregiver, the child may be able to return to the overwhelming emotions and use dyadic play to understand and master intense feelings.

Development and Regulation   

Development itself can be a victim of the passage of time, even for a preschooler. Since developmental gains build on previous mastery, lags or challenges in specific domains can have a cascading effect. It is challenging to keep pregnancy, infancy and toddlerhood in mind when assessing and intervening with children of this age, but it is imperative to explore all phases of the child and family’s life so that the gaps in development and areas of regressive behavior can be recognized and used to inform and support the family. This highlights the difference between a child’s chronological age and developmental age, especially when the child is under stress. Through observation, an adult can take this developmental knowledge and begin to learn the child’s subtle cues of competency and distress and through this understand the underlying need for scaffolding and support. This discernment can lead to more sophisticated assessments and ports of entry for the dyadic work. This detective work can be difficult and requires patience, practice, and a calm center from the responsive adult.

As we have discussed, development takes place on both an internal and external level, and is a unique journey for all children. Unfortunately, all development is highly susceptible to inner and outer stressors and regulation capacities. Why is it that the same child who can discuss the correct prehistoric age of a dinosaur at one moment becomes unable to access this coherent language when distressed? When too stressed and unable to stay well regulated, a child may revert to previously mastered coping and communication skills to feel safe and in control. Similarly, when an agitated or fearful toddler suddenly trips and falls, he will revert to more toddler-like communication and strategies. This can be confusing for the adults in their lives, especially secondary caregivers like teachers. Less familiar adults may expect these children to use their new expressive language skills at all times, which may heighten anxiety in an already stressed child. For example, a well-intentioned adult may instruct a child who is in a conflict with another child to “use your words.”  Unfortunately, the acquisition of a skill and the mastery and use of that skill as the default mode of communication can take many more years of practice, patience, and learning. To complicate things even more, often there may seem to be a dissolution of skills out of the blue when triggered by a purely internal stressor.  Without a developmental lens this screaming child may seem to be manipulative or even spoiled because he needs to connect with the adult, but has fewer resources and capacities in that moment.

Many unseen stressors can also overload the preschooler’s ability to cope with new developmental anxieties: For example, the new mastery of bodily functions, such as toileting, can be a source of worry regarding any failures in maintaining this milestone.

The focus on peers and friendship also opens up concern about rejection and disapproval, while their feelings of anger can elicit fears of being out of control or of being inherently bad. Magical thinking, while a source of joy and curiosity in play, can lead to false beliefs through the lens of egocentrism. Emotionally evocative situations, such as parental divorce, can lead to misunderstandings for the young child. In the absence of information and understanding at their developmental level, the child may use their inconsistent grasp on reality and cause and effect to develop an alternate narrative, with themselves as the central player in the story. The more aware we adult companions are of these internal struggles, the more we can give voice to assumptions and clear up misperceptions.

The role of the nurturing, in-charge caregiver re-establishes the world as a safe, predictable, understandable place, allowing the child to return to a curious, engaging stance.

Through self-talk by the parent, or co-construction of an emotional narrative, or a reassuring glance, an attachment figure can shore up the child to do the hard work of growing into new skills. Over time, adults learn the child’s patterns of stress and skill regression and can use new attachment tools of language, storytelling, and play to support the child through challenging times.

Understanding Attachment in the Preschool Period

Ultimately, the role of the attachment figure still plays a foundational component for the preschooler’s development. To better understand the expression of and role of attachment during this time, researchers Cassidy and Main, and Cassidy and Marvin adapted Mary Ainsworth and Mary Main’s infant and toddler attachment classification system. Ainsworth and Main developed these categories based on observation of infant-caregiver separations and reunions using the Strange Situation, a standardized laboratory procedure. Through their work, reunion behaviors were found to be indicative of the quality of attachment, due to the importance of reconnection with the caregiver as a safe haven, a place to be received, calmed, and restored. Cassidy, Marvin, and Main found that based on changes in internal and external developmental skills in preschool, the ways in which the 3- to 6-year-old and their parents negotiate the attachment relationship changes greatly throughout this period.  Therefore, preschool attachment was expanded to include: Secure, Insecure-Avoidant, Insecure-Ambivalent/Dependent, Insecure-Disorganized/Controlling, and Insecure-Disorganized/Other. (For a through explanation and description, see Humber and Ross 2005.)

Secure Attachment in Preschool  

The Secure preschooler displays increased ability to remain calm and either play alone or seek out the “friendly stranger” at separation. Upon reunion, this child is usually calm, relaxed, and confident. They demonstrate openness to verbally expressing their dissatisfaction about the separation, and are more willing to accept the parent’s explanation and response about the separation as part of their ability to regain composure. Secure preschoolers use language in increasing frequency over the strategy of proximity seeking. The parent is open and accepting of the child’s dissatisfaction and negative expression about the separation, and is able to validate their feelings, provide context for the stressor, and follow the child’s lead. The child then is able to return to play, providing a narrative about what she was doing in the caregiver’s absence and plans for future play and engagement. Original attachment strategies, such as proximity seeking and gaze and affective holding are still important for the secure preschooler, especially during heightened times of stress, such as long separations and novel or evocative experiences.

The Securely attached preschooler has a consistent, sensitive, responsive parent, similar to the infant and toddler. These caregivers increase their use of language and play to provide the emotional scaffolding needed for the child. Through open emotional expression of increasingly complex feeling states and use of self-talk as a way to model problem solving for the child, there are ample opportunities to practice self-regulation skills. These parents demonstrate vulnerability and openness about themselves and are socially competent and accepting (Cassidy & Main, 1993). Secure caregivers see the negotiation and co-creation of narrative and problem solving as growth for the child (though the constant “whys?” can try even the most patient parent). Through attunement, balanced emotional expression, and respect for reciprocity, the preschool parent encourages the initiative and engagement of the child.

Insecure-Avoidant Attachment in Preschool

The preschooler with an Insecure-Avoidant classification displays “neutral coolness toward the parent, with a minimizing of physical or verbal contact” (Moss, Berrera, et al, 2004) upon reunion. During the Strange Situation assessment, this child deflects any attempts by the parent to reconnect. The child turns away to play, does not answer questions from the parent, or responds in a curt fashion, and chooses not to engage in any conversations about the separation, themselves, or their play. The children become detached from the caregiver in stressful situations, and minimize any expression of negative affect. One noticeable effect on learning and expression is this child’s “falling into parallel play … (or) highly individualized task-oriented mode with little interpersonal content” (Humber & Moss, 2005) seemingly due to the inability to use the caregiver as a safe secure base.

Insecure-Ambivalent/Dependent in Preschool

The second insecure classification is Insecure-Ambivalent/Dependent. Similar to the ambivalent infant/toddler style, these children show exaggerated involvement with the caregiver. Contrary to their developmental level or skill level, these preschool children stay connected with their caregiver through immaturity or can display subtle signs of anger.  Separations are long, arduous negotiations, with high degrees of conflict and highly evocative content. The child may disintegrate to the point of tantrums, cajoling the caregiver to stay though the triggering of guilt. The caregiver on the other hand is less emotionally available, with lower use of language for connection or elaboration (Huber & Moss, 2005, Moss, Bureau et al, 2004).

Disorganized attachment in Preschool

Disorganized attachment styles become two different categories in the preschool period: Insecure-Disorganized/Controlling and Insecure-Disorganized/Other. Lyons-Ruth et al. (1999) describe the Disorganized/Controlling strategy as “one partner’s initiatives are elaborated at the expense of the other partner’s.” Marked by the presence of role reversal, the child becomes either punitive or excessively caregiving to assert control within the environment. In relationship with the victimized parent, the child provides an emotional framework to compensate for the passive, inconsistent parent. Driven by hypervigilance, the child works hard to bring the parent to life or keep them in a good mood. This may be the overblown “performer child” or the child who is excessively comforting to their parent when they are distressed. On the other side, the punitive child becomes verbally or even physically aggressive, demeaning, and derogatory in the face of fear or through over-identification with the aggressor (Moss, Cyr, & Bureau, 2005; Marvin & Britner, 1999).  The final category, Insecure-Disorganized/Other retains the lack of predictable attachment strategy in the face of stress, displaying erratic, inconsistent behaviors and regulation.

Caregiving in the Preschool period — “Oh baby it’s a wild world” 

Attachment styles, and their corresponding IWM, are strong but are also sensitive to intentional, attuned caregiving. Parents through dyadic work can repair the challenged relationships with their child. Through the disconfirmation of the child’s expectations, attachment figures can create a different lived experience. In his article about a therapeutic preschool, Doug Davis speaks of supporting teachers in identifying each child’s IWM. From this curious mindset, he encouraged them to identify how these children viewed adults in their lives. Were they helpful? Hurtful? Predictable? From these explorative reflections, teachers were encouraged to demonstrate predictability, sensitivity, and empathy (Davies, 2010).

Through the safe holding environment of the therapist-parent relationship, parents too can develop a curiosity about what their children are displaying and learn how to respond to the need, not the lead in their interactions. Through ongoing consistency and predictability there can be healing. This process can be slow, and change seemingly microscopic, but it will benefit the child throughout their entire life.

Let us also always remember the importance of relationship for both sides in the preschool-parent dyad. As parent and child move together out of toddlerhood, the parent does not know what lies ahead: good and bad days, filled with dinosaurs, tea parties, skinned knees, and tears. We should keep in mind the developmental challenges for the preschool parent to stay present and attuned, while also celebrating the separateness of their courageous preschooler. Erna Furman, in Early Aspects of Mothering: What Makes it so Hard to be There to be Left, writes about the difference in parenting a dependent toddler versus the outward facing preschooler. “The anxiety is separate from and unmitigated by her (the mother’s) pleasure in her child’s growth as well as by her ability to recognize and feel sad that his (her child’s) new achievement implies a loss of earlier closeness in their relationship” (Furman, 1994).

The transition for the caregiver to more of a secure base is indeed bittersweet, yet it is vital to allow the child to focus on their own curiosity and learning.

These preschool years are filled with hopes and excitement about future victories, school parties, and the first best friend, as well as new challenges of the child who found his voice, wants to let you know when they disagree, and wants to be comforted when they do something wrong. Fortunately, the rollercoaster of preschool prepares us for the next stages of development and all the challenges of school-aged and teen children. So let us celebrate now the “Whys” and the “Nos!” of the creative, independent preschooler as much as we celebrated those first steps in infancy. I invite you to sit back, and enjoy the preschool ride — and join the race to space with Superman, a sparkly unicorn, and, George, the pet snake. Who knows where it may take you?

Bibliography

Brazelton, T. B., Sparrow, J. D. (2001). Touchpoints: 3-6: Cambridge, MA: Perseus.

Britner, Preston & S Marvin, Robert & C Pianta, Robert (2005). Development and preliminary validation of the caregiving behavior system: Association with child attachment classification in the preschool Strange Situation. Attachment & human development. 7. 83-102.

Bulgarelli, D., & Bianquin, N. (2017). 3 Conceptual Review of Play.

Davies, Douglas (2005, July-September). “Introduction to Attachment,” The Infant Crier, #109, Michigan Association of Infant Mental Health, 4-7.

Davies, Douglas (2010, Summer). “The Therapeutic Preschool: An Intensive Extension of Infant Mental Health to Meet the Needs of Traumatized 3-6 Year Olds,” Infant Crier, #133, Michigan Association of Infant Mental Health, 4-8.

Furman, E. (1982). Mothers have to be there to be left. The Psychoanalytic Study of the Child, 37, 15-28.

Furman, E. (1994). Early Aspects of Mothering: What Makes it so hard to be left. Journal of Child Psychotherapy, 20(2):149-164.

Handbook of Attachment, Third Edition: Theory, Research, and Clinical Applications, edited by Jude Cassidy and Phillip R Shaver, Guilford Publications, 2016.

Humber, Nancy, and Moss, Ellen. “The Relationship of Preschool and Early School Age Attachment to Mother-Child Interaction.” American Journal of Orthopsychiatry, vol. 75, no. 1 Educational Publishing Foundation, 1/2005, pp.128-41.

Meins, Elizabeth, Bureau, Jean-Francois, & Fernyhough, Charles. “Mother-Child Attachment From Infancy to the Preschool Years: Predicting Security and Stability.” Child Development, May/June 2018, Volume 89, Number 3, 1022-1038.

Moss, Ellen, Cyr, Chantal, Bureau, Jean-Francois, Tarabulsy, George M., & Dubois-Comtois, Karine (9/2005). “Stability of Attachment During the Preschool Period.” Developmental Psychology, 41(5), 773-783.

Moss, Ellen, Bureau, Jean-Francois, Cyr, Chantal, Mongeau, Chantal, & St-Laurent, Diane (2004). “Correlates of Attachment at Age 3: Construct Validity of the Preschool Attachment Classification System.” Developmental Psychology, 40(3), 323–334.

Piaget, J. (1999). Play, dreams and imitation in childhood.

INTRODUCTION

From the first days of life, long before birth, the course of development runs on multiple tracks — distinct yet totally inseparable. The challenge is to recognize their unique components while simultaneously fitting them into relationship with each other. This journey is complicated enough during the first year, with rapid brain development, periods of regulation, disorganization, and reorganization, but then comes toddlerhood!

Suddenly, or so it seems to caregivers who have been learning and practicing nurturing ways, a whole new order of caregiving must be learned in order to respond to a whole new set of complexities. The toddler’s second and third years are increasingly centered around the internally driven and all-encompassing task of developing a sense of self. At once sharply focused and broadly activated, this task that brightens and widens the toddler’s world view with new awareness and possibilities is a daunting process, especially when being guided by amateurs, i.e., the toddler, the parents, the family, important caregivers, and all supporters, some of whom may know about toddlers but none of them knowing this toddler. Critically, while a toddler’s often confusing actions and responses to “guidance” may shout SEPARATENESS, every second- and third-year child needs every bit as much consistently nurturing love and support as the newly born and first-year child.

Indeed, there is an abundance of scientific and anecdotal evidence to support developmentalists’ proclamation that no developmental progress just happens. Yes, the newborn’s central nervous system is on a neuro-biological mission, but its exact course is charted according to an increasingly complex interweaving of natural occurrences and nurturing experiences. Throughout the journey, particularly at its almost dizzying speed at outset, that course is vulnerable to even the subtlest of challenges, each one capable of producing profound shifts in direction.

Each toddler’s profound request to be securely held while being actively encouraged to explore gives ample reason to consider, with as much care and depth as we can gather: What do toddlers need? What does this toddler need? When? Why? What might get in the way? What might “satisfaction” look like? And so, let’s ask the toddlers. Let us closely attend to the many ways they communicate their needs and reflect on the impact of caregiving responses on their developing understanding of what it’s like to become and to be a “me.”

THE TODDLER IN CONTEXT IS THE TODDLER IN RELATIONSHIP

Let’s begin with every toddler’s deepest need, the need to be understood (Gold, 2011).

While this is a basic need across all stages of life, it is particularly salient for toddlers as the developmental tasks of toddlerhood (here loosely defined as the 12- to 36-month-old) can be so difficult to understand — by the toddlers as well as their caregivers. Then, too, each toddler’s behaviors and interactions are imbued with a tightly woven mixture of genetics and experience and are carried out quite uniquely according to health and well-being status, temperament, developmental timetable, and lessons learned since before birth.

This seems a good time to call upon the work of Erna Furman, one of toddlers’ champion-grade interpreters of their support needs. Mrs. Furman was a classically trained psychologist whose early work was with Anna Freud’s nursery school for very young children in WWII England. Her writings about toddlers were firmly anchored in the perspective of the toddler, with clear and caring intentions to help caregiving adults understand and support the toddler’s struggle for mastery of bodily and emotional self-care (Furman, 1982a, 1987, 1992). She clearly understood that while not much stops a toddler from moving toward and becoming part of a wider world, their caregivers could easily become confused, hesitant, reactive and avoidant, even while wishing all the while to say, do, and be the right thing at the right time to protect as well as guide these very determined explorers.

Toddlers do so much to show us the kinds of help they need in their continuing quest, and how those needs change as they practice and build skills toward owning their bodies and using their feelings. They are eager to discover new areas of “needing less” and then “not needing,” all the while being blissfully unaware that it is their dependence on sensitive, consistent, predictable, nurturing support and guidance from their most trusted caregivers that carries them into successful mastery. Furman’s organization of this developmental journey into four successive stages of maternal-child interactions provides an interpretive roadmap for parents and caregiving adults through this, at times, mind-boggling illustration of the powerful driving force that embodies all development.

Please note that, in reviewing this developmental roadmap, I have intentionally retained Mrs. Furman’s focus on the role of mother and her primary importance to the developing toddler (Furman, 2001). While much has subsequently been written and considered to challenge and expand our understanding of primary caregiving roles, especially that of fathers, but also including grandparents, foster parents, and early care providers, it can be helpful to sometimes be reminded of the reality that every infant’s very  first relationship experience, in every culture, in every part of the world, is with a mother who carried and gave birth. Every additional relationship, including substitute care placement, is then added to that first “knowing” rather than replacing it. I believe that toddlers really need us to keep this in mind as we seek to understand and support their rapidly widening world of essential and important relationships. 

Stage One: “Doing For”

Infants are born with neurobiological needs for connection and survival. As their needs are expressed, it is mom’s job to consider those expressions as signals and, as she responds to those signals, to observe and learn her baby’s preferences for how the needs are best met by this very unique little being. The newborn has only an awareness of a feeling that is a “something” and, as the feeling grows and becomes more uncomfortable, reacts in the only way open at this time — a cry, followed by another cry, followed by continued cries until the discomfort stops. When the feelings of discomfort are discovered, addressed and replaced by brain-activated feelings of “no discomfort” that are experienced in a context of increasingly familiar holding arms, cooing voice, rhythmic rocking, and perhaps even calming music, and when those sensations are repeated and repeated, the baby’s distress signals recede and mom feels like she’s found the Holy Grail! Through repetition of what begins as trial and error, mom begins to recognize that her baby needs her in increasingly distinct ways. She is able to recognize and resolve more and more of her baby’s discomfort cues. She is also able to recognize and feel the satisfaction of seeing her baby’s comfort cues when she has alleviated her little one’s alarms of distress. By the end of the first year, under “good-enough” circumstances, the baby has developed expectations and the mother has developed confidence in her role as nurturer of this baby. When Timmy’s mother arrives at the day care and calls Timmy’s name, the look on his face and the sight of him beginning to reach out to her fills her with feelings of oneness with him. When she picks him up and he buries his head into her neck, they both experience a sense of the whole world coming round right. Together, they have been learning and practicing a sense of shared predictability that makes it possible to sort, organize, predict, and enjoy their relationship. (For an extensive review and discussion of early attachment development, see Ribaudo, J. (1)

Stage Two: “Doing With”

Throughout the initial period of care-needing and care-giving interactions between mothers and infants, there are both subtle and strong indicators that things are going to change. As soon as the infants can become mobile enough to respond to an increasingly strong central nervous system command to MOVE, they do! For infants whose development is proceeding according to typical-for-age expectations, their second-year label of “toddler” says a lot. It says, “I want to direct my mind and body to try, to practice, to do whatever catches my interest until I get really good at it! Then I will try, to practice, to do something different! I want to try, practice, and do everything!”

Let’s consider how the toddler’s expressions of this drive change the mother-child relationship. First, she may become confused. The infant at the brink of toddlerhood often signals total independence — rejecting mom’s attempts to feed him pureed fruit while working hard to pick up slippery chunks of banana, but then clearing his tray of all food and opening his mouth wide for another spoonful of pureed fruit. It takes a good deal of practice time for the toddler’s attempts to become skills. The understanding, support, and patient assistance that nurturing caregivers give to young toddlers is such an important gift to their development — not just in promoting this bundle of energy’s motoric successes, but in allowing, assisting, and celebrating such determination. It is mom’s readiness to join with her toddler’s efforts at self-care by noticing and, as needed, assisting her toddler from initially clumsy effort to eventual satisfaction of success that introduces and encourages a new level of base security — that of the toddler’s gradually developing a positive sense of being a “self.”

Stage Three: “Standing Back to Admire”

Through considerable practice, and with more and more self-care achievements made possible by a very rapid development of the central nervous system, toddlers grow increasingly focused on exercising preferences, including moving quite quickly from one place to another without assistance, gaining skills in self-feeding and, above all, making and acting on decisions about which room or area, and what clothing, food, toys, books, activities, etc. are desired at any one moment. The toddler has many opportunities for learning what’s possible, what’s not possible, and what just maybe might be possible under certain circumstances. It can be very difficult at times for even the most consistently nurturing caregivers to remember the importance of allowing toddlers clear successes in their explorations in “self-doing,” particularly in light of other adult obligations such as searching for keys and getting to work on time while helping a distraught third grader recover from having spilled juice all over her eggs, the table, and her very favorite outfit.

Parents, too, need encouragement to keep believing and trusting that their expressions of acceptance and approval now will result in greater relationship satisfaction later, since even the most super-self-determining toddlers still depend on the parent’s continued loving support. The emotional see-saw of the toddler’s experience in this many-faceted drive toward mastery means that, even when most fervently insisting on self-caring, he is also needing mom to “step back and admire, but not any farther back than I can tolerate as I walk this new and sometimes very scary path!” Thus, undergirding all the surprises that mothers experience during this phase, her greatest challenge is to learn new ways to hold her toddler while letting go.

Stage Four: “Doing for Oneself”

This stage, even more than the third stage, continues well into the preschool years. But it is important to note that it is the successful navigation of becoming a self that supports the toddler’s ability to internalize the security of being held by a loving parent, even when the parent is not physically present. The child’s ability to feel held while being separate lays the foundation for the preschooler to approach the tasks of the preschool period with an already experienced measure of self-confidence.

THE LIFE-CHANGING REWARDS — FOR TODDLER AND PARENT — OF A TODDLER’S NEEDS MET

Before turning to close consideration of just what it is that toddlers need — and from whom — to successfully support their developing drive toward self-hood from within the security of connectedness, let’s take a minute to highlight the impact of  “goal satisfaction” on the toddler, the parent, and their relationship.

For the toddlers who signaled their need to try mastering multiple aspects of self-care until something from deep inside told them that they, at least for now, could stop doing heavy battle at every new practice opportunity, they gain:

• The continuance of nurturing relationships with their most special caregivers.
• The deeply satisfying feeling of being safely secure in felt closeness with their most special caregivers.
• The assurance of constancy in being supported in all the self-mastery challenges yet to come.
• The joy of successful experiences in communicating and connecting with others.

For the parents whose significant history of successes in providing for their wholly dependent infant strengthened their abilities to access their best selves to meet their toddlers’ insistent needs for permission, support, and approval, they are hereby awarded:

• The distinct and cumulative pleasures of strengthening and deepening a thoughtfully built child-parent attachment relationship.
• The joy of having newly complex ways to relate to and learn from their uniquely growing child.
• The hard-earned satisfaction in becoming a successful negotiator.

So, when we recognize parents’ generally enough meeting their toddlers’ needs, to what are we actually referring?

Let’s zero in on the infant’s primary, most central need: ongoing nurturing relationships. And let’s ask the developing attachment relationship of the dyad to set the stage for a close-up consideration of how toddlers use that primary relationship to guide their journey through the increasingly complex tasks of toddlerhood.

Right from the start, as babies experience caregiving, they generally become increasingly close to their mother or mothering (primary caregiving) person. As days and weeks turn into months, their developing dependency on this person for felt security can easily be seen (and heard) in how they search for and latch onto this person, and how they are more quickly comforted by this person over any others at times of distress. Repetitions of such call and response interactions with a central caregiving adult teach the infant lifelong foundational understandings of interpersonal trust.

As mobility and brain power increase, the infant who has experienced the ready availability of the attachment figure is able to use the felt closeness as new steps are taken toward a new developmental task, that of selfhood. Calling again on Erna Furman, when the “doing for” lessons are comfortably internalized and the efforts to take some initiative in the doing are welcomed, these new tasks can be “felt” as right to try, especially when the successes are so reinforced with parental smiles and displays of joining-with joy!

Thus, the infant gradually crosses over from basking in being given to by mom, to partnering with mom-the-giver, to the toddler who is beginning to experience and wants to re-experience and so “practices” what it is mom-the-giver has been giving. We might even enjoy imagining the toddler being able to realize: “Wow! When I do things for myself that she’s always done for me, I get a really good feeling. All the ways that I’m taking care of myself are the ‘givings’ she taught me!”

Realistically, it’s reassuring to know that

when toddlers beam with self-pride at doing-for-self, they are on the way to internalizing life-strengthening lessons about the importance of relationship.

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A CLOSER LOOK AT THE DEVELOPMENTAL GROWTH-WORK OF TODDLERS AND THEIR NURTURING CAREGIVERS

Let us turn now to the developmental journey of toddlerhood through the experiences of one child and her parents.  At each developmental stage of this journey,

we’ll first observe Silvie in social interaction, and then consider what Silvie might tell us, if she could, how those interactions will provide life lessons for her next developmental steps.

By reflecting on the role that ongoing nurturing relationships play in the realization of selfhood, let’s examine how we might respond when specialized support is needed to guide a caregiving adult through the critical toddler-developmental period. 

Silvie and her family

 Silvie is a healthy, sturdy, easily engaged Latina child, whose first year was relatively free of emotional upheavals, physical challenges, and health concerns. She lives with her mother and father in a safe and comfortable environment. Both of Silvie’s parents teach full-time at a Spanish immersion K-8 school near their home. Since Silvie’s mother returned to work when Silvie was four months old, Silvie’s weekday care has been provided by her mother’s longtime friend, who is a licensed home care provider. She is “Tia” (auntie) to Silvie, who soon comes to call her MyTia. Both of Silvie’s parents are thankful for the support and advice they frequently seek and receive from their wise and encouraging friend, especially because both sets of grandparents and most of their extended family live in Mexico.

Initial considerations

First, let’s acknowledge that while stressors are part of everyday life, these vignettes suggest a caregiving context of manageable rather than toxic stress. In defining stress manageable, reducible, or even resolved through meaningful support, we can thus consider stress as opportunity for strengthening. I wish here to look to what early caregiving relationship health looks like, the better to 1) alert us to caregiving relationship risk and danger signs, and 2) guide us toward offering child-centered, relationship-focused interventions and support, whether informal, clinical, educational, or policy-determined.

Let us also pay due respect to the wisdom of the legendary baseball great Yogi Berra, whose oft repeated yogi-isms included a reminder that we “can observe a lot by watching.”

SILVIE AT 13 MONTHS: TRANSITIONING FROM BEING DONE FOR TO DOING WITH

Silvie is toddling around the kitchen, stopping periodically and plopping down to a sit to pick up and briefly explore some of the toys that are usually in the corner of the room, but are now scattered across the floor. Mama is rinsing dishes and putting them in the dishwasher. Suddenly, she drops a (polyurethane) cup and the water in it splashes onto the floor. Silvie quickly crawls to the cup and is just about to pat the pooling water with her hand when Mama swoops down with a towel, mops up the water and picks up the cup, saying, “No, no, Silvie. Mama do it. There. All gone.” Silvie watches and then reaches toward the cup with both hands, grunting her “request” with increasing insistence. Mama says, “You want water?” Silvie’s face brightens. “OK, but I’ll get your cup.” She finds a sippy cup, fills it and hands it to Silvie. “OK, Silvie. You take your cup. Mama’s busy.” Then she gets a metal bowl filled with small blocks from across the room and puts it in front of Silvie. “Look! Here are your blocks in the bowl! You like your blocks!” Silvie drops her cup on the floor, picks up the bowl and dumps out the blocks. Mama says, “OK, fill up the bowl again, Silvie. You can do it — one, two, three!” Silvie picks up one of the blocks, then drops it and crawls over to another toy. Mama returns to her work at the sink.

What Silvie needs us to know now about the help she needs to become a ME

I have just begun to walk, but I feel much surer of myself if you’re holding my hand. When I really want to get somewhere, I’d rather crawl because I can do that all on my own! Same with eating. I love cut-up food or Cheerios on my tray. Now that I can pick up tiny things, I can choose what I’ll eat next — or not! Papa and I have fun at diaper-changing time. He laughs when he sees me trying to lift my bottom up for the diaper. And I’m very proud that I can take a turn with you putting my blocks in the bowl you gave me, but I like dumping them out best!

SILVIE AT 18 MONTHS: THE PRACTICING OF DOING WITH

Silvie is walking around the kitchen, stopping periodically to pick up and briefly explore some of her toys. She picks up a board book, sits down and opens it, stopping to look closely at a page or two. She generally turns more than one page at a time, and soon discards it altogether. Her mother is putting dishes in the dishwasher. Suddenly, she drops a cup and the water in it splashes onto the floor. Silvie is quick to stand up, go to the cup and pick it up. She holds it to her lips, then holds it out to Mama. Mama says, “Oh, you want to practice? Wait, let’s mop up the water first.” She pulls down a towel as Sylvie drops the cup and puts her hand near her Mama’s; she laughs a little as they wipe up the water. Then Silvie points to the cup, looks at mama, grunts, points again, looks at mama and grunts. Mama says, “You want water in the cup?” Silvie brightens, wiggles a little, then puts both hands on her knees and grows still. Mama puts a tiny bit of water in the cup, holds it to Silvie’s lips, saying “This isn’t your cup, Silvie. There’s no top on it. Careful now.” Silvie puts both hands on the cup and pulls it away from her mama. As she lifts it to her lips quickly, some of the water spills and mama shakes her head, grins, and says, “Oh, Silvie!” as she uses the towel to pat Silvie’s face and shirt. Silvie laughs and bounces up and down. Mama laughs, too. “OK, Silvie! All gone.” Silvie says, “All gone.” Mama then points to the cupboard door that has Silvie’s “kitchen toys” in it. “What’s in there today, Silvie? You look and see while mama washes dishes.” Silvie stands up, walks quickly to the cupboard, opens the door, pulls out a large metal bowl, and sits down. She begins to pull out some small plastic cups and plates and toss them into the bowl, looking up at her mama with each one she pulls out. She looks for and finds a sponge in the cupboard and starts to “wash” the cups and plates. Mama says, “That’s right, Silvie! Silvie washes and Mama washes!” They smile at each other and mama returns to the sink.

What Silvie needs us to know now about the help she needs to become a ME

I really like to be wherever you are, Mama. And you have found ways to let me do that by putting things that are just for me in every room! Sometimes my things get all over the room, but you usually don’t get bothered by that, which is good because I like to play with lots of things. I can be busy for a long time when I’m able to pull things out, play with them, and then find different things. I love having choices. BUT … I’m always watching you and what you’re doing. Why? Because lots of times, I want to show you something, or ask for help, or watch what you’re doing and try to do what you’re doing. That way, we can still be close, but I don’t have to be actually right up close all the time. Sometimes I even leave the room, but only for a minute. It feels too … I don’t know what. I need to keep practicing this leaving and coming back thing. And you know what? When you show me that you like me being with you, like when you talk to me or help me, even if something goes wrong, I can do things you want me to do, even when I don’t want to do them, more than you might expect. When I don’t have to fight for my choices, it’s easier for me to let you have choices! Oh, but sometimes that’s very, very hard! My choices are really important to me! I guess it’s just that when you’re happier, I’m happier, so I try to (sigh) give in when you make it really clear to me that I have to. Mama, thanks for not making me do that too often.

SILVIE AT 26 MONTHS: TRANSITIONING FROM DOING WITH TO STANDING BACK TO ADMIRE

Mama is washing dishes at the sink and Silvie is sitting on the floor in the adjacent breakfast room, “reading” a book. Suddenly, she gets up and runs to mama and says, “Water, Mama!” while tugging at Mama’s jeans. Mama says, “You want a drink of water?” Silvie nods vigorously and says, “Drink of water.” Mama reaches for one of Silvie’s cups and begins to fill it. Silvie stamps her feet and shakes her head, saying, “No, no! Other cup!”  She points to a cup that does not have a lid. Mama pauses, sighs, and then says, “OK, Silvie, but it might spill. There’s no lid for that one. Careful now.” She puts a little water in the cup, crouches down and hands the cup to Silvie. Silvie begins to drink but loses her grasp and the water spills onto the floor. Mama says, “Oh, Silvie! It spilled!” and reaches quickly for a towel. Silvie again gets upset, grabs the towel and says, “Me do it! Me do it!” Mama sighs again and says, “OK, Silvie. You wipe up the water.” She stands up, takes a step back, folds her arms, and watches as Silvie holds the cloth in one hand and keeps turning it over to find dry places on it while she wipes and wipes and wipes the water away. Finally, she stops and looks up at Mama, who laughs softly. “You did it, Silvie; you did a fine job! Thank you!” Silvie grins broadly and says, “Welcome!” She returns to her book and Mama returns to her dishwashing

What Silvie needs us to know now about the help she needs to become a ME

Mama, I know it’s sometimes really hard for you to be patient with me. It used to be easier for me to stop doing something I chose to do and do what you wanted instead. But lately, now that I can think more about what I want to do, and I can actually do more of what I want to do, I just don’t see why I shouldn’t be able to keep at it! I’m so busy! I’m working hard! Look here, my protests are not really about you, they’re all about me! Actually, I think you do know that, because you try so hard to let me keep going, and when you have to stop me, you always talk to me about it. You try to explain, either why I have to stop, or that you know I’m not liking having to stop. Sometimes you say both. It doesn’t necessarily calm me down, but what I really hear is that you’re trying to help me. I may have to lose my choice, but I don’t have to lose you. What a relief. Whenever I “lose” me, you help me “find” me. This business about being a separate person takes a LOT of practice, and I can’t do it alone. Thanks to you, Mama, I can better focus on all there is to see and hear and learn about. I play better, I eat better, I sleep better.

SILVIE AT 30 MONTHS: SILVIE AND HER MOTHER’S PRACTICING OF STANDING BACK TO ADMIRE

Mama is washing dishes and Silvie walks into the room, saying, “I want water, Mama. I need it right now. Can I have water right now?” Mama says, “Please?” Silvie nods. Mama waits a second or two and then just says, “Sure Silvie.” She gets a non-breakable glass from the cupboard, fills it half full of water and holds it out to Silvie, who is cradling a favorite doll in the crook of her arm. Silvie says, “Here, Mama. Hold Baby.” Mama takes the doll and holds it in her hand. Silvie shakes her head and says with firmness, “No, Mama! Not that way! Baby likes this!” She grabs the doll and thrusts it into her mother’s bent elbow and moves her mother’s hand to hold the doll securely. Mama (wisely) looks at the doll and whispers, “Sorry, Baby.” Silvie gives a strong nod, gulps down all of the water and, with a gesture that clearly conveys self-pride, sets the glass firmly down on the counter. Mama says, “Wow! You were thirsty! You drank it so fast, and you never spill anymore. You’re such a growing girl.” Silvie nods and laughs, then picks up the glass again, holds it out to her mama and says, “You can take it now. It’s all gone!” Mama says, “Thank you, Silvie,” and laughs, too. With considerable gentleness, she hands the doll back to Silvie while saying, “Here you go, Baby, back to your mama.” Silvie looks thoughtfully at the doll for a moment, then at her mama, then back to the doll. Then she walks over to a low drawer by the stove, opens it, scans the contents, and gets out a small measuring cup and says, “My baby wants water now. Bye-bye.” Mama calls, “Wait! Come back and close the drawer, please.” Silvie runs back, pushed it shut, and runs out of the kitchen, chuckling as Mama says, “What a good Mamacita you are.” Mama chuckles, too, as she returns to her task.

What Silvie needs us to know now about the help she needs to become a ME

Hey, we could have had a big fight just now! You might have called me out for being so bossy. I felt kind of funny for a minute, but you weren’t mad, and you acted like I’m still your best girl, and I was so relieved. I just get carried away sometimes by how much I can do! This morning I pulled up my own pants, and I almost got my sweater on all by myself. Then I climbed the stairs to go get my baby, and I didn’t even have to hold the railing. Yes, I know you want me to hold it, but I was in a hurry! This day is actually going better now than it started out. I woke up screaming this morning because that boy Jamie at MyTia’s punched me! You came in and held me. You told me I dreamed it. I don’t know about that. I think he came into my room and punched me. He always wants his way at MyTia’s. Sometimes he grabs other kid’s toys. Everybody’s afraid of him. When his mama came to get him, Tia talked to her and then she yelled at him for being so mean. She called him BOSSY! She grabbed his arm and took him out the door. I felt scared inside. I went and stood by MyTia until you came to take me home. Mama? I love it when we laugh together.

SILVIE AT 36 MONTHS: TRANSITIONING FROM STANDING BACK TO ADMIRE TO DOING FOR ONE’S SELF

Mama is washing dishes at the kitchen sink. Silvie and her cousin from daycare come in from the back yard, each holding a long stick. They put the sticks down on the floor, take their sweaters off, and Silvie says, “Mama, I am Princess Magic Melda, and this is Princess Magic Zelda, and we’re thirsty!” Asked if they want water, the girls answer loudly and in unison, “Yes, please!” and giggle in delight to each other. While they’re waiting for the water Silvie says, “We have magic wands.” She opens the screen door, puts the sticks on the porch and comes back to stand next to her cousin. Mama hands two-handled cups to them and says, “Okey-dokey, here you are, my giggly girls. Here, I’ll hold the door for you. Walk carefully down the stairs so you don’t spill the water!” “Okey-dokey,” says Silvie, as the girls giggle and rush out the door. As they leave, they almost bump into Papa, who is coming up the back stairs. “Hey, Silvie! What’s the rush?” Continuing into the kitchen, he almost misses her stern reply as she and her friend rush down the stairs. “I’m not Silvie! I’m Princess Magic Melda! Bye!”

What Silvie needs us to know now about the help she needs to become a ME

I’m so happy today. I love being with my cousin. She has such good ideas. We talk about things and make plans about things. She wants me to go home with her and sleep over, but I don’t think I’m ready to do that yet. I like my cozy bed. I like the stories you and Papa read to me before I go to bed. I like when I wake up and come out to find you and you hug me and say, “Good morning, Princess!” I tell you what I want to wear, and I can pretty much dress myself. I tell you guys which cereal I want, and I eat all of it! When you remind me to put my dish and spoon in the sink, I’m proud that I can do it. On the way to MyTia’s, we sometimes sing. You and Papa make me feel so special. When I’m upset, you listen to me and try to help me feel better — even when you’re the ones who made me upset!! All in all, what I really like is knowing just how things are going to be! It’s what my pediatrician calls “being secure.” So, thanks.

REFLECTIONS AND OPPORTUNITIES FOR WONDERING

Toddlerhood is a word that is generally understood to encompass a distinct phase of early childhood development. Most commonly, it is almost synonymous with a period of time that is primarily burdened by challenges to parental authority — “control.”  Indeed, the term “terrible twos” is typically used with a rolling of eyes or a shake of the head. And depending on who’s saying it, it is a term that turns our attention quite quickly to the parents’ responsibility to “Do something!” to correct the problem, the menace, the forecast of adolescent delinquency and adult imprisonment.

Thankfully, all manner of experts — developmentalists, psychologists, physicians, allied health practitioners, social workers, educators, and parents — have written clarifying and illuminating books about toddlerhood. And no wonder. It is a time that is at once exhilarating to behold and be a part of, and mind-boggling in its complexities. As for me, I have always been particularly drawn to the seemingly sudden and soon relentless call to “self-authority” that all but explodes soon after the first birthday of a previously mostly smiling “just-want-to-be-close-to-you” baby. I am even more captivated by the observable evidence that, when clear and limited authority is granted to this new monarch, there is a noticeable easing of tension that quite often restores, however briefly, periods of comfortable closeness and shared pleasure in being together.

I continue to learn much from toddlers, the stories of parents and caregivers, and from new as well as treasured writings in my library of wise ones. As I wrote this paper, the books written expressively for or in support of the parents and caregivers of toddlers were much called to mind: T. Barry Brazelton (1992), Claire B. Kopp (2003, Doug Davies (2011), Selma Fraiberg (1959), Claudia Gold (2011), Alicia Lieberman (2017), Kyle Pruett (1999), Alan Sroufe (1996), and of course, Erna Furman (1982a, 1987, 1992, 2001).

It is important to keep in mind that just as there are many ways to consider a toddler’s relationship needs, there are even more ways to consider possible, preferable and even prohibitive responses to those needs. As we ponder the best ways to promote optimal social-emotional development and well-being during this newly complex growth period, we are compelled to wonder: What helps? Who helps? How helpful can any one person with any one perspective or training or program funding sources actually be? We would be wise to periodically pause and call up the voices of developing toddlers and use those communications to quite consciously re-center us and strengthen our resolve to focus on and follow our best individual and collective steps of toddler-centered, relationship-based support and intervention.

We might also want to stop along the way and consider the “voice” of early adolescence. When children have successfully protested being too old for babysitters and are experiencing a new kind of “caring for one’s self,” they are often called on to be babysitters, perhaps even for toddlers! What makes them successful? Their parents are nearby and ready to support as needed. The adolescents who ARE able to call on their parents when caregiving presents unfamiliar dilemmas or perhaps serious challenges, are, no surprise, most likely to be those who have carried forward supports they have stored away from back to when they were toddlers themselves. That’s when they got their first but not only boost in validation of their forages into autonomy, their push/pull gut feelings of marching forward vs. being cradled in loving arms. This, to me, is my best response to those who look at me with some confusion, saying, “So?”

In response, let’s fast forward to a glimpse of Silvie as a 27-year-old who is, with her husband, parenting a 30-month-old. Grownup Silvie might very well want her parents to know:

As I took my first steps and toddled unassisted, you were there to help me up when I fell, and there to prompt me to try again. In the face of fear, I could be courageous — because that’s what you showed me, taught me, gave me. And so today, your encouragement  and the confidence you expressed (even as I now realize with clenched teeth at times), are with me. Thanks, Mama. Thanks, Papa.

And so it goes as each infant grows, one generation of toddlers growing up and begetting another, each new generation of infants striving first for selfhood and self-authority, and then very gradually growing toward the security of felt interdependence. I have written here in hopes of encouraging us to look, and keep looking, ever more closely, to learn the language and lessons of those who have no idea what toddlerhood is until given the opportunities to try it out and to practice, again and again and again. And let us take every opportunity to encourage the givers — those who do for, do with, and stand back to admire the developing sturdiness of selfhood, and remind them that their gifts will always be passed forward to future generations. All we can teach is what we know.

• Ribaudo, J. & Beckett, H. (Feb. 2019). What is Going on in There? The Neonate Becomes an Infant. The Infant Crier. 

REFLECTING AND WONDERING

While reflecting on the vignettes of Silvie and her mama at each developmental stage of toddlerhood: Doing With, Standing Back to Admire, and Doing for Oneself, explore the following:

• What are the key indicators in these vignettes that suggest the likelihood of Silvie and her parents’ successful practicing of:
  • Doing With?
  • Standing Back to Admire?
  • Doing for Oneself?

• Identify some possible examples of parental responses at each developmental stage that might have compromised or precluded positive practicing experiences and suggested a need for specialized support or intervention.
• As a relationship-based interventionist, how might you have supported Silvie and her parents in reducing stumbles and encouraging successes during each of these developmental phases? 

REFERENCES

Furman, E. (1982a). Mothers have to be there to be left. The Psychoanalytic Study of the Child, 37: 15-28. New Haven, CT: Yale University Press.

Furman, E. (1987). Helping young children grow. Madison, CT: International Universities Press.

Furman, E. (1992). Toddlers and their mothers: A study in early personality development. Madison, CT: International Universities Press.

Furman, E. (2001). On being and having a mother. Madison, CT: International Universities Press.

Gold, Claudia M. (2011), Keeping your child in mind: Overcoming defiance, tantrums, and other everyday behavior problems by seeing the world through your child’s eyes. Philadelphia, PA: Da Capo Lifelong Books.

Ribaudo, J. & Beckett, H. (Feb. 2019). What is Going on in There? The Neonate Becomes an Infant. The Infant Crier. 

RECOMMENDED READINGS

Berry Brazelton (1992). Touchpoints: Your child’s emotional and behavioral development. Cambridge, MA: Perseus Publishing.

Brazelton, T. B., Greenspan, S. I. (2000). The irreducible needs of children: What every child must have to grow, learn, and flourish. Cambridge, MA: Perseus Publishing.

Davies, D. (2011). Child development: A practitioner’s guide. 3^rd ed. New York: Guilford Press.

Squires, J., Bricker, D. & Twombly, E. (2002). The ASQ:SE user’s guide: For the Ages & Stages Questionnaires: Social-emotional. Baltimore, MD, US: Paul H Brookes Publishing.

Fraiberg, S. (1959). The magic years: Understanding and handling the problems of early childhood. New York: Scribner.

Kopp, Claire B. (2003).Baby steps: A guide to your child’s social, physical, mental, and emotional development in the first two years (2^nd ed.). NY: Henry Holt and Company.

Lieberman, Alicia (2017), The emotional life of the toddler (2^nd ed.). New York: Simon & Schuster.

Kyle Pruett (1999), Pruett, K.D. (1999). Me, myself, and I: How children build their sense of self. New York: Goddard Press.

Squires, J. & Bricker, D. (2009). Ages & Stages Questionnaires, Third Edition (ASQ-3). Baltimore, MD: Brookes Publishing.

Sroufe, L. Alan (1996), Emotional development: The organization of emotional life in the early years. Cambridge MA: Cambridge University Press.

Parents do not uproot their children to make a long and dangerous journey to an unknown future in the U.S. unless situations in their home country are so threatening that the risks of migration pale in comparison to more certain risks at home. Parents do it because they feel they must!

Zero To Three is one of many organizations feeling compelled to respond to young children being separated from their parents at the U.S. Border.  In a recent statement:

“The secure attachments young children form to their caregivers are the bedrock of healthy development and emotional stability, providing a sense of security and a buffer from the toxic effects of stress and trauma. Migrating to a new country is already stressful. 

Separating children and caregivers destroys the relationships that foster resilience.  Make no mistake: separation at this point is a trauma that can have long-term impacts on an infant’s well-being. 

Post-traumatic stress disorder, anxiety, depression, and sleep disorders can follow.

The practice of having border agents remove children from caregivers suddenly and place them institutional care, especially without any policy for visitation, or reunification, amounts to maltreatment.

Anyone with infant/early childhood mental health expertise – and anyone with a heart for children – will tell you that separating young children from caregivers at the U.S. border is appalling and must be stopped”

 – Myra Jones Taylor, chief policy officer
ZERO to THREE

As immigration enforcement ramps up, so increases the fear of undocumented parents about the fate of their children.  There are about 6 million U.S. citizen children with at least one parent who is in the country illegally.  Research shows that harsh immigration enforcement policies have consistently undermined the health, economic security, and overall wellbeing of children of immigrant families.

Specifically, the current administration’s immigration enforcement orders:

• Tear families apart
• Harm children’s short- and long-term mental health
• Undermine children’s economic security
• Threaten children’s access to education and basic needs
• Endanger the lives of asylum-seeking children and families

Last year, the current administration issued two executive orders that powerfully expanded the intensity and scope of federal immigration enforcement activities in the United States.  These orders have included policy changes that have negative consequences for children living in mixed-status immigrant families. Many of these children are U.S. citizens.  This policy enforcement has dire consequences for unaccompanied children seeking protection here.

The current administration’s orders call for:

• An increase in immigration enforcement activities for deportation, triples the number of immigration agents,
• Increased collaboration between federal Immigration and Customs Enforcement (ICE) and local law enforcement agencies to detain undocumented immigrants,
• Focus on immigration enforcement along the U.S. southern border,
• Significant expansion of immigration detention capacity.

Additionally, the current orders have resulted in the separation of at least 2300 undocumented children from their parents who are placed in governmental care in shelters and foster homes across the United States. At the time of this writing, few have been reunited despite judicial mandates.

Parents who come to the U.S. have to make very difficult decisions about whether or not to bring their children with them to a new country that is unknown to them.

There are policy changes that would return more migrants, including women and children seeking asylum, back into harm’s way and strip children of critical protections.  These orders and policies undermine the wellbeing and development of millions of children and are directly linked to the parent-child relationship, external stress factors, and family economic security.

Parts of these orders may face legal challenges and other parts require additional funding to be fully implemented making these policies not final.

Significant effects of current immigration enforcement orders:

1st – Immigration enforcement orders tear families apart and mixed-status families are now more likely to be separated by deportation because every undocumented immigrant is being seen as a priority for removal and quickly processed with deportation orders. The “official guidelines for implementing the orders” rolls back previous Department of Homeland Security (DHS) policy that gave immigration officials discretion in deciding whether to detain certain immigrants, including parents and legal guardians of minor children.

More than 5 million children in the United States live with at least one undocumented parent and 4.1 million of them are U.S. born citizens.

As a result of these official guidelines, children are at risk for having a parent or guardian deported.

The current administration has called for national raids which have captured hundreds of people (parents and young people) previously covered by the Deferred Action for Childhood Arrivals (DACA) program which was established in 2012 giving relief from deportation for undocumented youth who came to the U.S. as children.

Family separation is one of the most harmful effects of the current administration policies.  As we know, parents are extremely important to the wellbeing of their children and the sudden loss of a parent can have long-term consequences.

2nd – Immigration enforcement orders harm children’s short and long term mental health by increasing children’s anxiety about their undocumented parents. At very young ages, children are impacted significantly by parent stress, according to many studies.  High levels of parental stress can result in poor cognitive development in children as young as two years of age.  Persistent stress, also known as “toxic stress”, can have harmful effects on brain development in very young children affected by fear and worries of their family and community, and the trauma of watching a parent be arrested can result in behavioral changes.  Very young children are particularly vulnerable to the impact of toxic stress due to the rapid brain development taking place, as well as their dependence upon familiar, caring adults to assist in regulation of their state of arousal.  The social and emotional development that takes place during the earliest years will impact later functioning for years to come.

Children of all ages are affected by fear and worries of their family and community, and the trauma of watching a parent be arrested can result in behavioral changes. Children’s sleeping habits often suffer and increased anger or withdrawal is common.  Schoolwork can suffer.  Additionally, the remaining parent may experience depression and withdrawal.  Mixed-status families involved in immigration enforcement often lack access to mental health services that are affordable and culturally and linguistically appropriate.

3rd – Immigration enforcement orders can undermine children’s economic security. Parental deportation or risk of parental deportation can push children in low-income immigrant families further into poverty.   One study estimates that the sudden loss of a deported parent’s salary can reduce a family’s household income by 73 percent.  Poverty faced by children in mixed-status families results in barriers to basic health and nutrition supports available to non-mixed status families. We know that children living in low-income households when compared to same age peers often experience more hunger, decreased health outcomes, and increased learning disabilities and developmental delays. Poverty faced by children in mixed-status families results in barriers to basic health and nutrition supports. Additionally, poverty causes extreme stress on parents, affecting their ability to recognize cues and attend to their children.

4th – Immigration enforcement orders threaten children’s access to education and basic needs. The fear of deportation can cause parents to be reluctant to send their children to child care, school or after school activities.  Every day parental responsibilities – transporting children to and from school or childcare – become too risky for undocumented parents.  A routine traffic stop could result in deportation.  Anti-immigrant rhetoric increases parent fears to reach out for a variety of supports for themselves and their young children.  There are also concerns for schools, early childhood education and care programs, health clinics and other programs that serve immigrant children and their families regarding confidentiality.  Current ICE policy restricts immigration enforcements from occurring in “sensitive locations” like schools, child care centers, bus stops, hospitals, and places of worship.  Yet, we know of incidents where parents have been taken into custody at these locations.  There is a need to review policies and to provide protocols to ensure the safety of all children and families.

5th – Immigration enforcement orders endanger the lives of asylum-seeking children and families.

These are the children and families that have experienced significant trauma in their migration from their home countries: families primarily from Central America trying to escape violence and instability in their home countries because of drug trafficking, gangs, and organized crime.

When border patrol agents turn away migrants at the border, forcing them to wait for outcomes outside the United States, their children are exposed and vulnerable to trafficking, and young children are being recruited for gangs.  Policy guidelines need to define who qualifies as an “unaccompanied child” and to provide protections for these children.  The Federal government requires women and children to be placed in detention centers – a controversial practice that has been shown to be detrimental to children’s healthy development. This is being challenged in court.

These are not the values of America.  This policy enforcement is dangerous to the health of our most vulnerable children.  Separating families sends children deeper into poverty and jeopardizes their rights to basic human protection. Current immigration policies and practice go against MI-AIMH’s mission to promote safe lives and healthy social emotional development for all very young children.

“MI-AIMH believes that each infant needs to be nurtured and protected by one or more consistent and stimulating caregivers who enjoy a permanent and special relationship with the baby.  This relationship is essential for optimal social, emotional and cognitive growth. MI-AIMH also believes that the failure to provide and maintain nurturing relationships, at least one, during infancy may result in significant damage to the individual and to society.”

Infant and early childhood mental health specialists understand what is at stake and it is critical that we advocate for practices that protect and support the healthy development of every young child.

References:

Cervantes, Wendy, & Walker, Christine (2017) Five Reasons Trump’s Immigration Orders Harm Children. Center for Law And Social Policy, April 2017 1-8. mi.aimh.org

Njoroge, Wanjiku F. M. (2015) Complex Intervention: A Family’s Story of Loss, Struggle, and Perseverance. Zero To Three Journal, March 53-56.

Paris, Ruth, & Bronson, Marybeth. (2006) A Home-Based Intervention for Immigrant and Refugee Trauma Survivors: Paraprofessionals Working With High-Risk Mothers and Infants. Zero To Three Journal, November 37-45.

Prieto, H. Victoria. (2017) Considerations for Serving Immigrant Families With Young Children. Zero To Three Resource for Professionals.

Zayas, Luis H. (2018) Immigration Enforcement Practices Harm Refugee Children and Citizen-Children.  Zero To Three Journal, 38(3) 20-25.