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.
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.