PART II
SHARING MINDFUL TALK AND UNDERSTANDING
- Revising the Story (Example)
- Eight Levels of Transactions
- Physical and Bodily States
- Somatic and Sensory-Motor Experiences
- Attachment and Engagement
- Social-Emotional Contingent Communication
- Mental Processes and Symbol Formation
- Family Function Stories
- Meanings from School-Achieved Sense of Self
- Multiculturalism and Relational Organization
Download Part II
The following are guidelines in gathering and sharing information in response to an identified need. Since communication is the heart of understanding, then the content of a conversation may be likened to its mind. It is necessary to focus on the broad scope of where a conversation is going while selectively taking in each part at one level, and consciously processing to the next.
The Developmental/Contextual Health Assessment – First, determine the developmental foundation of a child and his or her family, then suggest ways to build upon existing levels. The eight developmental levels below, will pin point where a child may be stuck based on the story that is told. The assessment becomes a process of discovering the balance between risks and protective factors embedded in the child’s niche and uncovering his or her level of developmental experience. While some learning and language deficiencies may stem from a disordered brain, with many disorders and conditions, which are biological, they will be affected by psychological responses to distress coming from severe insults and mismatched with the environment.
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Stress and Trauma – The negative impact of excess stress and trauma on relationships, thinking, and other developmental levels can be significant. Both secure attachment and a person’s development of critical thinking are very sensitive and vulnerable to stress and adversity in the social environment. Life is naturally unpredictable, and presents many challenges and losses, ups and downs, and periods of grief that often trigger resentment, disappointment, fear and anger. Much of biology and psychology stem from the social environment, and much of psychopathology and secondary impairments of genetic disorders have their origin in losses, abandonment, fear, rejection, victimization and powerlessness. Severe stress can actually impede brain functioning; however, recent research findings provide hope that such neurological deficits can be modified by promoting optimum experiences.
Coping – Much of a person’s mind includes a brain, subjective life and experience, and skills in coping and adapting. Thus, the mind is a healing machine. Illnesses, breakdown and congenital catastrophes happen, but generative assets are available in the mind within given contexts or optimal spaces. The mind’s healing process is dependent on new connections and pathways that can be formed in the process of life.
Stories – Individual perceptions differ, but perception can be altered by new interpretations. Coping abilities based on newly-acquired perspectives and interpretations are critical. Healthful reactions to individual stressors can greatly assist a person in dealing with life’s problems. Coherent and self-expressive narratives using such language as is promoted through therapeutic storytelling, can modify pathological progression. The grist for a story comes from what the family says at a distance from the problem, when the problem has less influence on their lives. They may talk about times, beliefs, events, thoughts, feelings, actions or ideas outside of an awareness of a problem’s influence. These subsequently become openings for discovery of new and different stories. Such alternative stories often uncover competencies, commitments and skills to solve the very problems. Articulating these new stories assists people in reconnecting with their preferences, hopes and ideas. Eliciting and identifying a client’s skills and abilities through alternative stories will likely modify the client’s physiology, as well as affect and improve his future functioning.
| Download Revising the Story Example |
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After we attuned ourselves with the family through many conversational exchanges around the family’s values, interests and significant experiences, we made discovery of the family’s background and history through many valuable contexts. For our practice, we have reduced these multiple influences to several areas from which we draw both understanding of the problems as well as strategies of seeing them as related resources and assets. These story themes brought forth from the child, family, school and cultural community, begins with the formation of safety and protective boundaries, feeling a sense of belonging, and finding a voice by having it acknowledged and validated. Further we offer these enriched anecdotal experiences to test out one’s reflective and relational capacities, increased sense of understanding, which hopefully leads to a clearer definition of one’s multiple identities. Taking the role of an ethnographer, questions are asked for gathering information as well as for generating a new experience from the interchanges. These experiences regard interaction between the demands of the social-emotional environment, as well as that of the physical environment.
As we surmised, the EK family was under a great deal of stress and conflict in coping with both parents’ previous life trauma, such as abuse, loss, violation, current remarriage, conflicts, job stresses, bills, medical bill collectors while having no health insurance, hassles from school and numerous moves. The measured stress was 10/10 with a coping effectiveness gap of 5/10. We asked Ella to give a name to all of the trauma as though it was a plot that was driving the conflict. She thought of "down-and-out feelings". We encouraged her to describe the impact of these feelings on her life, and she tearfully expressed her sense of being gobbled up and depleted, being unable to express her desired lifestyle, feeling criticized by teachers and feeling shamed.
Relative Influence questions were seen as a way to map the influences of the problem as well as measure the impact of Ella’s life on the problem. We externalized or put the problem outside the person so that the whole family could position themselves together against the "oppressor" or the problems. We wanted to open space with examples of unique outcomes where events from the past, present or even the hypothetical future might be found as exceptions to the problem to levy against oppressive forces. The question was asked, "So in the last week or so, the conflict continued, but were there times when some hope was still around? What ideas, habits, or feelings came to perhaps supplant some of the problem? What about times when arguing could have pushed you further into "down-and-out feelings" but didn’t?" Such exceptions seemed to connote continued commitment to the marriage, taking the initiative to look for help, and continuing to keep up some good times together.
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In revising a problematic situation, it’s important to seek out special moments called sparkling events and fill in details from various sensory modalities. For example, questions could be asked such as, "What was the situation when you first decided you needed help?" "Where were you?" "What was the first step you took?" "Was there someone in your mind who encouraged you?" Remembering an example from an earlier "crossroads experience" often brings forth a similar example to "thicken" the present event wherein you reached for help. Such reviewing and researching of memories gives a richer story-line construction and development aside from the problem story, where Ella now sees herself more in control, and better knows what to do as an active agent in enacting a more preferred pathway.
Of course a story is more than just what happened. After eliciting the “what, where, when, and how”, we are interested in assessing the more personally-subjective opinions of the narrator and by reflection in bringing forth new meanings from what was performed. This aspect of re-storying explores making new sense of the actual lived experience in relation to one’s purpose, desire, preference, motivations, thoughts, and feelings. Ella’s actions now magnify more of her life, who she is, and her sense of identity as a wife, mother, sister and granddaughter. Such questions of story meaning and identity might include, “Having made this happen for you, what does this say about your hope for Adam?” “Now that things are a little better, what about renewed confidence for the future?” “Where does this take you now?” “Acting on this decision the way you have, what does this say about your commitment to keeping the family together?”
Solutions-focused interventions are another practice we use to transform newly discovered strengths and assets into something more compelling and richer for our clients. We present this now, after the restoring phase, because it is still a part of collecting information in a way that converts problems and deficits into needs and eventual goals. These goals are defined by alternatives to the problem and what people do instead of focusing on the problems, in finding ways to start dealing with the realities so that the client can become useful in managing and coping with them. We start taking a solution approach right away so that by the time we are actually writing goals in Part III, preparation has already been devoted in defining the goals in measurable, specific and concrete ways. A brief introduction with references for getting started is included in the appendices for this section. Much of what Solution-Focused Therapy is, has given us important ways to convert a pathology-based approach to something more life giving, motivational and sustainable. [See Solution Focus Handout]
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Protective Factors – With a holistic and comprehensive approach, we look into each of the eight levels of historical experience for complementary strengths, talents and exceptions to disorders. If done appropriately, resilient resources are found, and old stories are re-told in a newer, more encouraging way. And, though the disorder may persist, its effects may begin to become background with new adaptations from the client’s own arising foreground experience.
-Eight Levels of Transactions-
The following are a few questions on critical developmental levels to ask the child and family which include links to our philosophy. On one end of the spectrum is the child with his or her constitution, maturation and temperament. At the other end are the family and community. But all are within the context of the child or client’s genetic and cultural heritage. The development of the child and the child’s mind comes from both his or her chemistry as well as the socio-cultural environment. Energy and information flow both ways and each part affects every other part. If we make sufficient interventions along the flow, we achieve positive outcomes.
In one of our examples, Adam’s parents got right into this by completing a 1-10 Assets questionnaire which includes the above (Eight Levels of Transactions). The parents give him plenty of credit (7/10), but in the areas of physical and temperament reactivity, he gets a score of 0 or less than 1. The helpers completed a more holistic and interdependent 1-10 scaled version, and felt the same way. Our experience is that when comparing these two evaluations, we see a remarkably close assessment of child-environment features. [See Child Assets Scale, and Parent Summary of Child Health Asset]
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1. Physical and Bodily States. Conventionally, this describes what is understood as health today, but is quite different from our view when working with complexity. Our Euro-American culture takes a narrow view, assuming a biological objectivism that reduces health and medicine to an excellence at “fixing the plumbing and reassembling the wires.” On the other hand, ABLE uses the ancient meaning of health, e.g., from the Old English, “haelth (heal),” which is broader and subsumes the collective and systemic as well as the biological and medical. The ABLE health provider uses a biopsychosocial-cultural context that connects bodily states to social and cultural narratives.
A genogram may be helpful to elicit genetic conditions in understanding how family members get along with each other over generations, and to learn the dates of family historical events. Pedigree sketches show squares as men and circles as women. Horizontal lines indicate marital and parent-child relations. Dates of marriages, separations and divorces are written above a slashed line. Many themes of experience as marriage, death, birth, graduation, losses, illnesses, roles, and resilience can be noted. These patterns can give insights leading to changes in attitudes and beliefs. Old and renewed stories can be told, and family trees then become a powerful way to explore these systems and improve understanding of people, things and events. [See Four Generation Family Genogram]
Some questions asked from this particular genogram include: “What are the patterns of uniqueness, belonging, power, and role models in the family?” “Who are the heroes, heroines, as well as possible scapegoats or ‘black sheep’?” “What about employment, career, academic performance or financial success?” “Where might we find traits of leisure or hobbies?” “Can we find evidence for spiritual expression or other religious identity?” “Who might be regarded as sick or ill or with alcohol or substance use or mental illness?” “In spite of these afflictions, who seemed to bounce back and deal a winning hand in spite of the odds?”
It is appropriate here to have a nurse obtain the weight, height, head circumference, blood pressure and pulse of the client, and to chart them on a graph to show the child’s stage of growth. [See Nursing Checklist and Child Development and Family Life Experience, Supplement A:School and Supplement B:Pre-school and Guidelines for Physician Evaluation] The Nurse may also be available to help summarize, assess needs and act as a liaison among many possible health providers. He or she may also facilitate an District Health Care Plan.
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The following are reminders of some of the biological systems we attempt to assess in evaluating special-needs children. This may be most helpful for the “health” person consulting with the team.
The Following is the Pediatric Assessment:
Growth and Hormones: Short stature and failure to thrive, growth failure, prematurity, small and large for gestational age puberty, and systems review. Possible pediatric referrals for screen: U/A T4/TSH, Lead, CBC/Diff, IGF-1, IGFBP-3, Bone Age, Lytes/BUN.
Unusual Physical Features: (Beyond family resemblance): small head, skeletal, spine, face, limb, especially hands, and skin abnormalities. Genetic syndrome. Pediatric referral. Fragile-X. Fetal Alcohol Syndrome.
Neurological Status: Responsiveness, strength, coordination and balance, tremor or tics, vision and hearing, headaches, head injury, seizures, and cerebral palsy.
Mental Status: Orientation, arousal, alertness, over/under focus, mood-anxiety, thoughts, feelings and behaviors, suicidal/depression, perceptions or hallucinations, memory and speech.
Autonomic Nervous System: Regulation, gas, constipation, sweating, flushing, belching, drooling, arousal, attention and diurnal rhythms.
Immunity: Sicknesses, regressive coping with stress, fever or rash, hospitalizations, allergies, rheumatoid symptoms, and other immune diseases. Are immunizations up to date? What about school attendance? Is there herbal use?
Confirm Nutrition: Appetite, eating from a variety of food groups? Chronic vomiting or diarrhea, food sensitivity, obesity (weights, lipids and cholesterol, pulmonary function, apnea, BP) calories, mid-morning and afternoon snacks, breakfast, water bottle on desk, multi-vitamin supplements and special diets.
Bodily Functioning: Dental (brushing, preventative flossing, flouride,) toileting, sleeping (apnea, disruption), enuresis, encopresis, energy, activity menu, vitality, stamina, safety habits, exercise, stress control, relaxation, meditation and yoga.
Medications or Herbal Preparations: These may either help or interfere with learning. Consider what the benefits vs. side effects might be? (The article Muses on Medication lists many web sites for further information.)
Presence of Medical Assets: Health provider, health insurance, and a possible school health plan.
Chronic Conditions Screening: Diabetes (control, HgA1C, fasting Sugar, oximetry), allergies, asthma, accident-proneness.
Exposure: Drugs/alcohol, sex, violence, or harsh discipline.
Summarize: How do these medical/physical features influence other levels of functioning?
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Adam’s early history confirmed premature smallness for date of birth as described above. His early history evidenced difficult temperament with dysrhythmia in biological sleep and feeding rhythms, high activity, intensity, and slowness to warm up. He seemed sick a lot as an infant with otitis and asthmatic illnesses. He has always been a picky eater and worrying his mother. We had to keep encouraging her by showing her his current growth chart with height and weight being exactly in the middle demonstrating how well she got Adam to grow. Vision and hearing were normal, and in fact, he heard too well, being sensitive below the 0 baseline and was distressed at spoken sounds above 70db. There were all those doctor visits paid for out of pocket (no insurance), and vitamin drops. Mother liked Valerian drops (herbal) too for soothing him from time to time.
It was pointed out to the mother how well she and her husband had both helped Adam. “You have worked together. Dad has worked hard to earn the money for food and doctor appointments, and you have prepared well and taken him to the appointments.”
He was immunized and eventually was well with a sense of vitality. Too much so! Along with a family history for ADHD, Adam was also impulsive, distractible, and hyperactive. We actually felt he had mixed attention disorder with a bit of over-focused periods making transitions hard and exhibiting some anxious OCD features. These were further explored with the school’s contribution later.
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2. Somatic and Sensory-Motor Experience (Temperament and capacity for self-regulation).
Sensory Maps. We must assess the way the body organizes itself into sensory and perceptual systems with underlying precognitive and motivational tendencies, because this comprises state of mind. The body processes the elemental experiences at organismic levels before integrating them into whole gestalts and larger schemas. This physical processing forms neuron maps in which outputs are assembled digitally into motor ideas, and thus praxis or planned motor output is achieved.
An Occupational Therapist (OT) or Physical Therapist (PT) may help assess the integrity of the motor-sensory system, including motor planning and sequencing, in order to accomplish goals. The OT/PT may also assess strength, activity, tone, coordination, fine motor skills and posture. In addition, the OT assesses the sensory-processing system, its sensitivities and soothing capacities, and its regulation or modulation of the system to attain a calm, alert state. Some of these dimensions include tactile, visual (acuity), proprioceptive, vestibular, auditory (hearing, sensitivity, processing), taste and olfactory elements.
Self-Organization. Self-regulation is reflected in sensory-motor strategies to achieve and maintain an organized and regulated state in dynamic situations. Arousal, alertness and attention are on a continuum with basic arousal and alertness at one end of modulation, and attention and curiosity at the other end. Some children fail to orient and have poor registration and under-responsivity, and may be sensation seeking. On the other hand, some children may over-orient with over-sensitivity to fight-or-flight, or may be avoiding sensation with freezing or sensory avoidance.
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Temperament. The attributes above, along with individual differences, suggest a child’s temperament, or learning style, which is a constitutional quality of the favored ways the child responds to his or her environment. Temperaments include innate attributes such as high or low activity, intensity of mood, self-control, adaptability, threshold for being ticked off, persistence (or single-mindedness) and regularity of such physical functions as sleep and appetite cycles. These constitutional features are precursors of nature and personality, depending on how the environment reinforces behavioral styles. “The Sensory Profile” (1999) by Winnie Dunn, The Psychological Corp., is an excellent scale to evaluate traits of sensitivity of touch, smell, movement, vision and hearing. It describes low-tone, low-energy, sensation-seeking and over-responsive children.
Direct Experience. Concentration on what one sees, feels and hears tends to embed one in direct experience, which offers better coping and managing of extremes. “The Out-of-Sync Child,” by Carol Stock Kranowitz, is about sensory processing disorder, includes many interventions, and is popular with parents. Specific experience supporting these physical foundations potentiates developmental progress, the origins for Erikson’s early stages, and Piaget’s sensory-motor and circular reactions, which elicit ideas and early emotional thinking. The sensory experience is lived in the moment, in the here-and-now, although it is fragmentary and fleeting. The ego and self are intertwined in the experience. Thinking may be magical and disjointed, as it includes impulsive and inattentive thought or sensory streams. Although focus is on bodily and sensory explanations, it is recommended to ask questions about meaning. How does the client make sense of these experiences? Logical, sequential thinking comes later when, in story-fashion, you speak about what happened.
Finally, Goodness of Fit becomes the bottom line in this part of the assessment between Adam and his social and physical environment. The worker might ask himself, “What is the match between the client’s sensory motor characteristics, biological rhythms and individual learning style, and the environmental demands made upon him by his parents, teachers, and physical requirements? Before any clinical conditions can be diagnosed, hunches, observations and descriptions of his bodily reactivity are required, as well as understanding about what’s required by those around him. What is Adam’s adaptability in negotiating these constraints? We have seen problems almost dissolve since last year, solely due to the greater congruence between the child’s temperamental style and those of the teachers at this time.
Team member: “ It is important that Adam’s way of learning is understood by all of us.”
Parent, “Oh, now you are telling me he has even more problems. We have a noisy house and now I find out that that bothers him.”
Team member: “I can tell you are growing in understanding Adam’s unique and individual needs.”
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3. Attachment and Engagement. A child’s ability to discover the world is dependent on healthy relationships with family caregivers, siblings, peers and teachers. Psychologists and social workers make assessments of the degree of security, comfort and safety of shared relationships, which are primary. The attachment behavioral control system is biologically based and strategic motivating us toward survival and protection of our evolutionary heritage. The system consists of protective and nurturing behavior from caregivers in response to signals from children, which include vocalizing, smiling, crying, yearning, and approach behaviors.
Disorders. For some children, developmental conditions and their secondary psychiatric sequelae interfere with attachment security and with the child’s achieving proximity behaviors. Professionals ask about the three basic attachment functions: proximity, seeking a safe haven in stressful, dangerous situations, and having a secure base from which to explore the world. Attachment disorders include the following: having no attachment status (rare); indiscriminate and inhibited attachments; and aggressive-angry and role-reversal types. Some of the behaviors that express these syndromes may include: showing no or little caregiver preference; accident-proneness and recklessness; lack comfort-seeking; no boundaries, dysinhibited; anxious-clingy; non-compliant; oppositional and over-controlling; and ignoring and avoidant. These latter characteristics may be a part of “secure-base distortions.”
Righting of Disruption. The question of whether severe early deprivation and disruption can be overcome depends on its duration and severity, as well as the age and developmental level at which deprivation occurred. It also depends on external resources, understanding attachment resolution, the availability of emotionally sensitive caregivers and caregiver support. There is strong biological pressure to alleviate disruption and form multiple attachments. Recent research suggests a category of “earned secure” status. Examples show that after intervention by healthy caregivers, distressed, anxious and attached-disordered children may gain a secure outcome. We contend that a child’s attachment security can change from anxious to secure by inclusive practices, nurturing transactions and support over time. Primary and secondary caregivers (important extended kin, teachers, and mentors) can accomplish this through constructing alternative, coherent narratives of meaningful experiences with the child. Cooperation in dialogue means defining a coherent narrative. This can be done by fulfilling Grice’s maxims of quality of truthfulness, namely, having evidence for what you say with sufficient examples, being succinct in quantity, being complete in relation to the topic, offering enough information and, finally, speaking understandably, with order and clarity through time.
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Predicting Attachment by Telling Stories. Since we all listen to and tell stories, assessment of attachment is a responsibility of each team member, as a hunch or a feeling from our own attachment experience may come to mind. Some questions from the Adult Attachment Interview are offered in subtle ways and may predict the secure attachment of the offspring wherein parents narrate coherent texts about their own lives. Such non-probing questions may include: “Give me five adjectives to describe your relationship with your mother as far back as you can remember.” “To which parent did you feel closer, and why?” “When you were upset or sick as a child, what did you do, and what would happen?” “Describe significant separations from your parents.” Ask questions about rejection, threat, illness or loss. “How did your certain experiences influence your adult personality, or cause setbacks?” “Why did your parents behave the way they did?”
Out of these hunches and questions, four categories of attachment may come forth: 1. secure , (balance of avoidance and ambivalence in safety and comfort, with information processing in two modes), 2. avoidant, (avoiding closeness and emotional connection; dismissing, flat affect, with more logical, objective or reality-based left mode processing), 3. anxious/ambivalent (more anxiety, uncertainty, preoccupied, rambling, right mode, subjective processing) and 4. disorganized, (dissociation, freezing, fragmentation, unresolved fears, trauma). What best fits the child you are seeing? Are elements of other patterns overlapping? Can the child have a different attachment with alternative caregivers? Is contingent communication enhanced or hindered in the interactions?
Case Study
Adam has an enmeshed style with his Mother, and an avoidant style with his step-dad. These can be described as adaptive forms of anxious attachment health requiring further accommodating for those working with him. The teacher and school psychologist are now secondary caregivers and have become important sources of security and help toward righting these insecurities. (different than last year where he felt so unsafe that he had to have a knife, and the typical responses were punitive.) Although we did not diagnose an attachment disorder, (only Reactive Attachment Disorder is available in DSM 1V), we did feel there was some disturbance of the secure base (anger, anxiety, ambivalence, and oppositional and controlling behavior). Attachment health is so important and can lead to much understanding of the case as well as attempts to stimulate “righting” toward an “earned secure” base over time with steadfast pervasive social connection, emotional acceptance with strong boundaries, and limit setting. This can be initiated with the child and fostered in the parents, providing the domino effect, if you will.
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Team member: “It will help Adam feel safe if he has firm family rules and consequences.”
Parent: “We have tried that, but he doesn’t listen.”
Team member: “Are the family and the family therapist working on making family rules?”
Parent: “Yes, we are working on his cleaning his room, but it is not going well.”
Team: “What rewards does he earn….what is the cost?”
Parent: “Explain the program.”
Team member (with gentle yet serious affect): “Every time you follow through with this program, each day that you give his consequence, you show that you care enough to be consistent, which is hard to do. This will help Adam feel safe, and that he can count on calm, consistent parents.”
4. Social-Emotional Contingent Communication.
Wants, Desires and Preferences (requirements for a higher order of thinking and achievement). It is recommended that psychology, a language pathologist, a social worker and a health provider initiate inquiry into the strength of this function. We believe this aspect of attachment is a major feature to further developmental levels.
This level is a step above attachment and engagement, previously described. Now the dyad can engage in mutual, back-and-forth, non-verbal as well as verbal communication. Each responds to the other and gains the satisfaction of being heard, seen and felt. This process is enabled by having satisfied the other person’s behavior-control systems of exploration, affiliation beyond attachment security, and in having a secure base. This acquisition enables an elaborate cooperative interaction to occur, involving two-way circles of communication. It is a mutual process.
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We assessed the ABC’s of Contingent Communication in the attachment mode as it applied to Adam. We looked for attunement, or the vital sense of the way he connected and engaged with another mind. Adam and his mother were very close, but over involved in each other’s sense of separateness, which created angry eruptions. Attuned, back and forth exchanges seemed to be missing with his many interactions. A balance between the biological, psychosocial, and cultural elements all within his multiple states of mind suggested a sense of incoherence, poor integration and lacking in meaning.
Team member: “Adam, you’re a growing boy with many interests. Does your family know about your interest in frogs?”(Team member smiles, beholding and admiring Adam.)
Adam: “Frogs creep my mom out”
Team member: “That’s a way the two of you are different. This is a way you are your unique self, Adam.”
Team member (smiling, and with direct eye contact to mother and child): “Do you have a place to go to see frogs?”
Mutual Process. “Goal-corrected partnerships” assure an admixture of minds between the child and the mother so that each shares and enjoys the other’s determination and goals. Co-constructed and collaboratively planned ideas for mutual action come from more than one mind. When the child heads toward his or her preferred pathway, although somewhat altered and modified from original plans by the mother, the mother too has an altered state of mind as well as a different outcome from the transaction. The child assimilates the mother’s feelings and motives as well as having his or her own. This level is a lynchpin, enabling further relations, and having empathy as well as language horizons. Intention and inter-subjectivity or the desire to experience the other–and early theory of mind is formed. Large memory structures take in the social, subjective experience and form a template for representations of intimacy and wellbeing, which are foundations for later milestones in development.
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In summary at this point, with a much more concrete developmental level, and where action and doing are anxiously expressed, we see Adam making great progress. He is moving away from a less optimal fit between constitutional regulatory problems and maturational development, as well as from an early history that included harsh home and community environmental contexts. These latter conditions can interfere with integration of attachment and contingent communication dimensions contributing to attachment distortions. [See Child Health Assets Form]
Emotional Communication. Through a contingent attachment relationship, basic emotional and social needs are met, leading to themes of security, trust, acceptance of self and others, pleasure, a sense of control, empathy and shared power. These emotional themes are part of implicit memory processes and may initially be entirely non-verbal. These emotional themes are reflected in the child’s face, body posture, tone, and gestures. Working memory is promoted. These emotions are also an energy system and so contribute to motivation, and also promote action.
These communicative gestures are multiple and involve long chains of interactive shared exchanges. These loops of sequential communication now start to depend on motor planning modules in both parties. This is a pre-language skill and is mastered before higher cognitive capacities are developed. They are the foundation for building interventions that promote readiness to master academic skills later on. We initially target self-regulation and control, cooperativeness, relatedness, confidence, curiosity and interest, intentionality, and capacity to communicate. These are the emotional themes and patterns upon which language builds. The child is now ready for language and symbol infusion amplifying communicative ability.
Our focus on social-emotional strengths provides ways to get through the ordinary day, which is our way to embrace methods to connect children such as Adam to the “here and now”. We offer several methods of inquiry, evaluated by the caregiver and helper, using the Daily Strength Scale, which the child fills out using his own perceptions. We matched fairly well around 7/10, higher than we thought, so in spite of assessed difficulties earlier, Adam was now seen as more functional through-the-day. The specific elements comprising coping, elf-direction, relationships and creative play are elaborated fully on the Child Strengths Checklist, and are broken down into those categories. They are completed by teachers, parents, other kin and friends, and eventually become the grist for intervention on the Family Health Promotion Plan.
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Team member: “Let’s look at what Adam said about, How Well Do I Get Through the Day. Is that okay with you, Adam?”(Team member looks at Adam seriously with eye contact and a questioning look.
Adam: “Sure”
Team member: “This says you are getting through the day quite well, and the Child Strength Checklist says you are good at creative play. You are getting stronger and more sure of yourself. (smiles at Adam and then to the parents) And I notice you had said you had many fun things to do during the day. (smiles) Your Mother told us you were very good at creative play. Have you been creating some fun things since we last saw you?” (smile at Adam)
Adam: “I have made a Frog Play with my friends.
Team member: “There you go, now is that good creative play. I don’t think I have ever heard of a frog play. What a good idea.”
Adam: “Yes, I wrote and …..(expounds on his strengths).
A number of maturational concerns are now assessed, and we have diagnosed over-focused inattentional behaviors. Thereafter, once an alliance was achieved with the parents, they gave us permission to use a more appropriate stimulant, which clearly gave a jump start so Adam could begin to self regulate better and control his impulses. These several child-centered developmental infrastructures also give us a clear view of protection factors along with the established risks. These have been enumerated sufficiently in part 1A describing many interests and aspects of Adam’s strengths and motivations, along with activities that rewarded him and helped manage his behaviors as well.
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Team member: “I think now that your body is calmer, your good mind is shining through. I know your parents are proud of you. Who is most proud of you at school or with the Scouts? Have they been good at noticing you?”
Adam: “Yes, my Scout leader said I could work on a Nature badge for my frog stuff.”
Although there were initially a number of interventions aimed at molecular and bodily systems, relationships, soothing and calming, to help Adam start to have academic success using his good cognitive potential, much of our thrust will now take on family, school and cultural intervention which is described in the last half of the eight transactional influences.
5. Mental Processes and Symbolic Representation.
Types of intelligence, such as Attention, Perception, Memory, Thinking and Reasoning, Visual, Spatial and Auditory Language, Non-Verbal Language, Executive Functions, and others are generally explored by a referral to Special Education, along with Psychology and/or Language consultation.
It is a miracle when everything in a human being operates as it should. It is difficult to believe we can be creative, use symbols, reason intelligently, invent new things, figure out problems, cope in effective ways, and survive—sometimes even thrive. Our potential is vulnerable, but also has powerful biological and innate origins.
Mind-Making. Once we feel secure, achieve self-regulation, and engage in nurturing two-way relationships in which we communicate our wants and needs, we can separate and further reflect and explore our world and create symbols. Symbols make up our thoughts and ideas in myths, stories, art, science, religion and humanities, and they represent our lives. We communicate ideas expressing them by using gestures, images and pictures, play, music, words and numbers. We look, hear, feel, smell, taste and attend to our environment,, and perceive its precepts in objects, things and events. We learn by holding on to meaningful memories and by making associations and links to them with symbols. On the workbench of memory we see things again from a different view. We sort them out and reason them into new ideas and new meanings. In this way, our mind is formed, in part, from our brain, wherein information and energy are taken in and new knowledge and adaptive outputs are formed, making us who we are.
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Conserving Functions. The child transacts through his or her biology and environment using emotional behavior, imagination, play, language, and emotional thinking all in the service of development. Higher levels of thinking and being also include the lower functions; therefore, exceptional abilities are constructed and conserved into newer forms of thinking and doing. Earlier emotional ideas (e.g., using dolls fighting each other) bridge to other themes (dolls making up and hugging) and, by using many circles of communication to express desires, a child negotiates the balance between pretend and reality, giving a coherent story to his or her unfolding drama.
First Things First. Traditionally, developmental science has made evaluations explicit, promoting standard testing that is separate from the whole person. Traditional developmental science assesses language, cognition, behavioral functions, and academic achievement, which has uncertain relevance to the unique life-space of a child within his or her family, community and culture. Clearly, the organization of life experience and learning abstract concepts can not come before building a firm foundation for self-regulation, curiosity and interest, attention, trust, engagement and intimacy, secure attachment, intentionality, inter-subjectivity, initiative, empathy, imagination and play. For obtaining a history, see Nursing Checklist and Development Life Experiences Form.
Clinical Example:
So far the dynamic model we have worked from is exemplified by an interaction of multiple interdependent variables represented by the biology and strong evolutionary forces being influenced by the social-physical environment. The EK family, primarily profiled by mother and child through a case discussion, is characterized by many of these risk and protection factors enumerated.
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Team member: “Do your parents know about your interest in frogs?”
Adam: “I don’t know.”
Team member: “ Mom, did you know this wonderful energy Adam has around frogs?”
Mom: “Sort of. He talks about them and wants to have one as a pet which would mean I’d be taking care of it.”
Team member: “Well, I’m noticing how Adam’s eyes light up, and he’s so focused when we talk about this”. Dad, with your enjoyment of the outdoors, do you remember when you were a boy and first noticed frogs?”
Dad says, “yeah”, and smiles. “I liked them.”
Team member, “So you like them, too. I see you are kind of like a frog: being good at moving and liking to be outside: like your own mom and dad also like to be outside.”
To a degree, we have also discussed the impact of two-way talk in which salient aspects of the family are highlighted within a balance of foreground and background information and the back-and-forth dialogue is captured by our metaphor of the child developing within the family culture in transactional ways, wherein the exchange from both sides interacts contingently. Such is exactly how a conversation proceeds and changes what is generated and influenced by both mutual parties toward a surprise ending, though within the expected goals, and not necessarily ending or being defined unilaterally.
Our model also appreciates and gives vision to the growth and developmental nature of childhood, beginning at a level of physical and physiological growth. The model is circular with the elemental and more experiential linking up with multicultural complexity showing sequential and hierarchal growth. These early foundations describing Adam are built upon each other so that “higher” levels are comprised of all earlier “stages.” Knowledge of these levels may lead to greater understanding where the child or parent-family may be located in the sequence and what interventions might be helpful. For example, Adam’s regulatory disorder is described best within the first couple of dimensions, as it may also involve parts of emotional-communication at the fourth level. We envision the flow however to be bi-directional so intervention could be conceived within the environment and culture which may impact lower levels as well as directly focus at the child’s physiology and attachment dynamics.
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6. Family Functioning and Shared Story-telling and Enactment.
Healthy Functioning. Children grow and develop in family groups that have broad diversity in composition. If our parenting is only good enough, our children will likely survive with a variable quality of life. However, if the transaction between children and families is closer to optimum, mostly satisfying daily needs, with healthy family function, satisfaction of economic, domestic, recreational, spiritual, socialization and self-identity features, then children may gain resiliency. Our hope is that children will have outcomes that include wellbeing, security, affection, acceptance and understanding, as well as boundaries, confidence and a sense of discipline in their transition into the larger world. What more could a parent ask? Experts from teams with experience in this area must surely include the family itself: parents, child, siblings and extended family. The school may also have a social worker or other family-oriented social science worker who can mediate and elicit a family’s preferences and desires. A family advocate representing community support might also be called upon.
Infusion of Multiplicity from Higher Sources. The family funnels biology, genetics, physical health, culture, customs and norms to a child. It comes together from either a traditional two-parent family (70% of the U.S.) or alternative social groupings composing of step- and blended, bi-racial, gay/lesbian, single, grand-parented and other families. A child’s development comes from these social-cultural systems. More complex contexts or social groupings likely establish additional niches that may stimulate development beyond the usual dyadic care-giving to other levels of caretakers in the group, and to triadic levels from varying parental-sibling-extended family sub-systems. Additional relationships contribute geometrically to non-shared experiences and affect the way stories are organized at family levels.
Several remedial family interventions were tried following enhanced motivation. The voices of Adam’s parents were heard regarding his safety and protection in going back to school. Thereafter, many resources opened up for him which enabled buffering of the realities of his home. Further outreaches from school temporarily offered a lynch pin, as usual sources of help would have come from mental health, couple counseling, career development and parent skill-building (See Family Health Promotion Plan). More information can be found in Parts III and IV. At times, it is necessary to mobilize less desirable formal support systems, including the school, health department, housing, workforce services, etc. to jumpstart critical care areas until informal extended family and friends can be organized, while the others can hopefully be weaned off. We identified a minimal family network as well as a reluctance to depend on state agencies, due to the strong sense of family self-determination.
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Team member says: “Adam, now that you are becoming more focused at school and learning your math in an after-school program, I wonder if you and your brother could help remind each other to do math at home. If the two of you work together and finish your math homework, what could be a reward each night for the two of you?”
Day-to-Day Communal Stories. Family stories are concrete and describe everyday reality–what, where, when and how–with emphasis on action. When stories are told in fellowship, they are valued and shared. Stories are drawn from life’s multi-faceted backdrop and, in retelling, offer children significant advantages in understanding the world. This narrative process is like the lens of a camera: family stories select and focus on specific content while filtering less-meaningful experiences. Stories draw from formal and post-formal developmental thinking and shape a person’s perspectives. Family stories shape life differently for different family members.
Return to the Attachment Narrative, which becomes the Family Narrative. Physical and psychological wellbeing is supported by the social environment, as well as secure attachment, which is manifest in coherent narratives. Such narratives are truthful and have credibility. They are succinct, yet complete. Conversations are relevant to the topic at hand and are clear and orderly. Shared family stories that lead to action will promote a child’s development toward greater logical awareness of experience, and will organize experience in the concrete of the here-and-now, offering a simple causality and problem-solving approach, as well as the beginning of empathy-building.
Family stories co-enacted through members during intervention are transformative of older, marginalized stories of the individual members independently trying to shape their own destiny by pulling themselves up by their own bootstraps. Coherent and integrated stories told by family members ultimately have health-related outcomes supported by attachment-related research literature. Getting a family to revise their accounts has a life-giving effect. Systematized case management, with the coordination of helping community agencies, has been able to help move thinking from pre-operational or magical-egotistical thinking to more concrete strategies, then on to more relational, reflective and flexible coping.
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Father says: “We have always been a family with many hardships. I never learned to read. I flunked out of school and the school didn’t care.”
Team member: “Look how you are changing this story for Adam. You and your wife have cared, have worked with the school, and have cleared the path for Adam’s success.”
7. Meanings from School-Achieved Sense of Self.
School experience creates new meanings through accomplishment and successful management of the peer experience. The school encounter is a source of formal, abstract and reflective thinking and feeling resulting from the attainment of a sense of self. The team is augmented by the child’s teacher and, perhaps, other members of the school’s various interdisciplinary groups. Many groups we participate in have included the school principal who takes responsibility in assuring positive outcomes for his/her children and their families.
Child’s Personal Experience. Paulo Freire says, “Teachers should attempt to live part of their dreams within their education space.” A classroom can be a space for hope, where students and teachers glimpse the more perfect society that is possible, and where they gain the skills needed to make social improvement a reality. Children have an innate curiosity, sense of wonder, and a capacity to learn that is closely related to their unique experiences. What is taught should come from personal experience in order to promote reflection and self-awareness.
We seek ways to transition children from home to school. Although the family is a collective resource for early development and will always exert strong influence, it will many times yield to the impact of schools where dominant cultural values prevail. Value conflicts, peers and alternative interests will come between family and child. The first day children leave for school they expose themselves to new ideologies, to peers with different expectations, and to different systems of conflict resolution.
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Dealing with a Complex Environment. A child has to cope with much. Consider a child’s multiple settings: walking or taking the bus to school, the school halls, playground, lunchroom, classroom and the library. Then he or she goes home again. The mini-settings in school are also various: seatwork, teacher and peer-directed groups, recitations, sharing time, independent work, computer time and worksheets. Following rules and transitions for all these settings, tuning out countless distractions, being aware of who is top dog, and negotiating social hierarchies and gender issues are quite a feat.
We expect kids to show up for school bright and spunky, and we expect them to be punctual and prepared. They must have their homework finished, have pencils and a daily planner, sit still, and keep their hands to themselves, except when raising a hand to give a correct answer. They must be intelligent about reading, writing and arithmetic, have friends, but don’t push or shove, and ask for help yet don’t rock the boat. Above all, they must protect their self-esteem from taunting and humiliation. Mastering these extraordinary demands has a significant effect on developmental milestones.
Life’s complexity increases for children as they grow older. They must adapt to puberty and major physical changes. They may encounter gender stress, racial and ethnic differences, peer stress, mood-altering substances and sexual activity. If they are disabled or have a health condition, they especially need substantial support at this time.
Accomplishments. Besides the major task of achieving social and academic competence, other school-developed accomplishments include higher problem-solving skills, decision-making, development of an internal sense of control and positive self-concept, orientation, morality, handling multiple choices, and a higher sense of empathy. Successful experience with and mastery of these tasks are great milestones. Developed levels include: greater causal and attribution thinking with less black-and-white literal concreteness, understanding from greater reflection, and being able to stand apart from a situation and separate feeling from thinking. More of a sense of self is achieved by seeing one’s self in relation to a problem, which allows development of formal operations, and seeing patterns by observing similar behaviors over time. Comparisons to others are sometimes painful, but they help develop an internal sense of measurement and standards. Later, school development forms personality and a sense of the future, including goals, occupation, a sense of independence, and deepening intimacy. Many of these tasks are social, related to self-development, and not necessarily academic.
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Accelerated Development. To sum up the crux of the matter, the school experience broadens a child’s roles and expectations by integrating successful coping with the demands of a precocious culture of new lessons, skills and knowledge, while bringing an influx of friends and family-school interfaces. All of these experiences create exposure to more sophisticated multidimensional realities and encourage rapid development. Cognitive and social capacities are experienced earlier with abstract and formal abilities unleashed at a younger age.
The optimal school experience shapes not only an achieved sense of self, but consolidates other self-determined needs of creativity, adequate coping, feeling worthy and having a sense of bodily intelligence in relation to the social aspects.
The goodness-of-fit between the school environment and the child, in other words, the balance between school demands on the child and what the child can give, determines the child’s success. We must witness this goodness-of-fit, or lack of it, and stand with families who make requests of the school. Better goodness-of-fit can be accommodated with support for higher expectations, extra help, mentoring, incentives and rewards, opportunities for recognition and responsibility, connection to a caring person. Other help for goodness-of-fit include providing alternative ways to achieve, alternate protective factors supporting positive development, encouragement of hope and a sense of importance, as well as preventive options for promoting stress-resistance.
Clinical Example:
A premise of our work is that screening for protective factors and resources as well as risk- reduction strategies within the school environment highlights our belief in the cultural knowledge of the community and school, distilled through a healthy receptive family, can mediate established risks in the child. EK’s family experienced high stress from realities of a poor working class, economic pressures of low income, budget problems, a lack of health insurance, and unresolved past traumas. The result was depletion, strained relationships, and shame-based functioning. Although at the same time we saw a strong commitment, endurance, legacy from past generations, spiritual orientation, a sense of humor and willingness to ask for help. See previously “Tell us about the influence this has played out in your life.” See also School Conferencing.
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Mother says: “Our family came from Europe being poor. Things have always been hard and we have done it all on our own. “
Team member: “Given that past, it is so impressive that you are hard working and working with the community for your son.”
8. Multiculturalism and Relational Identities.
Thinking About Culture in Two Ways. Culture is the total of who we are. In its abstract and largest sense, culture is a universal template for a body of people’s methods for coping and figuring out the world. Culture helps people understand themselves and others, and it is thought that if we go by our culture’s rules and assumptions as we grow up, everything makes sense. Culture gives coping skills that satisfy the need to acquire resources. Culture imparts customs, norms, patterns of thinking, behavior and learned prescriptions for identification with a group. Culture defines problems and specifies solutions to them.
In its most personal way, culture is funneled through families and temperaments giving us our own stories and creating our individuality. Singleness of agency is part of that identity. Identity is likely constructed from multiple social sources and is much influenced by context and changes in its facets. The ABLE Program model takes an inductive, ethnographic approach to determine the impact of culture on family. Our approach is bottom-up. We do not stereotype cultures onto people and impose exotic universal principles from top-down. We prefer to help people draw forth their own preferred cultural life-stories rather than to adopt oft-repeated, problem-saturated stories from a predominant culture.
Culture-Centered Stories Integrate Levels. Culture-centered narratives bring together various developmental experiences of biology and body awareness linking family, school and community. We seek ways to draw all layers together with multiple levels of information processing. We may ask a patient for an image at the sensory-motor experience level, or draw out a story through a concrete, linear narrative. We work on reflection and the way a patient relates to situations with thoughts, feelings and actions, as well as the way the patient relates to multiple issues within the context. A culture-centered treatment and family plan comes from this involvement, which results in seeing patterns from family and culture of origin and finding new meaning from several points of view. We add community resources as dialectical systems to integrate a plan that includes support for sensory-physiological concerns, medication, relaxation training, a cognitive behavior plan for distorted thinking, and reflection on information about a problem on the patient’s sense of self.
ABLE also takes a position that culture is not unitary in its expression. Culture comes from many sources: ethnicity, race, gender, class, age, ability, religion, language, nationality, family history, education and occupation. As multicultural beings, we define our roles in relation to all that we experience, which contributes to the whole question of who we are. Of course, we continue becoming who we are as our stories unfold.
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Cultural Competence. Multicultural assessment becomes sensitive and competent by using tools and ideas from developmental and family-systems medicine, as well as from social-constructionism and language-determined systems. These tools provide proactive ways to unpack the dominant cultural discourses and to re-author the parts back into a whole that is more in keeping with the world of our multicultural patients. Competent assessment practices include knowledge and respect for other lifestyles, including healing folkways and their practitioners. We must also be aware of our own Euro-American culture, especially its subtle and covert misappropriation of power and prejudice (racism). Sometimes we oppress out of ignorance. For example, sometimes our ethnocentric beliefs assume the relative superiority of our ways of life, which leads to the assumption that our beliefs are good for all. Be aware of the tendency to stereotype and prejudge people. Learn the secondary mal-effects of cultural diffusion, which is when two cultures meet in unequal contact, there is resulting acculturation and cultural loss from the minority client’s perspective. Awareness helps circumvent exploitation and injustice and helps find respectful ways to render assistance.
Examples of cultural sensitivity include asking how the patient understands a given problem and how they would solve it in their own culture. The truth is, a helper can’t know all the cultures of the world, so transparency and humility is essential. Ask the patient to tell you what solutions they see. Other culture-centered ideas include: family networking, case management, communal teams, balance in confidentiality, consulting an ethnic resource, using outside witness groups, working with a religious leader, seeking ethnic health remedies, suggesting ceremonies or constructing rituals, applying the power of music and dance, and suggesting a genogram. Some of these ideas may elicit family support and community activities.
Seeking Fitness Again. Additional mutuality between parties with dialogic and reflexive two-way thinking brings out many perspectives. Diversity is systemic, multiple and complex contexts, with many storied accounts and an acknowledgment of other voices. Relational thinking stirs co-construction of vital understanding.
Coming from our biological-environmental and cultural transactions, the dialectical processes of reciprocity and mutually respectful turn-taking helps sort out and select elements that offer the most advantageous solution. Good fit leads to novel adaptabilities and alternative identities, new levels of agency and renewed power, reconnection, appreciation for contexts, new awareness and consciousness, and a sense of coherence, vitality and wellbeing all of which serve to enhance developmental progress.
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Originally, when the idea of multiple contexts was brought forth from the work of Greenspan et al., Ivey and O’Hanlon and Bertolino, (Constructvism, Developmental Therapy and Ericksonian Therapy) the intention was to enumerate a variety of contextual influences, all of which moderate their effects on each other. We hope we have described Adam’s different settings which have multiply contributed to his progress and development. There is greater credibility in this idea of multiple causality in understanding what happens to him, as well as likely many solutions in helping him. Seeing many solutions to a single problem. (Different than the prevailing medical mode.) Single cause and effect thinking leaves open the child-EK family to be embedded within the person with having oppressive politically dominating consequences from society centering blame and guilt within the self, whereas it should be situated in the problem, with its source in the larger culture.
Examples of this abound in the many “isms” around children, they to be seen but not heard, so called economic truths of pulling yourself up by your own boot straps, or Adam “should” do what he is told. Finally these two opposing organizing systems of child-environment holds the metaphor of “fit”. We’ve previously described this under temperament and sensory features. It becomes another therapeutic tool to look at these two entities from their congruent or incongruent positions. It’s likely that our continued conversation to bring together pertinent information from the outset wherein we have a chance to accommodate and negotiate the two sides with mutual appreciation produces a “goodness of fit” where the environmental demands are in synch with the child-family’s abilities and challenge capacities in a way that makes for “flow.” This is also worthy curative space for family healing. Hopefully these several model advantages speak to their benefits on behalf of Ella and Adam, his teacher and other relationships so that everyone is just a little bit better off.
Team member says: “Adam, all these grown-ups are getting better at understanding all the different parts that come together to make you up.”
The End, and Adam looks down at his Frog Book, smiling.
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