PREVENTING A VICIOUS CYCLE OF ANOREXIA

NEW YORK TIMES COLUMN: FAMILIES TODAY:
PREVENTING A VICIOUS CYCLE OF ANOREXIA
By: T. Berry Brazelton, M.D., and Joshua Sparrow, M.D.

Q. I dealt with anorexia nervosa for 10 years. Though I am now healthy, I still consider myself a recovering anorexic. I’m terrified there may be some truth to the idea that eating disorders can be inherited. My mother has also struggled with her weight. How can I protect my 14-month-old daughter from this legacy?

A. Perhaps you can think of yourself not as a recovering anorexic but as a person recovering from anorexia.

Anorexia nervosa can seem to take over your life. By reaffirming your identity, you may help your daughter discover and assert her own.

Young adolescents with anorexia often seem to have a fragile sense of who they are. They may focus on attending to everyone’s needs except their own.

In the movie “Black Swan,” Natalie Portman’s character, Nina, is scripted to follow this pattern – she lives her tortured life as a dancer to fulfill her mother’s unrealized dreams. Sometimes people with anorexia discover that as children they felt pressured to sacrifice the development of their own identities for a parent’s sake. Their parents didn’t mean to pressure them. But sensitive children may pick up on parental needs and problems, misunderstand them and hold themselves responsible.

Awareness of a parent’s fragility can turn into self-deprivation, self-punishment and self-hatred: “I don’t deserve to eat or to enjoy eating. I am fat and greedy and need to stop eating so that everyone else can have what they need – everyone but me.”

If this pattern has passed down from one generation to the next, psychotherapy can help. A new mother recovering from anorexia can learn to free herself from her own past and leave room for her baby to become her own person.

Psychotherapy can help stop a vicious cycle when parents worry that their problems may affect their young children. Parents may unwittingly urge their children to appear happy – thus reassuring themselves they have done no harm. This pressure can keep children from experiencing all their own emotions, including sadness and anger. As a result, the pattern continues.

Under the weight of pressures from one generation, the next one fails to develop fully. Nobody is at fault. But the pattern is hard to see and hard to stop – without help. Studies have shown that anorexia nervosa may be inherited. However, despite the increased likelihood, many children whose parents have struggled with this disease will not inherit it.

A hallmark of anorexia is loss of pleasure in eating. Studies have focused on how mothers with a history of anorexia feed their babies. These mothers seem to be more anxious and to take less pleasure in the feeding process than other mothers.

Psychotherapy can help them to relax and to attend to their babies’ cues about feeding and to enjoy these interactions.

Pleasure is a powerful motivator and an important part of the feeding experience throughout life. By the end of the first year, parents can help their babies start taking pleasure in feeding themselves. The babies will soon want to take over. At that point, avoiding struggles over food can help prevent bigger struggles later.


Responses to questions are not intended to constitute or to take the place of medical or psychiatric evaluation, diagnosis or treatment. If you have a question about your child’s health or well-being, consult your child’s health-care provider.

Prior to his passing, Dr. Brazelton was the founder and head of the Brazelton Touchpoints Center, which promotes and supports community initiatives that are collaborative, strength-based, prevention-focused sources of support for families raising children in our increasingly stressful world. Dr. Sparrow, a child psychiatrist, is currently the Director of the Brazelton Touchpoints Center. Learn more about the Center at www.touchpoints.org.

Reprinted with permission from the authors.

WHAT FRIENDS ARE FOR

NEW YORK TIMES COLUMN: FAMILIES TODAY:
WHAT FRIENDS ARE FOR
By: T. Berry Brazelton, M.D., and Joshua Sparrow, M.D.

Friends offer opportunities for a child to try out different aspects of her developing personality: her likes, dislikes and ways of relating.

She must learn how to socialize, to give without expecting an equal return, to share, to elicit positive responses and to care about someone her own age.

She can use friendship as a safe haven, and as a mirror. She can try out different styles and new adventures through the encouraging eyes of a friend. In the process, she’s learning about herself, and about how to attract and hold onto a friend.

A friendship’s necessary give-and-take is different from relationships with parents and siblings.

A child without friends is a poor child indeed. While a child must learn to deal with her own temperament – for example, her shyness or high activity level – it’s even more important for her to learn how to adapt to the demands of a group. A friend who is like her will help her do this. It has always intrigued me to watch two small children play and learn from each other.

First Friends

When should parents start introducing a child to other children outside the family? In the second year, it becomes important for a child to learn how to cope with other toddlers. In a large family or in a busy neighborhood, she may already have begun to learn about sharing, rivalry, teasing and coping with older children or a new baby. But the kind of relationships a child can make with children who aren’t her age are different from those she will make with her peers. Older children tend to protect, tease or overpower younger ones.

In healthy peer relationships among toddlers, children first learn the give-and-take of equality. They learn the rhythms of reciprocity – when to dominate and when to submit. This is basic to important relationships in the future.

In the second year, children are both demanding of others and learning to be sensitive to their needs.

Just watch 2-year-olds at play. If parents set up regular play groups of two or three toddlers, they can all learn about each other.

At this age, learning occurs by imitation. In so-called parallel play, two toddlers can putter alongside each other without ever appearing to look at each other. And yet, they’re already far more interested in and capable of learning from each other than the concept of parallel play would suggest.

Each child imitates the other with entire hunks of behavior. This ability to pick up and imitate whole sequences of a peer’s activity is astonishing at this early age. As one toddler stacks a row of blocks to make a skyscraper, the other will stack the same number of blocks for her building – using similar gestures as she does so. I’ve seen 2-year-old children absorb whole new sets of behaviors from other 2-year-olds and perform tasks to which they had never before been exposed.

Aggression

What if toddlers aren’t able to get along? What if one is too aggressive and overpowers the other, who is temperamentally a quieter, more reserved child? Is it healthy for either of them? Not really.

The parents of these unequally matched children will likely be drawn into taking sides and risk reinforcing each child’s imbalanced behavior.

When parents of toddlers get into their children’s play, they risk changing it entirely to an adult-oriented occasion. The opportunity for the children to learn about each other is diminished.

Here are some tips to help create balanced friendships:

  1. If the children can’t right the imbalance on their own, find another child more your child’s speed. If possible, find a playmate who’s suited to your child in temperament.
  2. If your toddler is a quiet, thoughtful, rather sensitive child, try to find one like her. She’ll learn a lot more from a peer who is learning to handle a temperament like hers than she will from your urging her to be more aggressive or gregarious.Though you mean to encourage her when you rally a hesitant child to fight back or to act differently, she will sense that you don’t approve of her as she is. Her self-image is at stake.
  3. If your child is aggressive and impulsive, look for another like her. They’ll build up to peaks of frantic activity but will probably find ways of subsiding. In this way they will learn – gradually – about not overreacting to their impulses.

After playing together regularly two or three times a week, such children will eventually become bosom buddies and will be learning as much about themselves as about each other.

(This article is adapted from “Touchpoints: Birth to Three,” by T. Berry Brazelton, M.D., and Joshua D. Sparrow, M.D., published by Da Capo Press, a member of The Perseus Books Group.)


Responses to questions are not intended to constitute or to take the place of medical or psychiatric evaluation, diagnosis or treatment. If you have a question about your child’s health or well-being, consult your child’s health-care provider.

Prior to his passing, Dr. Brazelton was the founder and head of the Brazelton Touchpoints Center, which promotes and supports community initiatives that are collaborative, strength-based, prevention-focused sources of support for families raising children in our increasingly stressful world. Dr. Sparrow, a child psychiatrist, is currently the Director of the Brazelton Touchpoints Center. Learn more about the Center at www.touchpoints.org.

Reprinted with permission from the authors.

Supporting the Development of Self-Regulation in Children

Maine Association for Infant Mental Health

Supporting the Development of Self-Regulation in Children
By C. Michael Sandberg, MA

Recently the world of early childhood education has once again been echoing with terms like self-regulation, executive functioning, and social skills. This is a welcome moment! Not that STEM (Science, Technology, Engineering, and Mathematics) and literacy are not important, but, rather, that it is once again being realized that success academically, socially, and personally is more dependent on these “soft skills” than it is on the content of the knowledge being taught and learned!

Flavell in 1977 called these skills “one of the really central and significant cognitive-developmental hallmarks of the early childhood period.” Their importance has been well demonstrated by several recent studies that followed children over time. In one, done in New Zealand, 1037 kids were followed birth to 32 years. They were looking specifically at what they call self control, certainly one of what might today be called the executive functions. They defined self control as being willing to delay gratification, able to control your impulses, and able to modulate your emotional expression. Even though some of the study’s participants improved their ability to control themselves over the period of the study, they did find that self control at older ages could be largely predicted by self control at 5. Children were first measured at 3-5 with a 90-minute scored observation. They were scored again in their preteen years. In adulthood they were evaluated for several social, health, and financial outcomes. Their heath score was a composite of their cardiovascular health, respiratory system health, dental health, sexual health, and their inflammation status. They found that self control at 5 was highly predictive of improved finances, better physical health, lessened levels of substance dependency and fewer interactions with the justice system. They also found it to be predictive of better decision making in the teen years. Higher self control children were less likely to become pregnant as teenagers or to leave school early. They also had significantly fewer interactions with the authorities. They were also able to do an analysis comparing the differences using social situation as a child and IQ with those found using self control and they found that self control was a much better predictor.1

These kinds of results have been found by several other long-term studies.2 Interestingly these findings echo the findings of studies of the impact of quality early childhood programming such as that done of the High Scope programming evaluated by the Perry Preschool Project. There, even though the initial finding of improved IQ washed out over time, the children still had improved outcomes in terms of social, academic, and financial success. It could easily be argued that what they had gained was improved executive function. 3 For me, these are important findings because the children failing and being expelled by our schools and preschools are mostly being excluded because of poor self-regulation skills. 4 At the same time most researchers and educators agree that most executive function skills can be taught.

While most evaluators use teacher reporting to assess self-regulation skills, (the most responsible researchers recognize that there may be bias included in these ratings and evaluate the ratings across different ethnicities and SES (Socioeconomic Status) to guard against as much as they can), there is interestingly one evaluation method in relatively common use. It evaluates cognitive flexibility in 3-5 year olds by using cards featuring different attributes. There are different shapes, such as bunnies and turtles, and among each shape there are also two different colors. Children are asked to sort the cards by shape and then to switch and redo the sort by color. What is being evaluated is their ability to let go of the old references and switch to the new one. Most 3 year olds struggle with this change, while most 5-6 year olds can easily shift. This method, known as the dimensional change card sort, can separate the age at which children are able to succeed and show that cognitive flexibility is used as an indicator of emerging self-regulatory skills. 5 For me, this is reminiscent of Piaget’s work with classification and it may demonstrate a link between cognitive and social skills!

For a while, people also thought the marshmallow experiment conducted at Stanford could become an assessment tool. The method tried to evaluate the ability to delay gratification by tempting children with a marshmallow, while promising them a second one if they could wait about 15 minutes before eating it. While the researchers reported good predictive power of later success, when people tried to replicate the experiment controlling for SES, they found SES had a higher impact than any maturity measure. The kids, who could wait, were those who had not experienced scarcity!

In order to decide what we need to be teaching and come up with teaching methods, we need a more specific definition of these executive or self-regulation skills. They include the ability to monitor and manage emotions, thoughts and behavior via impulse control, maintaining attention and focus, filtering distractions, emotional regulation, problem solving, and prosocial behavior. When we know what we are trying to promote we can both appreciate and protect it when it is happening and know more about how to create situations that will enhance the learning of those skills.

Interestingly, even fetuses have some self regulation skills. We know that because their activity level often varies dependent on the mother’s activity and mood. After birth, many newborns also illustrate their ability by turning away to take a break after an intense social interaction. They know how to shut down in the face of too much stimulation! So we are not starting with a blank slate. Reading last month’s piece on perinatal psychology might give you some ideas on how to support higher skill levels even before a baby is born!

Once they are born, what can we be doing! We can help children learn that their emotions can be regulated. We do that by allowing them to become upset, and then intervening when they are no longer able to regulate and coregulating them through our calmness and nurturance. We do it by honoring when a child needs a break and waiting for them to come back online before proceeding. We do it by recognizing when they are losing focus or becoming too frustrated to continue and then supporting their efforts and directing their attention back to what they were working with. We do it by scaffolding their explorations (Tools of the Mind, a Vygotsky based curriculum has been shown to be very effective at building self-regulation skills for those children who are starting further behind. It was less effective for those who already had higher skill levels6).

The first key to all of this is that if we expect children to learn self regulation skills, we as the adults must model those skills and remain centered and calm. It is only when we are calm that we can use our support to calm children. How can we give teachers and caregivers the supports that allow them to be present and listening most of the time? When teachers become stressed by their jobs, they may react with frustration and anger to misbehavior in the room, leaving the children who are acting out feeling alone, without an ally. As allies we are engaged in trying to assist children in meeting their goals for themselves, while doing so in socially acceptable ways. When you see yourself getting that kind of support it is easier to let go of the emotionality of the moment and to begin to use and improve the functioning of your thinking brain. Mark Rains, a board member of the Maine Association for Infant Mental Health and a psychologist, suggests that when children lose it (Flip their lids to use Dan Siegel’s expression), they need us to help them feel safe, connected to others, help them learn language to talk about feelings, gradually support their ability to see the patterns in behavior, before we can expect them to be ready to plan better actions.7

In general, we have to ask, how can I support the child’s autonomy and self-regulation rather than working to control them. As one example, if we have a child who is struggling with entering groups and tends to charge in and destroy things, what method can we come up with that might help them learn the skills needed. Could we ask them to try something new and then sit down with them to play alongside the group they want to join, without ever asking to join (the child who has poor executive functioning will often be told no if she or he asks to join a group)? Soon the child will be playing with the other children, and depending on their play skills you may have to remain and continue to support their involvement, or you may be able to leave. Later we could talk about what had worked and give them another tool (By the way, this may have to be repeated multiple times before it begins to take).

How can I help them learn to evaluate risk and make decisions? Instead of saying, “No that isn’t safe!” could we ask about where they would be landing the jump and do they want to land on that? That can be followed with, “well how could we make it safer.”

Executive functioning can be built better, and if it is, children are likely to be better citizens and parents when their time comes. Join me in trying to learn more about how to do this every day.

References:

  1. Moffitt, T. E., Arseneault, L., Belsky, D., Dickson, N., Hancox, R. J., Harrington, H., Houts, R., Poulton, R., Roberts, B. W., Ross, S., Sears, M. R., Thomson, W. M., & Caspi, A. (2011). A gradient of childhood self-control predicts health, wealth, and public safety. Proceedings of the National Academy of Sciences of the United States of America, 108(7), 2693–2698. https://doi.org/10.1073/pnas.1010076108
  2. Jones, D. E., Greenberg, M., & Crowley, M. (2015). Early Social-Emotional Functioning and Public Health: The Relationship Between Kindergarten Social Competence and Future Wellness. American journal of public health, 105(11), 2283–2290. https://doi.org/10.2105/AJPH.2015.302630
  3. Heckman, J., Pinto, R., & Savelyev, P. (2013). Understanding the Mechanisms Through Which an Influential Early Childhood Program Boosted Adult Outcomes. The American economic review, 103(6), 2052–2086. https://doi.org/10.1257/aer.103.6.2052
  4. Gilliam, W. S. & Shahar, G. (2006). Preschool and child care expulsion and suspension; Rates and predictors in one state. Infants and Young Children, vol. 19, No. 3 p. 228.
  5. Zelazo P. D. (2006). The Dimensional Change Card Sort (DCCS): a method of assessing executive function in children. Nature protocols, 1(1), 297–301. https://doi.org/10.1038/nprot.2006.46
  6. Blair C. (2016). Executive function and early childhood education. Current opinion in behavioral sciences, 10, 102–107. https://doi.org/10.1016/j.cobeha.2016.05.009
  7. Rains, Mark. “‘Getting It Together’ Healthy Start Community Forum.” YouTube, YouTube, 21 Oct. 2009, http://www.youtube.com/watch?v=evikiqovSVw.

 

THE POWER OF PLAY

NEW YORK TIMES COLUMN: FAMILIES TODAY:
THE POWER OF PLAY
By: T. Berry Brazelton, M.D., and Joshua Sparrow, M.D.

Play is a child’s work. As he plays, he has a chance to relive his experiences, ask questions about his world and, most of all, act out his dreams.

In play, he may feel the safety of not being watched or directed, and the freedom and exhilaration of enacting his own ideas. In play, a child can embellish his new developmental achievements, experimenting as he goes.

For example, when he has learned to walk, he may pick up a large wooden block that’s too heavy for him, drop it, and lean over to try to pick it up again. He may hold it in both hands this time, teetering as he concentrates. Losing his balance, he sits down hard but still holds onto the block.

Now he can turn it over, mouth it or push it to make it go, growling like a car engine.

What has he learned?

  1. To enlarge on the new task of walking
  2. To balance while holding a heavy toy
  3. To turn a wooden block in his imagination into a noisy car

In this one bit of play, we see an athlete, a scientist and a builder of dreams. When does play begin? At each diapering, each feeding, each time he’s put to bed, the baby starts to respond to his parents’ rhythms, smiles and strokes.

By 4 months, play can become more complicated. A baby can add peekaboo or play with a toy strung over his crib. If he bats it, it will swing around.

The baby sees that he can have an effect on his world. This is a time when play can postpone more basic requests – such as crying to be fed. The baby learns to fill up his own space with independent play. A parent can begin to push him into a schedule.

Much of play is to test how the world works. By 7 to 8 months, he can crawl toward a forbidden TV or lamp. As he advances, he looks back to check his parents’ watchfulness.

Then a parent rushes over to pick him up. He is learning to predict and control important adults around him. He tries his maneuver again. His mother drops the phone to come to him. He squeals with delight. What a source of power!

Once a child can walk, all kinds of new experiments are possible. He can walk around the corner and out of sight of his parents. If that doesn’t bring them, he may screech, partly afraid he has lost them, partly to get a response. When his parents rush to him, he has learned more about himself and them.

By 14 months, one toddler may sit beside another. One of them picks up a block to shake it. Without seeming to look, the other shakes his block in the same motion. Their play becomes matching. They try out rhythms, hiding the toy, throwing it, testing the friend by stealing his toy.

They are starting to explore social skills, communicating without words, joining and not joining a friend.

By 18 months, a child will imitate much of the world around him. He takes a teddy bear and cuddles it. He wraps it up in a blanket. He has taken the step into symbolic play. He play-acts what he has experienced in his own nurturing.

At 3, a child can even try out a variety of grown-up roles. A little girl might put on her mother’s jacket like a dress. She has incorporated her mother’s femininity and is trying herself out as a grown-up woman.

A boy will do the same with his father or an older brother. Fantasies are thus not an escape from the world but an exploration of how it works.

As children grow older and play more elaborate games, they learn about rules. Even here they experiment, and they may try to cheat to see the reaction it brings. They also learn to play cooperatively: Building forts, playing hide and seek, or acting out a story all require working together.

It’s easy to see how a heavy dose of television or video games can usurp some of the learning and joy of free play. It substitutes ready-made fantasies and passive watching for independent, active exploration and freewheeling imagination.

The extra richness and freedom of outdoor play, with its endless discoveries and new sensations, can be a high point of childhood. There the child can step fully into the roles of explorer, experimenter, builder and dreamer.

(This article is adapted from “Touchpoints: Birth to Three,” by T. Berry Brazelton, M.D., and Joshua D. Sparrow, M.D., published by Da Capo Press, a member of The Perseus Books Group.)


Responses to questions are not intended to constitute or to take the place of medical or psychiatric evaluation, diagnosis or treatment. If you have a question about your child’s health or well-being, consult your child’s health-care provider.

Prior to his passing, Dr. Brazelton was the founder and head of the Brazelton Touchpoints Center, which promotes and supports community initiatives that are collaborative, strength-based, prevention-focused sources of support for families raising children in our increasingly stressful world. Dr. Sparrow, a child psychiatrist, is currently the Director of the Brazelton Touchpoints Center. Learn more about the Center at www.touchpoints.org.

Reprinted with permission from the authors.