Promoting Child Social-Emotional Growth in Primary Care Settings: Using A Developmental Approach Michael Thomasgard, MD1 W. Peter Metz, MD2
Summary: Clinicians are often faced with meaningful child/family mental health concerns, and yet suggesting a helpful course of action can be very challenging. While pediatricians routinely use a developmental framework to evaluate young children’s cognitive, motor, and language skills, this occurs much less frequently for social-emotional development. Only recently have newer models of child development been put forth that emphasize the central role that emotions play in organizing the interactions among cognitive, motor, and language development across the lifespan. We review such a model of social-emotional growth and consider its implications for use in primary care settings. Clin Pediatr. 2004;43:119-127
Introduction
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linicians are frequently faced with meaningful child/family mental health concerns, and yet suggesting a helpful course of action can be challenging. While the recently published Bright Futures in Practice: Mental Health, Volumes I and II (Jellinek et al 1) represents a positive step in this direction, its
developmental framework is cumbersome, complicating its use in primary care. There is, however, a complementar y conceptual framework of early social-emotional growth, the Developmental level, Individual differences and Relationship-based, Model of Inter vention (DIR, Greenspan et al2). This framework is currently underutilized for 2 reasons. First, information exchange between
1Department of Pediatrics, Ohio State University, College of Medicine, Children’s Hospital, Columbus, Ohio; 2University of Massachusetts Medical Center, Division of Child and Adolescent Psychiatry, Department of Psychiatry, Worcester, MA.
The authors wish to thank Dr. Ellen Perrin for reviewing an earlier draft of this manuscript. Supported, in part, by Maternal and Child Health Interdisciplinary Leadership Training Program Grant MCJ-T73MC00049A0 and Children’s Research Institute, Columbus, OH. Reprint requests and correspondence to: Michael Thomasgard, MD, Behavioral-Developmental Pediatrics, Children’s Hospital, 700 Children’s Drive, Columbus, Ohio 43205-2696. © 2004 Westminster Publications, Inc., 708 Glen Cove Avenue, Glen Head, NY 11545, U.S.A.
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the disciplines of child psychiatry and pediatrics is relatively limited. Second, while Greenspan’s model was initially developed for those with pervasive developmental disorders, the same normative stages of emotional growth apply to more typically developing children. Before reviewing this pragmatic model of social-emotional growth it is important first to consider the reasons why it has taken so long to acknowledge the significance of mental health in young children.
Mental Illness and Mental Health The related topics of suffering, shame, and stigma help to explain why it has taken most physicians so long to acknowledge the importance of the mental health
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Thomasgard, Metz needs of children. Emde3 defines mental health as “the development of competencies and successful adaptations in the midst of opportunities and challenges. Pathology, on other hand, has core features of an inability to change and some degree of pain or suffering, [emphasis added] that distinguish it from (mental) health.” It is difficult for some adults to recognize that infants and young children can experience pain, disorganization, and a narrowing of their adaptive capacities to develop.3 The mental health needs of young children have been minimized owing to a fear of labeling the child with a mental illness. The latter continues to be associated with maladjustment and stigma.4 Labeling can also lead to shame and humiliation because there remains a widespread belief that emotional and behavioral disorders result from laziness or moral weakness. When adults experience shame . . . we feel or believe that we have been acutely exposed (to others and/or to ourselves), as not measuring up to ideals or standards that we have set and accepted. . . . On a cognitive level, there is a painful awareness of being defeated, deficient, exposed, a failure, inadequate, wanting, worthless or wounded. The def iciency seems per vasive; the ver y essence of the self feels wrong.5
Clinicians also need to recognize that it is “. . . shameful in itself to admit that one feels ashamed.”5 The stigma associated with mental health continues to have an enormous bearing on self-blame, silence, and mistrust and affects not only the child but the entire family.6
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Feelings and emotions are downplayed in our society owing to the nature of linguistic communication. Thoughts represent concrete actions and experiences, whereas emotions are relatively elusive. It is hard to describe a feeling; the example of having “butterflies in one’s stomach” effectively illustrates this point. While feelings are clearly linked to our thoughts, feelings can also interfere with cognition. When one is overwhelmed with anger or anxiety or is having “a fit,” that individual’s capacity to maintain perspective and think clearly is temporarily impaired or even incapacitated. Children’s mental health needs have also been overlooked owing to a lack of financial support for the necessar y time required to address those needs adequately and insufficient training regarding attention to mental health needs. In addition, there are limited evidence-based data for eff icacy of treatment approaches to mental health needs versus the treatment of physical disorders. A noteworthy exception to this lack of attention to mental health needs is the empirical DIR model of Greenspan et al.2 This developmental road map for early social-emotional development examines how language, cognition, and affect function as an integrated unit across the entire lifespan. The remainder of our paper considers in some detail the developmental component of the DIR model and its implications for primary care.
perficial views that merely rate social adjustment skills, achievement in various endeavors or a lack of conflict or tur moil.” Mental health is more expansive and includes a tolerance for life’s frightening and painful emotions, a deepening of intimate relationships and the development of more meaningful inner reflection. Social-emotional growth is not confined to early childhood. While physicians generally think about developmental milestones as being either met or not met, developmentally appropriate experiences in social relatedness continue to evolve across the lifespan. Whereas the material that follows suggests a rather linear path from one social-emotional stage to another, development also includes periods of regression and disorganization in reaction to stress and as new skills are learned. Such turbulence is expected and is ultimately followed by a period of relative calm as newly acquired skills are further consolidated.8 At each stage of social-emotional growth, the following elements are considered: (1) the nature of the developmental challenge, (2) the child’s age when this skill is typically first encountered, and (3) the clinical utility of such information. In the developmental stages that follow, the ages in parentheses for each stage reflect the time of major consolidation, with growth in such skills sometimes preceding and inevitably following the indicated age range.
A Newer Approach to Social-Emotional Development
Developmental Stages of Emotional Development
Greenspan’s developmental model7 of mental health “highlights the inadequacy of more su-
Can the Individual Attend and Feel Secure (Birth to 4 Months)? This most basic level of socialemotional development involves
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Promoting Social-Emotional Development the ability to regulate attention, process sensory information, and remain calm. Although not emphasized by Greenspan,7 a number of parental relationship domains relate to the attachment component of feeling secure, such as emotional availability, warmth/empathy/nurturance, the provision of comfort and protection, that also support attention to the larger environment.9 Attention span can be affected by stimulus novelty, the sensor y channel(s) by which the individual can best process information (e.g., auditor y-verbal or visualspatial) and one’s sensory threshold. The latter includes how much and for how long a stimulus needs to be presented for it to be registered by the nervous system. Attention span can also be influenced by our neuromuscular system’s ability to respond to our wishes. For example, if there are significant difficulties initiating and controlling body movement owing to abnormal muscle tone, more energy than normal is expended and can lead to early fatigue. Clinical Implications. Since each of us processes sensory information (e.g., touch, vision, hearing, smell, movement) in a unique manner, clinicians can help caregivers recognize these types of individual variations in sensory processing by performing one of the initial newborn examinations in the presence of the parents.10 Some infants require only minimal assistance to settle down when upset, such as talking in a soothing voice, whereas others need multiple forms of sensory input, such as being spoken to, rocked, and swaddled, to achieve the same result. Clinicians may not think to ask what interactions with the child are most enjoyable. Such infor-
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mation may provide important clues to the type of activity that is organizing for both the child and the caregiver. The clinician should also remain open to the possibility that what appears to be maladaptive to an observer, such as an older child noisily tapping a pencil on a school desktop, may be helping the child to pay attention. Such an individual often has a high sensory threshold and thus requires more input to feel energized and engaged. In contrast, another child may appear inattentive owing to a low sensory threshold leaving him or her more vulnerable to being overloaded by the same stimulus. In the former circumstance, such motor input may improve attention, whereas for the latter individual it may be more helpful to first work on establishing a calm environment that promotes attentiveness and social interaction.
Can the Individual Feel Close to and Engage with Others (4 to 6 Months)? Once children or adults are able to adapt successfully to environmental changes, it becomes increasingly possible to remain calm and organized. Successful regulation of internal sensations gives rise to an enhanced capacity to develop and sustain external relationships, and vice versa. An infant studies her parents’ faces, cooing and returning their smiles with a special glow of her own as they woo each other and learn about love together. We see it in a 7-year old, working independently at his desk, who greets his teacher as she approaches him with a beaming grin and proudly shows her his work. We see it in the 12-year-old who strolls over to a group of his friends at re-
cess and begins to joke and talk with them. . . .11
These examples reinforce the notion that unlike many of the more traditional “developmental milestones,” those for social relatedness continue to be elaborated upon and refined across the entire lifespan. Clinical Implications. Caregivers sometimes attribute beliefs to their children that are not developmentally possible (e.g., believing that an infant is trying to get even with them because of drug use during the pregnancy). Such thoughts can significantly interfere with a caregiver’s ability to gradually develop a close and war m relationship with the young child. There may also be significant differences in sensory processing between individuals that diminish opportunities for enjoyable interaction and play. Clinicians can help caregivers identify the types of activities that appear to calm and organize the child. This information can then be used to establish regular, mutually enjoyable activities between caregiver and children (i.e., “special time”). Such data are often overlooked owing to the caregiver’s overwhelming sense of frustration that is closely linked to unsatisfying and often conflictual interactions with the child. “Whether because her ner vous system is unable to sustain the sensations of early love or her caregiver is unable to convey them, such a child is at risk of becoming self-absorbed or . . . self-centered. . . .” (Greenspan 11 ). A more nearly complete discussion of issues regarding the related topics of “fit” between child temperament and caregiver style and expectations can be found in Thomasgard.12
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Thomasgard, Metz In an older child, it is important first to establish whether the caregiver can feel warmly connected and close to the child before one makes suggestions about discipline or limit setting. Some refer to this process as “special time”; however, its exact meaning is often not fully appreciated. Special time is, first and foremost, being able to take pleasure in playing with or enjoying the company of another. As the child’s need to connect positively through play with the parent increases, the need to connect through misbehavior with the parent decreases (see Appendix, Case Study). In the absence of such a close, mutually enjoyable relationship, the caregiver’s disciplinar y actions may be more punitive and serve to further widen the gap between child and caregiver. Children who aren’t able to relate to people in this warm, tr usting manner—children who are aloof, withdrawn, suspicious, or who expect to be humiliated—become isolated and unable even to hear what someone is saying. They may decide that it’s best to be a loner or to treat people as things, hurting others because they don’t expect to get what they want.11
In contrast, as the mentally healthy individual grows and matures, there is more tolerance for remaining positively connected to another even when angry, disappointed, or sad. In short, inner security helps promote intimacy with others.
Can the Individual Grasp Nonverbal Communication (12 Months)? The ability to connect with another person leads to two-way communication and with it an
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evolving realization that “[t]here is intent in the world—a smile leads to a smile; a frown leads to something else” (Greenspan7). It is important to remember that the motor system is the final common pathway for expressing one’s wishes nonverbally (e.g., touch or via eye contact/gaze and facial gestures). At first children communicate only nonverbally, but they can carr y on rich dialogue with smiles, frowns, pointing fingers, squirming, wiggling, gurgling and crying. By 18 months children are often very good readers of nonverbal cues. For example, when Daddy and Mommy come home from work, an 18-month-old will know by their facial expressions or their posture whether they are going to get down on the floor and be playful or whether they are going to have a temper tantrum. That 18-month-old knows what kind of a mood they are in, and he can gauge his reactions accordingly.11
Importantly, such nonverbal gestures are reciprocal. The caregiver speaks excitedly and the infant nods in reply. As this cycle of interaction repeats itself with ever more complex elaborations, behavior and emotions become linked with a physical consequence such as getting a hug. 7 This evolving ability to both send and receive nonverbal messages lays the foundation for the lifelong process of separating one’s own intentions from those of others while also acknowledging areas of connectedness over shared feelings and thoughts. This evolving ability to appreciate and recognize thoughts and feelings in the other as well as in oneself is described by Stern13 as the capacity for intersubjectivity.
A child whose motor system does not operate efficiently (e.g., owing to abnormally high or low muscle tone) may have more difficulty expressing nonverbal communication to others. If the caregiver is able to grasp the child’s nuances of communication, all may be well; however, the child may become fatigued or frustrated before this occurs. Clinical Implications. Some individuals need extra help “reading” the innumerable nonverbal clues that maintain continued social interaction and learning. For a caregiver and/or child who needs practice at this level, it is critical first to obtain the other’s undivided attention by being playful, challenging them to smile or by flirting with the child in an effort to energize the interaction. Children who can use and understand nonverbal communication comprehend the fundamentals of human interaction. . . . They tend to be more cooperative and attentive in school. They are able to pick up on the unspoken cues and figure out situations that might baffle other[s]. . . . A child who can’t figure out these cues may distort or misperceive them and is likely to get sidetracked from the situation at hand. . . .11
When caregivers’ gestural communication skills are poorly developed (e.g., they don’t see the child’s outstretched arms signaling a need to be picked up), they may come to believe that the child doesn’t need them anymore. This can lead to a profound sense of loneliness and isolation until the child is better able to express his/her needs verbally.
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Promoting Social-Emotional Development Can the Individual Send and Receive Gestural and Verbal Messages (12 to 18 Months)? Cognitive skills and a well-developed sense of self are enhanced when individuals can recognize those behavioral patterns that consistently achieve a desired response. As a toddler’s gestural repertoire grows in richness, he begins to discern patterns in his own and others’ behavior. Mom usually responds when he makes friendly requests but not when she’s cranky. Dad loves to roughhouse but not to sing lullabies. . . . He gradually draws these items on the map delineating himself as a person and, when others impinge on him, adding to his expanding notion of how his actions, intentions, and expectations fit in with those of the people around him. Which actions get him affection and approval? Which yield only rejection or anger?7
The ability to send and receive gestural and verbal messages between individuals is essential to the process of forming new relationships while deepening those already in existence.13 Clinical Implication. If the child’s receptive and/or expressive language skills are weak, it is important first to strengthen attachment via nonverbal communication between the caregiver and child. As a child unifies distinct and even conflicting affects into his sense of self, he also forges emotional bonds across space and eventually across time. Earlier he felt only Mom’s warmth when lying in her arms or Dad’s playfulness when sitting in his
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lap. Now, however, he can look up from blocks, glance at Mom across the room, see her smile, and feel the security of having her near.7
If toddlers have difficulties in this skill, they may remain close to their caregiver and not explore the wider world. Additional nonverbal reinforcement from the child’s caregiver in the form of brief physical (e.g., a touch on the shoulder) or visual (e.g., a comforting look) reassurance encourages development of the child’s internal security through the use of more distal cues.14
Can the Individual Substitute a Thought for an Action (More Than 18 Months)? At this stage the individual begins “to substitute a thought or an idea (I am angry!) for an action (e.g., kicking or hitting).” Children “not only experience the emotion, but they are also able to experience the idea of the emotion, which they can then put into words or into make-believe play. They are using an idea, expressed in words, to communicate something about what they want, what they feel, or what they are going to do.”11 Clinical Implications. The regular opportunity for pretend play with another offers a safe environment where strong feelings such as aggression (e.g., “I am mad”) can be expressed and mastered without actually hurting others. In such play, both the child and the caregiver can experiment with role reversals that would be impossible in the real world (e.g., the child becomes the father and vice versa). Some adults may need to be reminded that in pretend play, one must first enter and become part of the child’s imaginary drama.
Pretend play can provide practice with transitions (e.g., starting and stopping an activity), lengthening attention span, by thoughtfully responding to the child’s last action and/or statement in an effort to keep the dialogue moving, or broadening a child’s emotional range. Children naturally lear n . . . emotional labels in their families, through the day-to-day experience of connecting words with what’s happening in their interactions and in their bodies. Children learn by hearing others use words to express their emotions in certain contexts, and then when they experience the same emotion or experience, they tr y the words out. If their efforts are greeted with empathy and are amplified upon, it consolidates the connection of that word or concept to the feeling.11
During pretend play there are often opportunities to move beyond aggressive actions toward others by helping the child develop a sense of empathy and caring for others (e.g., one toy or play figure can respond, “Ow, I’m hurt, get me a doctor”).
Can the Individual Connect Feelings and Ideas (21⁄2 to 3 Years)? Between 21⁄2 and 31⁄2 years, children begin to make connections between different categories of ideas and feelings (e.g., “I feel mad because you took my toy”), laying the foundation for future logical thought. The child who does not attain this level can experience her feelings only at the level of behavior or visceral reaction. Rather than knowing that she feels lonely or disappointed or
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Thomasgard, Metz apprehensive or scared, she feels an emptiness in her belly, or she cries, or her stomach tightens or her hands sweat. She can’t give a particular state of being an abstract name that will allow her to identify and understand it.7
Clinical Implication. Caregivers can model the use of words to label what are otherwise vague internal sensations for the child. For example, “I feel scared” becomes associated with the internal sensation of fright. Psychological growth is a function of the person’s competence in 3 areas: (1) security of attachment, (2) cognitive ability to make meaning of the world15 and (3) the ability to regulate affects. Caregivers who themselves take pleasure in communicating foster this new ability. They can encourage symbolic interaction by not being intimidated by the child’s fierce desires and by helping the child reflect. Something as simple as a child saying “I want to go outside” can be responded to with a yes or no on the one hand or, on the other, “What do you want to do outside?” The latter response helps the child reflect on his wish, while the former only gives in to it or inhibits it.7
An improved ability to connect a feeling with an idea makes possible the next stage of development via planning ahead to master a problem (e.g., if the date of an examination is known in advance, one can begin studying).
Can the Individual Connect Present Actions to the Future (4 to 7 Years)? This ability helps the individual build bridges between ideas
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and across time. The individual is able to “control their impulses and to concentrate and plan for the future. ‘If I do something bad to someone else, I may hurt the other person, and I may get punished.’ They begin to understand the world works in this logical way; actions have consequences.” 11 This logic can support both imaginative play and help the individual negotiate and solve problems with others in the world. If all goes well, a strong self-image begins to form that can be connected across different settings and times (i.e., past, present, or future). In adulthood, these same skills are applied to love relationships, raising a family, career choices, and responsibility to the larger community. Clinical Implications. If the child or the caregiver has minimal understanding of the connection between actions and their consequences, there is little incentive to plan ahead. Helping the child begin to link “the feelings and behavior of ‘being good’ with the rewards of praise and respect or the inner feeling of self-respect”11 can be accomplished through regular child-focused conversations, also known as “problem-solving time.” When problem solving, instead of following your child’s lead, you are an equal partner with your child in creating the agenda. Problem solving is . . . an opportunity to discuss and negotiate differences and difficulties. Maybe you want to help your child figure out why she’s having trouble with her friends, or difficulties with social studies, or why she’s grumpy and irritable around the house. The idea behind problem-solving is to help children to learn to be logical in
their interactions and anticipate and solve challenges so that they can grow well intellectually and emotionally.11
There may be times when it is helpful to expand the child’s social world so that more complex feelings can be worked out with more than one individual, thus potentially yielding a range of options. Similarly, caregivers and children may need help moving beyond polarized positions toward a more flexible middle ground.
Conclusion This framework of early socialemotional development provides clinicians with an important tool for helping children and their caregivers. Its application in clinical practice may help health care providers to understand better why certain behaviors are more challenging than others for a given caregiver. This model also lends itself to straightforward behavioral interventions that continue to promote ongoing socialemotional development across the lifespan. With practice, clinicians can learn quickly to assess the developmental profile across socialemotional stages for both caregiver and child. Starting from a shared level of competence, the clinician can then suggest a path by which the child and the caregiver can move forward while continuing to enhance existing skills. We hope that our paper will lead to more developmentally appropriate mental health assessments and inter ventions that address both the needs of the child and the caregiver. Over time, we believe that clinicians will become increasingly aware of the central
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Promoting Social-Emotional Development role that social-emotional skills play in organizing early and subsequent child development. If this approach became more routine in primar y care practice, it is hoped that the phrase mental health will begin to take on a more positive connotation.
Appendix: Case Study To further illustrate the developmental approach to promoting social-emotional growth, a brief vignette is provided. Key socialemotional developmental levels are denoted in boldface type. These include: attend and feel secure, feel close to and engage with others, nonverbal communication, send and receive gestural and verbal messages, and substitute a thought for an action. We acknowledge that many factors contributed to the success of intervention such as the role of clinician’s support and parental grieving. However, for the purposes of this paper, we emphasize the developmental aspects of socialemotional growth. B is an 18-month-old boy who lives at home with his mother, Ms. P, and 30-month-old sister, S. Ms. P is concerned about B’s high energy level and physical aggression toward others. She is uncertain about how best to respond to her son’s aggression. Ms. P was spanked while growing up and does not want to do the same with her children.
Background History Past Medical History. B was born at term to a 20-year-old mother and weighed 6 pounds, 13 ounces. Ms. P had several previous pregnancies that ended either as miscarriages or abortions. B did well as a newborn but was very colicky in the first months of life.
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Family History. S has a speech/ language delay. She had witnessed her father being physically abusive toward Ms. P for the first 18 months of her life. Mr. P has a history of drug/alcohol abuse. Social History. Ms. P finished 8th grade. She had difficulties with reading and is presently working on her GED. Ms. P has 2 younger sisters, ages 5 and 6 years. Her fiancé, Mr. F, has known B since he was an infant, who in turn views Mr. F as his father. Ms. P identifies her fiancé’s extended family as being very supportive to her. Her involvement with Mr. P ended with the birth of their son B. When B was 6 months old, Ms. P left for Florida to be with her extended family. There was no further contact between Mr. P and the family until Ms. P moved back to Ohio when her son was age 13 months. Since that time, Mr. P has had supervised visits with B and S for 8 hours each weekend. During these visits, B is said to be physically hurtful toward Mr. P.
his activity table. He enjoys activities that are noisy and that involve gross motor skills such as being chased around the house by his mother. B’s expressive language consists of about 20 single words. His current understanding of language appears to be age appropriate and he is just starting to engage in pretend play. B can be affectionate toward others, however, he does not like being held. Ms. P completed the Child Behavior Checklist for Ages 1 1⁄2–5 (Achenbach and Rescorla16) before her clinic visit. She underlined the following statements: “gets hurt a lot,” “easily jealous,” “punishment doesn’t change behavior,” “shows too little fear of getting hurt,” and has “temper tantrums.” Her greatest concerns were that “nothing hurts him” and “he never stops going.” The best thing about B was that “he’s usually happy.” Syndrome scale scores were in the clinical range— T score >70, for Withdrawn and Aggressive Behavior.
School History History of Present Concern When things don’t go B’s way, he either has a tantrum or he may bite, hit, or “head butt” others. These behaviors worsened about 3 months ago when B was aged 15 months. When Ms. P carries B to a chair for time out, he sits for about 10 seconds, then gets up. She tries to remain nearby but doesn’t return him to the chair once he’s up. B “never really calms down.” When Mr. F is present, all that he has to do is raise the tone of his voice and B settles down. From the moment B awakens at 8:30 AM, he’s on the go, although he typically naps from 11–12 daily. Most of his meals are consumed while he’s walking. B likes to ride in his Little Tikes car or pound on objects at
B has attended a half-day center-based early intervention program for the past 6 months where he has received speech and language services. Syndrome scale scores were all in the normal range on the Caregiver-Teacher Report For m for Ages 1 1⁄2 –5 (Achenbach17).
Initial Formulation B is a very active 18-month-old who has difficulties with aggressive behavior, primarily in the home setting. He and his mother enjoy activities that involve lots of noise and movement (attend and feel secure—birth to 4 months); he appears to be most connected to his mother during and shortly after these types of activities (feel close to and engage with others—
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Thomasgard, Metz 4 to 6 months). He seldom stops long enough to either send or receive gestural communication in the home setting by parental report (nonverbal communication, not well developed—12 months). B’s expressive language skills are improving (send and receive verbal messages—12 to 18 months) and pretend play (substitute a thought for an action—more than 18 months) has just begun to emerge. While B’s chronologic age is 18 months, his social-emotional development in the home setting is restricted, even at the most basic levels. Ms. P’s ability to regulate emotion and to remain engaged with her son has been compromised by a histor y of multiple pregnancy losses and domestic violence that continues to be echoed by B’s aggressiveness toward her. A review of strengths and challenges at each stage of social-emotional development, starting at the most basic level, revealed a potentially useful intervention strategy to enhance psychological growth for B and his mother.
Plan Since “time out” was increasing in frequency, an important f irst step was to increase the amount of child-focused “special time.” Ms. P was instructed to let B pick an activity for them to do together for 15–20 minutes twice daily. She would follow his lead even if he wandered off to another activity. These mutually enjoyable interactions helped support attachment and promoted an internal feeling of security for B. Ms. P understood that this extra “special time” would allow B to express his anger and frustration without anyone getting hurt.
frequency of having to place B in a chair for misbehavior had decreased from once every hour to about 3 times a day. He still pulled his sister’s hair and bit or pinched his mother when mad. In the course of recounting these experiences, Ms. P commented about her own childhood, stating that she could never understand why her mother wasn’t home very often. It was only later that she began to understand that her mother was working an extra job to provide for the family. When her mother was present, Ms. P vividly recalled “misbehaving to get her attention.” When asked how “special time” was going, she remarked, “I’ve been playing regularly with both children for about an hour each day and I have the rug burns to prove it. When he’s good, I ask his sister to clap for him. He enjoys that.” During a brief unstructured play obser vation, when S took a toy away from B, he responded by hitting her. Ms. P promptly told B “no hitting, chair,” then followed through by placing him in a chair. He cried but did not attempt to hit or pinch his mother. As soon as he began to settle down, Ms. P let him out of the chair and he played well until the next episode of difficulty sharing a toy. Ms. P noted that her daughter S responds well to a change in her tone of voice; however, this didn’t work with B. Interestingly, when Ms. P told B, “no hitting, chair” she had smiled. In contrast, when she wanted to change S’s behavior, her facial expression was serious. I pointed this out and Ms. P practiced looking serious when the next opportunity arose with B.
Formulation/Plan Follow-up Visit (30 minutes) Ms. P. stated that “his behavior was getting worse.” However, the
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Ms. P had made excellent progress by playing regularly with both children. “Special time” was
helping to promote attachment via positive interactions in which B experienced Ms. P as engaged and supportive. She had continued to use time out rather than spanking. We reviewed the importance of basic behavioral techniques such as getting physically closer to B to praise him for good behavior or to express disapproval for aggressive behavior. Similarly, the importance of having her face match her words was reinforced (gestural nonverbal communication—12 months). She would indicate disapproval with a serious face and approval by smiling. In response to this, Ms. P indicated that she felt scared as a child when her mother came near her. This disclosure provided an opportunity to reinforce the potentially positive role that nonverbal gestures could play in shaping her son’s behavior.
Second Follow-Up Visit (30 minutes) Ms. P has noticed during her “special time” with B increased smiling and eye contact (feeling close to and engages with others—4 to 6 months; improved nonverbal communication—12 months). His expressive language now consisted of several 2-word phrases. Aggressive behaviors toward others at home continued to decline. B now stays in his chair during time out. Some consistency has been achieved in that others also place him in time out if needed. Ms. P reported that B is starting to show an interest in using the toilet at home. He continues to attend early intervention in a small group setting. A return visit was not scheduled. In summary, the developmental approach outlined in this paper led to interventions that first targeted the most fundamental aspects of social-emotional
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Promoting Social-Emotional Development growth such as feeling secure, regulating affect, being close to and engaging with others. Without such a model, the clinician may have focused on the fine-tuning of “time out” procedures, expanding B’s expressive language at the expense of further elaboration of his nonverbal skills, or letting development run its course. A final benefit of a developmental approach to social-emotional growth is that it helps the clinician both anticipate upcoming challenges and design potentially useful behavioral interventions. In the case of Ms. P and her son, this would include the opportunity for B to experience strong feelings in make-believe play in a manner that promotes further competence and mastery.
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REFERENCES 1. Jellinek M, Patel BP, Froehle MC, eds. Bright Futures in Practice: Mental Health, Volume I, Practice Guide; Volume II, Tool Kit. Arlington, VA: National Center for Education in Maternal and Child Health; 2002. 2. Greenspan S, Weider S. Floor Time Techniques and the DIR Model: For Children and Families with Special Needs.
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