Here's another great article from Alessandra Longo, LMSW, MA. For this submission, a $100 gift certificate to childtherapytoys.com will be given to a public agency or program of Alessandra's choice.
Kevin was an energetic toddler; he entered the classroom not really knowing where he was in space. I remember him flinging himself hard onto the floor, into objects, running laps around the classroom and not responding to his name. Toddlers are normally in their own egocentric space but we all agreed something was different about this child. He had an otherworldly quality that made it seem as though he was not interested in establishing any relationships with teachers or peers. I was faced with the challenge of developing a therapeutic relationship with a child within a preschool setting.
The agency where I work assists toddlers through the separation process from parents and caretakers. This child did not have an exceptionally hard time leaving his mother. Few children at this age play with peers but most seek out interaction with adults in the classroom. My client was not really noticing anyone. He had a very difficult time focusing on anything and a lot of the day was spent trying to get him to stop running in circles or keeping him out of the closet. It was evident that Kevin needed extra attention and I became invested in responding to his specific needs. As the year went on we developed a very strong bond fraught with highs and lows.
Kevin is 3 years old. He is bilingual and in the beginning of the year favored Japanese over English. Early in our relationship he would emphatically tell me things in a stream of Japanese, especially when he was angry. He showed clear frustration when I did not understand. There came a point when he became extremely agitated with the difficulty of communicating through language and he began to hit. This would mainly happen when he would get hurt or drop something. These were all situations where he did not feel a sense of control. I was his safest object in the classroom and therefore also experienced the rage. If someone else reprimanded him he would be sure to find me somewhere in the classroom and hit me. I tried to stay calm and consistent in my response to physical aggression and as his English developed further his hitting disappeared. All of these issues of control and attachment naturally pushed my thinking into the realm of psychodynamics with this child.
My client began potty training midyear. During this time his desire for control really became magnified. In the playroom next to the classroom we had a basket of plastic balls that the children liked to throw around. One day my client suddenly decided he hated the playroom and would become hysterical each time we entered. He would desperately grab his shoes and try to put them on so he could leave. When I asked him what was wrong he initially wouldn’t say but finally identified the problem as the balls getting stuck under the play structure. He wanted them in the basket and put away in an orderly fashion. The mess was unmanageable. During this time he also had an obsession with making sure the closet door was closed, the cabinets were all shut with locks fastened and no puzzle pieces were missing.
This desperate seeking of order at school seemed like a direct reflection of his inner conflicts. He was experiencing incomplete control of his bowels and this anxiety appeared to be manifesting itself in daily activities. Blum and Blum (1990) discuss the turmoil of the toddler during this phase of establishing autonomy and separateness in the world. I felt this article applied to Kevin because he had a dawning awareness of being his own person but also realized that person still needed a lot of help from adults tofunction in the world. The realization of not having complete control over one’s self can be highly frustrating and it did not surprise me that this manifested in the classroom. His mother told me he came home and said, “I went pee-pee on the potty with Alessandra.” This did not actually happen. It was a fantasy where he seemed to be working through his bowel control issues. It also informed me that he considered me a safe person to help him through this anxiety, even if it was just in fantasy. He also loved looking at the toilets, especially if another child was using it. Whenever I would attempt to actually take him to the bathroom he would insist that he didn’t have to go.
Clearly, Kevin and I did not sit down and talk about goals in such blunt language. In essence he was a “mandated” client and was going to stay in the classroom all year even if he didn’t want to. A goal that was beneficial to us both was to establish a secure attachment. His mother would not be in the room so I hoped for him to come to trust me. A hopeful side effect of this would be his ability to explore the classroom freely. Another big goal was to help him through his anxiety in the playroom. The agency and I were largely responsible for setting these goals. Kevin made his opinion clear in the way only a toddler can. De Cooke and Brownell (1995) discuss young children’s tendency to seek out help when they desire to “master” a challenge. The cues I got from Kevin were not always verbal. When he was at the pinnacle of anxiety and unable to verbalize what he wanted he was able to take me by the hand and point out the troubling situation. This is how I discovered the plastic balls getting stuck to be the cause of his distress. He also had a strong opinion about me being his attachment object, which I will discuss further.
His anxiety lessened considerably in the playroom as he progressed in potty training. Even though his joy was rekindled and the balls no longer frustrated him he would still tell me he was “very sick” and that he “hated the playground” before we entered the playroom. He would then either crawl into my lap or motion for me to pick him up. I don’t think it was coincidental that he would seek physical contact whenever this topic was broached. The stress of the incident was clearly imprinted in his mind. I think it may have been a comfort to verbally work through the residual feelings in close proximity to me. I would usually say to him, “You feel sick? What hurts? What part of you is sick?” or some variation on the theme. At first he would only say, “I don’t know” or “I am not sure.” One day his answered changed. He shook his head adamantly and insisted, “I am very very sick…Alessandra, when I am sleeping I miss you!” A few weeks later it hit me that this was not just a very sweet thing to say. I was working with a child desperately seeking order in his newly, somewhat, independent life. In his statement I heard echoes of the original themes that caused such angst. Where does the poop go? Where do the balls go? Where does Alessandra go? Why does she belong at school but not at my house? Later on the answer evolved into, “I miss you. I do not like sleeping.” Sleep is another common power struggle for toddlers. It felt like a logical addition to the equation. He seemed to be saying, “I do not get to control when I see you. I do not get to control when I sleep or what I think about when I am sleeping.” It appeared as though verbalization and exploration of categorizing helped him resolve some inner conflict and therefore meet our shared goals.
Play therapy was a wonderful aid in establishing a secure attachment and client directed relationship. I was also able to explore his positive transference towards me. I found his anxiety was lessened through working on ego functions, specifically reality testing and affect regulation. If I were working with adults in the context of psychodynamics then the method would be talk therapy. Through talk, adults establish rapport with therapists. Children do the same thing but in their language, which is, play. When Kevin became highly anxious it was a struggle not to absorb that anxiety. I would find myself getting lost in his feelings and wanting to “make it better”. This did not work and I eventually figured out that giving him space to experience his feelings (whatever they were) and then exploring his ego functioning afterwards was far more effective.
As mentioned before, this child was challenging to connect with in the beginning. He seemed to be functioning on another plane. Axline (1974) is adamant about letting the child lead the therapist into his world and not the other way around. If the therapist is too directive and makes various demands on the child, the relationship may be compromised. In the beginning of our relationship I would make too many demands on him. I insisted he sit for art projects or participate in circle time. It was not working and didn’t feel right. At this point rapport was nonexistent. I had him pegged as the stubborn, resistant one but in reality I was the one not listening. He didn’t like art but he loved trains. His favorite activity was building train tracks on the floor and running the wooden cars along the tops of the bookshelves so they were at eye level. Once I truly accepted that this was where my client was and he was doing exactly what he needed to be doing our relationship blossomed. Instead of resisting him I joined him and began to build train tracks alongside him, even if everyone else was at art. If he wanted to dance at circle time I complimented his dance moves and didn’t pull him onto the carpet. Slowly, he began to notice me.
Attachment is an extremely important part of a toddler’s life. From what I observed Kevin’s mother was extremely attentive to his needs and was able to share experiences with him. Holmes (1993) wrote a comprehensive article illustrating how a healthy therapeutic relationship shares many of the same elements of attachment theory. When I played with Kevin I tried to be mindful of his needs, as I had seen his mother doing. She set clear boundaries with him and allowed him to explore the world while remaining a comforting presence to return to. Through play my relationship with Kevin began to mirror the one he had with his mother. Over time I was able to recognize when he needed independence (getting puzzles from the shelf, climbing the play structure, and self soothing when he got physically hurt). Then there were other times when he needed my support (holding my hand in the hall, working through his quest for order and identifying unknown objects in the classroom). Once the boundaries of our relationship were clear and my behavior became predictable he was able to use me as a tool to explore the classroom more fully.
Bowlby (1988) noticed that children have an internal sense of who to go to for comfort. When the main attachment figure leaves the room a child will seek out another person who they believe will offer comfort. Bowlby’s theory is in keeping with the previous paragraph. I received much of Kevin’s mother transference since I was his second choice and replacement in the classroom. Children at this age are appropriately egocentric. It is very difficult for toddlers to understand that people do not all have the same needs and wants at the same time. Lyons-Ruth (1999) mentions the phrase “decoding another's subjective reality” (p. 583). This refers to parent’s initial attempts to figuring out what their infant is trying to tell them through nonverbal communications. When an infant cries there is no definite way to know exactly what they are saying. Parents are constantly trying out solutions that will fit. Lyons-Ruth (1999) believes this trial and error and acknowledgement of not being able to read the child’s mind is an integral part of “coherent communication” (p. 583). Kevin exhibited a behavior that I assumed stemmed from these types of early developmental interactions with his mother that went hand in hand with the fact that he was not fully individuated from her. On multiple occasions Kevin would say things such as, “Alessandra, you don’t like this book at all” or “Alessandria doesn’t like John” (another child in the class). These types of statements embody a toddler’s egocentrism or inability to see others as independent thinkers. It also reminded me of what Lyons-Ruth discussed because before a child is verbal parents are constantly trying to guess at the child’s needs. The chance of guessing right is probably much higher if the parent is more attuned to the child. This may appear as a sort of omniscience to the toddler. If parents seem to know what is going on in a child’s head it may appear to offer support of all thoughts being the same. Also, children this young are just realizing the fact that they do not share the same body or mind as mother. Since he had mother transference feelings towards me it makes sense that it would be extremely difficult to tell where his thoughts ended and mine began. Whenever he made these statements I would acknowledge the fact that he was thinking about me but would also inform him of my true opinion. I would also tell him things like “people like different things” or “you may not like the book but I do.” Through our attachment bond I was able to test and expand his reality in small ways as well.
When Kevin first got upset about the balls all over the playroom I would try to soothe him by giving him a hug or other physical contact. This made him more agitated and he would lash out. I was at a loss of what to do. This incident repeated itself a few times. Eventually I remembered a case illustrated by Lenore Terr (2008). A child went into a hysterical tantrum in Terr’s office and nothing Terr could say or do would ease the child. Eventually, she stopped trying to talk the child down and went about her office tasks. Terr’s calm tolerance of her client’s emotions sent a message of unconditional acceptance. The next time Kevin melted into hysterics I sat a moderate distance away and told him I would be there if he needed my help and said nothing else. Ultimately, he tired himself out. He walked over to me and asked to go look at cars out the window in the classroom next door. I agreed. While we looked out the window he said, “Mommy is in an airplane, Mommy is in a car, Mommy is at the store.” Since he couldn’t see Mommy anymore it was a mysterious to where she had gone (Piaget 1954). In addition to unstable object permanence this statement came juxtaposed to the ball upset. It felt like just one more thing Kevin could not control. Since he had calmed down I figured it would be a safe time to question his reality a little further. I asked, “Do airplanes fly in the sky?” He nodded. “Is Mommy in the sky?” He thought for a minute and then said, “No! Mommy is not in the sky.” I reassured him that mommies always come back and didn’t his mommy always pick him up from school? He visibly relaxed after processing the familiar fact that Mommy did indeed pick him up everyday. It’s possible he had troublesome memories of his mother going on an airplane trip in his very brief past but I didn’t think it was the time to probe that deeply. I got the sense that the residual feelings from his intense upset caused his reality to become very chaotic and unmanageable for a brief amount of time. I wanted to help him see what was really happening in the outside world and not let the stress of his internal world make him doubt that.
Kevin displayed a desire for order and knowing things were in their proper place. In the classroom he would check the latches on the cupboards and close the closet doors before entering the playroom. These ceremonies paid homage to the order he so desperately sought. The world is a big place and small children cannot control all aspects so they construct rituals that are meaningful (and controllable) in order to become centered amidst the chaos (Feygin, Swain & Leckman 2006). Sometimes these rituals are not enough to ease the stress loss of control brings on. When the stress becomes too much children have an incredibly hard time regulating their affect. Their emotions get away from them. An incident that followed was similar to the previous scenario where Kevin struggled with object permanence and distorted reality. After we had looked at cars together I went over to drink from my water bottle. Kevin noticed and asked, “What are you eating, Alessandra?” We both noticed the mistake and laughed. Before this he was pretty calm, definitely not happy but managing. I was delighted to see him laugh and seized the moment to engage in some verbal world play. Johnson and Mervis (1997) explored humor development in children under 3 and would identify this type of verbal humor as “incongruent label jokes” (p. 190). Here children call things the wrong name but know what it is really called. I am unsure if Kevin labeled my drinking as eating on purpose or not but it then developed into a game that allowed for a lot of shared joy. I answered with, “Kevin! I am not eating! I am drinking…Why are you sleeping??” He laughed wholeheartedly and then said, “Alessandra! I am not sleeping! I am standing!” We went back and forth for a bit and when I assumed he was truly happy I took a risk and said, “Kevin, why are you crying?” I was afraid this would set him off since he had been in hysterics not too long ago. It happily had the opposite effect. He laughed again and said, “Alessandra! I am not crying. I am laughing!” Through play and humor his affect became regulated. The fact that he picked up the game so quickly and enthusiastically made me hopeful that he could carry the memory with him next time he was upset. This is clearly not something that happens overnight but if I could provide tools to help regulate his emotions, even after a huge upset, perhaps the lows would not be so overwhelming and scary. There is something comforting about knowing a way out of emotional turmoil.
The language barrier was an obstacle in the beginning of the year when Kevin would express himself only in Japanese. This was the time he began to hit out of frustration. As the year went on he began to master both languages. At times he will say things in Japanese to me. This has turned into a running joke as well. When he does this I will say jokingly, “Kevin, I still don’t speak Japanese!” Then I will throw my hands up in mock desperation, which he finds funny. This enables us to share a laugh. But I believe that it might also be a way of Kevin working through his original stress of not being able to communicate with me. Only now that he has the mastery of two languages can he make a joke out of it. It reminds me of children who master potty training and then enjoy potty humor. A previously stressful situation suddenly turns hilarious once conquered.
Working with this child gifted me many takeaways for future work. We were capable of establishing a strong therapeutic bond within the classroom setting. Once I was able to put aside my own anxieties and expectations, Kevin was free to truly ask for what he needed to flourish. Play became our shared language and allowed me to join in on the inner workings of his developmental challenges. It was gratifying to see how much progress Kevin was able to make once he began directing the play and I began following his lead. Arriving at this place of acceptance permitted me to wholeheartedly experience shared joy with my client.
Axline, V. M. (1974). Play therapy. New York, NY: Ballantine Books .
Blum, H. & Blum, E. (1990). The development of autonomy and superego precursors.
International Journal of Psychoanalysis. 71, 585-595.
Bowlby, J . (1988). A secure base: parent-child development and healthy human development. Great Britain : Routledge.
De Cooke, P.A., & Brownell, C.A. (1995). Young children's help-seeking in mastery-oriented contexts. Merrill-Palmer Quarterly: Journal of Developmental Psychology. 41(2), 229-246.
Feygin, D.L., Swain, J.E., & Leckman, J.F. (2006). The normalcy of neurosis: Evolutionary origins of obsessive- compulsive disorder and related behaviors. Progress in Neuro-Psychopharmacology and Biological Psychiatry. 30, 854–864.
Holmes, J. (1993). Attachment theory: A biological basis for psychotherapy? British Journal of Psychiatry, 163, 430-438.
Johnson, K. E., & Mervis, C. B. (1997). First steps in the emergence of verbal humor: A case study. Infant Behavior and Development. 20(2), 187-196.
Lyons-Ruth, K. (1999). The two-person unconscious: Intersubjective dialogue, enactive relational representation, and the emergence of new forms of relational organization. International Journal of Psychoanalysis. 19, 576-61.
Piaget, J . (1954). The construction of reality in the child. Great Britain: Basic Books Inc.
Terr, L. (2008). Magical moments of change: How psychotherapy turns kids around. New York, NY: W.W Norton and Company, Inc.