Pediatric Disorders of Regulation in Affect and Behavior: A Therapist's Guide to Assessment and Treatment

Pediatric Disorders of Regulation in Affect and Behavior

A Therapist's Guide to Assessment and Treatment

Second Edition

Georgia A. DeGangi

Integrated Therapy Services: Psychological and Learning

Support Services (ITS:PALSS), Kensington, MD, United States

Contents

Cover

Title page

Copyright

Preface

Acknowledgments

Chapter 1: Problems of Self-Regulation in Children and Adolescents

Abstract

1. The concept of self-regulation and its development

2. What is a regulatory disorder?

3. Clinical significance of regulatory problems in children

4. Outcomes of regulatory disordered infants

5. Early symptoms and their relationship to later diagnostic outcomes

6. Impact of early symptoms on later developmental outcome

7. Types of regulatory problems

8. Case illustrations of the different subtypes of regulatory disorders

9. Identifying problems of self-regulation in infants and children

10. Summary

Chapter 2: Treatment of Irritability and Other Mood Regulation Problems

Abstract

1. What is an emotion?

2. Cognitive appraisal

3. Physiological aspects of emotion

4. Expression of emotion

5. The socialization of emotions

6. Modulation of emotion and mood states

7. A developmental–structuralist approach to organizing sensory and affective experiences

8. Application of developmental–structuralist model

9. Case example of a child with difficulties in various emotional stages

10. Identifying causes of mood dysregulation

11. Treatment approaches

12. Case examples

13. Summary

Chapter 3: Anxiety Disorders: How to Calm the Anxiety Cycle and Build Self-Confidence

Abstract

1. Symptoms of anxiety

2. Neurobiological mechanisms underlying anxiety

3. Types of anxiety disorders in children

4. Posttraumatic stress disorder

5. Strategies to alleviate anxiety

6. Summary

Chapter 4: Dealing with Depression

Abstract

1. Types of depression

2. What causes depression?

3. Neurobiological bases for depression

4. Four portraits of depression

5. Effective treatments for children suffering from depression

6. Summary

Chapter 5: Eating Disorders

Abstract

1. The many facets of eating?

2. What can go wrong?

3. The developmental stages of eating

4. The assessment process

5. Treatment intervention

6. Case example 1: it’s a family affair

7. Case example 2: the impact of early deprivation and an attachment disorder on feeding

8. Case example 3: food aversions and behavioral resistance at mealtime

9. Summary

Chapter 6: Sleep Problems

Abstract

1. Sleep problems in children

2. Impact of sleep problems on development

3. Development of sleep–wake cycles

4. Stages of sleep

5. Self-soothing and the process of sleep

6. The sleep environment, cultural beliefs about sleep, and family sleep patterns

7. Sleep problems in children with dysregulation

8. Evaluating sleep problems in the child

9. Management of sleep problems

10. Summary

Chapter 7: Obsessive–Compulsive Disorder: How to Build Flexibility and Budge Compulsive Thinking

Abstract

1. What is obsessive–compulsive disorder?

2. Is there a difference between healthy rituals and obsessive–compulsive behavior?

3. What causes obsessive–compulsive spectrum disorders?

4. How can this disorder be treated?

5. Steps to overcome obsessive–compulsive disorder

6. Common pitfalls: things to avoid

7. Case example 1: facing a germy world

8. Case example 2: stuck in endless repetitions

9. Case example 3: compulsive checking

10. Summary

Chapter 8: Treatment of Attentional Problems

Abstract

1. Types of attentional problems

2. The processes that underlie attention

3. What is attention? Some historical perspectives

4. Arousal, alerting, and sensory registration

5. Sustained attention: attention getting and attention holding

6. The role of effort in attentional tasks

7. Selective attention: screening and selection

8. Motivation, persistence, and self-control

9. Treatment applications

10. Case example of child with attentional problems

11. The assessment

12. Case example: the plight of the procrastinator

13. Case example: when a whole family struggles with ADHD

14. Summary

Chapter 9: WITHDRAWN: The Sensory Defensive Child: When the World is Too Bright, Noisy, and Too Close for Comfort

Chapter 10: Addressing Attachment and Problems of Intimacy: How to Build Healthy Emotional Connections

Abstract

1. Overall philosophy of treatment

2. Attachment patterns of children with dysregulation

3. Assessment

4. Treatment approaches

5. Case example of CCA with a dyad with a disorganized attachment disorder

6. Reparenting the client to provide nurturing and safety in the therapeutic relationship

7. Case example

8. Conclusions

Appendix: All Skill Sets

1: Self-Soothing

2: Activities for Problems of Touch

3: Moving for Mood Regulation and Sleep

4: Improving Attention Span

5: Distractions for Emotional Regulation

6: Positive Self-Talk

7: Mindfulness: Stilling the Mind

8: Systematic Relaxation: Stilling the Body

9: Validation

10: Finding Pleasure and Making Connections

11: Creating Positive Life Experiences

12: Thinking With a Clear Mind

13: Increasing Personal Effectiveness

14: Observing Limits

15: Taking Control of Behavior

16: Keeping Track of Positive Behaviors

17: Eating Habits and Nutrition

18: Strategies for Improving Sleep

19: Installing Structure and Organization

20: Communicating Effectively With Others

Index

Copyright

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Preface

How to use this book

Pediatric Disorders of Regulation in Affect and Behavior (Revised) is a skills-based book designed for use by mental health professionals and occupational therapists who work with children experiencing disorders of self-regulation. These are individuals who are intense, highly sensitive to stimulation from the environment, emotionally reactive, and have difficulty maintaining an organized and calm state of being. This book incorporates treatment strategies for children who struggle with everyday decisions, who may be impulsive in their actions, are easily frustrated, and react in extreme ways to everyday experiences. Some children with these problems crave intensity in interactions and in the environment. This may result in an overwrought and overstimulated state, a quick anger trigger, and day to day disorganization. In contrast, some children with these difficulties respond by withdrawing from the world or becoming avoidant or socially isolated. They may battle with depression and anxiety. Children with these struggles often have difficulty adapting to changing demands at home and school. They may be highly irritable, or respond in extreme or unpredictable ways. Their inconsistent response to caregivers, teachers, and friends in their life makes interpersonal relationships very challenging.

The symptoms often vary for children with disorders of self-regulation. These are individuals who have a combination of constitutional and emotional issues. Sometimes the child has a diagnosis that may include any of the following: bipolar or mood disorder, anxiety, depression, obsessive–compulsive disorder, Asperger’s syndrome, eating or sleep disorder, and/or attention deficit disorder. Frequently the child also has sensory integration problems that have never been diagnosed and treated. The interplay of symptomatology is discussed to help professionals integrate treatment strategies that address the individual’s regulatory, sensory integration, and mental health problems. Chapters in the book are organized to address the varying ways in which the problems manifest for children. One of the premises of this book is that the children may have a physiological predisposition that makes it extremely difficult for them to control their behavioral responses. Their nervous systems often do not give them accurate internal feedback to help them mediate their world.

Book format

The first chapter provides an overview of problems of self-regulation in children. It describes the different types of regulatory problems in children, emphasizing how these difficulties impact relationships with others, school performance, and everyday functioning. Two checklists appear at the end of this chapter, one to define the symptoms and type of regulatory disorder, the other to evaluate how the child interacts dynamically using a developmental framework. These two checklists should help guide the diagnostic and therapeutic process.

The chapters that follow focus on specific types of dysregulation. Each chapter includes background information that emphasizes the developmental and neurobiological underpinnings of the problem. Clinical observations and checklists appear at the end of each chapter that may be used for diagnosis and treatment planning to help the caregiver and child learn more about themselves and their problem. The treatment strategies described in each chapter integrate three main approaches from the fields of mental health and occupational therapy. These include dialectical behavioral therapy, mind–body therapies and sensory integration techniques, and interpersonal therapy. Dialectical behavioral approaches help the child to understand what his behavior means, to learn how to reframe problems in a more positive way, and to take charge of their problems in proactive ways. Since many individuals with regulatory difficulties have sensory integration problems and experience bodily reactions during interpersonal interactions and stressful life experiences, principles from sensory integration therapy and other mind–body techniques are described to help the child to self-calm and organize their body. Finally, emphasis is placed on the relational dynamics between the child and significant persons in his or her life including caregivers, friends, and others. Therapeutic techniques are provided on how to foster engagement with others in positive ways and to improve attachments while attending to the importance of providing physiological safety and reducing averse bodily responses that interfere with interactions with others. The importance of building resilience, developing support systems, and nurturing oneself within the context of a balanced, well-structured family life is discussed.

Each chapter presents detailed therapeutic strategies to help professionals to evaluate what might work in addressing common problems related to eating, sleep, mood regulation, anxiety, attention, and behavioral control. These treatment strategies are integrated into clinical case examples of children who experience specific problems of dysregulation. These clinical examples are based on actual cases but were changed to protect the identity of clients while preserving the clinical decision-making process and the dynamics of the therapeutic process. Many of these case examples incorporate how the child’s problems of dysregulation impact their relationships with others and their ability to function in everyday life. Cases were selected to reflect how treatment varies depending upon the age of the child with examples spanning from infancy through adolescence. Some of the cases are longitudinal and depict children’s treatment beginning in early childhood up through adolescence to reflect how symptoms evolve over time and how the interventions need to be modified accordingly.

Twenty skill sheets appear in the appendix of this book. These are intended to be used during the treatment process to help caregivers and children learn and apply the strategies described in this book. Each chapter references specific skill sheets that apply to the treatment approaches described for particular problems of dysregulation.

Acknowledgments

Many people have helped me in writing this book. First and foremost, I would like to thank the many children, adults, and families with whom I have worked over the years. They have been my best teachers in discovering the most effective ways to help persons with dysregulation. Without them, this book would not have been possible.

Several superb mentors and collaborators have been instrumental in helping me discover new ways of working with and understanding individuals with dysregulation. I had the honor to be guided by Dr. Stanley Greenspan, child psychiatrist, who helped me in integrating sensorimotor, emotional, and developmental frameworks into a holistic model of working with children and adults. Dr. Stephen Porges, developmental psychologist, collaborated with me in researching disorders of self-regulation in children and taught me the importance of linking theories and research with clinical approaches. Both Dr. Greenspan and Dr. Porges helped me understand the profound effect that constitutional problems have on the person’s developmental course and the impact on relationships. I am indebted to Dr. Polly Craft who offered me the gift of discovering the special meaning that each child and parent have for one another. She helped me to learn parent–infant psychotherapy which was the basis for the child-centered therapy described in this book.

I am deeply appreciative of Dr. Anne Kendall who contributed her knowledge and expertise to many of the skill sheets that appear in this book. Dr. Kendall helped me to apply concepts of Dialectic Behavior Therapy to difficult clients. The blending of DBT, sensory integration, and psychodynamic therapy has been the inspiration for the skills sheets in this book.

I have had the good fortune of working in a variety of settings that have allowed me to grow as a professional. I would like to thank all of my colleagues at ITS (Integrated Therapy Services): Psychological and Learning Support Services, Inc. in Kensington, MD, and the Reginald S. Lourie Center for Infants and Children in Rockville, MD. These colleagues have provided ongoing support and insight that has allowed me to blend my knowledge of occupational therapy with clinical and developmental psychology and to integrate different therapeutic perspectives including cognitive–behavioral therapy with psychodynamic approaches. It was at the Louie Center that I learned the importance of fostering emotional health and development through the parent–child relationship and the value of early intervention and prevention in treating multiproblem families.

The case vignettes and examples that are described in this book are based on real clinical examples. The names and pertinent identifying information of these individuals and their families have been disguised to protect their identities.

Last, but not the least, I would like to thank my loving husband, Robert Dickey, who endured many hours of listening to me as I formulated ideas for this book. I am so grateful for his unconditional support and encouragement for my professional endeavors.

Georgia A. DeGangi

Chapter 1: Problems of Self-Regulation in Children and Adolescents

Abstract

Parents and professionals have often puzzled over the importance of early regulatory problems in young children and their impact on the developing child. Most normal young infants show irregularities in negotiating sleep cycles, digestion, and self-calming which usually resolve around 6 months of age. However, some infants and children show persistent problems in sleep, self-consoling, feeding, and mood regulation (i.e., fussiness, irritability) which don’t resolve and may continue through life. As the infant grows into the toddler and childhood years, problems often become more evident. Difficulties with self-consoling, sleep, eating, attention, sensory processing, intolerance for change, a hyper-alert state of arousal, and mood regulation (i.e., irritability, anxiety, and depression) often occur. Children experiencing these symptoms have been termed as regulatory disordered (Greenspan, 1989, 1992; Zero to Three, 1994). When the regulatory disorder persists over time, the child may become diagnosed with disorders including bipolar or mood disorder, anxiety, obsessive–compulsive disorder, Asperger’s syndrome, eating or sleep disorder, attention deficit disorder, and sometimes, posttraumatic stress disorder. Since children with these behaviors are commonly observed in clinical practice, it is important to understand the symptoms underlying the regulatory disorder and how early problems with self-regulation impact later development, adaptive behaviors, and interpersonal relationships.

Keywords

self-regulation

mood regulation

sensory processing

regulatory disorder

interpersonal relationships

Parents and professionals have often puzzled over the importance of early regulatory problems in young children and their impact on the developing child. Most normal young infants show irregularities in negotiating sleep cycles, digestion, and self-calming which usually resolve around 6 months of age. However, some infants and children show persistent problems in sleep, self-consoling, feeding, and mood regulation (i.e., fussiness, irritability) which don’t resolve and may continue through life. As the infant grows into the toddler and childhood years, problems often become more evident. Difficulties with self-consoling, sleep, eating, attention, sensory processing, intolerance for change, a hyper-alert state of arousal, and mood regulation (i.e., irritability, anxiety, and depression) often occur. Children experiencing these symptoms have been termed as regulatory disordered (Greenspan, 1989, 1992; Zero to Three, 1994). When the regulatory disorder persists over time, the child may become diagnosed with disorders including bipolar or mood disorder, anxiety, obsessive–compulsive disorder, Asperger’s syndrome, eating or sleep disorder, attention deficit disorder, and sometimes, posttraumatic stress disorder. Since children with these behaviors are commonly observed in clinical practice, it is important to understand the symptoms underlying the regulatory disorder and how early problems with self-regulation impact later development, adaptive behaviors, and interpersonal relationships.

Poor self-regulation is a process deficit that impacts the person’s everyday functioning and interpersonal relationships. Oftentimes problems of self-regulation are life-long and have roots in the person’s early childhood development. As problems with self-regulation become entrenched, the person struggles with self-soothing and mood regulation. It impacts the capacity to modulate arousal for sustained attention, to be motivated for purposeful activities, to process and tolerate a range of sensory stimulation, and to tolerate change and handle everyday stress. Frequently the child struggles with coping skills, impulsivity, and self-control, especially as they grow older. As a result of the regulatory disorder, the child is apt to have difficulty developing a clear sense of identity, purpose in life, and self-efficacy.

An overview of regulatory processes in infants and children is presented and a conceptual model of self-regulation is proposed. The symptoms that constitute a regulatory disorder in children are described. The outcomes of preschool children who had regulatory disorders during infancy are described and how early symptoms may lead to these outcomes. Finally, the different types of regulatory disorders that have been proposed by the Diagnostic Classification: 0–3 are described. Case examples are presented to depict the symptomatology of the different subtypes. Checklists are provided to assist the clinician in diagnosing children with problems of self-regulation. The Infant-Child Symptom Checklist can be used in helping parents and clinicians to understand the child’s regulatory profile. In addition, a version of the Functional Emotional Observation Scale is presented for use by therapists to better understand the child’s capacity for self-regulation and to serve as a guide for treatment.

1. The concept of self-regulation and its development

1.1. Overview

The early regulation of arousal and physiological state is critical for successful adaptation to the environment. The development of homeostasis is important in the modulation of physiological states including sleep–wake cycles, hunger and satiety, body temperature, and states of arousal and alertness. It is needed for mastery of sensory functions, self-calming, and emotional responsivity. It is also important for regulation of attentional capacities (Als, Lester, Tronick, & Brazelton, 1982; Brazelton, Koslowski, & Main, 1974; Field, 1981; Sroufe, 1979, 2005; Sroufe, Coffino, & Carlson, 2010; Tronick, 1989; Tronick & Beeghly, 2011). The foundations of self-regulation lie in the infant’s capacity to develop homeostasis in the first few months of life when the infant learns to take interest in the world while simultaneously regulating arousal and responses to sensory stimulation (Greenspan, 1992; Lachmann & Beebe, 1997). As the infant matures, self-regulation depends on the capacity to read and give gestural and vocal signals, to internalize everyday routines, and to respond contingently to expectations from others (Kopp, 1987, 1989; Tronick, 1989). Although there are individual differences, the child must learn to adapt to changing family and parental expectations to master self-regulation.

Self-regulatory mechanisms develop and refine early in the person’s life. Some of the important milestones include the formation of affective relationships and attachments, reciprocal communication and language, the use of self and others to control internal states, an understanding of causal relationships in human behavior, and the development of self-initiated organized behaviors. It is generally recognized that self-regulatory mechanisms are complex and develop as a result of physiological maturation, caregiver responsivity, and the person’s adaptation to environmental demands (Lyons-Ruth & Zeanah, 1993, Rothbart & Derryberry, 1981). If these essential processes are not in place early in life, it impacts the person life-long, compromising their ability to develop self-control, and mindful behavior.

1.2. Fundamental skills needed for self-regulation

1.2.1. Level 1: Homeostasis

1.2.1.1. Reading and interpreting one’s body signals:

The foundations of self-regulation lie in the child’s capacity to develop homeostasis early in life. This is especially important for self-soothing and the ability to read one’s own physiological responses and bodily rhythms (e.g., body temperature, sleep–wake cycles, and hunger-satiety). In a normally developing individual, the child regulates internal arousal states and attentional focus for learning and processing information. To accurately read bodily states, the person needs clear internal feedback from the body, the ability to differentiate and interpret body states (i.e., I’m hungry and it’s time to eat), and the ability of the mind to control the body under different environmental demands or situations (i.e., I’m tired but it’s not time to sleep; I need to find a way to increase my arousal to stay awake and alert).

There is a complex interplay between the person’s psychological experience and internal physiological state which makes self-regulation possible (Porges, 2003, 2009). A dynamic bidirectional communication occurs between the peripheral nervous system and the brain, providing a feedback loop between the vagal system and the brain. For example, increased changes in heart rate help support fight or flight behaviors while decreased heart rate supports social interactions and affective and communicative signaling. Specific cues in the environment elicit physiological states associated with safety or danger (e.g., high piercing scream). Internal feedback between the vagus nerve, a primary component of the autonomic nervous system, and the brain help the person with breath control, physiological relaxation, and achieving an overall state of calmness when self-regulation is needed. This is accomplished through the vagus nerve’s influences on the heart and breath control. The polyvagal system also provides feedback to the body to prepare it for flight or fight when physical threat is imminent. In the polyvagal theory, the autonomic nervous system responds to social interactions, environmental demands, and sensory stimulation. It also provides feedback to the brain to modulate how the nervous system should react to real world challenges.

1.2.1.2. Processing sensory stimulation:

Self-regulation depends upon the person’s capacity to observe and process sensory stimulation from the outside world (DeGangi & Greenspan, 1988; Greenspan, 1989, 1992; Lachmann & Beebe, 1997). This includes the child’s ability to process and tolerate a range of sensory stimulations, such as touch, movement, visual, auditory, and olfactory inputs. Greenspan (1992) described the infant’s first task as learning to regulate him or herself and to take interest in the world. Modulation and processing of the range of sensory experiences allows for social engagement and attachment to others. A child who is easily overwhelmed by sounds, touch, movement, or visual stimulation may avoid interactions with persons or situations that are highly stimulating. Or in contrast, the child who does not process sensory input unless it is very intense may develop a pattern of thrill seeking, high stimulation, and risky behavior.

Distortions in the sensory systems can cause a child to misconstrue or misinterpret attempts at soothing from caregivers. For example, a child who cannot stand to be touched or held because of tactile sensitivities may arch, pull away, or cry when touched. A responsive caregiver may develop a hands-off approach to soothing a tactually defensive child, using movement or visual or auditory stimulation as a means to soothe their baby. This can have wide-reaching implications for later development. Karena cried constantly as a baby and wanted to be held, yet she couldn’t stand to be stroked or rocked by her parents. The only way they could soothe her was to hold her in a bear hug and stand still. Because no other soothing techniques worked, her mother construed Karena’s screams as a rejection and she consequently hated to be alone with her baby. There seemed to be no solution—either to hold her for long periods of time while she screamed, or listening to her scream from her crib while she clawed at the air. As Karena developed into the preschool and school age years, she often yelled at children from across the room, You’re hurting me! and Don’t touch me! when there was no contact whatsoever. By the school-age years, Karena sat stiffly at the lunch table at school and preferred to be left alone. Over time, Karena wanted friends, but didn’t know how to be with them in play, conversations, or learning experiences. She continued to perceive touch in ways that felt disorganizing and intrusive.

1.2.1.3. Internalizing self-soothing from others

In early development, self-regulation depends upon the responsiveness of caregivers. In a young infant, the caregiver soothes the infant when distressed and facilitates state organization (Als, 1982). As the child develops, they internalize the soothing role of the caregiver, learning to recognize signs of internal distress and finding suitable ways to self-soothe and modulate states of arousal and alertness for everyday tasks. To facilitate sensorimotor modulation, parents normally provide sensory input through play and caretaking experiences, such as dressing and bathing. Touch and movement, together with auditory and visual stimulation are integrated in a range of experiences in the context of the parent–child interaction. The infant learns how to self-soothe early in life by sucking, holding onto one’s hands or feet, or by looking at sights or listening to pleasant sounds. As children develop, they find a range of sensory experiences that are organizing. The more attuned the child is to understanding what helps them stay calm, the more able they are to access these sensory systems for self-regulation. Most individuals are soothed by a collection of senses (i.e., sound, movement, touch, scents, visual, or auditory), but need to learn which ones are calming versus arousing.

The neural mechanisms that allow for self-soothing also include the polyvagal system. This system provides a feedback loop between the autonomic nervous system and the brain, and the hypothalamus and reticular activating system which help the person develop an internal awareness of physical self-states (i.e., arousal levels, fatigue, hunger, agitation, or stress reactions). Children who are unable to take in the soothing of a caregiver, who have unreliable internal feedback mechanisms of self-states, or who cannot plan and organize their own soothing activities will be highly compromised in self-regulation.

Just as the baby learns how to self-soothe early in life by sucking, holding onto one’s hands or feet, or by looking at sights or listening to pleasant sounds, the child must engage in self-soothing activities to maintain a well-balanced nervous system. This may take many forms—sitting in a rocking chair and reading, taking a long run in the park with the dog, or playing music on the piano. Frequently children who are over-scheduled with activities or overloaded with things like homework become highly stressed and have no time for self-soothing activities. Without daily self-soothing activities, a child can quickly deregulate into high irritability, impulsive actions, withdrawal, explosive or anger reactions, and high stress or overwhelming feelings.

In normal development, a caregiver who is responsive to the young infant’s distress helps the child learn to self-soothe. The child internalizes these self-soothing activities and gradually learns to apply these soothing activities for himself. As the person matures, they learn to self-observe, to read their own bodily cues, and to predict what strategies will work for them in different situations. Without a responsive caregiver, the child may never learn this task or they may develop extreme dependency on others to do basic tasks for them. It can also impact their internal emotional life in a negative way. For example, Hannah was an 11-year-old girl who was born 10 years after her three older siblings. One of these children was 24 years old and was severely impaired, wheelchair bound, unable to speak or feed himself, and required intensive care. Hannah felt overlooked and was expected to be the good child, not causing any extra demands or problems for the family. She remembered staring at her dinner plate full of food, wanting to tell her parents about her good report card, but being put off by them as they struggled to feed her older brother. Hannah felt invisible, that she did not deserve to be nurtured, and that she was a person unworthy of attention from others. Her regulatory adaptation was to shut down and withdraw from the world.

Even in a well-regulated person, times of high stress, trauma, or exceptionally unpleasant or devastating life experiences can induce dysregulation by elevating stress hormones (e.g., cortisol levels). The person who is overwhelmed may stop taking care of himself, not eating or sleeping right which in turn compromises his ability to function at near optimal levels at school or home life. The child may cope by spending long hours on video games or sitting in front of the computer; or the child may be overscheduled, starting projects, but not completing any of them are examples of how high stress may dysregulate a person. Trauma can exist in many forms and result in extreme dysregulation. A child may live with a disabled or depressed parent, or the child may witness something terrible, such as seeing their house burn down. For example, Elise was a 12-year-old girl who was frightened that someone might come to her school and shoot her and her classmates. Getting her to school and to feel safe throughout the school day was very difficult. When she was only 5 years old, there were two snipers who randomly shot people in the Washington, DC area. One of the victims was a woman vacuuming her car at a gas station near her house. Elise would lie down in the back seat of the car, hiding under a blanket as they drove past the gas station to her school. Many children exposed to these kinds of things never get over worries for personal safety. Each one of these situations can cause a person to dysregulate and if the parent and child do not pay extra attention to their need for self-regulation, they may remain in a state of dysregulation for years to come.

1.2.1.4. Signaling communication about one’s own needs for self-soothing

Self-regulation is dynamic and requires that the child take in feedback from others while also communicating effectively through gestures and words to signal information about their internal state of being and physiological needs. Mirror neurons in the brain help the person take in and process models of self-soothing or other adaptive behaviors for use in a variety of situations. Mirror neurons are located in the frontal and parietal lobes and are activated when one person sees another doing a specific action. Neurons in the motor cortex fire to create an imitative response in the observer (Rizzolatti & Arbib, 1998; Rizzolatti, Fabbri-Destro, & Cattaneo, 2009; Rizzolatti & Fabbri-Destro, 2008). The baby cries in distress when uncomfortable, the mother places her hand on the baby’s abdomen and soothingly talks to her baby. Her smiling and loving face is processed in combination with the tactile and vocal input and soon, the baby mirrors her soothing, modulating from a scream to a content and calm state. In this way, the child adapts to incoming signals from others and the environment to help modulate a regulatory response. Mirror neurons play a vital role in facilitating mutual reciprocity and signaling between persons during self-regulation (Solms & Turnbull, 2002).

Lucy was a 10-year-old girl with autistic spectrum disorder who had difficulty in taking in verbal, affective, or gestural communication from me and other persons in her life. She usually paced back and forth in my therapy room, talking at rapid speed about Pokemon and video game characters. On a few occasions she would glance fleetingly at my face but clearly had difficulty processing facial cues and was often overwhelmed by the facial expressions of others. On one particular day, I greeted her and as we entered my therapy room, she noticed that I had on a light shade of green eye shadow. She put her face close to mine and exclaimed, There’s something wrong with your eyes! I replied, Let’s look in the mirror, Lucy. What could be wrong? As we gazed at our faces in the mirror, I said, I see what it is! It’s the green eye shadow. Should I rub it off? Lucy looked puzzled as she gazed back and forth between our eyes in the mirror. I said, Let me see your eyes. What a pretty blue they are! So different from my brown eyes. Is there anything else you notice about our faces? This began a series of mirror experiments of us comparing funny or interesting attributes about our faces while we wore sunglasses, hats, clip-on earrings, and other accessories. Once we started the mirror experiment, Lucy became much better at maintaining eye contact with me and surprisingly, her pacing diminished. It seemed to calm her down and in the upcoming years, she would often sit cross-legged on the floor in front of me, looking directly at my face as we talked or played games.

1.2.2. Level 2: Purposeful communication and planning of thoughts and actions

1.2.2.1. Planning and organizing thoughts and behaviors

In the typically developing child, the next level of self-regulation involves the capacity to process and generate effective gestural and verbal language to communicate intentions, the ability to adapt to a range of everyday routines, and the ability to respond contingently to the expectations from others (Kopp, 1987, 1989, 2009, 2011; Tronick, 1989). This stage occurs between 8 and 18 months of age and is important for the development of intentionality, reciprocal interactions, and organized affects. Kopp (1987) further elaborates that during this time the infant learns to modify actions in relation to events and object characteristics. Around 9 months of age, the infant becomes intentional in actions and becomes aware of situational meanings. For example, the baby learns to distinguish between when daddy is putting on his coat to go to work or to take them for a stroller ride based on verbal and contextual cues.

The prefrontal lobe plays an important role in planning and organizing behavioral schemes. The language cortex and associated areas (temporal lobe, Wernicke’s and Broca’s areas) help the person communicate thoughts through verbal and gestural language. Likewise, the parietal lobe, basal ganglia, and cerebellum engage in planning and execution of motor actions. It is a complex neurological process for the individual that can be derailed if basic homeostasis is not accomplished at the prior stage of development.

As the child develops the capacity to plan and organize thoughts and behaviors, he learns to adapt to changing interpersonal and learning expectations and to plan for future actions. We see this in the individual who can control his body and mind for a specific purpose or goal without becoming distracted. Individuals who have learned to meditate, slowing their active minds and bodies down to concentrate on a precise, single stimulus is one example of how this is accomplished.

This level of self-regulation requires the development of intentionality, reciprocal interactions, organized affects, and an awareness of situational meanings. This stage is critical for the child to learn how to modify actions, thoughts, or feelings in relation to events in his life. It is accomplished through the child learning to initiate, stop, modify, or change responses as situations occur, thus allowing them to engage in more adaptive behavior (Zimmermann, 2005). The child may need to inhibit the desire to leave the dinner table before finishing the meal or the urge to grab a toy when waiting is required. This ability to inhibit actions may prevent the child from fleeing from a stressful situation when staying and coping is required. It can also help a growing child to stop himself from yelling at his parent for doing something upsetting like grounding them for doing something they shouldn’t have done. Or it can help the child inhibit doing or saying things that pop into their mind while playing with peers. For instance, when Terry would get agitated in a group situation, she would poke the other children or do things like throw the game dice around the room, disrupting the fun of the other children.

At this stage of self-regulation, the person learns to initiate, maintain, and inhibit physical actions or impulses. This is the basis for problem solving, intentionality, and awareness that actions lead to a goal. On a neurophysiological level, higher cortical control (e.g., prefrontal lobe) overrides lower brain centers (e.g., reticular activating system and hypothalamus) that control basic bodily functions. Feedback loops between the reticular activating system, deep limbic structures to the cortex, and the prefrontal lobe help the child to develop intentionality, purpose, and motivation. The prefrontal lobe plays an especially important role in self-stopping, in generating ideas and maintaining motivation for adaptive behavior. It is this dynamic feedback loop that helps the child evaluate his internal bodily state, to self-observe readiness to respond, to read external situational demands, and to integrate past learning and responses to apply to the current situation. There are three main components that go into the ability to plan and organize thoughts and actions. These will be described in the sequence in which they occur in behavior.

1.2.2.1.1. Developing ideation

This is the first step—to develop a clear thought, desire, or target behavior. It is a function of the prefrontal lobe and involves turning the search light on a particular idea and making it clear for execution. If the idea is not well formed, as often occurs with attention deficit disorder or executive functioning disorder, the child may be aimless, disorganized, and restless. Even when there are clear environmental cues, the child may not register the importance of the goal and the need to act. For example, many children are not phased by a messy bedroom overflowing with toys, clothes on the floor, or food wrappers scattered about. They may not even experience distress when an important, unfound object is frustratingly hidden away. Sometimes the child exists in a constant state of competing ideas and cannot act on an idea, or they start things never to finish anything. Taylor was a 6-year-old child who was in constant motion. Within 2 minutes of her entering my play room, toys were pulled off shelves, cabinets hurled open, and toys strewn about. She had great difficulty containing her urge to touch everything in sight and resisting the impulse to begin yet another play idea. She never finished even a simple sequence of a project, pretend play scenario, or game. When I showed her that the sand-filled hour glass was almost finished indicating that our session was about to end, she started even more things—expressing her wish to paint a bowl, to sew an apron for her doll, or play a long involved game in the remaining 3 minutes. In children like Taylor, the inability to resist acting on a new thought is a typical problem that occurs when the lower brain centers prevail over the executive planning frontal lobe.

Another common problem when a child cannot develop a clear idea and goal-directed focus is cognitive indecisiveness. This is common among children with high anxiety or obsessive–compulsive disorder. They may ruminate over and over again about when to start, what to do, will it be right, how to do it, etc. Often they have multiple ideas in their mind, but cannot focus on one or prioritize them in proper sequence. Isabella was a 7-year-old child who would compulsively clean my doll house, setting up the furniture, and placing dolls in the beds. The process was repeated exactly 3 times. Isabella was unable to make anything happen in the story and was stuck in a state of constant set-up. This spilled over to her needing to eat food in multiples of three, washing her hands three times after using the bathroom, and repeating things under her breathe three times. She was in a constant state of frustration, stuck in time.

1.2.2.1.2. Self-control and self-monitoring

The emergence of self-control is the next level of planning and organizing thoughts and behaviors, beginning at 18 months of age. The child of this age can create mental images that can be manipulated through his or her pretend play and functional use of language. Because of these skills, the infant is able to internalize routines and requests made by others. Kopp describes the toddler as learning to delay his or her actions and to comply with social expectations without needing external cues. The development of representational thought and recall memory is central to this stage. Volitional control requires self-monitoring, self-control, and self-limiting behavior. The child must be self-aware and mindful of his own actions while engaged in doing a task. Verbal mediation of thoughts and actions helps the child organize self-regulatory behavior (Kopp, Krakow, & Vaughn, 1983; Kopp, 2009). As the child begins to differentiate emotions and his or her sense of self from others, expressions of negative affects and aggression are apt to occur. The caregiver attaches affective meanings to situations and provides social expectations and values related to specific emotional responses, which helps the infant to label and understand emotions (Kopp, 1987). The development of action schemes (e.g., vocalizations, self-talk, self-distractions, or other motor responses), cognitive organization (e.g., representational thinking, self-monitoring), motivation, and external support from caregivers (i.e., list making, timing devices, and other prompts) appear to be key elements in attainment of emotional regulation (Kopp, 1989, 2011). If a child is derailed at this stage of development, he is apt to be constantly frustrated, explosive, and aggressive toward others.

As the person develops self-control, he learns to internalize routines and requests made by others. These routines are established early in life—a set bedtime, meals at certain times or doing certain activities, such as exercise at specific times. There are considerable individual and cultural differences that influence these schedules and routines, but what is important is that there is an established rhythm and pattern to the person’s daily activities that allows them to function well in life. Many children with severe ADHD live moment-to-moment with no capacity to plan for a regular schedule. Jason was a 9-year-old boy who went to bed at different times each night, often awakening in the wee hours because he wanted to play video games or read. His parents tried to establish bedtime rituals for Jason, but sometimes let him do whatever he wished to avoid a huge tantrum that followed their limit setting. Jason was in a constant state of sleep deprivation and irritability as a result.

In the process of planning and organizing actions, the child needs to attend to relevant details, gather important information for the task at hand, then engage in proper actions for task achievement. The child needs to be mindful of their actions and self-monitor as they engage in the task. Allocating attentional resources is critical for self-monitoring. Many children think they can multitask efficiently, but often they allocate only part of their attentional resources for each task (i.e., doing homework, surfing internet, and watching TV at the same time). Often they don’t complete any of the tasks optimally unless the activities are rote or habitual in nature (i.e., reading a book while eating). Self-monitoring requires that the child resist urges to respond to off-task or impulsive wishes. They need to delay gratification and stay focused and intent on their goal. Children who struggle with self-monitoring have poor self-control, poor self-awareness, restlessness, and usually cannot delay gratification. This is often seen in children who are chronically stressed and have poor mood modulation. Living with them is overwhelming to parents and siblings because they blow up easily. A child may have poor self-awareness and not read that they are about to lose it before it is too late (i.e., the child who insists on jumping wildly near the edge of a trampoline, then injures himself seriously).

An important aspect of this phase of development is the learning to delay one’s own actions and to comply with social expectations without needing external cues. Self-control relies upon the person’s development of forethought, planfulness, volitional control, and self-reflection (Zimmermann, 2005). In forethought, the person analyses the task before him, sets goals, and plans a strategy to accomplish his goal. If the idea is not well formed in his mind which is often the case with children with attention deficit disorder or executive functioning problems, they may struggle to get started. The child needs to be able to attend to relevant information about the task and feel motivated to do it. Self-control depends on being able to sustain effort, manage time, remain focused on the goal, and resist distractions that might divert them from their goal. Common problems at the ideation or forethought stage might be aimlessness, disorganized or risky behaviors, procrastination, or conflicting or ambivalent goals (Baumeister, 1991a,b). The child is apt to feel indecisive, emotional distress, or confused about his own identity because he lacks purposefulness.

Breakdowns in self-control are commonly observed in clinical practice. Hostility, aggression, irritability, high frustration, and violence may be manifested in persons with poor self-control. The ability to resist temptation, to resist the urge to respond when it is inappropriate, and to delay gratification are central to self-control. To develop better self-control, the child needs to be able to evaluate himself while in the process of doing a task or engaging in an interaction, all things that require mindfulness of self and others. Lev was a child adopted at age 4 years from an institution in an Eastern block country. Despite nurturing and good parenting, he never learned to control his impulses and from the age of 4 through adolescence, he would demand that his parents buy him toys or video games every day. If they did not give in to his demands, he would become very violent, ripping out a banister or a bathroom sink, smashing holes in the walls and even the car windshield with his feet, or punching his parents on the head and arms. He was completely unable to delay gratification and the only thing that eventually worked for him was to place him in a residential school where he had to earn the simplest of rewards like getting dessert for doing learning activities and chores and showing respectful behavior. After several years at the residential school, Lev developed much better self-control and was able to return and live with his family.

Finally, the capacity to self-stop or self-limit is important to self-control. It involves both mental and physical exertion and control to override the impulse to act when the task or situation requires them to inhibit or stop. Some persons cannot resist temptation as in the case of overeating, video gaming for long hours, or other addictive behaviors. There may be extreme peer pressure or external forces that urge a person to act when he shouldn’t. In addition, internal states of fatigue or high stress may break a person down and cause poor self-control.

1.2.2.1.3. Planning and organizing adaptive responses

This is the last observable step in the planning sequence. It is when we see the child engage in purposeful actions for task completion, adjusting his behavior as the task unfolds. The child gathers feedback as he does the task and receives internal feedback to allow for motor or cognitive adjustments for errors, mistakes, and performance standards (i.e., go faster, make smaller movements, etc.). Self-discipline and the capacity to stop oneself are important features to organized behavior. For example, the child may feel fatigued and wish to stop performing, knowing that it is time for a break or he will fail in the task. He may feel highly stressed by the situation (i.e., performing on stage or in front of the classroom) and a wish to escape. There may be outside pressures to do something else such as peer pressure that distracts the child from their primary goal. The child may derail himself by engaging in a behavior that impairs his cognition (i.e., sleep problems, overuse of electronics) or may be unable to resist sensory pleasures—eating sweets, random movement activities, etc. at times when they need to focus efforts on more purposeful, goal-directed activity. For example, William was a 16-year-old boy adopted from Ethiopia at age 9 who had extreme problems with self-control. He couldn’t stop his urge to go on the internet and surf porn sites and even broke into other people’s homes to use their computers for this purpose. He had a sugar addiction and stole candy from stores, leaving candy wrappers jammed under his bed. The lack of impulse control that William experienced resulted in lying behavior, sneaking around, and delinquency from school. To make a difference in William’s life, we used a combination of treatment strategies that focused on behavioral inhibition, developing healthy and fulfilling attachments with others, as well as minimizing stimuli in the environment that could trigger William’s urges.

Emotional dysregulation can cause a child to lose the capacity to plan and organize the daily tasks of life from home to school activities. However, there are also instances of short-acting emotional dysregulation, such as when a child has a frustrating event, such as a toy breaks on him, a limit is placed on him by his parents that he feels is unfair, or he’s working on the computer and the power shuts off from a thunderstorm, thus losing what project or game he was working on. The child may tantrum, take a break to regain composure by moving or other activity, then return to begin the task all over again. In contrast, a child can have long-standing, chronic stress, such as a mother who is very depressed, abusive, or who makes nasty comments to them all the time. The rage that is elicited is apt to persist for quite some time and become part of the person’s behavioral repertoire. Distinguishing the source of the dysregulation is important in understanding the problem as well as guiding next steps for treatment.

In clinical practice we often hear examples of how poor inhibition and problems with self-initiation impact the entire family. In one family, the mother complained that when she would walk in the door after a long day at work, she would find her 2-year-old child hungry and crying for attention. Her husband, Curt, was unemployed and depressed by his plight at staying at home with the toddler. As soon as Stacey would see her husband lying on the sofa reading a magazine, still in his pajamas and oblivious to their child’s distress, she was instantly triggered. Within moments, Stacey would begin shrieking at her husband for not starting the dinner for their child, raving that the house was a complete mess, and that he was clueless to her work exhaustion. Curt’s lack of intentionality and awareness of the situation not only led him to being dysregulated in a withdrawn—shut down state, but the whole family was pitched into a state of dysregulation. The child spent long hours parked in front of the TV with no purposeful activities or outings. She had started engaging in masturbation as a means of self-soothing and looked tuned-out, almost autistic in her presentation. Stacey’s dysregulation went to rage and was in opposite action to Curt’s withdrawal, but both felt distress, frustration, and irritability at their terrible situation. Support was provided for the parents and child, and in particular the little girl was placed in a nurturing and stimulating day care that helped her develop skills, motivation, and socialization. The self-stimulatory behaviors that the little girl had been engaging in stopped shortly after the parents learned better ways of providing structure, routines, and nurturing activities for the child. An important aspect of the treatment was helping the parents learn to engage in interactive play with their toddler during a range of routines and activities and providing ongoing support for both parents—father’s depression and mother’s level of stress.

1.2.2.2. Differentiating one’s own thoughts and actions from others: theory of mind

A growing awareness of self as a separate identity contributes to the child’s ability to differentiate his responses from the actions of others. Brianna, a young mother with a history of emotional and physical abuse, could not see herself as separate from her 30-month-old child. At our multifamily group therapy session, we asked Brianna if we could serve her child some cottage cheese during snack time. She replied, Oh, he won’t like it. I don’t like it, so he won’t like it. When we further inquired if he had ever eaten cottage cheese, she replied, Of course not. It is a simple example, but this spilled over into many activities for Brianna who could not tolerate her young child exploring new things. When playing with her child, she was very controlling of what he was allowed to play with and how, often introducing play ideas that were nowhere near what a 30-month-old could do. For example, she might tell him, Count the pieces. Now tell me the colors. Don’t touch that. Do as I say. Let’s start over and count them right this time. Unlike most 30-month-olds, the boy stood frozen in fear, staring at the colored puzzle pieces and not knowing what to do or say. In our work with Brianna, she frequently expressed how she was raised with an iron hand that she never grew up to know who she really was. It was like I was invisible, even when my mother looked at me. I had to do what she wanted me to do and never could do anything I wanted to try. Now she was doing the same thing with her young child and we were trying to stop the cycle and allow both Brianna and her young son to blossom.

The ability to mentalize affective experiences first develops through the child exploring the many meanings of their own actions and the actions of others. In this process, the child becomes increasingly aware of his own emotions as he interacts with objects and persons (Fonagy, Gergely, Jurist, & Target, 2004). Two key processes help the person construct an internal experience of affective experiences. One way is through the symbolization of experiences or pretend play expressed in young children. The child picks up a little acorn, animates it in her hand, bobbing it up and down on top of a piece of bark. The child then exclaims, Look. It’s a fairy. She’s going on a magic carpet ride. And off the bark and acorn fly into the air. The symbolization allows the child to express a range of emotions- pleasure and excitement, separation and individuation, assertion and aggression, as well as negative emotions of frustration, fear, anger, or sadness. As the child enacts emotions through play, he begins to make sense verbally and nonverbally of his internal emotional life.

As the child grows older, they continue to do this through expressive arts like dance, art, music, and story writing. Sometimes it is only after a person has symbolized a story that he truly begins to understand what might have been troubling them in early childhood. Sam was a very intelligent 10-year-old child with a strong desire for friends, but lived in a chronic state of isolation because he didn’t know how to engage in social interchanges. Sam was an avid reader and loved to dream up stories, but his narratives were difficult to follow by others. When Sam would become distraught, he would go off by himself and do odd things like smell mulch on the playground or twiddle leaves in his fingers while composing a song in his head. One day in his therapy session, he wrote a story about Flippity-Floppity Fish who was a rare breed of fish that no one had ever seen before. He did amazing tricks in the water that caught the other fish’s eyes, but soon they lost interest and swam away. A pelican flying above noticed Flippity-Floppity and alighted on a rock to watch. Flippity-Floppity paused his beautiful swim among the coral reef and looked at the pelican. He said, You’re the first one to really notice me and know I’m here. Sam turned to me with tears in his eyes and said to me, I want you to have my story. You know what I live with all the time. Through the symbolization of the written narrative, Sam helped gain a new perspective and insight into his life experience.

A second major way that we mentalize symbolic experiences is through empathic affective-mirroring. It is very powerful to experience the reflective mirror of another’s face and voice attunement, response, and reflection as we express our own internal emotional experience. Emma, who was a highly anxious child, repeatedly played that she was injured and had to go in the ambulance to the hospital, then once healed, she could finally feel free, riding the horses at the stables with abandon. Her attuned father joined her play, reflecting on the overwhelming fear that Emma felt. Emma was a selective mute and was paralyzed by new situations and places, not being able to speak or move. As her father reflected on her worries that something dangerous would happen to her and validated her fear that something was seriously wrong with her, Emma began to relax more, gain her voice, and feel heard by others.

Below is a summary of the conceptual model for self-regulation in children.

Summary of the Self-Regulatory Process

1. Level 1: homeostasis

1. Read and interpret one’s own body signals: Basic physiological readiness.

2. Process sensory stimulation from the environment and others: Take interest in the world.

3. Internalize self-soothing from others.

4. Signal communication to others about one’s own needs for self-soothing.

2. Level 2: purposeful communication and the planning of thoughts and actions

1. Plan and organize thoughts and behaviors

a. Develop ideation.

b. Self-control and self-monitoring.

c. Plan and organize goals and future actions.

2. Differentiate one’s own thoughts and actions from others: Theory of mind

d. Symbolization of experiences.

e. Empathic affective mirroring.

2. What is a regulatory disorder?

There are a number of etiologies that can cause problems of self-regulation in infants and children. In most individuals with a regulatory disorder, the problem is life-long and is often constitutionally based (Thelen, 1989), while others are not. For example, infants frequently display sleep disturbances and/or colic which resolve spontaneously by 5 or 6 months of age. If however, early signs of irritability do not resolve by 6 months, the fussiness experienced by the infant persists and is coupled with other symptoms, such as poor self-calming, intolerance for change, and a hyper-alert state of arousal, then it is likely that the child has a problem with self-regulation. Using Greenspan’s clinical constructs, these children have become recognized as regulatory disordered. The diagnostic criteria for regulatory disorders are provided in the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (Zero to Three, 1994). A regulatory disorder is one in which problems exist in both behavioral regulation and sensorimotor organization. Typically the regulatory disordered child displays problems in sleep, self-consoling, feeding, attention and arousal, mood regulation, and/or transitions. Often these children are hyper-or hypo-sensitive to sensory stimuli including auditory, tactile, visual, and vestibular stimulation (DeGangi & Greenspan, 1988). Because the diagnostic category of regulatory disorder is a relatively new one, there are few studies documenting the various clinical diagnoses associated with this problem.

Some persons are born with a difficult temperament and struggle with irritability since they were a baby. Hereditary mental illness, such as bipolar illness, anxiety, and depression become evident in early to middle childhood and have a major impact on personality formation, mood stability, attachment relationships, coping skills, and adaptation to change. When these problems are accompanied by sensory hypersensitivities which is often the case, the child often reacts