Mental Health Consultation: A Psychologist in Preschool

(Published in The California Psychologist, Volume 43, Number 5, September/October 2010)

I observe children in preschool classrooms. Sometimes, as I am watching, I ask myself how it is possible to get paid to do the job that I do. Perched on a chair at the edge of the room, I apply the same principal that I did when I was a child, crouched over tide pools: watch long enough and something is bound to happen. A child with low frustration tolerance will have an outburst when she cannot complete an activity. How will the teachers handle her tantrum? A child with a history of abandonment will become distressed when the teacher leaves the room. What meaning will the remaining teacher make of his behavior? On a lucky day, a prized moment will occur. At a nearby table a conversation begins.

“My mom says that when somebody dies, they become another person,” one little girl says to two others.

“Like becoming a baby again?” her friend responds, using what she knows about the world to grasp this new and elusive concept.

The third, already envisioning her friend’s inverted development, blurts out, “Are you going to be a baby and wear diapers again?!?” All three explode into a fit of giggles.

Observation is the core of my work in preschool. But as an Early Childhood Mental Health Consultant, it represents only a small (and fun!) part of a much more complex job. I use my observations to 1) Identify children with mental health issues and link them with services and 2) Identify problems in the preschool system as a whole and work to address them. All of my work is embedded in the relationships that I have cultivated with the teachers, parents, children and staff over a period of months or years. The model of Early Childhood Mental Health Consultation that I implement is long term and relationship based (Johnston, K. & Brinamen, C., 2006).

The Case of James

James spent his first two weeks at preschool intently watching the other children and the teachers from a safe spot at the entrance to the classroom, attempting to make sense of what he was supposed to be doing there. When he finally joined the group, the teachers and I quickly noticed that James had some difficulties. During one-on-one conversations and classroom meetings, we brainstormed answers to the following questions: “Why does he provoke the other children with mean language?” “What is the meaning behind his aggression towards his classmates, his teachers and even himself?” “What can we do to help him relax and ease his rigidity when he gets upset?”

Feeling that we needed more answers, we decided to call a meeting with his parents. Since we did not know them very well, the site director, lead teacher and I decided that the meeting should be geared towards building a relationship and finding out more about their family. During the meeting, James’s parents were very forthcoming. We discovered that they were struggling with foul language, aggression and rigidity at home, and asked them to share their strategies for supporting and calming him. My ears perked when James’s mom told us that James had observed her getting attacked by a dog a few weeks before he started preschool. She also shared that, at age two, James had split his forehead and had to be held down by his mom and dad while the doctor gave him stitches. I recalled Alicia Lieberman’s (2008) term “emotionally costly stress” and wondered what James had internalized from these frightening experiences.

Before the meeting ended, I asked James’s parents for their written permission to keep a closer eye on their child, and suggested that we meet or speak on the phone again soon. In a private conversation, I suggested to James’s parents that they address the issues their son is having by engaging in dyadic therapy, and offered them the names and numbers of some agencies and therapists who could help. I expressed my concern about how James’s “emotionally costly” experiences might be preventing him from developing friendships, learning new things in school, and hence progressing developmentally. I explained the neurological processes in the brain that allow young children to be so flexible and hence so amendable to early intervention. Thankfully, James’s parents were willing, and able, to take my advice. The child is now more relaxed and less aggressive, has better relationships with his parents, teachers and peers, and is learning and growing every day.

A Presence in Preschool

With parents like James’s, helping teachers by helping the children in their classroom is easy. More difficult to address are systemic issues in the classroom and the preschool as a whole: a team of teachers in a classroom who don’t get along; differences in approaches to handling children’s problems; discrepancies in teacher training and education; even underlying race and class tensions amongst the staff.

In the beginning, all these problems felt overwhelming to me. I took them on and did my best to fix them, feeling frustrated when I was not successful. As I gained experience, knowledge, and confidence, I began to realize the importance of mere presence. Being there to listen, to reflect and to bear witness to their difficulties is extremely powerful. If there is an argument or misunderstanding between two teachers, I listen calmly, mediate with neutrality and attempt to cultivate understanding about each other’s perspectives. I coach teachers individually on how to communicate effectively, being careful to practice what I preach with my own words.

When confronted with disagreements about approaches to child rearing, I work to create an environment in which the teachers and I can all think together about what is best for the child or group of children. Oftentimes during these conversations, I take on the perspective of those with the smallest voice: the children themselves.

To address discrepancies in education and training, I draw on my knowledge base of psychology and my years of experience in the classroom. Cautious of taking on the expert role, but acknowledging that I have useful information to share, I tactfully interject psycho-education into my conversations. I additionally have created tools to hone observation skills and better understand children’s behavior that I continue to refine. The teachers and I implement these tools together, in vivo, in the classroom.

On rare occasions, I am given the opportunity to do groups with all the teachers and school staff. During these groups, I incorporate exercises that encourage self-reflection and perspective taking. For example, I ask each person to reflect on a difficult experience in the classroom: what they felt, where in their body they felt it, and how their feelings influenced their consequent treatment of a child or co-worker. Each person then shares his/her answers out loud. These exercises highlight how everyone struggles to do the emotionally taxing job of being a preschool teacher, and how similar their struggles are. They additionally create empathy for their fellow teachers and staff, and allow for a release of pent up stress and tension. Following these groups, it is as if the entire center has taken a collective sigh. They are gentler on each other and on themselves, and better able to attune to the children’s needs.

As an Early Childhood Mental Health Consultant, I know that I cannot solve the complicated dynamics and multiple layers of problems so often present in preschool. But I can create a safe space for people to express their points of view, to find meaning in children’s difficult behaviors, and even to talk about how larger issues of race and class intersect in the preschool classroom. By being open to what comes and present for the teachers, parents, children and school staff, I create a container for their experience. By creating a container for the needs of the adults, the adults are then able to create an effective container for the needs of the children. And at the end of the day, that is the real reason why I am a psychologist in preschool.


References
Johnston, K. & Brinamen, C. (2006). Mental Health Consultation in Child Care: Transforming Relationships Among Directors, Staff and Families. Washington, DC: ZERO TO THREE Press.
Lieberman, A & Van Horn, P. (2008). Psychotherapy with Infant and Young Children: Repairing the Effects of Stress and Trauma on Early Attachment. New York: The Guilford Press.

Montessori and Ego Strength

My first year of work as an Early Childhood Mental Health Consultant in a public Montessori preschool, I learned a lesson that would forever expand my thinking about the field of psychology. I was the individual therapist for a little boy in one of the classrooms. This boy, whom I will call Erik, was identified as a therapy candidate because of his low frustration tolerance, his outbursts of rage, his rigidity, and his declarations about hating himself and his life. I was learning that these symptoms were classic of children, especially little boys, who could find no reasonable explanation for why their fathers were not around except that they were fundamentally unlovable. This child was acting out his depression through his behavior in the classroom... and driving his teacher nuts in the meantime!

As a novice therapist and mental health consultant for preschool aged children, my heart broke for this child. I wanted him to feel good and to know that he was a lovable, worthy person even though his father had abandoned him. Seeing such a young child in so much pain is a difficult thing to manage. My immediate reaction was to be protective of Erik. Since my coping mechanisms for working with this age group were still developing, my feelings about him were raw.

At Erik's school, I had one and sometimes two other children I was working with in therapy. I was also acting in my role as mental health consultant for the teachers and administrators, helping them to support the children by supporting the whole school system. Needless to say, I was not only at the preschool to work with Erik. But that is not what he thought!

On Wednesdays, my day at his preschool, he would wait for my morning arrival at the school. As soon as he spotted me in the hallway rolling my yellow backpack stuffed with play therapy toys, he would pop out of the classroom and yell, "Hi Ms. Becka! When are you going to come and get me?!?" And every time, his teacher would come storming out after him, scolding him about leaving the confines of his classroom without her permission. Erik would watch me with curiosity and confusion, particularly if I was with another child. "I have work to do," I would tell him, tyring to adopt the Montessori concept of "work" but lacking the conviction. "I will come to the door to get you as soon as I am ready." With that, his teacher corraled him back in the classroom while he screamed, cried and dragged his feet.

The reality of the situation was that I wanted to hide from him that I was working one-on-one with some of his classmates. 'He couldn't handle it if he knew,' I would tell myself. I wanted him to feel special and not experience further rejection from the adults in his life. He needed to feel that he was my one and only.

The Montessori Implementor at the school soon caught sight of the awkward routine that had developed between me, Erik and his teacher. In her presence that particular morning, Erik had grown so upset when he ran into the hallway and saw me walking towards the play therapy room with another child that he screamed after me at the top of his lungs: "You are ugly! I never want to play with you ever again!" Upon his forced reentry into his classroom, he grabbed his classmates' chairs and threw them to the floor one by one.

"What was going on with Erik this morning?" she inquired of me a little later in the day. I explained to her that Erik had apparently grown really jealous when he saw me with another child in the hallway. "I try my best to hide it from him," I confessed, shrugging my shoulders.

She paused as she contemplated this in silence. "Why would you try to hide that from him, Rebecca? You need to explain to him that you work with him and other children when you are here, and that you will come to get him when it is his turn," she explained casually. "The reality is that he knows it already. He is probably really confused about why you aren't being more straightforward with him about it."

I was dumbstruck by this conversation. I had never even considered how, in trying to protect Erik from his own feelings, I had actually made the entire situation a confusing, intolerable mess for him. It instantly clicked for me that by "protecting" him I was depriving him of the opportunity to learn the skills he needed to handle his frustration. I could not believe my oversight, particularly in light of the fact that this was Erik's very issue! Erik not only had to cope with the abandonment of his father, but he had an older sister who spent a lot of time with her daddy over the weekends. He could not for the life of him understand why she got to see her father and he did not. If I did not become more clear to Erik in explaining my intentions, he might jump to the exact opposite conclusion of what I wanted him to take away: that people reject him because there is something fundamentally wrong with him.

The insight that I learned from the Montessori Implementor that day was a turning point for me. It marked the beginning of an expansion in my psychological conceptualizations of people, particularly young children. Schooled as a psychodynamic psychologist, I was taught to identify pathology in patients and to treat their symptoms by bringing unconscious conflict to light. I was also taught to hone in on patient's feelings and find meaning and patterns in their behavior.

In the Montessori school where I was working, there was less of a focus on children's feelings and more of a focus on building their skills. This was achieved through the thoughtful layout of their classroom environment, and by providing them with materials that were interesting, developmentally appropriate, and just challenging enough for children to establish independent mastery over them. Skill building in the Montessori classroom was also achieved by the prevailing Montessori philosophy that children are competent and strong if you give them the opportunity to be so.

The difference between Montessori philosophy and psychodynamic psychology is epitomized by the phrase coined by positive psychologist Martin Seligman. "Doing well in the world versus feeling good." (Seligman, M. The Optimistic Child, Harper Paperbacks, 1996). According to Seligman, you cannot achieve the state of feeling good without first achieving competency, or doing well. As a psychologist, I was skipping right over the mastery building in my effort to relieve Erik's pain (and perhaps my own), in the service of making him feel better.

I have not traded my psychodynamic lens for a Montessori (or positive psychology) one. In fact, a large piece of my work as an Early Childhood Mental Health Consultant at the Montessori school has been in expanding the Montessori philosophy to include more of a psychological perspective in the classroom, given the large numbers of children experiencing mental health issues.

I still believe that psychodynamic psychology is greatly effective in alleviating people's pain and helping them understand how their early experiences shape the present relational patterns they find themselves stuck in. I find this approach particularly useful for parents of young children.

As for the children themselves, I am now very mindful about focusing on their feelings so that they feel nurtured and loved without trying to create a false sense of contingency (a world without pain) or unconsciously communicating that I do not believe they can handle things. Montessori has taught me that children are very resilient and have a great deal of ego-strength.

The very next time I saw Erik, I explained to him that it was my job to come to his school and take different children for "special play time" (e.g., therapy). "But," I continued, "I will always come to get you as soon as it is your turn." Erik showed no visible sign that this was a climactic moment of understanding for him. In fact, he continued to run out into the hallway to greet me when I arrived at his school, and to check if it was his turn yet. However, to our great relief, the hallway tantrums stopped. Erik was additionally more relaxed and secure in his classroom knowing what my intentions towards him, and the other children, were. Our "special play time" could now progress into deeper areas of psychological conflict.

Parenting for Kindergarten Readiness

When parents hear the words Kindergarten Readiness, their minds immediately jump to a child's ability to write their name, count to ten, cut with scissors, and sound out words. But what most parents aren't informed about in regards to Kindergarten Readiness is that the ability to perform these academic tasks requires a previously learned skill set. We take for granted that underlying the ability to read, write, count, and cut paper is a child's ability to concentrate on new tasks and engage appropriately with the people in their classroom environments, namely their teachers and classmates.

The ability to focus and concentrate is a skill that requires mastery. It is, in fact, the developmental task of preschool aged children. This ability to focus and concentrate depends directly upon a child's ability to regulate his or her emotions. Self-regulation, as it is called, is defined as the ability to control reactions to strong emotions, such as anger, sadness and even joy, and to recognize and interpret the emotional states of oneself and others.

If self-regulation leads to the growth of attention and concentration, which then fosters the ability to learn about all of life's wonders, how can parents best support their preschool children's growth? Where should parents focus their efforts to help prepare their children for kindergarten?

As an Early Childhood Mental Health Consultant, I have had the pleasure of watching children, barely three years old when they enter preschool, blossom into self-assured, expressive, cognizant Kindergartners. I have also experienced the heartache of seeing children who are not thriving when they set off for Kindergarten. Children who are not in command of their bodies; whose emotions are marked by negativity, frustration, anxiety, and dissatisfaction; children who do not have positive relationships with their classmates or the adults in their lives.

In my work, I have witnessed the impact of parenting practices on children and noticed that they tend to fall into two divergent sides of a continuum. I call this the great chasm of childrearing. On one side are the parents who are very focused on obedience in their children, and hence have rigid expectations about their behavior. When there is misbehavior, there is a large focus on punishment. Underlying this kind of parenting is a fear about what will happen if absolute control over the child is removed. Most often, those who parent this way were raised in exactly the same manner.

On the other side of the childrearing chasm are parents who have little or no expectations of their child's behavior. These parents are overly attuned to their children's needs and desires, wishing only to "make them happy." Misbehavior is rarely punished for fear of damaging the child's emerging sense of self. Underlying this kind of parenting is a fear about what will happen if perfect contingency (e.g., a world without hurt or frustration) is removed from the child, so they allow the child to set the tone, the parameters, and the rules of the relationship. These parents want to be different from the more rigid and demanding parents they were raised by, but have difficulty finding a healthy middle ground.

The interesting thing about both of these styles of parenting is that they often create similar kinds of emotional dilemmas in children, leading to behaviors that are taxing and frustrating for both parents and teachers. For example, children of parents on both sides of the great chasm of childrearing tend to be highly anxious. The anxiety from the former is created by a fear of retribution and judgement from adults, as the parameteres are so harsh that these children do not learn to trust their own abilities. Children raised with the opposite side of the great chasm of childrearing are burdened with anxiety about not having enough parameters or by having to create them on their own. Both of these types of children test adults to see how far they can push the limits. Neither of them is given the opportunity to internalize appropriate boundaries. These children are left merely reactive to the world around them, as they lack the internal competencies that guide them.

Parents who have well adjusted children, or children who are most likely to succeed in kindergarten and beyond, fall in the middle of these two styles. These middle ground parents have clear expectations of their children's behaviors, and repeat these expectations frequently, knowing that children need a lot of reminders. They try to put themselves in their children's shoes and see things from their perspective, without being lax about rules and expectations. They are attuned to their children's needs without being unrealistically focused on them.

Middle ground parents save harsh rebukes or punishment only for the most severe situations, as they know that too much focus on obediance and punishment only creates fear in children and does not give them the space to develop skills to regulate their own behavior. Middle ground parents know that children can (and should) tolerate a certain amount of frustration, as they will need a healthy tolerance of frustration throughout their lives. These parents use language that is more elaborate than just commands (ex. "Sit down!" or "Let's Go!") but not so elaborate as to include talk about adult worries or problems. Middle ground parents know that language is not only how children learn to communicate but it is how they learn problem solving skills. These parents allow children to ask questions and speak to the frequently about what is going on in the world around them.

If you are curious about your own parenting style, the first step is to ask yourself the following questions: What do I fear as a parent? Am I being too lax or too severe on my child out of my own fears? In what ways is my parenting style similar to the one my parents used? How can I avoid being (fill in the blank. ex. hurtful, mean, shaming) while still holding my child to expectations and rules that are important to me?

If you are having difficulty becoming a middle ground parent, seek out help. Ask your child's teacher for suggestions. Make an appointment to speak with the mental health consultant at your child's school. Find out who the professionals are that work in your community, either privately or in the public sector, and how they may be of help to you. Dialoguing about and reflecting upon the challenges of raising children will help you better arrive at the effective middle ground in the great chasm of childrearing.

In addition to having an awareness of parenting styles, we all need to be mindful that our culture places a large emphasis on cognitive development. Mathematics, language and deductive reasoning are emphasized, sometimes to the exclusion of emotional wholeness and relationships. The irony is that children cannot thrive academically without the emotional health that comes from secure, nurturing relationships. These relationships foster the true Kindergarten Readiness skills: patience, flexibility, emotional-regulation, self control, sharing, listening, collaboration and respect. 'Reading', Writin' and 'Rithmetic will fall into place naturally in the context of healthy relationships and reflection.