#48 -Assessments For 5 – 8 Year Olds – Part 2

The Family Drawings

The last section of the previous post discussed several clinically notable elements of childhood family drawings, to include: who of the family are included; who’s left out; extra characters included; the presence of a yellow sun; the streaking of the yellow sun with orange; the usage of red and black; baselining; and the relative size of the characters i.e. who is portrayed significantly bigger or smaller that real life relative to others. Not discussed there but obviously of central importance is the nature of the family activity and the affects portrayed by the drawing client. 

This next area involves pieces of the drawn picture that are missing. These include drawing everyone in the family drawing with no faces, hands, or feet, or having drawn no people at all. The constriction of colors to the use of only one for the drawings turned out to be clinically associated with these missing pieces as well.

As mentioned in the previous post, for evaluative purposes I went back four years prior the study and pulled out all the 5 – 8 year olds, producing an N of eighteen 5 – 8 year olds. All these cases save one produced the three drawings requested. The family drawings as a whole produced previously unregarded and completely unanticipated results.

Out of the eighteen, they included:  

Four who drew characters with no faces, hands, or feet

Four who drew those with no hands or feet

One who drew no people at all 

Four who used only one color (three of them included among the three types above)

Note: Using only one color is associated with perfectionism (look up on Google). At the time these cases were being seen, the significance of one-color usage was not recognized, but neither did the broader problem of obsessiveness and its various sub-categories receive fair due either. The data above was the result of research for this post, and not particularly noticed at the time of services.

The question then became what distinguished these ten cases clinically from the other eight.  What follows are brief case summaries, as might appear in a chart of the ten.

No faces, hands, or feet  

#1. 7 year old 1st grader; parents divorced 2 years; mo. in custody; father ? depression, acted out; client is dysthymic, occasions of aggression, ?ODD; 2 older bros. w/Aspergers; mostly conjoint process with later split sessions, initially mother and all three boys, later just with client; father never involved; 72 sessions, over 2 1/2 years; mutual term, much better, normal functioning

#2.  7 year old 2d grader; fa.?bi-polar w/ family history, aggressive, suicide gesture w/ gun; mo. situationally depressed, marriage in trouble; pt. ? OCD/ODD or RAD, but no family history suggesting the latter; poor social skills, rocking, hard time with directions, obsessive, easily agitated and reactively aggressive; IEP at school; also drew with one color; 8 sessions, split session format; did not respond well to tx, difficult to have him focus; unilateral termination; likely getting psychiatric eval.

#3.  8 yr.old 3d grader: both parents professionally successful, Ivy League bright, depressed; fa. w/ culturally-based belief that depression is moral failure; mo. situationally depr.; pt. non-compliant, easily irritated, situationally aggressive, soc. probs, ODD(?); drew w/ one color, playful but no faces, hands or feet; two processes a year apart, seven conjoint and six split sessions each; doing much better at term., significant gains; pars pulled out, unanticipated unilateral term, but kid picked up soc. skills, more extroverted, prognosis good

#4.  6 yr old 1st grader, adoptee from eastern Europe; obsessive, perseverates, falling behind in school, OCD-type, can’t stay on task at school, takes up “80%” of mo’s time; adoptive father tech exec, mother homemaker, both OK; Picture of self included two sisters and “another kid” hanging on a playground jungle-gym type apparatus, no face, hands, or feet; ten sessions, conjoint process; showed good progress during #s 4, 5, 6 and 7, then mother’s mother suddenly died at home in Northwestern Europe, process interrupted for a month, came back, client regressed, started to pick up again; the tenth session ended the school year, mother and children returned to Europe; cancelled Sept session; unilateral termination, got the sense they were pursuing an OCD eval.

No hands, no feet             

  1. 7 yr. old 2 grader;  Pars separated, going through divorce, both OK mental health, fa. may have had OCD in family history; child reported perfectionistic, hyper focused; since 6 1/2, has rapid escalation of OCD-like symptoms, irritability, uncommon aggressiveness, i.e. throwing rocks a classmate in a pique, and adamant non-compliance at home; in assessment, he was nervous, fidgety, but made an effort; drawing picture of family was almost tortuous, all in black, dividing page into four squares, the X-ing out each, flipped paper and did the same thing on other side, except drawing his father in the last, bottom right box with vaguely angry look, no hands, no feet, all evidencing seriously contradicting self-directives beyond the youngster’s ability to manage;  conjoint process w/both parents, client active and involved, showed nice improvements over sessions 4, 5, 6, increasing and sustaining; went for psychology group OCD eval resulting in dx. of PANDAS and Lyme Disease, and they took over treatment; mother later wrote re: finishing co-payments, said progress was slow, up and down but overall getting better.

 2.   8 yr.old 3d grader; marital conflicts; fa’s parents divorced when young, hasn’t seen father or 25 years, OCD in his mo’s family; evidencing OCD-type behaviors, ritualistic, hyper-focused, considerable anticipatory anxiety, easily irritated, memorizing license plates, recognizing and naming people by their plate numbers, as a toddler could roll toy train wheels on his palm for long periods of time, etc; family pictures bright, big yellow sun, colorful, no hands, no feet; conjoint including older brother; 30 sessions over a year, mutual termination; modest gains,  improved in areas  w/some cycling back and forth; more social, stabilized school performance; probably heading for OCD eval.

3.  8 yr. old 3d grader; father OCD, off-on-off meds, depressed, caustic, agitated w/son when fa. was off meds, not recognizing own behavior at the time; mother stressed, marital probs; client defiant, aggressive, interruptive, controlling, bit perfectionistic, ?ODD; fam pic. characters indistinct, no hands, no feet; 21 sessions, modest gain w/ compliance, fa. stayed on meds, social, school perf. better, case looking long term; headed for ADHD eval.  

4.   7 yr.old 1st grader; ? RAD/PTSD; parents divorced when two years old, live in rural area, mother in a commune, father re-married with two step-children about clients age; client mostly with father but parents basically split care; huge child for age, more height than weight but has both; multiple concerns about boundaries, often casually acting like none exist, occasional bursts of anger the might include throwing rocks, pleasant when not limited, multiple behavior issues, “management problem everywhere” as per father; both parents report their own self-control issues as younger parents, fa depr., aggressive, mo. alcohol, boy lives with fa more; family drawing immature, no hands, no feet, all black, both parents smiling, he’s not in the picture; conjoint involving several family members over three generation; began living more with the mother by agreement of all three, mo. reduced alcohol; started getting better reports all the way around, including school via school counselor; had ten sessions, took off summer, cancelled just before school began.

No people at all in family picture:

8 years old, 3d grade; Family of three, father in business, mother at home and volunteers; client dx. w/Aspergers, no previous treatment; obsessive, perseverates, dropping school performance, only one friend, out of 3d grade social loop, does self harm, other symptoms of depression; mothers sister died suddenly a year before process began, client responded by carrying a large clock 24/7 for a week; OCD in mo’s family, probably depression in father’s who chose to not participate; picture of family was a bowling alley, ball scattering pins, family member’s names on an alley scoreboard, all in nice detail, yellow lanes, blue scoreboard, and black ball and pins, no people; picture of self was a pool game with numbered balls, a cue held by a hand on an odd, wavy non-table surface, almost like a small bay;  69 sessions, conjoint with mother over two years, significant progress all the way around, 5th grade started well.

Use of One Color

6 1/2 year old girl, 1st grade; father corp. exec; mother job shared in retail management; fa. no mental health history, mo. MDD as adolescent, two recurring episodes since, controlled with medication; family referred following traumatic event on playground w/ badgering autistic child; ?PTSD, initially seen as anxiety manifesting in a number of daily routines, phobic, obsessing, controlling, aggressive when distressed, could be early OCD (said now in hindsight); mother’s level of expectations, constancy, and persistence also suggests her own  perfectionism; three drawings each one color, light purple, pink, then brown, drawing with no faces, family members sitting watching TV; conjoint process; 15 sessions; considerable settling at home yet still mixed results, some problems emerging after others subsided, worked on accommodation/assimilation, particularly with mother; +50% results; parents comfortable w/ direction; mutual termination.

Client Likely Dx. Summary

6 OCD-like

1 PTSD, (evidencing possible OCD onset)

2 ODD

1 RAD

Family Histories

5 OCD in parent or in family history

2 with one parent dx. Bi-polar

1 MDD

2 Basically negative

In contrast, N = 8 Diagnostic Summary

Client

1 Autistic

3 Adjustment w/Anxiety

3 Adjustment w/Depression

1 Adjustment w/Behavior

Family 

5 divorced, or separated and filing for divorce

2 Significant marital problems w/paternal depression

1 Marital problems w/ ?OCD mother, ?depressed father

The disparity in parent’s marital status between the “obsessive” group of ten cases and the other eight is notable as well. Of the OCDish group, three set of parents had divorced, and the other seven marriages were intact. Five of seven marriages were reporting marital distress, but none appeared to be threaten the marriage itself. Within the other eight cases of the affective group of clients, though, two were divorced, four were separating and in the process of divorcing, and two marriages were intact. One of those last two were adoptive parents. Only one of the eight cases involved natural parents whose marriage appeared to be intact and functional.

The most obvious interpretation is the affective stress of marital dissolution on the child. That event is not necessarily the precipitant of the child’s mental health issues, but rather a driver into treatment that serves to bolster the child’s coping mechanisms. The question left is whether the existence of cognitive disfunction of a child acts as a relational binder for the parents. Of course, the differential findings within this small sample may not be statistically significant, but they are intriguing. For the parents of the cognitive group, the child therapy process implications lean toward parental learning and experimenting rather than correcting. With the affective group, the parents may get a recommendation to seek marital counseling – I did not do that very often – but again, the process focuses on growth and coping with considerable reinforcements, particularly those that are random. The marriages that heal may be those who take sincere random reinforcement to heart.

Heart v. Brain

Note: The following information is largely taken from the article “Yes: The Symptoms of OCD and Depression Are Discreet and Not Exclusively Negative Affectivity”, by Katherine A. Moore and Jacqui Howell, published in the Frontiers Of Psychology, 5/2017. 

In their review of the research comparing depression with OCD, Moore and Howell made several points about the similarities and differences between these two major clinical categories that are germane to these particular findings concerning the 5 – 8 year old clinical population. While the differences between the two are clear and clinically relevant, ultimately in treatment some of the core interventions effectively used with the depressed can be equally effective with the “obsessive” of OCD-type client.

Citing earlier research by Steketee (1993) and others, the authors concluded that OCD is fundamentally a disorder of disturbed cognitive processing, and not a mood disorder. Several streams of thought are used to make the point.  For example, Moore, et.al. state that while “OCD positively predicted depression within the OCD population, depression was a negative predictor of OCD…These results support the hypothesis that OCD and depression are discreet disorders. (Moore and Howell)” In other words, OCD individuals often get depressed, but the depressed seldom develop OCD-type symptoms, all creating a significant etiological separation. 

While “disturbed cognitive processing” is a clear descriptor, an overarching descriptor for all those disorders that involve emotions and behavior does not seem so readily available. Assuming human affect management difficulties manifest into behavior problems as well, perhaps ‘affective management’ 

Quoting the authors again, “High negative affect is composed of a wide range of factors, including fear, nervousness, anger, guilt, hostility, sadness, loneliness, self criticism, and self-dissatisfaction”. Negative affectivity is found in both OCD and depression; both generate mental health and coping problems as a result of mounting negative feelings about oneself. The difference is in how these emotions are processed.

The authors cited research that found depression was linked to inward but not outward aggression, presumably allowing for the uncommon outward aggression under extreme circumstance, i.e. “blowing up”. Depression is linked with “intro-punitiveness”, or inner directed hostility. On the other hand, they cite theory and supportive research that asserts OCD generates external aggressions when the levels of negative affect about oneself are high and one perceives external threats to their being, usually off-based. 

Among other applications to casework, this manner of OCD reactivity also explains the often bewildering aggressiveness of an upset youth who fits the diagnostic criteria for Oppositional Defiant Disorder. Which leads to the question of what characteristics and diagnoses fits into this area of ‘disturbed cognitive processing’. The term OCD is not an umbrella.

Paradigm of Obsession

In going through the chart notes of these ten young clients, several behavioral descriptors appeared multiple times. In emotional terms, they were feeling the negative affectivity of anxiety, insecurity, tenseness, and/or helplessness. Those are almost taken for granted in a children’s mental health office. Each one also exhibited obsessiveness, perfectionism, ritualism, and/or perseverating. As a group, they included likely diagnoses of OCD, ODD, Aspergers, and RAD. Are these four broadly linked in some disorderly cognitive processing way? 

Treating ODD was a specialty in my practice. The parents’ presenting problems were generally affective in nature, plus behavior management, more the former than latter. The work was more successful than most, hence the referrals, but probably still 10 – 15% less effective than the rest of my practice. OCD did not enter the clinical equations, and obsessiveness in general was seen as a behavior issue. 

The treatment was conjoint as much as possible. In that setting, a considerable amount of clinical energy toward the client was focused on the understanding of others’ thoughts, feelings, actions, and the client’s own reactions to life, the latter of which obviously included ODD patterns and outbursts. Self-understanding was seen as the byproduct, and not the central theme. Outside of reinforcing the opposite behavior, which was rife for these cases, behavioral work was done only on an as-needed basis.

That a young client had negative affectivity was presumed. A desired baseline outcome always involved lowering the negativity, both toward self and others. When evident, aggressive outbursts in response to losses, limit setting, and senses of deprivation were included. That the externalized aggressiveness generated by self-negativity was an OCD characteristic is new to me. Thinking of ODD as a cousin to OCD is also new, but the notion satisfactorily explains a whole lot. These kids do get obsessed, hyper-focused, some probably perseverate could on one  or another activity of life, in the next instance become purely chaotic, and in the aftermath with little cognizance of that paradox dwelling within. Paradox is not their forte; black and white can be more descriptive. ODD belongs in this broad category of disturbed cognitive processing.

The Asperger’s boy in the study had rituals and obsessions, not many, but enough that their disruption could cause a stir. Two other Asperger clients, a boy and a girl and both sixth graders, were seen for 30+ session treatment processes over the last few years of the practice. The boy clearly had obsessions that could pose serious social trouble, and the girl had interests in nature’s phenomena that were often preoccupying to the point of disappearing. As with the client in the study, both did well. Some kind of connection with obsessiveness exists with the Asperger’s cases I saw, but not to the point of being subsumed into OCD. Still, they do have cognitive processing issues and may belong in this paradigm.

Comparing basic outcome data between the ODC-like group of ten to the emotionally troubled group of eight, both groups averaged close to 20 sessions. Most cases were done prior to the study, hence not rated for gains made. My guesstimate is that the cognitive group’s overall outcomes were about 15% lower. The corresponding fact is that I was less knowledgable about their treatment needs compared to the more common ‘depressed’ group. 

RAD’s diffusion of maladaptive personal, familial, scholastic, and social behaviors that include externalized aggressions of one sort or another an can be dangerous to one degree or another seem obsessive in their persistence in spite of the meaningful attempts to connect of others. The diagnostic label suggests the affective etiologies of PTSD and major loss, but I do now wonder about an underlying kind of obsession for connection with little skill to do so?

Implications

To the degree that this correlation between a child’s obsessions and the dearth of detail on their drawn human figures is significant, some kind of explanation that could lead to enhanced clinical treatment would be helpful. One is offered here, fairly concrete but at least a place to start. The fact that this age group operates on a cognitively concrete basis may lend some support. 

The basic idea is that as the child’s preoccupations with rituals, hyper focusing, and rigid ordering absorb their small worlds, they lose sight of the broader social world.

Concretely, they can’t envision the important details of what constitutes another person. The portion of meaningful inter-personal engagement that leaves impressions is bereft. Two kinds of therapeutic actions come to mind. One is a slight alteration to the child assessment process, and the other is to incorporate a bit more drawing into the individual therapy process with the child, starting in this assessment itself. 

Virtually always, the presence of obsessiveness behaviors among a child’s pattern will be disclosed during the intake with the parents. In anticipation, I could have changed the sequence of drawing and have the child draw a picture of themselves first, the picture of anything they wanted to draw second, and saved the family picture for last. If the child leaves out features, then guide them to do fill in, starting with themselves. Then perhaps help the client pick out affects for each family member, and if needed, help them with their depictions. Then they could even develop a story about a family experience or adventure, and draw in a background. If the child is OCD-like, is accepting of me, and is invested in the drawing, this clinical intervention will begin to expand their sense-of-other, and set a precedent for doing so later in the therapy process. The problem is that the parents won’t see the unadulterated family drawing, but that’s a trifling matter.

The second approach is to incorporate drawing into arranged individual time with the client during one or more sessions. The process could also include some kind of gently guided story-telling done by the client, including the creation of facial expressions, activity, and movement. That may distract from the conjoint process, but again, if other-awareness is enhanced, missing some conjoint time is a worthy sacrifice. Or perhaps his or her drawing and story-telling could be incorporated into the conjoint process itself.

Other Points About Family Drawings:

These are common observations that were usually of interest to the parents.

Size distortions – I think these are usually the product of children under 5, and not seen much in 5 and up. They do have significance, but the clinician almost necessarily has to have parental input to determine what might be driving the new client to do so, personality or experience. The clinician’s role is to help determine if anything needs to be addressed, or if whatever the meaning to the child may be will simply dissipate with age and maturity.

Missing family members –  Separated parents, one or both of whom are in another relationship, can complicate this drawing for the children, particularly true if either or both parents have homes with children of the parent’s new partner. In my experience, the kids didn’t ask me something like ‘which family to draw’, so they went ahead and drew what they felt was their family, as per the instruction. If concerns arose on my part, again this would be addressed with the parent(s). 

Extra characters beyond extended family members  – uncommonly occurring altho that did arise here. The boy who drew an additional ten characters was the child previously diagnosed as RAD. He was certainly acting out, could be violent, scattered in his verbal interactions, impulsive, and socially inept, but the family history was negative for disturbed, chaotic, neglectful and/or abusive parenting. The identified problem behaviors did suggest an RAD-type picture, so his family drawing was intriguing, again in hindsight.

“No friends” came up three times in this cohort, not really surprising given the self-absorptions involved. That social state is often poignantly painful for the parents, and can bring out a depth to their individual and sometimes relational pain. Working toward an improvement to that parental sense of responsibility, feelings of guilt, or, sadly, blame on the spouse. The parents are apprised of that. “That must be difficult for you” is an easy entry point.

Picture of Oneself Doing Something

Again, the function of these drawings in the context of their assessment is threefold. First is to gather evaluative information in the anticipation of the following summary-and-recommendations session with the parents. The second is help create an atmosphere of familiarity and hence comfort for the new client. and the third is to facilitate the clinical relationship with the child by being there observing and interested, asking the occasional question, and remarking positively on what they have accomplished.

Because drawing is a major communication medium for a child, almost all these new clients are comfortable and even excited at the prospect. That helps with the development of trust and a clinical relationship, and the drawings add to clinically relevant information. The vast majority of these young clients were unhesitant as they began these drawings. At least in theory, their ease could be attributed to a normal child’s use of drawing at an early age to communicate with others. The child usually discloses to the parents about their drawings on the way home with some vigor, which helps the parents’ trust grow. The artwork is also a medium of reporting to the parents in the summary-and-recommendations session. Because of the latter point, I maintained an observer’s posture during the drawings.

The particular tendency to have missing bodily features continued into the self drawing, and thematically the second was usually a continuation of the family depiction. Coloration tended to be brighter and the pictures a bit more playful, their expansions presumably because they were getting more comfortable.

Picture of Anything

These drawings of the client’s choice were usually the most animated. By this time in the exercise, the youngsters are more comfortable and willing to spread their wings, so to speak. The contents run the gamut from space battles to gliding underwater. Unfortunately, as per the demographics of the practice in general during the last few years, the drawings are almost all by boys. With a couple of exceptions including the 6 year old who struggled to get much of anything drawn in the family drawing and couldn’t/wouldn’t continue, the artists were eager to narrate their stories.  The reactions, explanations, and color commentary by the parents in the next session helped lead into discussions which in turn led to treatment plans. 

Please remember these are almost all OCD-type clients. Examples of their work are as follows:

A 6 1/2 year old boy narrated his ‘anything’ picture as he drew, describing the volcano that was spitting out volcano balls (red fireballs) with two characters below, one of whom was doing flips because he liked volcanos and the other who tried to get into the volcano and “was spat out on fire.”

A family having dinner at an outside table with father cooking nearby at an elaborate grill that he made himself.

A space battle between good guy ‘Lightening’ and bad guy ‘Storm’ , shooting lightening bolts at each other as the good guy smiles and the bad guy frowns

A high school football field with bleachers by a boy who watches his older brother play in real life and he wants to play football too when he gets older

A space monster eating a spaceship

Swimming low beneath the surface with hair flowing and a big smile

A long squarish building with windows, an outside table, and a chair as smoke came out of chimney, no people, a picture with which I associated an Eastern European barracks out of which the boy was adopted. That attuned most precisely to the parents’ spoken concerns about loss and possible trauma.

The last one is example of the clinical material that can be generated by any one of these pictures. The drawings of ‘anything’ probably generated the most discussion with the parents in the next session.

Observation About The Drawing Exercise…In Hindsight

The pattern of the clients moving from a relative conservatism in the family drawing to a lighter, more artistically expressive picture of themselves, and then on to a more elaborative and sometimes narrative picture of whatever they wanted to draw was intriguing. This tiny bit of growth as they swept through these drawings could be seen as evidence of a burgeoning competence and independence, in a way a normal evolution through a new situation.  Half of the ten in the obsessive group demonstrated this progression, as did five of the affective eight.

Whether this represented a pattern or was a random novelty remains to be seen, and then the problem of meaning would need to be addressed.

Recognizing and understanding patterns of clinically relevant change, particularly those involving clinical gains, is a core element of developing and continually improving a therapeutic process. To recognize a pattern, obviously one has to notice, and this I did not until reviewing the charts of these eighteen  6 – 8 year old clients. As inferred earlier, I didn’t notice the relationship between missing identifying bodily features and the use of constricted coloration with obsessive young clients until now. Would that have made a difference in their treatment had this been known? I think absolutely. To spare myself, the number of times 5 – 8 year old children with obsessive concerns were seen for an assessment over the thirty year course of the practice may have been as few as 3% – 4% of the thousand children seen. An N that large would likely be needed to validate a significance. To be honest, though, I’ve used patterns to notable effect with lesser N’s. 

Other Evaluative Tools

The analysis of this OCD-ish group leads to the notion or hypothesis that a young child’s obsessiveness detracts from the development of other-awareness, something that can be addressed systematically in either individual or family therapy. Understanding of the ‘other’ was an intrinsic element of this therapy process, and did help with increasing a sociability that would have – almost surely did – reduced obsessiveness. If the clinical work facilitated the sociability of a client, i.e. having friends, the total obsessiveness would decrease if for no other reason than less time alone. Six of the ten in the obsessive group show social improvement, and two others began to evidence a progress in that direction before terminations in less than ten sessions. The following evaluative tools leant to that kind of process.

Note: Most commonly, three of these four evaluative aids were commonly used per child, two if the depression-anxiety inventory was used. Which ones were a matter of choice at the time. The feeling identification was used more often during a family session. The Talking, Feeling, Doing game was occasionally used asa regular activity during an individual therapy.

The Depression-Anxiety Inventory, Etc.

The depression-anxiety inventory, self concept scale, and ego development scale were occasionally employed with clients under 9 if need existed and the child’s capacity to do so having been demonstrated. The socio-moral was used very sparingly with this age group, and even then much later in the process. Perhaps this was underestimating the child’s objectivity and the parent’s faithful tolerance, but the Heinz Dilemma’s content of cancer, penurious insensitivity, and subsequent stealing seemed a bit much. 

The Feeling Identification Exercise:  

“OK, so there are five basic feelings that everybody has. It’s what makes us human. I’m going to ask you to name them, and what I’ll tell you is that you’ll be able to name three of them, you might be able to name four, you’re not be able to get all five, but I’ll help you.”

(Arguably) the feelings are happy, sad, angry, scared and guilty. Through the entire age range of the clientele, a large majority would identify happy, sad, and angry without difficulty. A handful of the thousand child and adolescent clients could not identify anger either. Maybe 7% – 8% would list “scared”. A very small number were able to identify “guilty” as well.

More often than not, this exercise was saved for some fitting moment in the first three therapy sessions (fourth, fifth, and sixth overall), but for younger clients I sometimes  to do this with them in the assessment. When we got into doing this in the first or second family session, I’d tell the youngster to let the others guess. Knowing something that the others didn’t would set them off into smiles and sometimes laughter as the others in the family struggled…and the others did so, just like all the kids.

The exercise also prepared the client for one aspect of being interviewed. If I asked a client how they felt about something that happened, and they answered “Well, that just wasn’t fair”, I would say “Well, I understand, but that’s not a feeling, so try it again and think about those five feelings.” Kids would catch on quickly, and that helped with both the maintenance of focus and pace of discussion.

Toward the topic at hand, this exercise may have a clinical value beyond facilitating the therapy process in and of itself. Developmentally, the basic personality is in place by age 5. Some standards say age 2, others later, but a general consensus is certainly by 5. They have moved beyond parallel play and are now engaging in friendship play in all its joys and struggles. Certainly by age 8, their social thrust is toward fitting in. The obsessive sub-population of 5 – 8 year olds is clearly struggling with this developmental task.

Where the statement “everybody has these five feelings…it’s what makes us human” is already presumed by most kids this age, for obsessive-type kids this may be an entirely new concept, i.e. “I have these feelings (they now know this as a result of going through the exercise) and everybody else does too, so, I’m kind of like them (and we know “…kind of…” is true), but this education is step by step. Plus, the exercise emphasizes an undeniable universality; this is being human, and wedges that door of other-awareness just that bit more.

Story Telling Using Blocks

A local Starbucks was selling small boxes of eight randomly shaped blocks, presumably for  caffeinated table entertainment, quite a few years ago. I bought one for office to use with younger clients, and found they were intriguing to kids. In short order, this became the basis for another evaluative tool.

“So, what I’d like you to do now is to make something out of these blocks, anything you want, and then make up a story that uses what you created, or use the blocks in some way to tell the story”.

A Rather Notable Example

This is the first time I’ve met with Joe, a young 7 year old brought in by parents with concerns about ADHD, anxiety, compliance, and a tendency towards obsessiveness. Joe came in quite willingly, very chatty, very friendly. He asked a lot of questions initially, lot of facial expressions. He seems to grasp concepts reasonably well. He also seems to take off in any direction from one particular topic and can get very tangential. He may have difficulty picking up on conversational inference. Eventually he acknowledged that he was here to “chat about school and how it’s going”, and then went on to say that school is good. In doing so, he went through an entire day’s schedule. I asked him if he had problems at school, and he replied “Can I think about it” and then talked about a reinforcement system they offer at school and then said “No, I don’t have any problems at school”. He has the ability to come back after excursions elsewhere. I explained what I did here and he then immediately started talking about a poorly behaved kid in school, so he seemed again to understand basically what was going on here, but had a hard time making reference to himself.

He does acknowledge the problem at home as far as bedtime is concerned and claimed he has a hard time falling asleep and is afraid of bad dreams. That would fit in with the overall picture.

I had him do the standard series of drawings. The picture of the family doing something was of a restaurant that was complete with tables, chairs, plates, wine bottles, windows, chimney, smoke, clouds, a sun, but no people. He used brown, blue, orange, and some yellow.

In the picture of himself doing something, he drew a picture of a playground with his two sisters on a piece of playground equipment and another unidentified kid beneath a slide, along with clouds and trees. He used gray, green, red, and brown. There are no facial expressions, no hands, and no feet. It was a nice picture with the exception of lacking of any sort of facial expressions and a somewhat young stick figure presentation.

Lastly, I had asked him to draw a picture of anything he wanted, and he drew a picture of a house with beds, a window, table, chair, smoke coming out of a chimney, and no people. It seemed mote like a barracks and it did make me wonder if this was some version of the place he lived while waiting for adoption in eastern Europe.

I then had him do the blocks and story telling. He initially made a path. He said the paths are for walking on. If there are no paths, you will fall down and not get a present.  And then he went into a functional description of paths which was very good itself, but didn’t tell a story. He then reconfigured the blocks and said it was a dragon in a faraway land, and inside the dragon was an egg and it popped out and then there were apples and then “it grewed up” and then the mother dragon said “You will have to find another dragon” and he found a girl dragon and “there was lots of fire in her tummy” and then there were more sentences about the experience of having a baby, and then there “was a big fire” and then “The End”.” The picture suggests some attachment kinds of issues, in addition to the apparent obsessiveness problems the parents had described  that may be worth talking over with them the following week. And ask about the dragon.

The activity is another way to acculturate the young client toward an expressiveness that aids our understanding of them during treatment. Ongoing issues can be highlighted and marked for clinical attention. As importantly, more elaborative material becomes available for the summary-and-recommendations session with the parents.

Again beyond an aid to the budding therapy process, this activity is also a lesson in parenting, one that emphasizes the interest that their child can generate with their own (probably special) creativity, and in doing so support and reinforce this perhaps developing ability. 

Matching Affects with Situations

Sometime in the early 00’s, I ordered two therapeutic games for young children on the spectrum from ChildsWork/ChildsPlay Inc. “The Understanding Faces Game” offered forty pictures of different children’s looks representing the gamut of feelings and circumstance. The child client’s task was to interpret the look. In the second game, “What Did You Say?”,  sixty situations that a child might encounter were posed, and the child’s task was to act out how they would react if they were in the situation. For example: “It’s pouring outside – what do you look like?”; “Your family is going on a great vacation – what do you look like?”;“You went to ride your bike but it has a flat tire – etc.”; “You are going to a new school and you don’t know anyone – etc.”; “You are staring but you don’t like what’s for dinner – et.”; You are worried about what to get your mother for her birthday – etc?”.

Neither game would be particularly helpful with my clientele, but when combined, they created a great game. I would distribute ten “Understanding Faces…” cards to each of us. Then one by one, I read ten of the situation cards. We would each present the Faces card that would best fit the situation, and decide between us whose card closest fit the presented situation. That card was then collected, as were all the rest, leaving us with nine cards left. Usually, the Faces cards between us would offer some reasonable facsimile of an appropriate response to the situations, and I would make sure both of us were in the game, the client ahead by one or two. The game ended with absolutely ludicrous faces for the last situations, and between the two of us we found these instances really funny. 

After talking about the presenting problems, what they thought and felt, how they impacted the client and family members, etc., just to establish the purpose and baseline of the process, the assessment sessions were really not particularly “heavy”. By this time the young ones were usually pretty comfortable. Having a game experience that offered the ridiculous humor kids this age generally adore is like icing. 

This exercise very directly works to expand other-directedness. 

The Talking, Feeling, Doing Game 

This is a board game designed by Richard Gardner, a well-known child psychiatrist in the 70’s and 80’s. Each participant moves their along a track with a roll of the dice. Most of the squares along the way are marked Talking, Feeling, or Doing. The player gets a chip if they answer the to the question posed by a card corresponding to where they land. The player who has the most chips when the game ends “wins”.

Examples of Talking cards: If you could make yourself invisible, what would you do?; Suppose two people were talking about you and they didn’t know you were listening – what would they say?; If you had to be changed into someone else, who would you be?

Feeling cards: What’s something you could say that could help a person feel good?; Tell about

 a time when your feelings were hurt”; Name a person you love very much. What does that person do that cause you to love her or him so much?

Doing cards: Act like a grown-up; Act out what you could do if you had magic powers; Do you believe there really is such a thing as magic?; Make believe you’re playing a musical instrument. What instrument are you playing. Why is it important to practice?

For the most part, the game was used during individual therapy sessions. One option was to have the family play during a session, but that was infrequent. rare occasion. This exercise was done if time remained in the assessment session. For this age group and regardless of their tech skills, the game does have a kind of timelessness, the questions are universal and non-controversial to most anyone, are educative, and can provide another source of assessment data to use with the parents. 

Having some option of this nature is helpful a child therapy setting, if for no other reason than the kids are interested in the clinician talking about themselves. For these particular clients with obsessive and isolationist tendencies, the give-and-take of interactive exercises like this directly promote other-directedness. 

One other factor to point out is that most of these young ones were not apathetic, displeased, negativistic, or in other ways avoidant in doing these evaluative tasks. With the occasional exception like the “RAD” child among this group of ten, a diagnosis that was to me dubious but nevertheless descriptive, they were active, reactive, interesting, interested, and capable smiles and the occasional laugh. All but two of these ten clients did show improvements in their behaviors and sociability, some just beginning on that track, but also some who showed  improvements to the demonstrable point that therapy was not needed, the parents wold manage. For OCD, this process may not have been everything, but clearly contributed.

Session’s Conclusion

Finishing the session was fairly simple when compared to the 9-and-up population.

The first question is “OK, so do you have any questions that you’d like to ask me?”

For the most part, the youngsters would shake their heads. “Am I coming back here?” was most common. Occasionally they might have a personal question which would be answered with a friendly dispatch. Rarely would they have clinically oriented question. Part of the reason for asking the question in the first place is to encourage asking questions.

The second question was: “So, I”m seeing your parents next week. Do you have any questions or concerns about that? “

Usually they would shake their heads again. The most common response, itself not very frequent, was: “What are you going to say?” The question about what I’d say led directly to the last point. 

The review that might take from two to four minutes began with a quick summation of the presenting problems and anything else in that regard that the client brought to my attention. Scanning the session notes while talking, something about the impacts of the problem upon the client would be covered. At least a couple of points about the clients strengths that were evident during the session itself, those that they could or would recognize as being a positive, were standard, necessary elements. Lastly, a reassurance, something like “I think I can be of help with the problems, and I’ll be talking with you parents about that, too.” And that would be it.

Harkening back to data mentioned in the previous post, two of the original 58 cases in this study dropped out after only that initial meeting with the parent(s). No cases dropped out after the client assessment appointment.

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