COPING WITH TRAUMA IN THE SCHOOL SET UP



In 2001 when the 9/11 attacks took place in USA, most of us were glued to the television sets, not realizing that our children who prima face seemed involved in their play were a witness to the trauma and were being affected by it. It mattered little that the incident took place in a different continent, miles away; the trauma was experienced by everyone around the world, including children. I have treated many children and adults alike after the earthquake of Latur in 1993 or more recent still 26/11 in Mumbai and the German bakery attack in Pune who were emotionally suffering after the traumatic terrorist attacks. But one of the most striking of them was this because we often think that a toddler who seems to be engrossed with his play is unaware and thereby immune to such events in our lives.

However, it is a well researched fact that stress is transferred from parents / care givers to children. They may viscerally transmit their own feelings of anxiety, rage and helplessness, and in doing so, colour the child’s internal model of self and the world. When caregivers are threatened or frightening, the intentional human to human quality of the trauma causes more severe negative consequences for the child than trauma from accidental causes (for example, a flood, fire or injury). In truth, however, all trauma may engender feelings of victimization, loss of control, despair and hopelessness and beliefs that the world is unsafe and life unfair. Young trauma victims often come to believe there is something inherently wrong with them, that they are at fault, unlovable, hateful, helpless and unworthy of protection and love. Such feelings lead to poor self image, self abandonment, and self destructiveness. Ultimately, these feelings may create a victim state of body mind spirit that leaves the child/adult vulnerable to subsequent trauma and re victimization.
In my next group Play Therapy session I saw to the trauma unfold itself. Rohan, 2 years old was a toddler having difficulty adjusting to the play school and was referred to me by the play school. He had been coming to me for the past 2 months and was gradually transferred to group play therapy sessions as he was now seemingly adjusting to the school. That day I was shocked at the emerging theme in the play session. As usual the 5 children assembled on the mattress and removed individual toys to play with. Shilpa started playing with blocks. Suddenly Rohan who was playing with an aeroplane and was keeping an eye on that Shilpa was making a tower; ran towards her with his hands outstretched and banged his plane on the tower that she had made and breaking instantaneously into hysterical laugh once the tower fell. Tears filled Shilpa’s eyes and she started crying softly while the others looked on. I was surprised by Rohan’s behavior as he had never in the past shown any signs of aggression, usually keeping to himself and playing with his cars / aeroplanes. I encouraged him to verbalize what he was playing and he referred to the bombings of the twin towers.

Play is a very powerful and natural medium through which children communicate. What happened in the group play session was an enactment of what the Rohan was observing around him. Enactment such as this helps children to understand the complex world around them. It also helps them to grasp and cope with difficult emotions of elders as well as their own reactions. In play children feel safe enough to demonstrate all this as it is an indirect manner of communication. Play session also helps them to work out their emotions and replace some with more constructive manner of communication. Instead of reprimanding the child (as usually the caregivers do), the play therapist attempts to understand the play and communicate the same to the child. This helps him to develop a thinking awareness about himself giving him the possibility to choose his actions. The failure of caregivers to sufficiently protect a child may be experienced as betrayal and further contribute to the adversity of the experience and effects of trauma. Traumatic stress may be transmitted by parents to their children.

School Principal and teachers play the role of care givers in school. Their function therefore goes much beyond the traditional belief of imparting knowledge or looking after their physical safety. Incident such as the recent attack by the MNS workers on the principal of DAV school can be quite traumatic for the children. This is especially true when the conflict is against the authorities (caregivers/ teachers / Parents) who are supposed to look after them. Children’s sense of safety both physical and emotional is thereby severely disturbed. If this is an ongoing conflict, the disturbance is more; effects of which mimic those of children of divorce. Those who are not addressed directly by the caregivers and kept in the dark face greater stress. Their curious minds seek information available through grape vines and media, leaving them more confused, misinformed and feeling disoriented. When the caregivers, in this case the principal and teachers directly impart information about the incident and address their anxieties, it reinstills faith in the protector’s ability to safeguard the child. Schools need to think along these lines too along with the safety drill. Just doing the terror drill without providing the emotional support needed by the topmost schools leaves a huge gap in the holistic development of the child.

Posttraumatic symptoms may encompass one or more of a broad range of behaviors, including the following:
§ Difficulty sleeping, eating, digesting, eliminating, breathing or focusing
§ A heightened startle response and hyper alertness
§ Agitation and overarousal, or underarousal, withdrawal or dissociation
§ Avoidance of eye contact and/or physical contact
§ Terrified responses to sights, sounds or other sensory input that remind the child of the traumatic experience(s),
§ Preoccupation with or re-enactment of the traumatic experience
Reestablishing safety or creating it for the first time involves setting up an external structure that provides a predictable, consistent routine for a child/youth and making sure their basic physical, emotional and social needs are met. Thus having their normal school routine is crucial. This also means to pay emotional attention to the individual child’s needs and allowing them to express their emotions in an appropriate manner. This could be done by the counsellor or a professional play therapist in group therapy sessions which could be short term weekend session or divided into 4 sessions spanned over the next one month.
Play therapy plays an important role in healing trauma victims, children use play powerfully to better emote their feelings rather than talk about them. It also provides an emotional distance to the children necessary to express threatening and negative emotions and thoughts. Thus through the use of play, we can reach out to both the younger children and the teenagers alike. Unfortunately this is a language that we as parents and teachers, have long forgotten and need to relearn it in order to understand what our child is feeling to help them.
This play way is used by a therapist trained in Play therapy to help children and parents understand and deal with their thoughts, feelings and behaviours. It aims to increase resilience and self esteem within each child enabling him / her to use this as a springboard to deal with difficulties in real world more confidently and to bridge the communication and emotional gap created by the trauma.

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HOW TO IMPROVE YOUR MEMORY



Ramesh (37 years old) had been coming for therapy for depression for a week now. One evening he came for the session really frustrated. He asked tentatively whether loss of memory could be due to his depression or the related antidepressants that he was given by his psychiatrist. He then went on to explain that he had excellent memory as far as numbers were concerned, so much so that as a child he could remember almost all 49 children’s marks in the class as the teacher called them out aloud before handing over the papers. Yet the previous evening when he had to give his new office number to his very important client he could not just get it right. It almost cost him his contract as the client got offended.

When I asked him when he started noticing this forgetfulness in him, he mentioned that a little before his divorce 3 years ago he had been noticing his forgetfulness but had been too emotionally wrapped up to pay further attention to it. He now realizes that the forgetfulness has been increasing over the years. Initially he thought that he was preoccupied and later brushed it off as a sign of early ageing and even hereditary. But yesterday’s incident was disturbing him.

First and foremost any physical disorder needs to be eradicated. Secondly causal factors as well as the mechanism of forgetting need to be understood. Usually mental decline begins by the age of 40 or 50. However people who are undergoing high emotional stress for an extended period of time also experience these symptoms as early as in their 30’s. Some of the stressors one cannot do away with given the stressful and competitive environment we live in, however we can counter them with certain changes in lifestyle. Health conscious people interested in living quality life introduce yoga/ physical exercises to their routine along with dietary changes. Similarly for mental health one needs to introduce what is called Neurobics in their life, a mental gym. Also contrary to popular belief, the mental decline most people experience is not due to the steady death of nerve cells. Instead, it usually results from the thinning out of the number and complexity of dendrites, the branches on nerve cells that directly receive and process information from other nerve cells that forms the basis of memory. Dendrites receive information across connections called synapses. If connections aren’t regularly switched on, the dendrites can atrophy.

The function of memory is primarily carried out by the cortex and the hypothalamus in the brain. Hypothalamus is the emotional seat of the brain. Anything which is emotionally laden is usually easier to recall, however if there is a flood of emotions it leads to confusion however if this flood continues for extended period of time, it can even cause atrophy in dendrites. This reduces the brains ability to put new information into memory as well as to retrieve old information. The good news is that aging brain, however, continues to have a remarkable ability to grow, adapt, and change patterns of connections. Therefore establishing associations and new pathways for connection have a healing effect on the brain.

The exercise program calls for presenting the brain with nonroutine or unexpected experiences using various combinations of your physical senses—vision, smell, touch, taste, and hearing—as well as your emotional “sense.” It stimulates patterns of neural activity that create more connections between different brain areas and causes nerve cells to produce natural brain nutrients, called neurotrophins, that can dramatically increase the size and complexity of nerve cell dendrites. Neurotrophins make surrounding cells stronger and more resistant to the effects of aging. Also, using multisensory approach, retrieving from the memory becomes easier with a web of associations supporting the matter. More often than not, adults don’t exploit the brain’s rich potential for multisensory associations. Think of a baby encountering a rattle. She’ll look at it closely, pick it up, and run her fingers around it, shake it, listen to whether it makes a sound, and then most likely stick it in her mouth to taste and feel it with her tongue and lips. The child’s rapidly growing brain uses all of her senses to develop the network of associations that will become her memory of a rattle. Adults miss out on this multisensory experience of new associations and sensory involvement because we tend to rely heavily on only one or two senses. As we grow older, we find that life is easier and less stressful when it’s predictable. So we tend to avoid new experiences and develop routines around what we already know and feel comfortable with. By doing this, we reduce opportunities for making new associations to a level that is less than idea. Simultaneous sensory input creates a neural “safety net” that traps information for future access.

Social interactions are also non routine and therefore socializing has similar effect. However we find more often than not that people who are undergoing emotional stress / depression want to be left alone and withdraw from social contacts. Is it any wonder why Psychiatrists suggest going for a walk rather that doing a fitness workout alone in your gym? Going for a walk allows one to experience all 5 senses and also provides the brain with social nutrients necessary to heal the brain.

Here are some of the ways in which you can use mental gym to improve on your memory:

1. Involve one or more of your senses in a novel context.
By blunting the sense you normally use, force yourself to rely on other senses to do an ordinary task. For instance: Get dressed for work with your eyes closed. Eat a meal with your family in silence.
Or combine two or more senses in unexpected ways: Listen to a specific piece of music while smelling a particular aroma.

2. Engage your attention. To stand out from the background of everyday events and make your brain go into alert mode, an activity has to be unusual, fun, surprising, engage your emotions, or have meaning for you. Turn the pictures on your desktop upside down. Take your child, spouse, or parent to your office for the day.

3. Break a routine activity in an unexpected, nontrivial way.
(Novelty just for its own sake is not highly Neurobic.)
Take a completely new route to work. Shop at a road side market instead of a supermarket. Normally, placing a key in a lock uses vision and “motor memory”—an unconscious “map” in the parts of our brain that control movement—which provides an ongoing feedback that allows us to sense where parts of our body are in space. (This is called the proprioceptive sense.)

Neurobics is recommended as a lifestyle choice, not a crash course or a quick fix. Simply by making small changes in your daily habits, you can turn everyday routines into “mind-building” exercises. It’s like improving your physical state by using the stairs instead of the elevator or walking to the store instead of driving.

Ramesh worked on these mental gym exercises for about 6 months and started regaining confidence in himself and also noticed his stress reducing, life feeling more meaningful, increase in interest and involvement in routine as well as novel things and social interactions and in general an elevated mood.

USING PLAY THERAPY TO DEAL WITH ENURESIS (BED WETTING) & ENCOPRESIS (SOILING OF CLOTHES)


Rahul was 12 years old when he was referred for bed wetting (enuresis) and passing stools (encopresis). He was referred by the family doctor who found a non medication approach to his bedwetting and encopresis a better solution, especially considering the long term side effects of the medicines and the fact that there were no physiological causes to his problem.
His problem had escalated soon after they had shifted into this new house. Parents didn’t think that shifting house could have been the reason for the same as he always wanted to shift back to this house. In fact he had many friends here and would initially quickly finish off his homework to go down to play. But soon he started wetting his bed in the night more often and the ‘accidents’ at school too increased.
By the time he started with play therapy, he was regularly wetting his bed in the night and the soiling his pants at least once a month. Rahul was so unsure of his own bowel movements that he refused to go for school trips or for a sleep over at his friends or cousins house. Off late he was fearful of going to school too, as he was now teased for being a sissy boy. At home too, he would play with his play station for hours on end and would be generally. His parents had tried every thing from making him visit the toilet at bed time and before going to school to more frequent visits when outside, but to no vain. Normally an active boy was now unsure and irritated most of the times.
During the case history on enquiring about any traumatic history the parents recalled that just before they had shifted the house he lost his grand mother and around that time the van in which the school children traveled had met with an accident. Although no one was injured Rahul had recounted the incident in great detail. They found it difficult to believe that these could again be the reasons as it was not the first time he was dealing with a loss of a grand parent or meeting with an accident. In fact he had lost his grand father the previous year, to whom he was more attached. Since his grandmother suffered from Alzheimer he hardly ever interacted with her over the years.
Bedwetting is considered to be problematic for children only above 6 years of age. Till about 5 it is considered normal if the child occasionally wets the bed. Usually children have considerable bowel control by the age of 4 and do not soil their clothes. Enuresis can be primary (the child did not grow out of using diapers) or secondary (child stopped wetting beds but suddenly after a period of time started wetting them again, as in Rahul’s case).
It is often connected to psychological issues of emotional stress / anxiety. Often the causes remain unknown to both the child and the therapist. Therefore using cognitive or reasoning approach is difficult with these children and it is not in their awareness or consciousness. Also emotions of shame and guilt are quite complex for the children to express verbally. This coupled with threats or punishment from parents (who feel an extreme sense of concern and frustration dealing with this problem) can become quite traumatic for the child. Play therapy, being dynamic, non directive and symbolic allows the child to reenact and work out his emotional issues leading to the problem in a safe and trusting environment without having to get into verbal communication. This is further supported by some parenting sessions where parents are usually asked to bring about certain changes in the child’s routine to support the sessions proves extremely effective.
The following are some of the changes that parents are requested to introduce:
• Having liquids at least 4 – 5 hours before the bed time.
• Setting up alarms at regular intervals and encouraging Rahul to visit the toilet.
• Keeping an extra pair of clothes and bed sheets so that Rahul need not wake his parents every time he had an accident.
• Not humiliating / threatening / asking too many questions to the child to rectify his behaviours .

Rahul began his play sessions. Initially he found it quite boring to play with toys that were around and often asked if he could carry his video games or whether there was access to computers. But slowly as the sessions progressed he started playing with animals, clay and balls. The therapist noticed that in most of his sessions he would give instructions to the therapist to follow. He would make loud noises and fight with the wild animals. With the clay he would often make snakes and then turn them into turbans which the therapist was instructed to wear and become the care taker of the animals. Some times he used the ball to knock down the animals. After many such sessions, he moved on to drawing. He initially drew only symmetric drawings but soon moved on to draw themes. Most of the themes again reflected anger, punishment and morality issues.
Around the 8th session, the mother mentioned that Rahul had wetted his bed only once and had soon woken up to change his clothes and the bedsheet. The therapist had given a list of instructions to the parents to follow. Soon after that Rahul showed greater interest in his play and also in the sessions.
After his summer break when he returned for the first session, he sent a message containing smiley face and to inform the therapist that they were on their way to the clinic. He seemed to have settled down with not a single mishap of soiling his clothes or wetting the bed. He had returned to his original confident self and seemed less tentative about things. Although he was apprehensive on the first day of school, he settled into his new routine pretty soon. On the follow up terminating sessions, the bedwetting and soiling behaviours had consistently shown improvement with no further accidents. His academic marks also returned to their earlier levels.

USING PLAY THERAPY AS A TREATMENT FOR AN AUTISTIC CHILD



Rima was a 5.5 year old ASD child when on gentle persuasion by a day care teacher her parents approached us for play therapy. Rima’s parents although both were paramedics, struggled to accept that their child was not normal. Initially they blamed themselves for the lack of time and hoped that their love and attention would reverse her ‘odd’ behaviours. The mother especially blamed her work hours or their decision to have another child (a normal 3 year old son) so soon for Rimas developmental issues.
When they first came to discuss Rima, they thought that the only issue with the child was that she was not very verbal. They claimed that although she was better than before after the day care center teacher spent extra time with her, they were worried how she would react to the big school which she would join in the 1st grade, next year. But as they talked they realized that the problem was far more complex and interlinked. They were able to identify other issues such as her hyperactivity, non communicative behaviour, usually preferring to play on her own, petrified of loud noises and animals, asocial by nature and find it difficult to share things. She also was easily irritated and was often teased and bullied by her cousins to whom she reacted by either crying or reacting violently. She loved to play in sand and go to the beach but didn’t much play with other toys. She was also at times mean and violent with the younger brother. She didn’t demand much, even in food and would be quite passive most of the times. She enjoyed watching television ads, and listened to religious mantras. She seemed to have an unusually bright memory in remembering lyrics of the songs / advertisement / mantras. Her favourite game with her father was to climb on him holding his hand and then throw herself backward head down. Although she does this regularly, the parents were very worried about this as she could seriously injure herself. They had tried to change this behaviour a number of times, but she would not pay heed to their warnings. Infact they thought that her risky behaviours such as this had increased and now she would take every opportunity to jump of the table or even fling herself suddenly at the opposite person, uncaring of how badly she might get hurt or hurt the other person. If shouted at or stopped, she showed an unusually strong temper and become very obstinate. Thus discipline and obedience or boundary setting were major issues with her. She would still wet the bed in the night although not regularly and at times soil her panties. The mother mentioned that Rima was very fond of sand; therefore they had made a sand pit in the balcony for her to play in. But her play in sand was pretty unusual. Instead of making something out of sand, she spent hours just sifting through sand humming to herself a tune. As we talked, the mother recognized other behaviours which although she had noticed, never paid much attention to it. Rima’s inability to generalize learnt behaviours to other similar situations, her inability to focus on two or more things at a time, her insistence of ritualistic actions, her inability to substitute one toy for another similar toy. She also realized that all these behaviours together indicated Autism, a neurologically based life long and severe condition and not merely a late developmental issue or an emotional problem.
The therapist helped them understand how play therapy can benefit an autistic child and how an autistic child’s play differs from that of other children. She also went on to explain how play is a complex phenomenon that occurs naturally for most children and how they move through the various stages of play development and are able to add complexity, imagination, and creativity to their thought processes and actions. However, for many children with Autistic Spectrum Disorder (ASD) various stages of play never truly develop or develop in a fragmented fashion. These skills which a ‘normal’ person takes so much for granted is actually an uphill task for an ASD child. An ASD child suffers at all three levels of understanding and mastering the skills, cognitive social and behavioural.
Initially it was believed that play therapy is not effective treatment for ASD, recent research has convincingly proved that it is one of the most effective forms of treatment when used at times in a structured manner and especially if it is taught to parents and incorporated in the daily routine by the parents. Extensive opportunities in play therapy for social skills and emotional development help the child by increasing his awareness of other people’s mental states and their intentions. Play therapy then becomes a safe practice zone for the development of these skills.
These play therapy skills can also be taught to the parent / care taker who can incorporate it as a part of the daily routine. Treatment of ASD is highly specialized and a life time task, therefore often very expensive. Play way parenting equips parents to incorporate these play sessions in daily routine of the child and drastically reduces the cost. Parents are also encouraged to introduce it to the rest of the family so that it becomes another support for the ASD child to learn and master the skills. It also indirectly helps the other family members cope with their emotions with regards to the ASD child in a constructive manner.
Play therapy provides ample of opportunities to develop following skills in ASD children, necessary for their learning:
1. Imitation: imitation is a skill that is learnt very early in childhood. But the most crucial aspect of imitation is the ability to generalize these imitative behaviours to other situations. For example a child through imitation learns to smile and then uses cognitive and social skills to generalize smiling behaviour to situations requiring it. But ASD child find it difficult to generalize this to other situations. During play therapy, puppets, role enactment, make believe situations etc are used to increase the generalizations of these imitative responses.
2. Object exploration: children suffering from ASD find it difficult to initiate an exploratory play. This is because they get over whelmed with multiple stimuli and over a period of time, due to past experiences they learn to be socially reserved. In play therapy, the sensitive manner in which the therapist approaches the child establishes a safe and trusting environment for the child to attempt to explore. Then when the therapist incorporates some specific techniques such as restricting the space during play and giving them toy one by one the child finds it easier to learn them. A combination of skills and emotional support substantially increases these initiative responses in the child. It also helps to increase the child’s self confidence and self esteem.
3. Exploratory and Experimentation with play: Play therapy is often one of the first experiences of play without any target response goals for an ASD child. Being socially withdrawn they rarely take any initiatives to play on their own. Since play sessions are directed towards play only, it provides them with an opportunity to experiment and explore with play in a safe and trusting environment. Manipulation of toys in play session helps them to practice varying characteristics of toys, classification of toys such as sorting and matching, establish causal relationship between events and how to influence the world around them.
4. Communication skill: Communication skills such as expressing emotions, expressing specific needs, using gestures and joint attention are mastered during play sessions. Play therapists create surprise events during play sessions, using visual information to communicate verbally something that the child wants. This provides the child with ample opportunities to practice putting their emotions into gestures and words and thus reduces their frustration about not being able to get their needs met. It also reminds ASD children that communication and play involves another person and acts as a bridge toward more complicated or symbolic communication using words assessing not only their emotions and needs but also to match it with the other person. This is especially a difficult area for an ASD child as these skills are highly dependent also on social skills, both a problem area for the child. This skill can be taught using substitution of the play object (such as dolls), role enactment using various toys (puppets), recreating real life situations with numerous alternatives, helping the child to elaborate on intentions (involving verbal communication), helping the child to master ideas / themes, discussing with the child abstract themes and using obstacles to generate alternative solutions.
5. Signing or acting: Play sessions provide ample of opportunities to use a combination of gestures supported by verbal communication. This helps in the transition from no communication to gestures and then to verbal communication. This also helps to reduce the child’s frustration with people, usually strangers who are unable to understand their sign language. It thus increases their confidence socially and also boosts their self esteem. We often find a simultaneous reduction in anger in the child.
6. Peer Play: Peer play also relies on social cues which ASD child finds extremely difficult. Therefore we often find and autistic child unable to share, wait for turns, negotiate with another child, imitate other role models, ask for help, request for events / objects, initiate inviting another child for spontaneous play, all of which a necessity for any school going child. Through structured play sessions dealing with each of these skills and then slowly moving on to group play sessions or introducing it amongst the siblings the child gains enough confidence in these skills to be able to practice them at school or with other peers.
7. Increasing attention and concentration: also requires the child to comprehend the object and hold it in his thought symbolically. Play sessions intrinsically provide these opportunities to the child. It then becomes a practice field where the child learns to master these skills and then be able to use them outside.
8. Motor coordination also increases tremendously using play toys. The child learns to explore and experiment with different shapes, sizes textures and colours of toys in a non threatening, goal less, safe environment where the only goal is pleasure.
9. Parenting skills are also improved. Very often without realizing parents facilitate the learned helplessness in the child as he is unable to communicate. We often find the parent not being able to push the child to learn the above mentioned skills or become too harsh and frustrated. Neither of these behaviours are conducive for further development. During play sessions parents get an opportunity to examine their play deficits as well as express their own emotions and frustrations with the therapist. This kind of self exploration helps in dealing with parental anxiety of their child and his future in a manner which will help the child become independent.

MANAGE YOUR CHILD’S HYPERACTIVITY USING PLAY THERAPY


It’s normal for children to occasionally forget their homework, daydream during class, act without thinking, or get fidgety at the dinner table. But inattention, impulsivity, and hyperactivity are also signs of attention deficit disorder ADD. ADD/ADHD makes it difficult for people to inhibit their spontaneous responses—responses that can involve everything from movement to speech and attentiveness. Having ADD/ADHD (for the child) can be just as frustrating as dealing with someone who has it. Kids with ADD/ADHD want to sit quietly; they want to make their rooms tidy and organized; they want to do everything Mom says to do, but they don’t know how to make it happen. They do not intentionally want to annoy you. If you keep this in mind, it will be a lot easier to respond to you child in positive, supportive ways. Like all kids, children with attention deficit disorder (ADD ADHD) sometimes make bad choices regarding their own behaviour.
Rima was getting ready to go for a swim with Akshay, her 10 year old son. Saturday morning is a planned outing with him and some of his school friends and their mothers and a special time for Akshay, something that he looks forward to the entire week. Rima asked Akshay to finish his breakfast, take a bath and pack his swimming bag while she went on hurriedly going about doing her household chores. Expecting Akshay to have finished at least with his breakfast and bath in the past half an hour, Rima went to check whether he needed anything. She found him sitting on the dinning table with the breakfast untouched and watching his favourite cartoon show. What is his problem? Yes, he has ADHD, but how hard is it to do three simple things? He loves to go to for the swim with his friends. Why is it such a struggle to get him to listen? As Rima hurries Akshay around, she is thinking of what her husband would say if he were around. ‘You are spoiling him by not being stricter with him and doing his work for him. He pays attention when he is playing with his video game, but not when we ask him to do his chores.’ Rima thinks that Akshay’s failure to comply is due to a lack of motivation – if he wanted to do it, he could. But Rima isn’t so sure. She’s been consistent with discipline. Rima also knows that Akshay feels bad about himself when he doesn’t succeed at school or when she constantly fusses at him at home. She knows that he has begun to compare himself to his peers. He seems frustrated with his inability to accomplish simple things that seem effortless for his friends. She has heard him refer to himself as “dumb.” She can’t understand why Akshay doesn’t comply with the instructions he receives from adults, but she doesn’t think it’s a lack of motivation. She knows in her heart that he would comply if he could. Rima has recently attended a talk by the school counselor on Executive Functions of ADHD. Equipped with this information she tries to understand what actually must be Akshay’s mental process.
Executive functions are mental processes that give organization and order to our behavior, allowing us to direct our actions through time toward a goal. Let us take Rima’s working of a single evening as an example of executive function. The previous evening, Rima left office for the weekend. She was tired and would have loved to go straight home especially with the heavy down pour since late afternoon. But she recalls that she needs to fill in some grocery first for dinner (working memory) and heads for the super market. She decides to pick up the lap top adaptor on the way to the grocery store (strategic thinking) so that she can work over the weekend and does not have to make another round this side of the town for the adaptor. She thinks of how comfortable her Sunday morning will be if she could in between the cooking do her work and then relax the entire day (internalized language). She begins to feel more energized as she weaves herself through the evening traffic (regulating motivation). As she reaches the grocery shop after picking up the adaptor, she makes a list of things that she would require to buy for the dinner (initialization action). Just as she gets her pen out, her cell phone rings, she checks the display and sees it is a friend who was returning her call. She makes a mental note of calling her later after dinner (strategic thinking) and chooses not to respond to the call right now (interference control). While entering the grocery store she sees that there are some attractive schemes on the 15 litre oil cans but decides to check on it the next week (interference control) as she is running late (a sense of time). As she heads for the vegetable section, she takes a quick look at her wrist watch. She has time to stock in the fruits and makes a bee line for section (self-monitoring). She decides to check on Akshay as she waits in the billing queue (shifting between tasks) so that his work is done by the time she reaches home. In the night before retiring in front of the television, Rima remembers to make the call to her friend (working memory) and calls her.
Rima’s executive functions work smoothly and efficiently. Because this functioning occurs without her conscious awareness, she takes it for granted. But the development of these functions took place over time. Imagine Rima at the age of 10, would she be able to do all this planning simultaneously? She would probably be able to only concentrate on her chore of buying chocolate at the super market. It was a gradual process for her actions and sense of time to become internally directed. Researchers believe that this capacity for self-direction is neurologically based and concentrated in the pre-frontal region of the brain. Rima learns that current research regarding ADHD is moving away from an emphasis on impulsivity and inattentiveness and toward an emphasis on executive functions. Many experts in the field recommend that individuals with ADHD compensate by using tools that “externalize” the executive functions. is a natural form of integrating these skills and Play therapists are specially trained counselors who use play appropriately to help children regulate their behaviour. The school counselor suggested Play therapy for Akshay. In many children’s games –Froggie May I, Statues, Simon Says, Freeze, mountain and river, saakli–while fun, also provide an engaging external framework for children to practice behaviors that are central to executive functioning. The therapist lets both Akshay and Rima know that a large part of each session will be devoted to play, and that she will even give some home assignments that involve play. Rima relates the history of Akshay’s diagnosis and treatment over the past three years her own attempts to firm up discipline and provide extra structure and support in Akshay’s day to day life. Both Rima and Akshay are tearful as they describe their frustrations and guilt and an overwhelming sense that they are not good enough. The therapist comments that they might want to add to their treatment plan is for Akshay to become a working member of the “treatment team.” The following weekend Akshay has an assignment from his therapist. Chores are a sore point in their household. Rima has always been frustrated that she has to remind Akshay each and every step of the way. Akshay’s assignment is to use the time honored habit of making a list to supplement his working memory and free him from dependence on his mother’s reminders. To engage Akshay’s interest and sense of fun, the therapist has given this tool a playful spin. An hour later, chores done, Rima and Akshay are on their way to the swim. “That was fun,” Akshay says to his mother. “And I got all my chores done by myself! Let’s do that again next week.” Rima reflects that it doesn’t matter whether Akshay relies on his working memory or uses a list. The results are what she cares about. She is pleased that the chores got done but is even more pleased to see that Akshay himself is so pleased. She was right; Akshay is motivated to succeed. But she had been expecting him to succeed in ways that were not in line with his development. She has now seen that, with the right external support, Akshay can experience the success that he so much wants for himself.