THE INNER, EMOTIONAL WORLD OF THE CHILD WITH CHD
AUSTIN E. WILMOT, M.S.W., L.C.S.W.
Many parents first associate the work of childhood with schooling rather than play - their child as student, whose progress is evaluated and graded. I do not disagree that schooling is an important kind of work, occurring in progressive steps, virtually every year of child and adolescent development. If we think that the work of adulthood is one’s job or profession, then we might consider school to be the job of a child. However, only thinking of the work performed at school or the homework sent home from school, misses the bigger picture in terms of child development that must precede school if schooling is to be useful and effective. School learning (book and social interactions) is preceded by and depends on child play. Where and how does play fit into learning…inside and outside the classroom? In this article, I will illustrate how play is a basic building block in emotional and psychological development, is minimized or devalued by our culture, as well as begin a larger conversation about reclaiming the value of play, mental health and exploring what can be learned from the play of children with CHD. How might you reclaim and use the value of play and mental health in your family?
Play in emotional and psychological development
Play is the foundation of all learning and crucial to healthy development. It was Jean Piaget, psychologist, who first understood that “[p]lay is the work of childhood”. However, what is play? Is play the time children spend outside running and adventuring with friends? Is playing on the iPad and engaged in an activity alone a better or worse kind of play? Is play always a happy experience or can it occur while frustrated at the challenges of the task, such as learning the ropes of playing a musical instrument or getting a swimming stroke honed in just right? As you will see, play occurs in many formats, involves a developmental process of its own and requires no specific mood or disposition.
For ease of discussion, we divide play into six types of play important for your child’s development (Gudritz, n.d.):
1. Unoccupied play – this is the kind of play the infant experiences without formal engagement with another (e.g., baby experiences sights, sounds, bodily sensations, smells, tastes – all occurring within a freedom to experience, think and move). "Play" with one's own body is a basic beginning of learning.
2. Independent or solitary play – this is play that occurs without reference to other people, such as building a puzzle, collecting rocks, drawing or reading. This stage of play helps build comfort with being alone and with one’s own mind, which is an important step towards being able to be with others.
3. Onlooker play – this is play wherein the infant or child does not formally engage in play herself, however is watching another play (e.g., a child watches basketball players on the court, mother gardening or another child painting). This stage of play helps the child in gearing up to play with others, as a shift has occurred from the immediacy of the experience of self to the separateness and activity of the other.
4. Parallel play – this is play occurring besides other children instead of immediately with them (e.g., building blocks next to each other, moving racing cars on the floor). This stage of play further builds the child’s ability to relate to others and can intensify the working through of boundaries between self and other. This is where the distinction between what is “mine” and what is “theirs” comes into contrast and provides a measure of learning of social skills.
5. Associative play – this is play occurring with other children, but without a common goal (e.g., building blocks, legos or sand castles together). This stage of play adds social pleasures (or grievances) to the mix, while a more intimate capacity to relate with others takes shape.
6. Cooperative play – this is play with other children with a shared goal or purpose (e.g., sports teams, a group project at school). This stage of play finalizes the ability to interact and communicate with and among others in a variety of contexts. Here is the arena for learning the social skills of working together.
If play is the foundation of all learning, there must be a lot of it! Where else does play show up, including in the parent-child bond? Here are some examples to consider:
We play “peek a boo” with the infant without knowing of its profound effect, that of helping the infant to internalize a sense of object permanence – the knowing that when things disappear, they aren’t gone forever. There is an important difference between hiding and disappearing.
We play “hide and seek” with the developing child without knowing that the game is an advancement of the earlier “peek a boo” game towards further abilities to play with re-finding someone lost, to hide oneself and be found, as well as work through separation anxieties that begin to emerge as the child ventures away from their secure base.
We play with finding the right words to help reflect what it is we see our child feeling through their nonverbal communication - becoming the narrator of their inner experience - without knowing that we are helping build their thinking muscles to master big feelings by making them smaller and understandable.
We play within ourselves to name and process what WE are feeling in response to our child’s actions, so that we may model an ability to handle big feelings while not always acting on them, without knowing this also reduces our child’s anxiety, reduces misbehavior and supports loving limits that create safety.
We play with the mistakes made by ourselves and our children, without knowing we are building emotional muscle through the practice of addressing ruptures in communication with mutual recognition, repair and connection.
As a psychotherapist, I am sometimes told by parents upon the initial consultation that they have tried “play therapy” in the past and it didn’t work, or that they want to make sure I am not “just” going to be playing during the therapy session with their child, but actually “giving them tools” and helping them feel better. There is usually much to understand in these sessions about parental fantasies of “play therapy”, what “play” means to them and also the parents’ capacity for play. From these kinds of presenting concerns, we can see how play gets a bad rap and is held as devoid of meaningful therapeutic value – that therapy must inject tools from the outside to help the child instead of helping the child to find their own answers, adaptable ways and voice. Might the parents need help, perhaps with play - playing with ways to listen, reflect and respond to their child? Play opens up an avenue through which we can access the inner world of the child and the issues which cause problems that neither parents or child can verbalize or repair.
The devaluing of play and mental health
Steeped in a culture where teens and young adults are pushed sooner and sooner to know their educational and career paths - what they think they want to do with their lives, picking a major, making perfect grades, racing to the finish line of prestige and money – the freedom to think, feel and imagine for oneself is curtailed by pressures from other “minds” – perhaps friends, well-meaning family, the media and elsewhere - that act to inhibit a fuller exploration and sorting out of one’s likes, dislikes, desires and passions. It has become “uncool” to not know what you want to do, looked down upon to press enter on the “undecided” major button and alarming to some the idea of taking a gap year or time off from moving at the highway academic pace. We have seen our "quick-fix" culture minimize the value that comes from understanding our inner lives and caring for our mental health with the biases against longer-term psychotherapies, the workaholic norm that leaves little time for self-care or the stigma surrounding reaching out for help. The situation is not helped by insurance companies who profit from the perpetuation of this "quick-fix" mentality, limiting therapy benefits and otherwise making decisions about the therapy that should rather be between the therapist and patient (e.g., limiting coverage to once weekly therapy or ending coverage whenever they wish). Their interest is financial, while the therapist's is to understand and treat.
Reclaiming play and our mental health
In order to tune into our child’s inner life, we must be able to tune into ours and build the emotional muscles for reflection. The space for that can be hard to find when the week is filled with activity after activity – little time for thinking or quality time-with. But, what are the rewards? What might you discover once you slow down to understand the lives of your nine-year-old daughter’s doll family that she’s been keeping to herself? What might this help you understand about her experience of CHD? Her body? Her position in the family? Her feelings about you? The reasons she has been nervous lately or having angry outbursts? Further, since the school year has started once again, let’s go back to schooling and grades. Some parents might think the following: If my child comes home with A’s and B’s, then they are doing extremely well academically and emotionally. but if they come home with C’s or D’s, then they must need (1) more tutoring, (2) a reduction in free time because they are playing too much and not working hard enough and (3) perhaps some punishments to address #2. The logic for this might be that he is "just procrastinating too much and doesn't care about grades or school. He has the power to change things around if only he set his mind to it.” It is problematic to assume that academic grades, whether good or bad, can tell us what we need to know about our child's mental health and what they need. Now, I posit the question: Where and how does play fit into learning…about the child underneath the grades? For example: Why is my son not playing with others at school or being invited to the movies? His grades are doing great, but he looks like he has been playing by himself a lot on the computer with “friends” in different countries. The games are always so violent, too. What might this mean? Why is my daughter failing in art class of all things? The teacher says she sits down to draw, starts drawing but always gets frustrated with anything she does and gets very angry and leaves the room causing commotion. She has been acting fine at home. What might this mean?
The play of children with CHD
If play acts as an avenue of access to the child’s inner world, what might we find in a child’s play that helps us think critically about the inner experience of the infant, child or teen with CHD? How might CHD impact development and mental health? We can look for answers in the play.
Directly intervening at the level of the inner, emotional world of the child living with CHD is often avoided or forgotten by professionals, parents and caregivers, alike. Many mental health providers do not know how to tread into helping children with chronic medical conditions, and many parents are afraid or do not know how to talk about such feelings or realities in a developmentally appropriate way. Such conversations are frequently ‘put off’ for later, in the hope that the child can resolve or ‘get over’ anxieties that seem premature or unfounded based on the child’s present medical status (e.g., being alive, having survived). In this way, feelings can become minimized and psychological symptoms can result in manifestations of emotional and behavior problems. It is known in the literature that the prevalence of anxiety, depression and trauma-related disorders is increased in the CHD population, and that addressing emotional distress earlier rather later benefits the child and family throughout the lifespan.
Caregivers and medical personnel are well-trained and well-meaning. However, just because intent is good does not mean the impact follows suit. These well-meaning caregivers and medical personnel may rather see themselves as only good, carrying out helpful acts, instead of as perpetrators of forced and intrusive acts. For instance, early surgeries can be experienced as attacks on the body, caregivers felt to be in collusion with allowing such attacks and torture on the body at the hands of medical professionals—people that are said to help, but also cause an experience of pain. It takes a particular degree of cognitive and emotional development to be able to understand that the person causing pain is actually doing a helpful, perhaps life-saving act (Shopper, 1995).
The story below, “Super Whale”, was written by a nine-year-old boy who had urgent, life-saving surgery at two-days old due to coarctation of the aorta (COA). Growing up, this boy was asymptomatic and had yearly appointments with his pediatric cardiologist. However, he was left largely alone with his inner, emotional experience.
After reading, what stands out to you from the story? If you consider that May 14th is this child’s day of birth, how does that adjust our hypotheses? This story, written in response to a school assignment that allowed the child freedom of expression – the space to play – gives a glimpse inside the mind. What is this child trying to tell the reader? What feelings are contained within the story? How might a parent or teacher respond?
This is a hero story, one that begins with framing Dixie, the whale, as a good and well-liked student. Dixie finds a family panicking and rescues a man drowning in the ocean. A lifeguard then completes the rescue, getting the “body to breathe”. Dixie is celebrated.
Jungian psychoanalysis would have us understand that there exist evolved cognitive structures, archetypes, that cannot be directly observed, but become evident through images or symbolic patterns within myths. This story, is a child’s play and practice at writing a personal mythology. It concerns the heroic journey of a whale-person who plunges into the ocean to save someone’s life with a lifeguard as eventual helper. A call to action comes from the realization of a crisis that resolves in victory.
This child is attempting to express something about their own experience of a crisis - being close to death and being saved by a whale-hero and lifeguard-helper. The child uses the man in the story as a substitute for their self - defensively serving to put distance between fantasy and reality. The whale may represent the pediatric cardiologist and the lifeguard, the surgeon. We don't know for sure, but we remain curious and wonder. The inclusion of a "family panicking" tells us something about the child's experience of their family's emotions, perhaps anxieties that cause additional worries and fears as well about their condition. Since the rescue happened on May 14th in the story, but we know the day of birth was May 14th and that the surgery was on day 2 of life, we are called again to be curious and wonder. This confusion in dates could signal us to the child's need for help in understanding the sequence and timing of what happened and when. This is a child calling out to understand himself and be understood. Perhaps if he wrote additional stories about the whale, we would learn more?
Children play with feelings (even scary ones) to help make them smaller. Isn't this what happens with "peek a boo" or "hide and seek" to help a child deal with the real feelings of separation? Children play to seek mastery of feelings, even feelings that concern traumatic events like surgery or the experiences of hospitalization. What might you discover if you tune into your child's drawings, stories and play? What is your child "working on" in their play? How can you help? How would each family member write their story about a helpful whale? Let this be your call to reclaim the value of play and mental health in your family.
Bibliography
Gudritz, L. (n.d.). 6 Types of Play Important to Your Child's Development. Retrieved from https://www.healthline.com/health/parenting/types-of-play.
Shopper, M. (1995). Medical procedures as a source of trauma. Bulletin of the Menninger Clinic, 59, 191–204.