b.p.s.o.4

Is Jenny being good or bad?

BODY PARTS AS SYMBOLIC OBJECTS 4

Summary

More cases were looked for at another facility for mentally handicapped, or �autistic�, children in Thailand, this time in the north, in Chiangmai. This took place over a period from August to November, 2005.
Even though I was at the institute for three months I did not see many cases of h.r.b., for some unknown reason. Eventually two only were found, both boys this time.

INTRODUCTION

CASES AND OBSERVATIONS

Case 1.
�Dear�
Date: 22.9.05
I noticed this boy looking at the palm of his right hand, with the fingers stretched out, really a �5� hand-shape. I did not notice a trigger, there was none that I could see.
One of the psychologists, W., also told me she had found someone looking at his hands. I go to look. It�s the boy called �Dear�. He is deaf. She says she saw him looking at his hand, not playing with it. He is with his grandmother.
They come every day to the institute. He looks at his hand and smiles, or laughs. Sometimes his laughing looks more like crying but it is certainly an emotional reaction.
They go to the living room and I sit with them. He dribbles a lot. He does a lot of hand looking and smiling at it. It�s always his right hand. The hand is in the �5� shape. I draw him a picture, he puts his right hand to my face and laughs. Then he�s off to crawl on the floor, and sits on the floor. Then he is taken off and goes into the class. They have colored pictures of fruit, have to say the name. There are also colored models of some animals. They have to match pictures to pictures. Then they use the little models of animals. Fold arms, and then with a group of three animals, two the same and one different, they have to put the same ones together. (In all this �Dear� continues his hand looking behavior.)

Date: 27.9.05
�Dear� comes into the Physical Therapy room. He�s doing lots of hand looking. Nurse tells me he has mild C.P., is mildly spastic. Nurse says mother had an infection in pregnancy. �Dear� came from class in the I.P. ward, I think, and will go back there after his session. Dear�s right hand was being held by his mother, and so he looked at his left hand. Possibly he preferably looks at his right hand.
Dear is looking at either hand now, and smiles/laughs at it. He also sucks his fingers. He puts his right index finger, or his right thumb, in his mouth but I don�t know if he is really sucking his fingers or whether he is feeling his gums and teeth, they say his teeth might be hurting. He has no top teeth, and only a few bottom teeth. They say the dentist took out the teeth, they were bad due to eating too many sweets. Fortunately I believe they were only baby teeth. He dribbles saliva from his mouth. Once we were trying to get �Dear� to play roll a ball back to us after we had sent it to him, but he just folded his arms. Nurse and/or parent said he was sulking and didn�t want to play.

Date:11.10.05
I see that �Dear� is in the I.P. department with his grandmother and father. I get one of the other psychologists, D. to fill in my internet form using father as the informant.
Date of Birth: 17.7.2540
Date form filled in: 11.10.2548
His age is 8years 3 months
Mental Age:?
How does he communicate with others? If he�s close to the thing he wants he will get it himself, if not he will point to it. If the adult doesn�t respond to his point he will get hold of the adult�s head/face and move it to face the object, to try to make him look at it. He can�t walk by himself and so his opportunities to explore his environment and take the adult to what he wants are very limited. He walks on the outside of his feet and so this makes walking more difficult.
The hyperactive question: he can�t walk so how can he show this? But parent says his attention span is very short. Father says he likes to watch cartoons on T.V. He is diagnosed as having spastic C.P. and dribbles saliva. He likes to be with people. He is not aggressive to himself, or to other people. His personality is described as �timid, shy, nervous�. Father says he doesn�t like dolls or teddy bears, and that there are dolls etc. in the house. Father is asked what he thinks the hand looking behavior means, and says he doesn�t know. He looks at his hand, usually the right, very frequently. It seems to be always a positive behavior, with him smiling or even laughing. It is difficult to know if there is a trigger, as it happens so frequently, the father doesn�t seem to think there is one. I tried the experiment of interacting positively with him, playing with him physically and tickling him, but the results were not clear-cut. Once I think he did look at his hand just after a tickle. He doesn�t slap his hand, kiss his hand, hit his head with his hands, bite his hands, suck his fingers or thumb, hit his chin with his hand, pull his hair or chew his clothes. Sometimes he sucks his clothes, e.g. the top of a T-shirt he is wearing. The behavior started one year ago when he was 7 years old. At that time he went to live with his grandparents and aunt in Chiangmai, (they live in the same house). Before that he lived with his mother and father in Bangkok. The parents try to come up from Bangkok to Chiangmai at least twice a year to see him. He has an older sister, 13 years old, who lives with her parents in Bangkok. The physiotherapist has recommended horse-riding therapy for him, and he might get this at Maharat, Chiangmai hospital. He is taking �Encephabol�, used for improving brain function. I want to check on the claim that he doesn�t like dolls or teddy bears and I take the dolls that �Earth� was so fond of onto the ward to see what he will do with them. He shows no interest in them, but now the father says that he likes Pooh Bear cartoons on T.V. and that he used to like to play with a yellow Pooh Bear doll and used to like to hug it. This was when he was about 6 years old, two months ago his interest decreased.

Opinion: He is a natural candidate for a photo communication system, but the mobility problem means he will have to jump to pure p.c.s. Is this possible?
Date: 18.10.05
Dear has come to the institute again and so I have the chance to get some idea of his mental level. Most of the scales are not relevant, he is deaf, so the language scale is irrelevant, he is severely C.P. and so the gross-motor scale is of little applicability, but I thought the fine-motor scale might be of interest.
Denver II
(18.10.05)
Results.
Thumb-finger grasp-a good precise pincer grasp of a pellet.
Bangs two cubes together, one in each hand
Puts block in cup
Scribbles
Dump raisin-demonstrated Tower of six cubes Imitate vertical line Thumb wiggle All the above were passed, although it took a lot of effort to get him to do the blocks properly. There was some silly behavior, and some head shaking. He failed the tower of eight cubes, the copy circle, the copy cross, and the draw a person. I tried him with the bridge item, and he tried to add blocks to my demonstration. In the gross motor he passed �roll over�, �pull to sit, no head lag�, �sit, no support�, and �gets to sitting�. He failed �stands holding on�, and �pulls to stand�. He can pull himself to standing if sitting on a little chair at one of the little, low tables. Really it�s �pushing� to stand, I think. But if he is on the floor and tries to get to standing with the table he cannot manage it. In the personal-social he passes �regards own hand�, (of course! But I don�t think this babyish behavior can be like my h.r.b., can it?), �works for toy�, �feeds self�, �indicates wants�, and �plays ball with the examiner�. In the course of the testing I asked him to give the rattle he was holding back to me by holding out my flat hand with the palm up. He promptly gave me the rattle. In the course of trying to get him to build the block tower he seemed to get a little annoyed, and seemed to be showing reluctance to do the task by making slight head shaking movements. At any rate he is observed to use his right hand to bring his left fist to his mouth, and I think opened his mouth. It looked like hand biting behavior but I don�t think there was any actual biting. It is often hard to get him to look at the task, as he tends to look somewhere else. As well as elsewhere in the room, another distraction is his highly frequent hand regarding behavior. I try him with the doll�s house and dolls but he does not seem to show symbolic behavior. He opens and closes doors and drawers of �fridge� and 'cupboards' etc., and stacks items of furniture on top of other items. He ignores the three dolls. It seems to be a mere physical manipulation of the objects. He dribbles profusely.

The results on the fine motor-adaptive section put his mental level at about the two and a half to three year level. This is in line with the mental level of many of my other cases of hand regarding behavior.

Another child was observed to engage in h.r.b., another boy. His name is �Earth�
�Earth�
On 6.10.05 the same psychologist, W., tells me there is a patient in the O.P.D. who she has seen looking at his hand. His name, or rather nickname, is �Earth� and he is 6 years 2 months old. He is by himself in a little playroom and I go in to observe him.
He is eating a bag of some type of snack and I am given this to dole out to him, apparently to obtain some kind of rapport. I play a baby game with the snacks, pretending they�re planes flying towards him, and so on. He plays with a truck for a while and I then play a game where I put a piece of the snack in the truck and roll it over towards him. He is supposed to get the snack out and send the truck back to him. I am not sure he fully understood this as sometimes he sent the truck back to me with the snack still in, but maybe he was taking over my role, and trying to feed me.

I tried a peg and board exercise with him, and he did this for a little while. Takes his top off.
Then he discovered a soft doll in one of the toy containers and played with this. This looked like symbolic play, he plays with the dolls �hair�, puts its head next to his face, lies on the doll looking at its face, makes the doll sit on the mat, and so on. I give him a second similar doll and he flings it away and returns to the initial one. But then he retrieves the second doll and plays with them together. He makes them sit together. He then says something loud to them. He then puts them face down on the mat, then takes off their shoes. He puts their faces together in an affectionate seeming way, a sort of kissing action. He then both the dolls in the truck and moves the truck along. He likes to brush their heads/hair against his face, and vice versa. Then he puts one doll to one side and just has one doll in the truck and moves it to and fro. Then he gets the doll to straddle the truck like a motorcycle, and then takes it off and holds both dolls again. He looks at one doll quite closely, says something to it. Then has both dolls in his lap and puts the room light off.
He then makes the dolls lie down together, then has them on his lap, and then goes to the door and tries to open it. Its locked however, then he says �Pai�, I think, (= 'go!') Then he throws the dolls down on the mat. Then he gets them again and goes to the box next to the tower of containers and lies on the lid of the box with the dolls. Then he goes back to the mat and lies down with one, and then gets up, gets both the dolls and goes to the window and looks out. He jumps up and then puts a big cuddly toy on the mat. Then gets up and goes to the door with the two dolls. He puts his face close to the face of one of the dolls and says something? and laughs?
He tries to make a doll sit in a child-sized chair by the table, but it�s hard to keep the doll in place. He sits on a chair at the table and has the two dolls sit on chairs on both sides of him. He has to hold them to sit.
I look for some doll sized things, such as plates, cups, bowls, spoons and forks to confirm that the play is symbolic/test the level of symbolism but unfortunately there are none in the containers in the room.
Earth comes up to me and sees another doll, a Cindy type, and takes this away. But he is not so keen on this.
He puts a toy out of the window, jumps up and smiles. I talk briefly with the doctor about what he is doing. He goes off with the dolls to the activity apparatus, then says "pa!"( = "go!")
He goes to the tower, gets the container with beads and a bottle and puts all the beads, and the thread, into the bottle. Says "gao" (= nine?)
He shakes it and goes back to the tower, probably looking for the lid for the bottle, he tries one object but it is not the lid. He can�t find the actual lid He tips the beads out into his hand and then puts the beads into a little blue bowl. Then he threads the beads and forgets the dolls for a little while. He �chats� a bit, single word level? He threads the beads well, his fine-motor skills seem pretty good, and he attends/concentrates on the task for a reasonable length of time. But he doesn�t do them all. Then he puts the beads into a little plastic pill bag. He holds the bag full of beads, and gets one of the dolls again and holds it next to him. He tries to twist the top of the bag shut, but the bag breaks and all the beads are scattered over the floor. He goes to the door. He pulls the fan�s plug out from the socket and goes to the other door. He picks up the phone, puts it to his ear and then replaces it. He walks away and laughs. He goes to the window and puts his arm and hand out as if he is trying to open the door. He puts the light on again, (he had previously turned it off).
I put the plug of the fan back in the socket and get the fan going again.
We leave the room with him still clutching the dolls. He refuses to give them up. Then the psychologist W. takes them from him by stealth and he tries desperately to get the dolls back from her, he is very upset and annoyed. We try to get him not to grab for them, but to hold his hand out palm up and ask for the dolls in an acceptable, polite manner, saying �chor� (= "please"). But it is very difficult to get him to do this, he keeps grabbing and saying �ao "maa!", (= "want it!"), in an aggressive and demanding way.
The psychologist W. says his mother and father left him, when he was very young, with his grandfather and grandmother in Chiang Rai. Neither he nor his grandparents ever see these two. He apparently doesn�t go to school. Three schools tried him but he seems to have been naughty, and the teachers say he didn�t understand what they said to him.
Comments
This child appears to have two of the very common features I have seen in the cases of hand looking which I studies in the U.K. and in Bangkok. These are:-
1. The child has experiences of parental separation and probably rejection
2. The child shows an interest in and liking for, dolls, and plays with them in a symbolic manner.
The psychologist W. says she saw him look at his hand when he was by himself in the little playroom in the O.P. department. It was not the hand playing behavior. He put one cupped hand by his ear and put the other hand in front of his face.
28.10.05
Psychology department
�Earth�
The psychologist W. tells me he is here again, but I do not remember him. We do a session with him but unfortunately I do not connect him with the boy I sat with in the O.P.D. and I forget to do my h.r.b. form with his grandparents.
In the session are W., myself, �Earth�, and two nurses from another hospital, who are visiting us.
At the start of the session he shows himself to be a demanding and disobedient child, who refuses to give up a toy on request. Then he is controlled, held at a small table and W. holds his hand to make circles. He attends to the imposed activity, and looks happy. Then she sees if he will do them by himself but he is non-compliant, just scribbles. We try to get him to do the Denver �imitates vertical line� item, but initially he is reluctant, just scribbles and tries to get out of the task. When I hold him at the table, both of us sitting, me holding him against my front we eventually get him to imitate the vertical line. The non- compliance or scribbling is responded to with either not looking at him, (as is his occasional squealing), or a No! , or taking the pencil away briefly, ( = "if you don�t use the object, here a pencil, properly, as I wish, I won�t let you have it.") Compliance and success is responded to with "Geng ma!", ( = "well done!"), hand clapping, smiling at him and patting him on his back
W. says he can do a horizontal line.
Then I try with the sequence of increasing difficulty of first presenting the completed circle, (�copy circle�), which results in a fail, then �imitate a circle�. After pressure, with me still holding him against my front, sitting at the table, not letting him get away, but not holding his hand, he eventually makes a reasonably good circle, at least a closed loop, in imitation of my circle.
All this requires a lot of pressure. After a number of consecutive successes with an item and the resulting praise, he begins to repeat the response again and again without being asked.

2-11-05
Psychology Department
�Earth�
Talk with grandfather, aided by W.
He communicates expressively, to show what he wants, by taking his grandfather by the hand to the thing/place he wants. If this doesn�t get the desired response from the grandfather, Earth takes his grandfather�s hair and pulls it!
(Obviously grandfather needs to be helped to teach Earth a better way of getting his attention and/or cooperation)
Grandfather says Earth understands by grandfather telling him. This is the usual answer.
Although it is true that a child�s understanding of language is always in advance of his ability to express himself, in an absolute sense, it is likely, in my experience and belief, that the parent is only thinking of very basic commands, and might also be signalling what he wants in non-verbal ways. So he imagines that the child does not need non-verbal modes of receptive communication.
He is overactive, fiddles with the phone, looks rather A.D.H.D.
Grandfather says he likes to play with others. (Remember he loved the soft dolls on our first meeting, in the O.P. department).
Asked if he has seen him look at his hands, grandfather says yes, and he adds that Earth also says something to the hand, �in his own language�.
Grandfather says E. doesn�t bite his hands, or slap them, or kiss them. He doesn�t suck his thumb, or hit his chin with his hand. Neither, apparently, does he chew or suck the top of his T-shirt.
If �disappointed�, i.e. if he doesn�t get what he wants, he will scream. Asked if he hits his head, grandfather says he sometimes does this, with his flat hand, when he is angry. This might happen if grandfather doesn�t let him go where he wants.
Grandfather says E. always looks at one hand only, and that this is always the left hand. Asked when he started looking at his hand, grandfather replies it was 2 years ago, when he was 4 years old. Grandfather says nothing important happened at that time to Earth. He still shows h.r.b. It has always

been of roughly the same sort of frequency per day, or week.
Grandfather says there is sometimes no evident trigger for the behavior, but sometimes grandfather hits him for being naughty, and then he looks at his hand. Grandfather is asked how he responds to Earth�s h.r.b. He replies that he puts his hand away from him if the behavior was spontaneous, but if Earth had looked at his hand after being smacked for being naughty, he would smack him again!
(The two different types of reaction of the grandfather to the two different types of situation in which Dear engages in h.r.b. might be thought of as indicating some degree of unconscious understanding of the significance and meaning of his grandson's h.r.b.)
Earth lives with grandfather and grandmother and 4 other grandchildren. They live in Chiang Rai, or Amphor Fang, or somewhere like that, quite a long way from the institute. As for schooling, grandfather says he will go to a special school next Monday. He used to go to school but he was naughty, and teacher said he couldn�t learn and was overactive. Earth will come back to the institute once a week.
I decide to try to get an idea of his level of intellectual functioning, using the Denver II, and W. and I take him into the little testing room nearest to the entrance door of the department. We lock both the doors to stop him from running out of the room.
Fine-motor
Scribbles - Pass. He uses a type of fist grip of the pencil
Imitate vertical -- Pass
Copy circle -- Fail (actually he makes a face in my circle, draws the two eyes, a nose, and a mouth, all in more or less the correct pattern, although the nose is rather too high and almost on the same level as the eyes.)
Imitate circle -- Pass. (At this point he was being held in semi-restraint on the floor, between my legs and in front of my trunk, me also sitting, because of his refusal to stay in his seat at the little table).
Copy cross -- Fail
Block tower - makes a tower of 7 blocks and then he knocks it down deliberately. I tried this again but the same thing happened.
Bridge with blocks (actually the D.D.S.T. older version) Fail - adds his blocks to my model.
Puts blocks in cup -- Pass
Dumps raisin - undemonstrated - Pass
Good precise fingertip-thumb-tip grasp of a tiny pellet
Thumb wiggle - Pass
Gross motor
Kicks ball forward --Pass
Jumps up -- Pass
Throws ball overhand - Pass
Broad jump -- Pass
Balance on one foot for one second - Perhaps, if we�re being really generous
Hops -- Fail
Heel-to-toe walk --Fail
"Ao ma!" as usual with kids.
In doing the gross motor section I thought he might do better if we took his shoes off, they looked big and cumbersome, and weren�t even on the right feet! But he got annoyed and I put them back on, on the right feet, this time.
Then I went out of the room to get a soft doll from the play therapy room, thinking this would be better than the tiny doll supplied in the Denver. I came back and asked W. to try to get him to respond to "Show me the doll�s nose, mouth" etc.
He then began to wriggle and wouldn�t concentrate so we held him in his seat, with W. sitting right behind him, as the parents are told to do with their children in the classrooms in the I.P. department. This did not control him so I put him between my legs on the floor. He is only small but very strong and there are no restraints or inhibitions over his behavior. His tantrum, with him screaming and crying loudly, got worse and worse, lasting a long time, perhaps 40 minutes. Sometimes I tried to hold him and sometimes W. did. At one point when W. was trying to keep him lying face down on the floor I thought he might kick her and so I removed his shoes again.
This probably just made matters worse and his tantrum got worse.
At one point when I was holding him I tried to cool him down by holding the fan close to him, but he didn�t want this. At one time he was shouting "mamamam----".
(It was obviously the wrong thing to give in to him and return his shoes while he was tantrumming, so I waited for a lull in the storm, even if this was only very brief. Eventually, after an age one did come and we gave him his shoes back.
Then he looked at both his hands, and said something to them. Then the behavior began to look something like a peek-a-boo game!
Then he stayed with me, sitting between my legs, and with my arms around him, both of us sitting on the floor.
Then, when we were filling in the personal-social items with the grandfather in the �lounge� of the department, Earth chose to come to squeeze in beside me as I sat in the single easy chair there, very close and friendly!
Note: in the course of this fight with Earth I sustained a bad pinch on the inside of my left upper arm, which resulted in quite a bad bruise for a few days.
Personal-social
(Information from the grandfather, given to W.)
He can feed himself
He can indicate his wants
He can wave bye-bye, at the right time
He can play ball with the examiner
He imitates activities
He drinks from a cup
He helps in house, e.g. would bring shoes, if he understood what was wanted
He can use a spoon and fork
He can remove a garment
Asked to feed the doll there is no response. But when we use sign/gesture, a bunched hand to the signer�s mouth, and a point to the doll and �bottle�, he immediately makes the correct response.
He can put on clothes, (but they might be the wrong way on)
He can brush his teeth, with help
He can wash and dry his hands
Results.
The figures resulting from this test data are approximately as follows:-
Fine Motor-Adaptive
About 3 years (but what about the face in the circle?)
Gross Motor
About 2 � years
So again we get a figure of about 3 years for the M.A. of children showing h.r.b., at least in non-verbal aspects of intellectual functioning.
Note concerning the facial expression in h.r.b.
In a previous article on cases of h.r.b. observed in Thailand it was mentioned that the children did not seem to adopt an angry expression, even in cases where the interaction must have been of the negative type, unlike cases seen in the U.K. It was presumed that this was a reflection of the Thai culture, wherein negative emotional expressions were disapproved of.
When asked about this D. says that there are different sorts of smile, even an angry smile, and that you have to look carefully at it to diagnose the emotion.
To this small number of cases of h.r.b. in children can be added an interesting example of this behaviour seen in an adult. This is from a woman working at the institute who had suffered a serious spinal injury in a r.t.a., at I would think, the cervical spinal level. Her legs were completely paralysed, and to get about she had to use a wheelchair. Control of her arms and hands was quite good, although there was some postural hand shape changes, especially I think in the left hand, and some involuntary movements of the arm, or arms.
She once described to me an interaction between herself and her father, in which she expressed anger and resentment over some of his actions. When recounting the incident she raised her left hand, presented the palm of this quite closely to her face, and glared at the hand! As far as I recall I had not discussed h.r.b. with her before this time, and she was not, as far as I know, using a culturally fashionable gesture.
Discussion of this case
How does this tie in with the child cases described previously?
a. The intellectual level
We talked about a figure of two or three years M.A. as being characteristic of our cases. Clearly this now needs qualification, our present case is an intelligent adult.
We can make adjustments as follows:-
either
the M.A. suggested is a minimum figure necessary for the phenomenon
or, rather more bizarrely,
the M.A. is an accurate figure, but for a fragment or aspect of the personality, the child within us. This could be justified on the basis of the principle that in phylogenetic neurological development older, more primitive structures are not eliminated as the N.S. develops, but are buried and enclosed by more sophisticated structures.
b. The parental situation
We talked before of parent-child separation and feelings of rejection as being frequently a common feature in our child cases. This woman was in fact describing to me the situation where her father had remarried, three years after the death of his first wife�s, her mother, and she was asking why he felt the need to do this. She had been helping to support him financially from her salary, and he had lost a lot of money through his gambling habit. This scenario could fairly easily be brought under the one we suggested, and further could easily be seen as a situation which might revive some rather infantile sexual attitudes concerning the father, (Freud�s �Elektra� complex).
c. The interest in, and/or ability to see dolls and similar objects as symbols of people
We might argue as in (a). So we can say that, as far as ability is concerned, the M.A. of two or three is a minimum figure, obviously an adult will retain the ability for this symbolism, but usually not the interest. Again we might say that an infantile part of the person might retain an interest in dolls.

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