Beauty Is In The Eye Of The Beholder. By Bridget Glenshaw, M.A., LMHC

Introduction (Bruce Hauptman, M.D.)

The title of this richly descriptive, impressionistic collection of clinical vignettes is a creative attempt to impose structure and discipline on a critical issue in psychiatry and in clinical medicine itself: an attempt to ascribe the inductive as well as deductive aspects of the diagnostic process. A gifted clinician takes her highly articulate pen, to capture one of the most difficult and crucial tasks of clinical practice: diagnosis.

What is our author getting at using an evocative poetic line to introduce her collection of clinical studies? The metaphor at hand could naturally and easily draw us to an intriguing reference point in our understanding of the development of the young child. A reference point informed regarding earliest development by Donald Winnicott, Dan Stern and Kenneth Wright, among a growing number of psychoanalytic clinicians.

I am referring here to Winnicott’s early paper, “The Mirror Role of Mother and Family in Child Development.” (1967) When the mother engages the young child, and the child looks at the face of the mother, what does the child see? According to Winnicott and Wright, when the infant looks at the face of the mother, the infant sees itself. Winnicott believed that if the mother was preoccupied, depressed, or otherwise not available to greet her infant, the infant would see the mother. The depressed or otherwise preoccupied mother would be unavailable to give back to her infant what the infant needs most, an experience of devoted reflexion. An experience which allows the infant to solidify a very beginning sense of its own nascent mind and self. Winnicott, in other writings, acknowledges that the mother may be fully able to reflect back to an infant, but the infant at hand at that point in time, as he notes in his paper on the “set situation” (1941) has its own incapacity and lacks the ability to use the mother in a way which allows development to proceed in a typical fashion.

The earliest critical “self” experience in the infant can be compared to experiences in analytically based therapies with children and adults, where the patient metaphorically looks to the therapist for “self” recognition, understanding, and an opportunity to be seen in a way which facilitates a more integrated, healthier state of mind. In this particular collection of vignettes, our writer has taken on examining a series of diagnostic encounters with the express purpose of describing this very process. It is the clinicians job, not a simple one, to understand the complexities, strengths and challenges, offered in the diagnostic process. To remove oneself from one’s own thoughts and experiences, so as to be able to hear, however faint, the voice of the other, the patient, the family, to be able to be available to experience whoever has come for help.

These thoughts hopefully create for the reader of “Beauty is in the Eye of the Beholder”  a “play space” (1971) to reflect on the significance of the diagnostic vignettes in their own life experiences, and to contemplate how one’s mind, self, and even brain, might evolve through significant interpersonal encounters. (Bruce Hauptman, M.D., 2017)

“Beauty is in the eye of the beholder” is a compilation of vignettes created to further the experience of the diagnostic consultation process and document the impressions that arise as a result of this experience.  The diagnostic consultation is a service provided by Community Therapeutic Day School wherein a family can bring their concerning child to discuss both what is ailing and, hopefully, glean what is intrinsically intact regarding their social, emotional, neurologic and cognitive development.  This is done during a 45 minute to hour-long consultation session in which a family brings their child to the school.  While parents are being interviewed by a team consisting of two psychiatrists, a social worker, and a licensed mental health counsellor, the child alternately plays with one or the other of these clinicians in the same room.  Prior to this session, the parents (or guardian) have had an opportunity to describe the child, the prior diagnoses, the presenting problem as they see it, discuss the birth history and send in prior evaluations of the child for our review.  A recent photo of the child is also requested.  This procedure introduces the parents to the consultation and warms them to the process.

Some families choose to come in for a tour and communicate relevant information prior to the diagnostic face-to-face.  From moment one, the involved clinician is opening the door to a unique extension of the school’s foundational philosophy, Winnicott’s “holding environment” (1960) If an individual is given a sufficiently facilitating environment, it stimulates the intrinsic drive to evolve.  In the relationship that we are initially establishing with the family through the history taking process, the review of evaluations, and a preview of the consultation to come, we begin to establish a “play space” (1971)  This space is conceptualized as a field of joined creativity and exchange of ideas into which we will invite the child. The diagnostic consultation is the opportunity to see the child in what Winnicott would call a “set situation” (1941) This is a situation that is static and predictable.  The child in this situation, through the use of the toys, the space, and the relationships available to him or her can then demonstrate aspects of their engagement, connection, attachment, and functioning.  From this static circumstance, we can begin to draw a hypothesis, and perhaps even to help.

The following vignettes are a personal account of the reflections gained from being a clinician in this process.  They are diagnostic not only of the family and child involved in the consultation but also of my own process in working together on this team of providers as we interface with a struggling family and child.  The “writing up” of these consultations helped to forge an imprint of the child in time and in the midst of a dynamic.  How our help in the diagnostic plays out in the child’s life and development going forward is often unknown.  Therefore, each vignette is a circumstance unto itself; a re-creation and subjective reflection that seals the experience, providing closure and a wonderful opportunity to hone insight and instinct.  It serves as another extension of the holding environment in that the writing creates a play space with which to further play with words, impressions, affect and reality.  The shared experience is deepened through this process of writer to reader.  The vignettes are written with care and creativity as they describe a brief sketch of the dynamics and impressions gleaned from this unique diagnostic consultation opportunity.

The Holding Environment

Winnicott conceived of the Holding or Facilitating Environment as one in which the “maturational process” of the child is facilitated through “the total environmental provision” (1960).This first vignette highlights the ongoing help the diagnostic consultation can provide in that families are invited to bring their children back in for a continued diagnostic, year after year.  This opportunity allows for the family to check in about their child, and continues our role in the family’s now extended “holding environment.


Seven year old Constantina arrived with mother for a second visit, her first being in the Spring almost two years prior to this consultation when she was five.  At that time, she presented as a quite adorable, adopted child originating from Guatemala with a host of disturbances, not the least of which were dissociative episodes tinged with psychosis, outbursts, and suicidal ideation.  This lethal combination landed her in the hospital and parents originally brought her to us to explore therapeutic school placement.  In this rendition, the town did not agree that Constantina’s behavior at home warranted an out of district placement and countered that at school, she was quiet, well behaved, and well adjusted.

Fast forward to the Spring following her first visit when mom made an appointment for another diagnostic but cancelled saying that (then) six year old Constatina, “didn’t want to come.” By this point, Constantina was medicated and still in great difficulty, mostly at home.  However, not having the opportunity to meet again to evaluate her, it was unclear as to the gravity of the situation.  In the fall, mom called again, and was desperate.  She described that Constantina was suicidal, self injurious, and running away a lot.  Several evaluations had been conducted between then and now.  Presently, at age seven, her depression had been documented, as was a diagnosis of PTSD as manifested in disassociation, anxiety, psychotic episodes, explosiveness and a question of reactive attachment disorder.

For our second visit, a now adorable second grader walked through the door.  Initially a bit shy and withdrawn but quickly able to disengage from mom, Constantina started to think about drawing and then declared that she was thirsty.  She moved out of the room and departed from mom needing only a little reassurance as we went to go find water and a snack.  Back in the consultation room, mom unveiled the tale of Constantina’s continued slippage.  Encopresis has now been added to the list.  Parents had employed a lawyer to help them remove Constantina from public school and place her in a private, therapeutic setting.  School was still “okay;” home far from it.  On top of it all, mother’s mother was living in the family’s home to die of cancer.  The compounded agony appeared to have worn away the entire family system most pronounced in this current iteration of Constantina’s somewhat wooden, shell shocked mom.

Constantina, once out of the evaluation room and away from her mother seemed to suddenly warm up.  She only continued to brighten as she was well received in our walk about the school community.  Many staff members recognized her from her last visit.  She stood out and smiled often, speaking to others with a quiet, somewhat genteel tone.  She appeared to enjoy traveling to the classroom building to see some of the classrooms and even go in one to inquire about gluten free items.  She shared her coveted gluten free crackers and seemed independent and able.  When asked why she was back for a second visit, she replied that she had no idea.  We explained that sometimes moms and dads come to us to get help so that they can help their kids.  She nodded, agreeably.  Back upstairs, she greeted her mother and showed her the box with gluten free crackers.  Mother acknowledged this and continued to wrap up about further calls to make, and declaring, again, her commitment to making this the school Constantina would be placed in.

Given the split between Constantina’s presentation at home and school mirrored by her capacity to split off into relatively good health and typical presentation during this consultation, it seemed crucial to start integrating some of these parts of herself to see if the health could influence more positively the dysfunction.  Our diagnostic impressions corroborated her prior diagnosis of a mood disorder with psychosis not otherwise specified, and depression with suicidal ideation.  Of note was the reported decrease in sensory and auditory hallucinations with use of anti-psychotic medication.  A recommendation for a consult toward medicating the mood disorder with a mood stabilizer was encouraged.  Certainly this child was caught between two worlds; one of sobering health and one of terrifying dysfunction.  She surely qualified for a therapeutic outplacement if only based on the pathology living in the dysynchrony of her opposite presentations.

The holding environment is not all play and talk.  There are times when the intensity of a child’s affect and regulation issues culminate in the need for limit setting and, in even a few instances, physical restraint.  These two vignettes are presented in an effort to describe the diagnostic not only as responding to our theory about what is happening with a child and what is needed, but the inclination to provide the action in the moment to meet a child and family where they are, and in the moment they are in.  It is a dynamic unfolding that flexibly absorbs and is influenced by a child’s disposition or developmental level.  We are constantly creating a play space that is safe; one that contains spontaneity and boundaries, creativity and structure, give and take.  To maintain safety is of the utmost importance for the family, child, and the integrity of the holding environment in and of itself. The next two vignettes describe this process.


Nora was a delightful little girl who looked much older than her five years of age, and acted much younger than she was old.  Petulant on first arriving to the consultation room, Nora was non-plussed by an offer of dollhouse play.  She whined and clung a bit to her mother who remained steady, pleasant and calm throughout.  Within a few minutes, with little to no verbal interaction, Nora was fully alight in a game of chase.  Touching her belly and running away, laughing and wanting repeated input, she appeared completely comfortable in the play of this earlier developmental level with language being a noted barrier to broadening or deepening the interaction.  Developmental delay seemed to fit in terms of diagnostic categories as she regressed and then inched her way up, just a bit, on the developmental scale.  Her peak seemed to be the stage of “rapprochement,” where she not only returned to mother again and again, but bit her once as if to announce her excitement.  In response to this, mother directed Nora to a small chair in the consultation room and demanded that she take a “time out!”  Nora sat, stomped her feet, and cried but in short order was able to respond verbally with, “Nora no biting?”  And repaired with, “I’m sorry,” which got her a hug from mom and a return to the play at hand. Recommendations were for more speech/language work, an integrated pre-school, a therapeutically trained nanny to structure and support her afternoons, and seeking out more socialization opportunities geared toward Nora’s younger developmental presentation.  An occupational therapy assessment had been conducted but a more thorough sensory integration based assessment was in order.  Individual play therapy and a parent guidance support piece were determined as icing on the cake to support this delayed yet spirited, delightful gift of a girl.


Darren arrived with his grandfather and grandfather’s lifelong partner.  Darren’s grandfather had been deemed his custodial caretaker and was now in the process of seeking guardianship.  Darren was the product of the couples adopted son, and thus, their grandson.  He had been born of their son’s union with a woman characterized as highly unpredictable, irresponsible, psychiatrically disordered, and drug abusing.  Blonde, rambunctious Darren was big for his four years of age with a very large head and notably smaller, almost disproportioned limbs and hands.  When noting his physicality, grandfather said that Darren distinctly resembled his biological father, grandfather’s adopted son, in “more ways than one.”  In reviewing the birth history, it was reported that bio-mom did not use drugs or alcohol during the pregnancy but that bio-dad used opioids and alcohol throughout.  Darren was affable but somewhat agitated throughout the consultation, presenting with delays, especially in speech and motor planning.  He wanted to play and would maneuverer clumsily and somewhat impulsively about the room, suddenly throwing a ball or bumping about trying to play chase and catch. With high energy and an intense need for constant attention, Darren gravitated toward engagement at all times, at all costs.  He was at a loss alone and did not seek independence, looking toward a navigator for ideas.  Grandfather described that Darren was given little or no attention in his mother’s home and that when he and his partner cared for Darren in their home over the weekends, they would never hear from his mother, not even to check in on him as an infant.  Darren was received as a burden upon his return to his mother’s home.  She eventually but gladly relinquished him permanently at approximately two-and-a-half years old to their care in one last brutal evolution of back and forth.  The play resembled this when he was finally able to settle somewhat and became preoccupied with a transformer toy that would be “nice” and then shape-shift into a threatening, attacking counterpart who continually beat the clinician’s toy figure, expecting it to return refreshed and guessing every time.   Darren went to preschool with a 1:1 aide but was expelled after an incident which occurred when the aide left him alone on the playground while she ran in to quickly use the bathroom.  Upon her desertion, grandfather described that Darren violently attacked the other children near him and threw one child off the slide.  Clearly an integrated preschool was in order and a therapist was recommended to help unfurl Darren’s attachment issues from his possible cognitive delays.  We sensitively suggested that his loving caretakers learn to some behavioral techniques to help hold, stop and even at times restrain Darren as he was prone to dysregulation and using his body demandingly to get his needs met.  Speech/language and occupational therapy were also raised as potentially helpful to shore up these foundational cornerstones of instability.  We referred an intern from our own therapeutic setting for further childcare/ respite care.  Darren was in desperate need of immediate support, as was his well meaning, wonderful grandfather who was at risk to be soon overwhelmed by the burden of what would be needed for the long haul ahead.

Initially the “holding environment” consists of the child’s relationship with the mother or caregiver.  The holding environment fosters and adapts to how the child’s development progresses and how this crucial relationship responds to that ever changing dynamic.  If all goes well, the holding environment expands to include the family, extended family, friends and outside caregivers, school and eventually community.  The nucleus is the child and the ripples move out and back in.  It is a fluid system; a sustainable one.  There are those things that influence, ignite and excite, while at the same time, sources of comfort, nurturing and acceptance that serve to contain the evolving child.  There are boundaries established; limits to what is acceptable and not.  A sense of self and other is a burgeoning dynamic and safely explored.  In the holding environment, these relationships and the “good enough” stimulation they provide foster the child’s internal and external world.

 The Play Space

 Winnicott defined the Play Space or Potential Space as the arena in which the individual is able to “engage in a significant interchange with the world, a two way process in which self-enrichment alternates with the discovery of meaning in the world of seen things”(1967). He further noted that “Psychotherapy is done in the overlap of the two play areas, that of the patient and that of the therapist” (1971). In the following vignettes, the CTDS therapists and family join together in the play space to creatively construct meaning with the hope that each of their lives will be enriched.


Isabel was a small, rather delicate four year old referred from her paediatrician for concerns around a constellation of difficulties including low muscle tone, motor delays and a confounding expressive language disorder.  In the parent interview during the consultation, with the support of the Newborn Summary from the hospital where Isabel was born, mother described a very traumatic birth and prenatal history.  During the pregnancy, mother had a high feotal alpha reading and an initial ultrasound that imaged Isabel’s neck to be large.  From this point forward, Isabel was monitored closely in utero to make sure her spinal cord was closed, with extra cardiograms always indicating that everything was well.  During the actual birth, however, labour took a gruelling 17 hours with Isabel presenting “sunny side up” and “not able to come out.”  Thus, an episiotomy was required.  When Isabel was finally delivered, she was positive for meconium inhalation.  Her Apgars were 6, 8, and 10 and she had very low blood sugar.  As her infancy and early toddlerhood progressed, Isabel had significant motor delays (still on her hands and knees and unable to pull up to standing until her first birthday).  She was taken to an ear, nose, and throat specialist to rule out hearing problems and was given ear tubes at seventeen months.  After this intervention, Isabel immediately began walking and mother describes her receptive language, “took off!”  She was entered into early intervention, speech/language therapy, and occupational therapy. The trifecta was helpful but still Isabel’s delays, especially her inability to speak, brought her to our doorstep.

Once in the actual diagnostic consultation, after an initial period of slowly warming up while still clinging closely to her mother’s side, little Isabel was drawn to the visual stimuli in the room much more than any auditory suggestion or directive.  She perused the basket of toys and twirled her hair around her thumb, humming to herself but saying nothing.  Not a syllable; not a word.  Despite this, she began really looking, pointing, and communicating her interests non-verbally.  She finally settled on a book.  Turning the pages carefully, Isabel examined each image and appeared entirely immersed.  No longer an appendage of her mother, one of the diagnostic therapists was able to pull her in as they began “reading” the book together.  Mother mentioned that signing had been somewhat successful with Isabel in her late infancy and this information inspired the therapist to begin giving gesture to image with Isabel.   Her delight and engagement in this game was palpable.  It was evident that she had the desire to augment communication and to be communicated to but the ability to speak simply eluded her.  There was a block between her desire and this specific medium of communication, but all other inroads were available, welcomed, and most remarkably, reciprocated.  As Isabel and the therapist developed a playful “signing” language between them, it became refreshingly clear how bright a child Isabel actually was.  She presented in this quickly cultivated play space almost as a deaf child who had momentarily been granted the gift of hearing might.  She literally dove into the sea of words and awakened in the deepened meaning to the relationship they offered.

Mother had scheduled an evaluation at Boston Children’s Hospital to determine whether an oral/motor apraxia was the deterrent to Isabel’s ability to speak and was also having a physical therapist at the hospital examine her mouth musculature.  Mother felt that based on the findings of these upcoming evaluations perhaps a ‘prompt’ speech therapy for Isabel would be next.  After seeing the excellent capacity for joint attention that Isabel exhibited, and how happy and social a child she was, a suggestion that the family (constantly) narrate to Isabel was strongly urged.  Narrating to Isabel and becoming fully engaged with her in the world of signing was imperative.  It enhanced a secure attachment and gave her a medium through which her curiosity in the world was rewarded.  A speech/language and occupational therapy based play group was also suggested.  It would further support the burgeoning physical and linguistic development of this beautiful, capable yet muted child.  Her mother was extremely helpful, thoughtful, and pragmatic throughout the evaluation.  She could be characterized as worried about Isabel but not to the detriment of her ability to appreciate, play with and love this precious, inspiring child.

The diagnostic impressions gleaned from this consultation were that of an early history of fetal distress and potential inconclusive abnormalities in utero resulting in a developmental delay with a major focus on expressive language specifically derived from an oral motor apraxia.  Fine and gross motor delays were evident.  The addition of ear tubes that were inserted ten months prior had not yet resulted in a full ten months worth of developmental progress.  Whether she would ever be able to conquer actual speech or not, she clearly had a strong, healthy interest in language.  Finding motivation for her to vocalize was one of the keys, much as we discovered once in the play space of this evaluation.  Utilizing music through lyrics and song was another suggestion to unlock the potential in this incredibly able but blocked, delightful child.

Some weeks after this diagnostic was conducted, we received a note from Isabel’s mother.  It read: “Thank you for taking the time to play with Isabel and listen to me.  It was such a positive experience, and I hope her Children’s [Boston Children’s Hospital] evaluations go the same way.  Thank you for seeing all the wonderful things I see, and for making me feel like I am on the right track.”

Sometimes a child’s gravitation towards health and resilience is demonstrated in his or her ability to not only inhabit and thrive in a provided play space, but to also seek out a broader play space in which he or she can experience additional, compelling relationships. This next vignette is an example of a young boy’s ability to seek out and explore that play space.


Sam, a spunky, handsome and rather slight four year old arrived with his mother in the waiting room.  He was engaged with the toys, looked up to greet me, and though he finished his thought in the play, had little difficulty transitioning out to explore what was next.  His sense of excitement and anticipation was palpable and his mother’s affect, too, was one of endearment of her little one, smiling and soaking in his energy, happy to let him move a bit ahead of us.  He was greeted at the door by one of our clinicians and again, demonstrated an open, happy, trusting demeanour, looking back with a quick glance to mother as we caught up to him at the door.  His innate curiosity lit up when he observed other children who were in the barn and engaged in a dance/movement therapy group.  He was more than ready to join them, in fact, taking off his shoes to mimic the bare feet of the children in the group.  With little protestation, he could be corralled into the library for the consultation but was (healthily) reluctant to.

Once greeted in the library, Sam went back to exploring and playing much as he did in the waiting room.  More language began to come as he directed one of the clinicians in the play and narrated the stuffed animals many ministrations.  It was a lively scene and a fun one.  Sam’s mom began to discuss the reasons for their visit which centred around a spontaneous movement that involved Sam bringing his hands up in an almost seizing gesture repetitively and seemingly without volition.  We had concurred that it was there, having seen it several times since the start of the consultation.  The movement did not appear to be linked to any particular negative or positive affect; more it seemed to be an artifact of an immature neurological system whose overflow was captured within this movement anomaly.  Though talking, Sam demonstrated delays in his expressive language skills and had some sensory needs that mother felt were being well met in his current school placement.  Additional occupational therapy and play therapy were recommended to meet him where he was most joyful and, given his excellent play skills, a strength-based touchpoint for maturation and change.  The genesis of the gestural concern and whether it might “melt away” someday continued to be explored especially in light of mother’s description of Sam’s father who had a similar but not as pronounced movement rubric which he displayed when not consciously “keeping it under wraps” during times of high affect.  In reviewing the birth history, another possible nexus was wrought out as mother described that upon his vaginal delivery, Sam had the umbilical cord wrapped several times around his neck and needed immediate oxygen which “instantly revived” him.  Mother described her relief with tears in her eyes that after this, they placed Sam in her arms and he promptly began, “wailing away!”  Though being followed by a neurologist who had ruled out anoxia as a potential cause of Sam’s repetitive hand movement, we still had some concern about this possibility and asked mother to please send us Sam’s birth records with the nurses’ notes for our review.

The diagnostic ended with Sam returning to the larger space and surreptitiously running over to place himself in the middle of the dance/movement group.  He was met with joy and delight by the other, older children.  Clearly a healthy, intact and joyful child who would, or would not, grow out of, or grow to monitor, his own compelling hand movement that perplexed and alarmed his mother in differing degrees.  Obviously, neither the movement or her concern were going to hold him back in any determined way from his love of life, and her joy and love for him.

The Set Situation

 The “set situation,” the situation in the consultation office that is the environment and known elements within it such as the toys, the positioning of the couch, the closet doors and where they open to (or not), our roles as clinicians and even how we position ourselves as a child and family enter the room allow for deviations in the patterning of these somewhat static elements, and sometimes they rise up in stark relief.  Such was the situation when the following child entered our midst, sat with his mother, and deviated in his absolute defiance of our solicitation, warmth, and concern.  This eleven year old’s anger bounced off the walls even though he sat as still as stone with his eyes piercing his mother’s in defence.  As clinicians who continually hold the parent-child interaction and impinge upon it, gaze upon it, or simply comment on it, the disturbance in this dynamic and the discomfort it produced in our team was notable.  This was another diagnostic “tool” that informed us as to what holding environment might be “good enough” for this child outside of the one provided him now.


Pre-teen Bruno arrived trailing behind his mother with a defiant air.  He listened to music with one ear bud in, the other hung down, dangling provocatively proving, perhaps, that he would only be half listening to what was about to go on.  He plunked down on the opposite side of the sofa in the diagnostic evaluation room, furthermost away from his very polite, articulate, and fairly wrought-looking mother.  Bruno made certain he did not meet anyone’s gaze but his mother’s, and when not glaring at her, simply nodded “yes” or “no” to our questions.  Numerous invitations, both subtle and overt, were made in an attempt to invite Bruno to engage in any way.  He simply would not.  The onus was on his mother to describe that Bruno had slowly but surely failed out of his previous private school placement where he had been placed to address his dyslexia and other learning needs.  Now getting close to age thirteen, Bruno was not only suffering multiple learning issues, but also a severe depression that presented in the form of self harm through cutting, and suicidality.  He had been hospitalized once in the current calendar year and had remained home for some months between leaving his private school, being hospitalized, and then attending the local public middle school where attempts were being made to program for him.  Bruno’s mother was desperate to fine tune what she considered were holes or weak points in the delivery of academic curriculum to Bruno.  She felt sure that if the academic supports were shored up and honed to mediate his acute learning needs, he would be a happier, more able child.  Any talk of an outside placement that could address both Bruno’s learning and his emotional needs appeared to be a last resort for her.  Likewise, when the subject came up of perhaps changing schools, the idea did not appear to appeal to Bruno either as he made abundantly clear by practically breathing fire, glaring at his mother and shaking his head, “NO.”  Staying at the public school and remaining with typically developing peers who did not carry an emotional stigmata was the goal in their eyes.  We offered potential assistance to the public middle school team in terms of translating Bruno’s learning needs (as documented in his current neuropsychological evaluation) into real world applications, if we were invited in to do so.  Again, we emphasized emphatically Bruno’s acute therapeutic needs.  In the end, mother and son left the consultation hopeful that we would be helpful in his remaining at the public school.  This could be done if, in their eyes, the public school would help Bruno feel less on the brink academically, and therefore more “normal.”  A tall order to be sure.

The diagnostic consultation’s primary goal is to enter into the relationship with the child and family with curiosity, focusing closely on both that which is splintering off what would be the natural unfolding of the child’s development, and those parts that resonate and are going well.  Creating an environment where we can look at the child in their family unit by inviting the child to play, talk, and/or interact in the family’s very presence provides many touch points through which to explore this snapshot of phenomena.  Through this construct of the set situation, we garner impressions that may be useful for the parents, supply some guidance, and even at times widen the holding environment to include our support.  Our ongoing support may come in many forms.  We may offer to communicate our diagnostic impressions to outside providers, write a letter detailing our impressions addressed to the parents for their use outside of the consult, provide referrals for therapy or further evaluations, or provide therapy, parent guidance, and further consult directly to the child’s school.  The consult may lead to a child and family being invited to join our school community if both are a fit, we are enrolling in the school, and we think there is a classroom grouping that would suit the child.  All of this is done in synchrony with the family and it is therefore imperative that the child and family both be present when conducting a diagnostic consult.  When the child is not present, the projection of the child by the parents is what is diagnostic and inevitably we are unable to be as helpful to a family as otherwise may have been possible. In this next vignette, the “set situation,” the static, known, predictable backdrop manifested by the clinicians is shifted to respond to the child’s desire to explore outside the diagnostic room doors.  The diagnostic consultation expands itself into the holding environment of the garden at the school, further away from the parents and into another world.  Upon reflection, this mirrors the child’s organic experience of himself and his neurology as it impacts his everyday life, and his use of relationship to steer him back to the present moment, and all the tiny wonders for him there. 


Gregory, an effervescent, other-worldly child, arrived at our diagnostic doorstep at seven and a half years old.  His parents, living apart part-time, were still reeling from an affair on father’s part.  Despite this, they were bright, devoted folk whose love for Gregory emanated as they spoke to us. This was especially visible when they communicated directly with Gregory during the consultation. The visit’s concerns were centered around Gregory’s low opinion of himself since the troubling onset of an absence seizure disorder also almost a year prior.  The two catastrophic life events coincided (father moving out, and the first in wave after wave of ongoing seizures) and had caused an anxiety and sadness that parents felt would best be dealt with in psychotherapy.  The therapist and type of therapy was quite specific in their minds.  The fit had to be holistic and whole child centered with someone who would follow Gregory’s lead, play with and enjoy him.  Not a difficult task, it seemed, given the happy, creative being who wished to go out into the garden during the consultation to check out the newly constructed birdhouses there, and just generally see what he could see.

The free spirit of this child was contagious.  The wind felt fresher, the birds were sudden and surprising, the garden a mystery to be unveiled.  Quite counter to this were the disturbing moments when Gregory would stop in mid-motion, stare blankly ahead for four seconds, and then veer to the left.  Sometimes, Gregory would cover for himself and pretend to be noticing something suddenly appearing in his (now left) sightline.  Other times, he would become a bit weepy and despairing with an, “Oh.”   Mostly, however, as the constancy of these disruptions became the norm, he would falter a bit and accept my reassuring presence, using my ego and continuity to pick up the thread where it was left off, and continue on.

Meanwhile, in a parallel universe to the one Gregory was encountering in the garden, parents were continuing with the consultation in the office.  The  possibility of therapy and of medication to mediate the seizure activity was raised.   Mother was pointedly adamant in her belief that the medical field would and only press for medication on the neurologic issue, as had been her experience, instead of offering alternatives such as diet.  She detailed how in response to the visit with the neurologist, she had avidly researched and then  independently began Gregory on a strenuous Ketogenic diet regime.  Quite out of left field came the sudden disclosure of a recent family incident in which Gregory was found partly unclothed atop his younger cousin.  The play scenario was interpreted by the cousin’s mother as an overtly sexualized act.  An aftermath consisting of questioning, accusing, and a trip to the emergency room for Gregory’s cousin to rule out rape had ensued.  Parents described that this misunderstanding had created a mile wide family rift leaving all parties feeling confused and disempowered.  The third in a trifecta of particles that appeared to have successfully punctured this would be typically developing, yet extraordinarily vulnerable child’s world view.  Parents concern for Gregory’s encroaching sense of shame and damage was warranted.  Gregory’s family left with diagnostic impressions of a primary seizure disorder, and a recommendation to rule out learning disabilities. The seizures were also at risk to create a chronic deleterious effect on Gregory’s cognitive process.  An adjustment disorder with disturbance of emotions was considered related to father’s separation and the incident with Gregory’s cousin, in particular its intensive aftermath.  Gregory was a highly coordinated, sensory seeking, wondrous child.  A little star in a constellation of unfortunate neurologic and familial events.

The opportunity to be in a process of admiration, revelation, and guidance with each family and child as they enter the diagnostic consultation is as communal as it is internal.  The vignettes described above are poignant descriptions of a clinical situation of engagement that requires the utmost care and integrity.  It is with these two imperatives in mind that what is presented here has been thought over and written.  Each child is beautiful in their own right.   Each family differently and uniquely on their own path that may or may not have been widened, influenced or encouraged in another trajectory due to the impact of the consultation; the beauty we beheld and hold.

Epilogue (Nancy Fuller, M.A., LiCSW)

 These sensitively rendered vignettes highlight the diagnostic consultation process at the Community Therapeutic Day School as intricately influenced by one of the school’s founders, the late Bruce Hauptman, MD (1938 – 2017).  In capturing the breadth of curiosity and insight needed to illuminate the diagnostic process, as well as describing the “holding environment” provided for families as they enter the process, similar to Donald Winnicott’s “set situation” in the pediatric consultation, the vignettes are a study in “attunement” (Daniel Stern, 1985 ) and the instrumental use of play.  They are deeply reflective of the necessity for “mirroring” as promoted in Donald Winnicot’s conceptualization of healthy attachment, and the condition of the“good enough mother,” as intricate to the assessment of the chid’s capacity to use relationship to tap into their own resilience. In both philosophical contexts, and as replicated in these vignettes, there is an inherent connection between the parent and child, and their experience of being “seen” as vital.  The diagnostic consultation creates a shared experience of holding the child and family in a moment in time while considering past and present developmental states.  Safety, resonance, trust, and a spirit of engagement with the clinicians is articulated in this sampling of the consultation process, as well as expressing the inherent hope that this unique consult experience can bring to a family and their child.


Stern DN. The inter personal world of the infant. New York: Basic Books; 1985.

Winnicott, D. W. (1941) The observation of infants in a set situation In Collected Papers London: Tavistock Publications, 1958

Winnicott, D.W. (1960) The Theory of the Parent-Infant Relationship. In The Maturational Process and the Facilitating Environment, (1965) London; Hogarth Press.

Winnicott, D.W. (1967) Mirror-role of Mother and Family in Child Development. In Playing and Reality, (1980) London; Penguin Books.

Winnicott, D.W. (1971) Playing: Creative Activity and the Search for Self. In Playing and Reality, (1980) London; Penguin Books.

Leave a comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.