Category Archives: behavior issues

Why Pediatric Occupational Therapists Need The Happiest Toddler Techniques: Neurobiological Regulation

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Pediatric occupational therapists are usually all-in when it comes to using physical methods to help children achieve affective modulation.  We use the Wilbarger Protocol, Astronaut Training, Therapeutic Listening, and more.  But are we using Dr. Harvey Karp’s Happiest Toddler on the Block techniques?  Not so much.  All that talking seems like something a teacher or psychologist should do.  Folks, it’s time to climb off that platform swing and look at all of the ways children develop state regulation.  Early development is the time when children experience attunement with caregivers and create secure attachment.  But this is a learning process that grows over time and can be damaged by events and by brain-based issues such as ASD.  The Happiest Toddler on the Block techniques aren’t billed as such, but they are the best methods to create attunement and attachment while teaching self-regulation skills that I have found.  Combined with sensory-based treatment, progress can be amazing!

Research has told us that the way we interact with children and the way they feel has direct effects on neurotransmitters and the development of autonomic reactivity.  If you don’t believe me, check out Stephen Porges’ work on the ventral vagal component of the autonomic nervous system.

When we use The Fast Food Rule, Toddler-Ese and Patience Stretching ( Use The Fast Food Rule to Help ASD Toddlers Handle Change and Stretch Your Toddler’s Patience, Starting Today! ) to get a child focused, calm, listening, and recognizing that we “get them” even if we don’t agree with their toddler demands, we shift more than behavior.  We shift their neurophysiological responses that can become learned pathways of responding to stressors of all kinds.  We are using our social interactions to create neurobiological regulation.  I believe that the use of Happiest Toddler techniques can make a significant neurophysical change in a young child even before we put them on a swing.  I am going to go out (further) on a limb and say that if our interactions aren’t informed by understanding attunement and engagement, our sensory-based treatment might be seriously impaired.

Long story short:  if you aren’t using effective methods of developing social-emotional attunement and engagement with young children, your treatment isn’t taking advantage of what we now know about how all children learn self-regulation.  And if the child you treat has ASD, SPD, trauma from medical treatment, etc…..you know how important it is to use every method available to build the brain’s ability to respond and self-regulate.

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Help Your Child Develop Self-Regulation With Happiest Toddler On The Block

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Children start learning self-regulation early.  Most kids eventually become reasonably skilled at it, given some help from loving adults.  The problem is they don’t learn it quickly.  Self-regulation takes a long time to become established in the slowly-developing brain of a young child.  While you are scooping up the puddle of Jell-O that used to be your toddler before she dropped her ice cream cone, think about how you can use this moment to build her ability to come back to a calm state:

  1.   Reflect her emotions without denying them or taking them on.  After all, you know that it isn’t the end of the world.  But at that moment, she can’t see it.  She is sad and maybe even angry.  Use the Fast Food Rule Use The Fast Food Rule For Better Attunement With Your Child to state what happened and how you think she feels.  Remember to use lots of gestures and alter your vocal tone to convey empathy.  Don’t be placid; after all, she needs to know that you get how unhappy this has made her.  Kids tune into your expressions much more than your words at this age.  You may think you should be soothingly quiet, but she is thinking ” You don’t see my pain!!”
  2. Make sure she knows that you care about what happened, and use this moment to identify what she is feeling.  Even if you intend to get her another cone, allowed her to be upset for a very brief period, and let her know that we call that feeling “sad”.  Kids depend on us to explain what happened to the dinosaurs, how to eat with a fork, and also how to identify and manage emotions.  Take that moment to explain that there is a name for what she is feeling, and that it is normal and understandable, even if you intend to fix it with another ice cream.
  3. Ask her if she wants another ice cream cone, but not too soon.  Sometimes children aren’t ready for our solutions, even if they do want them, and presenting one too early gives a message that we never intended:  I can’t handle your pain, you can’t either, and I need to fix it right away.  Look for that shift in body language, eye contact or verbal connection that tells you she is starting to pull herself together before you jump in with a solution.

 

If you find yourself more upset than your child, their pain ripping through you, take a moment to look inside and see what experiences in your past are contributing to this feeling.  You may have been taught the same lesson early in your own childhood.  If you received the message that pain is unbearable and should be avoided at all costs, you are not alone.  Well, I am going to tell you that an important part of your life, and a part of your child’s life is all about learning to feel feelings without fear and come back to a good place after a difficult experience.

Bad things happen to us all, and the most important lesson you can teach your child at this moment is that she can handle this feeling and come through it.  With your support, and with the support of other people who love her, she will get through the loss of her ice cream and other losses in life as well.

And it can start with how to handle the loss of an ice cream cone….!

 

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Use The Fast Food Rule For Better Attunement With Your Child

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What’s attunement?  The physical and emotional connection that a healthy parent makes with their upset child that brings them both back into a calm and balanced state.  Why is it important?  Because without attunement you don’t have healthy attachment, and attachment is the foundation for a healthy emotional and interpersonal life.  Attunement and attachment are some of the biggest issues in psychology today.  Everyone is talking about it, but once those early years are over, it takes a lot of therapy to repair rifts in this foundation.  So reinforce your emotional connection with your toddler, and know that the effort you make today will help them recognize healthy relationships for the rest of their life.

How does The Fast Food Rule help parents develop attunement?  By reflecting back the child’s perceived complaint with enough gesture, facial expression and vocal intensity to register in the mind of a child, your child will feel that you “get” them, just as they are, regardless of whether you agree that a broken cookie is the end of the world.  Knowing that a parent understand where you are coming from is essential.  For more details, read Stop The Whining With The Fast Food Rule.

Again, later in life, realizing that a partner isn’t “getting them” is important when deciding whether to develop or stay in a relationship.  From there, your child will be able to consciously decide to communicate more effectively, invest more time and effort in the relationship, or move on to another person who can connect more successfully with them.

Does this mean that you give in to every howl from a young child?  Of course not.  Even toddlers know that they won’t get everything they demand.  They may be unhappy to hear that they can’t have cookies for dinner, but they don’t actually think they will be having them for dinner.  What matters is that they know that you understand them, understand their feelings, and aren’t rushing to squash their anger, sadness or frustration.

Once you see those little shoulders drop, hear the scream become a wail or a whine, and get more eye contact, you will have been given the green light to offer a solution.  Wait for it.  And look for that moment when the two of you are calm and moving forward together.  That, my friends, it attunement at work.

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For Kids With Sensory Issues and Low Tone, Add Resistance Instead of Hand-Over-Hand Assistance

 

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One of my most popular posts, Why “Hand-Over-Hand” Assistance Works Poorly With So Many Special Needs Children , explains how this common method of assisting children to hold and manipulate objects often results in rejection or even aversion.  This post tells you about my most successful strategy for kids with low muscle tone and limited sensory processing:  using graded resistance.

Why does making it harder to move work better?  Because if the child is actively trying to reach and grasp an object, you are providing more tactile, kinesthetic and proprioceptive information for their brain.  More information = better quality movement.  Your accurately graded resistance is doing what weighted/pressure vests, foot weights and SPIO suits do for the rest of their body.  Could you use a hand weight or weighted object?  Maybe, but little children have little hands with limited space to place a weight, and weights don’t distribute force evenly.  Did you take physics in school?  Then you know that gravity exerts a constant pressure in one direction.  Hands move in 3-D.  Oh, well.  So much for weighting things.

How do you know how much force to use?  Just enough to allow the child to move smoothly.  Its a dance in which you constantly monitor their effort and grade yours to allow movement to continue.

Where do you place the force?  That one is a little trickier.  It helps to have some knowledge of biomechanics, but I can tell you that it isn’t always on their hand.  Not because they won’t like it, but because it may not deliver the correct force. Often your force can be more proximal, meaning closer to the shoulder than the hand.  That would provide more information for the joints and muscles that stabilize the arm, steadying it so the hand can be guided accurately.   If a child has such a weak grasp that they cannot maintain a hold while pushing or pulling, you may be better off moving the object, not the hand,  while they hold the object, rather than holding their hand.

Still getting aversive responses from the child?  It may be because the child doesn’t want to engage in your activity, or they don’t realize that you are helping them.  They  may think that adults touch them to remove objects from their grasp or otherwise stop them from exploring.  Both can be true.  In that case, make sure that you are offering the child something that they want to do first.  Remember, we can’t force anyone to play.  The desire to engage has to come from them, or it isn’t play.  Its just adults making a kid do something that we think is good for them.

 

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One of the most amazing places I have ever seen:  Australia!

How Hypermobility Affects Self-Image, Behavior and Activity Levels in Children

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Loose joints affect emotions and behavior too!

As rehab therapists, OTs and PTs are focused on skill building and reaching functional goals with our clients.  But feelings influence behavior, and so therapists have to be aware of more than joints and muscles when looking at function.  In this post, I would like to address the many ways that hypermobility can create social and emotional issues for children.  Without awareness of these experiences, we cannot be the best therapists for these kids, or help parents be the best advocates for their children.

Because hypermobility varies so widely in it’s severity, it’s presentation (generalized, primarily proximal, or primarily distal) and it’s progression (decreasing with age or increasing with repeated injuries and overstretching of tissues), the psychological impact on a child will also vary tremendously.  The child who has had significant and global hypermobility from birth will have a very different profile from the young teen who is only recently experiencing functional issues with instability or pain after years of sports-related injuries.

Here are some major points to consider:

  1. Hypermobility and it’s accompanying effect of stability and proprioceptive processing contribute to both sensory seeking and sedentary behavior, sometimes in the same child.  Add in pain and fatigue, and perhaps even POTS or dysautonomia, and you have a kid that is both active and inactive, both attentive and unfocused on tasks at different times of the day.  Self-regulation appears to be very unstable.  If a child’s entire physical condition isn’t taken into assessment, a referral for an ADHD diagnosis could result.
  2. Difficulties with mobility and stability make active play and engagement in sports more difficult.  This has social as well as physical effects on children at all ages.  For some kids, they can play but get injured at a more frequent rate.  Other children aren’t able to keep up with their peers on the playground and seek more sedentary or independent activities.  And for some other kids, they experience the pain of being the last kid picked for group play or being bullied for the awkward way they move.  The child that was more mobile and athletic when younger, and is now experiencing a loss of skill or an increase in pain, is also at risk for feelings of depression and fear of movement.  That fear is a real problem, with a name: kineseophobia.   This isn’t the same as gravitational insecurity, but it may look like it  to a clinician unless that therapist is aware of a child’s history or all of the current clinical problems.
  3. Kids with hypermobility can have problems with falling and staying asleep, which affects daytime alertness and energy.  It is well-documented that a lack of good-quality sleep results in childhood behavioral changes for typical kids.  Pain, lack of daytime activity levels high enough to trigger sleep, bladder control issues leading to nighttime awakening or bedwetting…the list of sleep issues for kids with hypermobility can be really long.  Evaluating a child’s behavior without knowing about these issues is going to lead to incorrect assumptions about the source of reactions and interactions.
  4. Hypermobile kids can have issues with feeding that contribute to patterns of behavior that extend beyond the dinner table.  Difficulty with eating, chewing, and even constipation can result in behavioral changes.  Crankiness is only the beginning.  Imagine being constantly constipated or gagging/choking on food.  Especially with younger kids, learning social interaction skills at the table can be lost in a parent’s need to alter food choice or their concerns over nutrition.  The development of persistent oppositional behavior can begin at the dinner table and spill over into all interactions.  Hypermobile kids don’t always have issues that restrict them from eating; some kids don’t get enough exercise or find eating to be a pleasurable activity that doesn’t take too much energy or skill.  Used along with media use or gaming, snacking is something that they enjoy.  The extra weight they carry makes movement more difficult and places extra force on joints.  But exercising in pain and fatigue isn’t an easy fix.
  5.  Children develop social and emotional skills in engagement with others.  The child who attends therapy instead of playdates, the tween that doesn’t have the stamina to go on a ski trip, the child who can’t sit still during a long play or movie.  All of these kids are having difficulties that reduce their social interactions to some degree.  Encourage the families of the children you treat to be mindful of a child’s whole life experiences and weave interventions into life, not life into interventions.

As therapists, we owe it to our clients to ask questions that help us understand the daily challenges of life and create treatment plans that support a child’s social and emotional development.  Waiting for mental health professionals to ask those questions isn’t enough.  And remember, if there is a counselor or therapist involved, share what you know about the impact of hypermobility on behavior.  Without awareness of the physiological and sensory basis of behavior, professionals may make an incomplete assessment that will not result in progress!

 

Are you a parent of a child with hypermobility?  Check out For Kids With Hypermobility, “Listen To Your Body” Doesn’t Teach Them To Pace Themselves. Here’s What Really Helps. and Career Planning for Teens with JRA, EDS, and Other Chronic Health Issues for some insights into positive ways to address the future.

Looking for more information on treating kids with hypermobility?  Take a look at Can You Use The Wilbarger Protocol With Kids That Have Ehlers-Danlos Syndrome? , Hypermobile Kids, Sleep, And The Hidden Problem With Blankets  and Can You K-Tape Kids With Ehlers-Danlos and Other Connective Tissue Disorders?.

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Why Telling Your Child “It’s OK” Doesn’t Calm Him Down (And What To Do Instead)

 

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In a few months I will be doing another lecture on managing difficult toddler behaviors, and I can’t wait.  I love teaching parents, therapists and caregivers how to help young children manage their most difficult behaviors.   The responses that most therapists dread (crying, whining, tantrums, etc.) are the ones I hope will happen in a session with a parent.  Why?  So I can demonstrate and explain how to handle these tricky moments.  How you respond to your child can do more than help you get them into the car and back home.  It can teach them how to deal with their feelings and how to communicate them to other people.

When faced with a crying child, telling them “It’s O.K.” right away seems to be the most natural response in the world.  For one thing, it is usually the truth; you can clean up the broken cookie and get another, their bump is a minor scratch, and they have another blue crayon to replace the one that rolled under the couch.  And we want to help them feel better; comforting an upset child is what we do as caring adults.

But for many kids, telling them “It’s OK”  elicits more crying, if not some wailing and even physical responses like throwing things or hitting.  You go over to console them, and they might even push you away.  The baby that used to melt into your arms is now a toddler, rejecting your best efforts at comfort!

Why?  Very likely because your response did not show them that you understand the gravity of the situation and the pain they are experiencing.  I know, pain from a broken cookie? Really? Well, when you are 18 months old, you can’t always comprehend that there could be more cookies in the cupboard.  The horror of seeing your favorite treat destroyed in front of you is just too great.  And the feelings inside of you really do hurt.  Young children need two things to recover:  someone to say that they know what your problem is and for that person to say that they are aware that you feel this way.

Note that I did not say that the other person has to agree that it is the end of your toddler world.  The adult is only agreeing that something has happened and that you feel badly about it.  As adults, we don’t always remember a toddler’s perspective, and we invalidate it more than we think we do.  This is why telling your child “It’s OK” is heard as “Your complain is without merit, sir, and you have no right to feel angry or sad about it”.

You would never intend to say that to your child, and yet that is the message many children get when you rush in too soon with this response.  

What could you say instead?  I first use Dr. Harvey Karp’s Fast Food Rule combined with his Toddler-Use communication style to respond to an upset child.  It is fairly simple:  State what you believe your child is thinking in simple phrases that match their comprehension level when upset (which is always less than when they are calm) and matches their emotional tone by 1/3.  So if your child is screaming  “COOKIE, COOKIE, COOKIE!!!” and you know that her cookie fell on the sidewalk into the mud, your response has to be similarly short and heartfelt.  Something like “COOKIE BROKEN!  You want cookie!” tells the sad story of what has happened to her snack.

This can be enough validation to calm her down a bit, as seen by a decrease in the volume of her screaming, more eye contact with you, and even a sad nod.  NOW it is time for consolation, and perhaps the offer of an alternate snack.  You have shown that you know her problem and her pain.  She has felt understood and her feelings accepted, and may now be ready for a resolution to this crisis.  If she continues to scream, repeat your statement once or twice while further shortening your words and slightly increasing the emotion in your voice/the emphasis of your gestures.  Sometimes it takes the toddler brain a moment to process.  Give her that time.

Good luck trying out this approach with the next upset toddler or preschooler you encounter.  I promise you, communicating your empathy and modeling acceptance of feelings delivers more than a calmer child.  It teaches important emotional skills and deepens the connection between you.

And it all started with a broken cookie….

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What Helps Sensitive Kids Handle Haircuts?

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Depending on your child’s age and issues, getting a haircut can be anything from a chore to a dreaded event that you put off, and then put it off a bit more.  So many kids fear them:  kids with ASD, kids with sensory issues, children that have had multiple hospitalizations or procedures, children with anxiety disorders.   I have been asked by parents of children well into grade school to help them with the problem of getting their child to the barber or hairdresser without a major fight.  My strategies are informed by my training as a pediatric OTR and as a Happiest Baby on the Block educator.

My approach to improving a child’s tolerance for a haircut is based on three goals: reduce the novelty of the experience, reduce the sensory impact of the haircut, and build their overall coping strategies based on their developmental level.

  1. You can borrow techniques from “exposure therapy” to make the experience of getting a haircut more familiar.  The very first step could be making combing or brushing their hair a non-event.  Explore what tool is the most comfortable for your child, and gradually introduce combs and even hair clippers.  Let them turn the clippers on and off ( establish safety rules first) and let them hear the clippers both far away and close to their ears.  Let them comb their hair first, then allow you to do so.  Washing their hair in the bath is another experience that you can use for pretending that you are giving them a haircut.  You can also get a bit wet and allow  them to pretend to cut your hair.  I have safety scissors that don’t cut anything but paper  Lakeshore Scissors for Toddlers That Only Cut the Paper, Not the Toddler  that work very well for this experience.  Expand grooming so that it can happen at different times of the day and in different locations in your home.  It needs to become as much of a non-issue as possible at home before a child is truly comfortable in the hair salon.
  2.  Remember that the entire experience of receiving a haircut has strong sensory components:  the salon and the sight, sound and smell of it’s other staff and customers, the tools used to cut hair, the feel of the chair and the drapes on your child.  They can all be contributors to agitation and aversion.  How can these be minimized?  Early appointments might be less crowded, there may be ways to apply water or lotions to reduce the experience of being sprayed, or children can be actively involved in saying that they are ready rather than feel attacked when they don’t expect touch.  Some kids just to be told before the event that their hair will be sprayed, or they need to feel in control of the timing.  Your child may seem too old to sit on your lap, but it could help them stay calm.  Ask if this is something they would like.  Your hairdresser is interested in doing a good job without a lot of drama.  Most of them will work with you.
  3. Many of the kids I see that struggle with haircuts also struggle handling frustration and anticipatory anxiety in general.  They are used to big dramatic exchanges when asked to do the things that are expected of them that they CAN tolerate.  These kids have often spent years developing a dance of refusal and opposition that they are now stuck in with their parents.  In my sessions, they quickly learn that I don’t engage this way; I am a no-drama girl.  I set limits and consequences, and I provide options so they feel they are working with me, not against me.  I use Dr. Harvey Karp’s Fast Food Rule and use all of his “Feed The Meter” strategies Turn Around Toddler Defiance Using “Feed the Meter” Strategies to build a sense of compassion and communication.  Both of these Happiest Toddler strategies work well with older children because anyone that is upset is thinking and behaving at a lower developmental level.  My best strategy is simple:  I stop a challenging task before a child has the chance to bail.  I may introduce another task that is similar and still offers challenge.  Stopping isn’t always ending the overall challenge.   The child’s experience is that they don’t have to fight to get a break, as for support or have adjustments made.  I am now their partner in learning to handle haircuts, dressing or nail cutting, not an authority making demands.
  4. Try not to minimize their distress, even if you can’t see why they feel that way.  In Why Telling Your Toddler “It’s OK” Doesn’t Work (And What To Do Instead)  , I wrote about how important it is to actively validate a child’s perspective.  with children that have sensory issues, this is huge, absolutely huge.

It is my belief that if you can help a child handle the daily challenges of their life with compassion, respect and skill development, that child will trust that you can help them with the other events in life that make them frightened or overwhelmed.  They have a new sense of how to manage their behavior, and believe that adults are resources for learning and partners in growth.

Looking for ideas on nail trimming or dressing as well? Read Why Cutting Nails Is Such a Challenge for Autistic and Sensory Kids and Dressing Without Tears: Sensory-Sensitive Strategies That Work

And don’t forget that my e-book on toilet training is out there to help you with this challenging skill:  The Practical Guide To Toilet Training Your Child With Low Muscle Tone isn’t just for kids with low tone; kids with ASD and sensory processing issues can use these strategies to build skills that help them make real progress quickly! You can buy my e-book on my website Tranquil Babies, at Your Therapy Source (a terrific site for OT workbooks and other products), and on Amazon.

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