Tag Archives: behavior

The Subtle Ways Chronic Medical Care Affects Infant and Toddler Development

 

hannah-tasker-333889-unsplashThe good news:  more and more extremely premature and medically complex babies are surviving.  The bad news: there is a cost to the extended and complex treatment that saves their lives and helps them to thrive.  This post is an effort to put out in the open what pediatric therapists know only too well goes on after the medical crisis (or crises) are over.   Only when you know what you are seeing can you change it.

This is not an exhaustive list; it is a list of the major complications of a complex medical course of treatment on behavior:

  1. Your child is likely aware that their coughing, crying, or other reactions will stop parents and even some medical professionals in their tracks.  I have had kids who didn’t get what they wanted learn to hold their breath until they turned blue.  If you have worked in medicine, you should know that if a child does this and faints, they will immediately begin breathing again.  It doesn’t scare me.  But it can terrify family members, teachers, and other caregivers.  They will stop whatever they were doing and may give in to any demand right away.  Many kids learn who will take the bait impressively fast.  It is very damaging to a child’s relationships and destroys their ability to handle frustration.
  2. Invasive treatments have been done while distracting your child and often without involving your child in any way.  This has taught your child not to attend to an adult’s actions or words in the same way a typically developing child will do naturally.  Since learning language and fine motor skills are highly dependent on observation, these skills are directly impacted by this consequence.  This pattern can be reversed, but it is highly resistant and has to be addressed directly.  Don’t think it will simply go away as your child recovers medically.  It doesn’t.  As soon as your child can be involved in self-care any way (holding a diaper, etc) you need to engage your chid and demonstrate the expectation that they respond and interact to the degree that they can manage.  All the time.
  3. Typical toddler attitudes are ignored because “He has been through so much already”  If your child is kicking you while you change his diaper ( a real question to me by a private duty nurse) then you react the same way you would if your child didn’t have a G-tube or a tracheostomy.  The answer is “NO; we don’t kick in this house”.  You don’t get into why, or what is bothering them right away.  The immediate answer is “no kicking”.  Not now, not ever.  Aggression isn’t unusual or abnormal, but it has to be addressed.  With understanding and as little anger as you can manage as your beloved child is aiming for your face with his foot.
  4. Children who are unable to speak to engage you or able to move around their home will come up with other methods to gain and hold your attention.  Some children throw things they don’t want and HOPE that you make it into a big deal.  Or they throw to gain attention when they should be using eye contact, vocalization or signing.  They wanted your attention, and they got it.  Without speaking, signing or any other appropriate method of communication.  This is not play, this is not healthy interaction.  This is atypical past 10-12 months, and should be dealt with by ignoring or removing the items, and teaching “all done” or “no” in whatever method the child can use.  And then teaching the correct methods of gaining attention and rewarding it immediately.  The biggest roadblock is that if one caregiver takes the “throwing” bait, the child will dig in and keep using that method.  Adults have to act as team managers, and if they fail, the behavior keeps on going.
  5. Children can request being carried when they don’t need the assistance, but they want the attention.  This can delay their advancement of mobility skills.  One of my clients has learned which adults will hold his hand even though he can walk unaided.  He likes the attention.  The clinic PT doesn’t know this is happening, even though the family brings him to therapy.  Like a game of telephone, each caregiver assumes that the child needs the help he is requesting.  He is not developing confidence in his own home, which should be the first place to feel safe and independent.  He depends on adults to feel safe.  Oops.

 

In many ways, my job as an OTR is to alter some of these behaviors to allow normal development to take place.  Long after those medical crises are terrible memories, the consequences of those days, weeks, months and sometimes years can have significant effects on learning and independence.

Looking for more ideas to help children grow and develop?  Read Need to Support A Child’s Independence? Offer to Help Them! and The Not-So-Secret Solution for Your Child With Motor And Sensory Issues: Dycem.  Do you have issues with your child’s siblings?  Read Are Your Other Children Resentful of Your Special Needs Child?

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Hypermobility and ADHD? Take Stability, Proprioception, Pain and Fatigue Into Account Before Labeling Behavior

 

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There is nothing worse than using a scientific study that correlates two variables and assuming causation. Translation:  If behaviors typical of disorder “A” are seen in a lot of people with problem “B”, we cannot assume that “A” is the cause of their behavior.   But we do it all the time.  People who love coffee adore studies that say coffee drinkers seem to live longer.  People who hate to exercise are validated by reports that find the number of heart attacks after exercise “is increasing”.

When it comes to labeling children’s behavior, we should take a couple of big steps back with our erroneous reasoning.  And when the label is ADHD, take three more.  Not because ADHD isn’t a big issue for families.  The struggles of kids, parents and educators shouldn’t be minimized.  We should be cautious with labels when two situations occur:  very young ages and multiple diagnoses that are determined largely by clinical observation, not testing.  Seeing ADHD in a child with hypermobility is one of those situations.

Hypermobility without functional problems is very common in young children.  Super-bendy kids that walk, run, hit a ball and write well aren’t struggling.  But if you have a child that cannot meet developmental milestones or has pain and poor endurance, that is  a problem with real-life consequences.  Many of them are behavioral consequences.  For more on this subject, take look at How Hypermobility Affects Self-Image, Behavior and Regulation in Children.

Yes, I said it.  Hypermobility is a motor problem that has a behavioral component.  I don’t know why so little has been written on this subject, but here it is:  hypermobile kids are more likely to fidget while sitting, more likely to get up out of their chairs, but also more likely to stay slumped on a couch.  They are more likely to jump from activity to activity, and more likely to refuse to engage in activities than their peers.  They drape themselves on furniture and people at times.  And they don’t feel as much discomfort as you’d think when they are in unusual positions Is Your Hypermobile Child Frequently In An Awkward Position? No, She Really DOESN’T Feel Any Pain From Sitting That Way

Why?  Hypermobility reduces a child’s ability to perceive body position and degree of movement, AKA proprioception and kinesthesia.  It also causes muscles to work harder to stabilize joints around a muscle, including postural muscles.  These muscles are working even when kids are asleep, so don’t think that a good rest restores these kids the same way another child gets a charge from a sit-down.

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When a hypermobile child starts to move, the brain receives more sensory input from the body, including joints, skin and muscles.  This charges up a sensory system that was virtually starving for information.  Movement from fidgeting and movement by running around the house are solutions to a child’s sense that they need something to boost their system.  But fatigue can set in very quickly, taking a moving child right back to the couch more quickly than her peers.  It looks to adults like she couldn’t possibly be tired so soon.  If you had to contract more muscles harder and longer to achieve movement, you’d be tired too!  Kids  develop a sense of self and rigid habits just like adults, so these “solutions” get woven into their sense of who they are.  And this happens at earlier ages than you might think.  Take a look at Hypermobility and Proprioception: Why Loose Joints Create Sensory Processing Problems for Children to understand a bit more about this experience for hypermobile kids.

Then there is pain.  Some hypermobile kids experience pain from small and large injuries.  They are more likely to be bruised,  more likely to fall and bump into things, and more likely to report what pediatricians may call “growing pains”.  Sometimes the pain is the pull on weak ligaments and tight muscles as bones grow, but sometimes it isn’t.  Soreness and pain lead some kids right to the couch.  After a while, a child may not even complain, especially if the discomfort doesn’t end.  Imagine having a lingering headache for days.  You just go on with life.  These kids are often called lazy, when in truth they are sore and exhausted after activities that don’t even register as tiring for other children their age.

How can you tell the difference between behaviors from ADHD and those related to hypermobiilty?  I think I may have an idea.

When a hypermobile child is given effective and consistent postural support, is allowed to rest before becoming exhausted (even if they say they are fine), and any pain issues are fully addressed, only then can you assess for attentional problems.  Occupational therapists with both physical medicine and sensory processing training are skilled at developing programs for postural control and energy conservation, as well as adapting activities for improved functioning.  They are capable of discussing pain symptoms with pediatricians and other health professionals.

I think that many children are being criticized for being lazy or unmotivated, and diagnosed as lacking attentional skills when the real cause of their behaviors is right under our noses.  It is time to give these kids a chance to escape a label they may not have.

 

Share Could Your Pediatric Therapy Patient Have a Heritable Disorder of Connective Tissue? with your therapist and see what reactions you receive.  The truth is that many kids don’t get a diagnosis as early as possible.  Rare syndromes aren’t the first thing your pediatrician is thinking of, but you can raise the issue if you have more information and feedback.

Looking for more posts on hypermobility?  Check out Should Hypermobile Kids Sit On Therapy Balls For Schoolwork? , Hypermobile Kids, Sleep, And The Hidden Problem With Blankets  and Should Your Hypermobile Child Play Sports? for useful strategies to manage  hypermobility and support both physical health and functional skills.

Negotiating With Toddlers? Why They Think That 90/10 Is A Good Deal

 

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Toddlers can make you doubt your sanity.  They really can.  How can a crushed cookie be the end of the universe as they know it?  Why do they think you can make more cookies appear on demand?  And how to explain to this person that thinks you hung the moon that you simply cannot erase crayon marks?

This post is an effort to explain how to successfully negotiate (most of the time) with children 18 months to 5 years old.  It is based on The Happiest Toddler on the Block strategies by Dr. Harvey Karp.  Once I learned his techniques, I never looked back and became a toddler whisperer.  Really.  You need to embrace his two most important ideas and then you are ready to hit the negotiating table with your toddler.

Dr. Karp’s most basic concept is that you need to understand that the toddler brain isn’t capable of much logical thinking due to immaturity.  This means that they cannot negotiate well, even when calm.  It gets better as they get older, so a 4 year-old will have flashes of rational negotiation, and an 18 month-old may never get it.  She can’t.  Her brain simply doesn’t “do” rational well at all until that frontal cortex is mature.  The other concept is true for negotiation with anyone, including your partner and your boss.  You have to see their side of the story and communicate to them that you are aware of their feelings….whether or not you agree with them!

Agreeing that they get 2 more bedtime stories but not a snack as well, agreeing that they get the giraffe cup but can’t spill half of it on the new carpet to make a pattern, agreeing that they can wear pajamas to the park but only with shoes are all successes.  Tell them that you understand that wearing Spiderman jammies is indeed cooler with Spiderman sneakers helps them negotiate the deal.  Honestly saying that you are too tired to read 6 more books using an exaggerated yawn and a sad look helps.  You need to go night-night too.  They may be able to see your perspective since they are tired as well (but may never admit it to you).

So here is where your paradigm shift happens.  You have to be OK with deals that seem unfair to you.   Adults want a 50/50 split at the very least.  But you aren’t negotiating with another adult.  Be prepared to leave your ego at the door.  If you are the kind of person that needs to be right, you are going to fail at toddler negotiation.  Toddlers negotiate from the heart and with heart.  A mature sense of fairness isn’t going to be helpful with an irrational mind.  Hint:  if you have ever had a totally irrational boss that you actually liked when things weren’t exploding all over the office, you will have had some experience with the toddler mind.

Successful initial negotiations with a toddler often yield a 90/10 split.  90% for them, and 10% for you.  If they walk away happy,  you should too.  This is why this is not only a good deal for you, it is the only way to teach fairness in negotiation: toddlers start out expecting 100%.  A 90% deal is, in their mind, having given in big-time. But if they feel OK about it and life goes on, you won.  If you can manage that, the next negotiation could be 80/20.

Many toddlers cannot manage this when tired, overwhelmed, hungry, etc.  So negotiations can start over something simple, something that doesn’t matter very much to either party, and when things are calm.  You are teaching a skill, not making a business deal.  But the results could make everyone’s life a lot calmer in the end!

Overwhelmed With Your Toddler’s Demands? How To Cut Tantrums in Half!

 

Do I have your attention?  Good, because to achieve this amazing feat you will need to learn some new techniques, and understand your toddler’s perspective more clearly.  Take a look at two of my popular posts on toddler behavior, then practice a bit until your new communication skills shine.  The posts that will teach you some new ways of responding are Stretch Your Toddler’s Patience, Starting Today!  and  Taming Toddler Tantrums Using Sympathetic Reframing.  They give you easy strategies to use two of the best Happiest Toddler on the Block techniques.  These moves build listening skills and enhance cooperation in little people who are prone to big reactions.  Tantrums happen less often when toddlers feel heard and feel powerful.  You still are the parent.  Set limits and create consequences, but start here to get your toddler calm first.

Why change yourself in order to change your toddler?  Because they are waiting for you to show them how to behave, and waiting for you to reward them for their great progress.  You are teaching them skills, and so you have to model them.  Trust me, this isn’t that hard to learn.  Once you see a potential tantrum dissipate into the air, you will want to practice these techniques all the time!

You need to know a few things about the toddler mind.  It isn’t the same as the kindergartner mind, and certainly not the elementary school mind.  It’s an immature brain, running on very little frontal lobe power and a lot of amygdala and hippocampus use, all in a frenzy.  Add sugar, some taunting from an older brother, shake gently, and watch the “fun” erupt!  But that is life, so accept that your toddler is who he is, and teach him some skills to manage his reactions.

I will mention that these techniques will come in handy in about 10 years, when you have an emotional teen standing in front of you!

Here are some highlights that you should know about the toddler mind while you practice:

  • They haven’t mastered language, so talking more isn’t helpful.  Pare down the amount of words you use, and use more expressions/ gestures to express yourself.
  • They always react emotionally, not logically.  Your responses have to acknowledge their feelings, rational or not, or you are going to increase tantrums, not stop them.
  • Brains grow slowly, like trees.  Don’t expect that success once or twice means you can stop using these techniques.

Yes, I am really promising you an actual 50% reduction in tantrums .  Maybe not today, since it does take some time to become really good at the Fast Food Rule and Patience Stretching.  And maybe not when you are in the nightmare trifecta of a very tired child who is also feeling ill and is changing schools or caregivers.  That is a super-stressed child!  All bets are off then, but I think you will be able to diminish even these tantrums.  But all those other tantrums over broken cookies and not being allowed to stand on the table?  The Happiest Toddler methods can help you stop those before they even start.

The other great Happiest Toddler on the Block techniques such as Gossiping and Playing the Boob ( Dr. Karp, I wish you would rename that one!) support a warm and loving relationship with your toddler, and they will give you another 10-15% reduction in tantrum severity, depending on how much your toddler needs a more positive connection with you right now.  But just these two techniques from Dr. Harvey Karp will give you more smiles and less whining, all day long!

Book Review: Raising Your Spirited Child

“Raising Your Spirited Child” is not a new book.  Some things just have value as time goes on.  The subtitle is “A Guide for Parents Whose Child is MORE Intense, Sensitive, Perceptive, Persistent or Energetic”.  The author, Mary Sheedy Kurcinka is a teacher and wrote a book that has specific, useful strategies for daily life skills with young children that really work.  Her advice is most successful, in my opinion, with children that are cognitively older than 4 years old.  That may mean that a younger child with special needs might not able to respond to all of her strategies, but her perspective on temperament and adapting the environment will almost certainly apply.  Her ideas definitely get people thinking about what could work for their family.

She gives special chapters to mealtime, bedtime, dressing, socializing and holiday/vacation periods.  Issues like autism, developmental delay and sensory processing disorder may require some adaptations.  But the author has a positive attitude, a loving approach, and sympathy for both the child and the parent of a spirited child as they navigate daily life.