Reading with Your Children: A Few Points to Touch Base On

A long-standing activity that parents make daily efforts to participate in with their children is reading books with them. Why? It is because it provides obvious educational benefits that intensive research doesn't have to tell us to make it true. Exposing children to reading activities at a young age encourages language and communication development. However, what else is reading with your child doing for them?

The New York Times published an article this year regarding a massive study with child participants and their parents. 675 families, which included parents of a child between the ages birth to 5 years old, participated in a randomized trial in which 225 of those families received intervention services from the Video Interaction Project (https://www.videointeractionproject.org/). The goal was to video record the parents reading and playing with their child and then working with an interventionist who would point out certain trends in the videos. This study was a follow-up of a study completed 2 years prior, which found that the children who participated in intervention had reduced aggressive and hyperactive behavior. 2 years later, this most recent study found that those behaviors stuck with them (2018, https://www.nytimes.com/2018/04/16/well/family/reading-aloud-to-young-children-has-benefits-for-behavior-and-attention.html).

What was so interesting about this study was the researchers' assessment of the parents' unique interactions with their child and how interactions shaped behavior. Examples included: using toys while reading, using silly and various voices to act out the reading material, relating characters to the child, explaining the book to kids, etc. Researchers noted the potential for children to better develop healthy social and emotional relationships through reading with parents.

So in simple terms, reading to your children can provide all sorts of developmental benefits if done in a positive way. Instead of droning out a book with stifled enthusiasm, consider what flare you as a parent could to the book:

  • Incorporating toys or costumes: Act out characters in the book using your child's favorite toys. Wear unique clothing items like hats, scarves, bandanas, sunglasses, etc. If the child is old enough and would like to give it a go, have them act out parts in unique attire.
  • Taking your child through imaginative play: Make the book come to life for your child by acting out the story with them. You don't have to go overboard with a formal stage. Use what you have in your own home. If the story is about saving the princess from an evil monster, act out the harrowing journey using the tools and toys within your house or out in your yard.
  • Comparing characters to your child: Talk to your child about the characters in the book as if your child was able to meet them and get to know them. Would they be best friends? Would they be scared to approach them? Would they be just like you or your child? This opens up a social and emotional connection that drab reading from page to page would not.
  • Discussing the book: Talk about the book with your child, during the story and after it ends. Ask your child if they had questions about the story and if there were parts that they did not quite understand. 
  • Guiding your child in reading portions of the book: If your child is approaching reading age, encourage your child to read some of the book with you. Be willing to sit down next to them and to guide them through the more complicated words and sentences.

Reading to your child does not have to be a burdensome chore, and you do not have to read to your child 24 hours per day to be a good parent. If you are not what you call a "reading kind of family", incorporate reading in small chunks. Commit to reading one children's book with your child once a week. Then, if you think you and your child can handle it, progress to reading one book per day at roughly the same time. There is no one size fits all when it comes to how often you should read with your child, so go with what works for you and your family.

References
Mendelsohn, A.L., Cates, B. C., Weisleder, A., Johnson, S.B., Seery, A.M., Canfield, C. F., Huberman, H.S., & Dreyer, B.P. (2018). Pediatrics, 141:5.

Inside the Terrible Two’s: This much yelling can’t be normal…can it?

p>period does in fact exist. Kiddos at this age can be so full of life and love, and wonderful memories can be made based on their adorable disposition. Then, in a split second, everything good morphs into an engulfing darkness that seems to last for months: intense temper tantrums at home and in public, endless crying over seemingly small things, weird shouting matches in strange tongues, and extensive trails of broken toys and household objects.

"Terrible twos" does not necessarily mean that your charming baby will transform into a raging tyrant at the very stroke of midnight on their second birthday. Depending on your child, this stage can start much earlier or slightly later (i.e., 18 months to 2.5 years of age). The goal for parents is to be able to discern from the typical signs of the "terrible twos" and atypical behaviors in need of unique attention. So, let's start with answering why toddlers often act so terribly during this time in life:

  • Language is developing: By the time a child turns two years old, he or she now has a handful of single-words and possibly a few short sentences. The majority of their verbal expression comes in the form of commands in order to get what they need or want (i.e., sleep, food, diaper changes, medical attention, toys, etc.). Unfortunately, their language is still quite limited compared to older children thus the frustration begins. Toddlers try desperately to communicate with their family, but misunderstandings come up and tantrums are thrown. This is a point of aggravation for both toddlers and their parents.
  • Motor skills are refining: By now, a typical-growing toddler is walking or maybe even running around the house. Other movements include navigating the stairs, climbing all over the furniture, escaping cribs or gated beds, getting in and out of the tub by themselves, partially dressing and undressing themselves, coloring on the walls, removing and replacing lids, ripping open packages or bags, etc. This is an exciting bag of tricks for toddlers and they can't wait to use their newfound skills. This often results in kiddos getting into things that they really aren't supposed to, causing minor episodes of household destruction.
  • Cognitive development allows for boundary-testing: Brain development helps toddlers see past simple black and white rules. Now, they want to test parents' boundaries and see how far they can go before they get into trouble. This often results in attempts to turn parents or other family members against each other because the child figures out that every adult varies in authority and rules.
  • Maturing expression of independence: Because the child is developing new language, cognitive, and motor skills he or she is going to want more and more opportunities to do activities on their own. Friction happens because as much as the child wants to do everything independently, parents realize that the child still has some limitations. In order to keep the child safe or to minimize frustration, parents naturally intervene and help which thoroughly irritates independent-minded kids.

Parents can't control all of the dismal factors of the "terrible twos", but they can conduct a few things to minimize problems and promote their child's growth:

  • Keep your own emotions in check: As a parent of a toddler, it can be very challenging to keep your cool when your child completely loses it 24/7. It is your job to keep your emotions under control in order to give your child a sense of love and security.  Call on family and friends for assistance when (and you will) need a break from your child.
  • Purposefully find moments for teaching: Your child may act like they have everything figured out, but two years of age is just a sliver of lifetime experience.  During those moments where your child gets angry or does something that breaks the rules, lovingly use those times to teach your child. Listen carefully to what they are trying to tell you, even if it's muddled or confusing. Guide them to finding the right answers and solutions
  • Maintain a structured day: Try to create a relatively predictable, daily pattern for your child. This does not necessarily mean that you have to do the exact same activities in the exact same order every day.  Attempt to grasp some consistency (meal times, community errands, nap times, bath-times, etc.). Structured days also means having consistent rules and expectations among both parents.
  • Consult with professionals if needed: Some children are going to require specialized and professional attention due to developmental delays or other childhood conditions. The "terrible twos" is a period of growth for a child that should come to an end before grade school, which means the child can regulate their emotions in order to successfully participate in activities outside of the home. If you believe that your child is behind or struggling with motor, language, cognitive, or emotional development, or if you think their behaviors are escalating beyond the toddler norm do not hesitate to consult with a professional. Start with your pediatrician who can then refer you to other relevant healthcare providers.

You’re not paying Attention: Working memory in Children and Functional Participation

As parents of young children, we are so easily blown away by the things that they say and do. The day she finally figures out the potty, the day she buttons her shirt for the first time, the day she recites the whole alphabet, or the day she says thank you without being prompted by you or another adult. These are just a handful of examples that highlight the potential growth of a young child.

On the other hand, parents are easily frustrated when our children do not do what they are told to or do not complete things in a timely manner. Some instances may include a child being told to go potty, a task that can be completed in less than 5 minutes. Instead, with consideration of the fact that the child is only 3 years old, she decides to take a few detours on the way: takes her socks off and on a few times, puts a sock on her sister’s hand, knocks a few DVDs off of the shelf, runs over to the table to finish that last bite of food from lunch, finds and fiddles with a pen that she has been looking for all day, throws herself on the floor and whines about how she never gets candy, and then slowly but surely she steps into the bathroom (which at this point could take an hour to just take the pull-up off).

How many times a day do parents reprimand their children for not paying attention? For families with small kiddos, the answer could be at least one thousand times. As children get older, their ability to attend to tasks, to situations, and to people matures so that they can participate in activities that matter to them. So, what about children who struggle with “paying attention” or with completing an indefinite number of tasks? Attention is influenced by several complex processes in the brain, one of which is called working memory. Working memory is a mental skill that allows a person to temporarily retain information that can be used in the moment. It is our ability to juggle thought processes in order to meet the demands of our environment: writing a book reports, cleaning up the playroom, drawing a picture, talking to a friend, etc.

Working memory retains a certain level of information in order for a child to be ready to use it immediately, such as following several steps of instruction from a parent. What happens when working memory does not work? According to the Child Mind Institute (2018), there are several childhood disorders that exhibit symptoms of limited working memory: learning disorders, ADHD, dyslexia, auditory processing disorders, and autism to name a few https://childmind.org/article/what-is-working-memory/. A child who has limited working memory may look something like the following scenario:

Dillon is a 6 year old boy who lives at home with his mother and his sister. His mother tells him that he needs to complete several tasks before he can go to a birthday party. His mother says, “Wash your face, change your pants, make your bed, and pick up all of the toys in your room. 10 minutes goes by, and his mother learns that Dillon did not complete anything according to her instructions. Instead, he placed his toys on the couch in the T.V. room and he took off his pants without putting a new pair on. He proudly told his mom that he washed his face though.
Sometimes, it is not as simple as telling our child that they are not paying attention. If working memory is impaired, then parents need to take some alternative steps to better guide their child. Examples include:

  • Breaking down instructions: Avoid bombarding your child with a long, wordy, verbal list of instructions. Instead break it down, step by step. At the beginning, maybe only give them one task to complete. As your child improves and consistently follows one-step instruction, give them two and so on and so forth.
  • Using a picture calendar: Working memory is part auditory (hearing) and part visual-spatial. If your child struggles with retaining verbal instruction, try visual cues such as picture calendars that the child can look at on a daily basis. Similarly to verbal instruction, do not overload the calendar. Provide pictures that represent a small number of tasks and then gradually increase the tasks as the child improves.
  • Exercising patience: One of the best things a parent can do is self-improve their capacity for patience. When we get impatient with children, they can see and feel it which only worsens their performance.
  • Consulting with a professional: If you are concerned about your child, specifically about their development and their ability to attend during the day, contact your pediatrician who can potentially refer you to some specialists (i.e. occupational therapy, psychiatry, behavior specialist, etc.).

Bath time with Children: Stages of Development and Independence

As a new parent, nothing is scarier than letting your mind run wild with all of the possible scenarios of things that could go wrong when your young infant interacts with a tub full of water. Bath time goes from an enjoyable experience to a period of heightened sensation and vigilance has you spend every millisecond protecting your baby from drowning. All good parents have been there, and it is because that fear is based on the reality that things can take a turn for the worst during bath time.

In the United States, drowning is one of the leading causes of death among children ages 1 to 4 (CDC.gov, 2017) and it is the second leading cause of unintentional death in children between the ages of 1 to 14 years. For young children, the source of drowning typically includes bath tubs, swimming pools, spas, toilets, and buckets full of water. Drowning can take place in a matter of seconds, and the time to take life-saving measures passes while parents aren't watching or supervising their children.

Now, let's take a deep breath. This does not mean you have to intently supervise your child during bath or shower time until he reaches adulthood. During the stages of development, there are times in which your child can gradually gain some independence in their bath time. Use the well-known stages of development for gross motor skills to guide you in deciding when and where to supervise your child:

0-6 months: rolls over, sits with support
Young infants are starting the very basic motor movements that lead to necessary movement performance in older childhood and adulthood. A baby of this age will not be able to sit up in a tub independently and is also had high risk for rolling over face down into the water without being able to roll back. So, parents must be fully supervising the infant in the tub the entire bath duration. Use a reclined bath chair with supports that prevent the child from rolling out of the chair. Keep water levels very low as in an inch or less.

6-12 months: crawls forward on belly, sits unsupported, pulls to a supported standing position
For this stage, the parent should still be by the tub at all times supervising their baby. Although the child may be able to sit up independently on the floor, this is not the same as a child sitting up in a tub full of water. The water moves and pushes against the baby's body, which tests sitting balance and can knock the baby over in the tub. At this stage, the baby will try to pull themselves into a standing position using the edge of the tub which can be slippery and dangerous. Progress to a supportive bath chair that suctions to the tub and maintain low water levels.

18 months: sits unsupported, crawls and walks independently
At this stage, the child is starting to exhibit some independence in the tub. He or she wants to walk around the tub, kick the water, play with the faucet, and attempt to crawl in and out of the tub. Parents should still be intently supervising the child, but can start giving the child some distance. So instead of squatting down at the tub the entire time, a parent can migrate out to the doorway of the bathroom.  Make sure you can still see AND hear your child from wherever you are at all times. A bath chair may no longer be required, but maintain low water levels and fully assist your child in hygiene tasks.

2 years: Walks and begins to run
Children 2 years and older still need to be supervised in the bath tub because even though they have excellent motor skills, they now have the capacity to experiment with dangerous stunts in the bathtub (sliding off the edge, holding their breath under water, messing with the water temperature, etc.). Allow the child to complete their own hygiene tasks in the tub (even if the tasks aren't done to your complete liking) and continue to keep a close eye on them.

Note: please do not use the age ranges as definitive margins for your child's motor development. Each child varies, and some who experience delays in development will not necessarily match the stages laid out. Instead, focus on what motor activity your child can currently do (i.e., rolling, crawling), think about the next motor activity that they are working on, and then compare that to the motor requirements for bath time.

Mental Illness in Parents/Caregivers and its Impact on Carrying out Home OT Intervention for Children

Every once in a while, even a seasoned occupational therapist needs to take a step back and re-assess all contexts of their intervention styles. Specifically, in regards to this article, pediatric OTs need to carefully analyze the surrounding and relevant details of a child’s life prior to carrying out interventions at home. Why??? Because even if the OT selects the most innovative and beneficial therapy interventions for a child at home, those interventions mean absolutely nothing when all barriers and influences are ignored.

A child and their OT participation are heavily impacted by their home environment and the people who care for him or her. Parents, guardians, caregivers, and other biological or legally binding adults are the facilitators of what OT brings into the home. Pediatric OTs can only visit a child so often per month, thus it is a huge responsibility for the parents to carry out learned interventions in the OT’s absence. More often than not, OTs can just safely assume that every parent or directly connecting adult will have the full physical and mental capacity to carry out those interventions.

This article blatantly discusses those times when parents and caregivers lack that capacity and what can be done to remediate the gap that prevents children from receiving full benefits of therapeutic intervention in the home. Take a look at the following scenario:

Kathy is a single mom of 3 children under the age of 9 years old. Her youngest child, Elsie, is 2 years old and was recently diagnosed with autism. Early intervention services, including OT, have been visiting the home regularly to work with Elsie and Kathy in order to improve Elsie’s ability to transition from one task to another without massive behavioral episodes. Kathy appears to be a very dedicated mother and actively attends all of her daughter’s therapy sessions. Unfortunately, Kathy has kept it well hidden from professionals and from her family that she’s been dealing with severe symptoms of depression. As a result, there are times in which she struggles to get out of the bed in the morning. Her decreased motivation and her emotional turmoil frequently prevents her from helping Elsie with her OT-related activities. Additionally, managing two other kids by herself and trying to keep the household running only adds to her depressive symptoms.

In pediatric occupational therapy, sometimes the OTs get so caught up with assessing the child that they forget that assessing parents and caregivers are equally as important, especially when it comes to their mental health status. Some children have parents or caregivers who suffer from a wide variety of psychiatric/neurotic and diagnosable disorders such as:

  • Schizophrenia
  • Bipolar disorder and other mood disorders
  • Autism
  • Obsessive compulsive disorder
  • Eating disorders
  • Personality disorders
  • Substance-induced mental disorders
  • Depression

Other informal conditions include stress, anxiety-like symptoms, and caregiver burnout may not be as obvious but can still dramatically impact a parent’s mental health and their ability to carry out tasks. So, what can proactive parents and caregivers do about it?

  • Don’t be shy and bring up concerns about your own mental health with the OT: As mentioned earlier, the pediatric OT might get so caught up in working with your child that they’ll forget to inquire about you and your personal struggles. Bring it up with the OT if you think that your mental health is strained or if you have a diagnosed condition that will impact your ability to carry out interventions with your child. It is very likely that the OT will welcome this discussion warmly and surprise you with adaptive strategies that consider your own mental health.
  • Consult with a professional for yourself if needed: There is a reason that flight attendants on airplanes tell adult passengers to secure their own oxygen masks in an emergency before assisting a child with their own mask. If you as the parent are not taking care of yourself, then you will not be able to effectively help your child. Consult with a mental health professional and get yourself figured out.
  • Recruit help for your child: Even though you are the parent and the primary provider for your child, there is no law saying you have to do all of the work. If carrying out interventions with your child is too much and is compromising your mental health, recruit friends and family who know and have a good relationship with your child. Involve siblings in some of the interventions if they are old enough to understand and to carry some out.

You aren’t alone in this. There are many parents and caregivers who are in your position and haven’t vocalized their personal challenges with mental health. Consult with someone immediately and prepare to have an open and honest discussion with your children’s therapy providers.

“He’s just doing it to get attention”: An OT’s Perspective about meeting Behavioral needs of Children

Your child has thrown themselves on the floor of the grocery store, right in front of your cart in a sprawled and tyrannical fashion. Or, your child has drawn letters in permanent marker all over your newly painted dining room wall. Maybe your child is actively picking on their sibling, spitting gum in their ear, taking scissors to their hair, tying them to the front yard maple tree, stealing food from their plate, or relentlessly teasing them. Even worse, maybe your child is showing up for a juvenile detention hearing for the umpteenth time for typical neighborhood vandalism.

How would a seasoned parent or caregiver react to these behaviors? Be honest. Would your initial reaction be full of sheer anger and shock? Would you automatically pull out your proactive, authoritative parent tool kit and tackle this problem logically? An experienced parent who has been exposed to endless behavioral issues from their child probably has the same reaction as everyone else: fatigue, numbness, eye-rolling, and a slight dash of sarcasm. Our verbal reaction is unanimous: "He/she is just doing this to get attention".

Here is why there is so much wrong with familiarizing ourselves with this saying: "He/she is just doing this to get attention":

  • Well of course your child is doing something to get attention! The second a child is conceived in the womb, he or she is asking for attention from a loving and caring parent. They heavily depend on adults for survival: food, liquids, medicine, etc. Methods for getting attention are loud and upsetting because the child is unable to verbalize their needs at an early age. As the child gets older and gets basic language down, they communicate in ways that can be very irritating to a parent because they can't quite formulate what they want on an abstract level. This often includes a need for social interaction to communicate their internal problems that parents struggle with seeing on the surface.
  • It's a very self-limiting and degrading phrase: By regularly using this phrase, you are telling your child that you are not going to do anything to help their situation. You have decided that their problems are smaller and insignificant as compared to yours.
  • It's an admittance of defeat: You have come to terms with the fact that you can do absolutely nothing to help your child. You, the parent who is supposed to be taking the lead and guiding your child through a life that they haven't lived yet.

Behavioral problems in children are many and can be very difficult to interpret, especially if they are unable to verbally communicate. For some parents, maybe you think you have tried to provide every solution known to mankind and nothing has worked. From an OT's perspective, take a step back and try or revisit some of these approaches:

  • Get off your phone: One of the sole problems with children attempting to get attention in the most maladaptive ways is because every adult on this planet is glued to their phone screens. Put down your phone and give your child the face-to-face attention that they crave and desire.
  • Prioritize your relationship with your child: Why do you have a child in the first place? It's not usually because you need a new wall decoration or because you want someone else to raise your child. Create a lifestyle for yourself that heavily involves connecting with and providing for your child.
  • Meet the basic needs: This is essential for young children or children who can't speak very well. Review basic needs that need to be met: dirty diapers, toileting needs, illnesses, hunger, thirst, and sleep. Get to know your child and memorize what unmet needs produce what behavioral responses.
  • Check your attitude: Being a parent of a complicated child is challenging and very wearing on your emotions. The last thing you want to do is to combat your child's behavioral outbursts with your very own.  Commit to a daily update on yourself. Consistently check up on your own attitude while communicating with your child. Arrange for breaks and time away from your child and your house. Find ways to actively participate in hobbies or tasks that you find enjoyable, no matter how time-limiting your daily routine is.
  • Consult with a professional: If you are a loving and committed parent who has tried everything you can think of, consult with a specialist. This may include primary physicians, therapists, counselors, behavioral specialists, nutritionists, psychiatrists, etc. Don't stress yourself out thinking that you have to know everything about raising a child with behavioral issues.

Yelling at your kids: Does it do more harm than good? An OT’s take on the Issue

Unless that rare person out there is doped up on a mild sedative, every parent on the face of the Earth as yelled or raised their voice at their child. Young people can state day in and day out that “when I have kids, I will never yell at them”. In the end, the experienced parents giggle because the kids start coming into young people’s lives writing on walls, ripping up bills, throwing the I-phone on the floor, urinating on the freshly cleaned carpet, cutting siblings’ hair with the so-called hidden scissors, hiding in the racks at the clothing store, barfing on mommy’s bed, pouring the cereal all over the kitchen, dumping all of the water out of the tub with a Dixie cup, and the list goes on. The frustration and anger only starts to fester and boil because these obnoxious acts happen not only once, not twice, but an infinite amount of times within a 24-hour period. Thus, the human instinct crawls out of us adults to yell and scream to make the problems go away.

There are two reasons that yelling at our kids is not an appropriate response:

  • Even though it immediately stuns the kids, it doesn’t end up being a very productive response in the end.
  • Yelling can be just as negative as physical punishment

According to the Child Mind Institute, yelling at your kids can result in several unsolved issues. Your child will be so caught up in the emotional reaction of you yelling at them that they may fail to see why you are disciplining them in the first place. The child may also shut down or ignore you because they’ve heard you yelling before. Additionally, if yelling becomes the primary mode for communication then your child will mimic that behavior and not be able to develop positive bonding opportunities with you (Arky, 2018). Let’s take a look at the following scenario:

Peter is a 4 year old boy living with his mother and older sisters. Lately, Peter has been getting into the habit of taking DVDs from cases and throwing the discs on the floor while tearing up the paper covering. His mother, stressed from working as a single mother, often approaches this situation by yelling at Peter. Unfortunately, Peter has done this on multiple occasions and has grown used to his mother’s screams. When his mom’s not looking, Peter yells in a similar manner at his sisters when he doesn’t get his way.

Wang and Kenny (2013) conducted a study with over 900 families. Their results revealed that harsh verbal discipline from mothers and fathers against adolescents led to incidences of conduct problems and depression. They argued that yelling could be equally as damaging to a child as physical punishment.

In many incidences, kids are simply not going to get it when parents yell at them about poor behaviors. They are either too young or they could possibly have some underlying developmental issues that further prevent them from understanding their parents’ intentions. Take a look at the following scenario:

Thomas is a 7 year old boy with high-functioning autism spectrum disorder. He has a very rigid routine, and even if a portion of it is interrupted or thrown off he has a complete meltdown. One day, his mom told him that he couldn’t bring his favorite water bottle to school because it had a crack in the bottom and needed to be replaced. As a result, Thomas through himself on the floor in a raging fit, banging his head against the ground and throwing any toys within his reach at the wall. His mother’s instinctive reaction is to raise his voice at him and to tell him to stop. As her voice gets louder and more shrill, his behaviors escalate.

Note that not yelling at your kids is not the same as not disciplining them. Children need structure and direction because they are learning and growing, which means they are prone to making some nasty mistakes until they get things right. Tell them no. Tell them they aren’t allowed to do something. Tell them that a punishment (not verbal or physical, but maybe taking a privilege or toy away) is on its way, but do so with a calm voice. Give them some credit for understanding you and explain to them why certain behaviors are inappropriate and why punishment is necessary. If your child has special considerations due to developmental issues, consult with a specialist about how to best communicate with your child during behavioral episodes. You will not get it right immediately, and you will lose it on occasion. However, push to do better to preserve your relationship with your child and to raise a healthy individual.

References

Arky, B. (2018). Calmer Voices, Calmer Kids. Child Mind Institute. https://childmind.org/article/calm-voices-calmer-kids/. Viewed on Oct 16, 2018.

Wang, M. & Kenny, S. (2013). Longitudinal links between fathers’ an mothers’ harsh verbal discipline and adolescents’ conduct problems and depressive symptoms. Child Development, 85(3). https://doi.org/10.1111/cdev.12143. Viewed on Oct. 16, 2018.

OT Tips for De-Escalating a Child’s Melt-Down

Before we discuss ways to reduce a melt-down, let’s clearly define what exactly a melt-down is and what it looks like. Popular pediatric occupational therapy terminology includes specific words to describe the differences between a “temper tantrum” and a “melt-down”:

  • Any child can have a temper tantrum, which is a set of poor behaviors exhibited by a child who is trying to get what he or she wants (i.e. attention, food, candy, phone, movie, toys, etc.). A temper tantrum usually resolves once a child gets exactly what they are after or once they’ve given up, and that’s up to the parents on how to best approach that resolution. Temper tantrums include the typical signs like screaming, throwing stuff, hitting others, flailing on the floor, and incessant crying.
  • A melt-down is caused by factors that are much more difficult to see or to understand. Children exhibit temper-tantrum like behaviors, but for other reasons besides trying to get something from parents. The most difficult part of dealing with a melt-down is that it cannot be simply resolved by giving the child items that normally would make them happy. Symptoms are similar to a temper tantrum including screaming, throwing things, and so on. However, depending on the child, melt-downs can display even more confusing behavior such as self-injury or abnormally aggressive behavior (i.e. biting their wrists, head-banging, hair-pulling, biting or scratching others, etc.). There may be pupil enlargement as well as other vital or physiological changes (i.e. increased heart rate, temperature changes, increased respiratory rate, etc.)

The causes for melt-downs vary per child, but may include some of the following: pain, sensory discomfort, an allergic reaction, over-stimulation, negative reaction to medication, lack of sleep, dehydration, and malnutrition or hunger to name a few.

The one thing that parents or caregivers need to understand about melt-downs is that yelling or firmly talking a child down does not usually work; in fact, excessive talking may actually worsen the behavior. With that in mind, here are some basic tips that should be considered when de-escalating a melt-down:

  • Conduct a quick assessment of the immediate environment: Once your child starts a melt-down, you will not be allotted a ton of time for the perfect set-up. Very quickly scan the child’s immediate environment. Are they at home? At school? At the store? Are there other people around? What sensory stimuli can be controlled and what cannot? Assertively ask people to move away from your child and to provide space. Scoot potential objects out of reach that could be used as weapons against the child and against others. Minimize auditory input if at all possible (i.e. turn off music, ask people to stop talking including whispering, etc.). Avoid moving the child to another location because that could worsen behaviors. If you must move the child because they are in immediate danger, do so in a quick manner.
  • Swiftly identify roles: In order to reduce how much verbal instruction the child will receive, figure out which adult will be taking the lead on talking to the child once the child is ready. Once the lead speaker has been identified, it is the responsibility of the other adults in the environment to “shut-up” and to simply observe the child’s behaviors and assist the leader as best as possible.
  • Minimize the need for restraint techniques: If the child confronts others in attempts to attack or to cause physical harm, do the very best to avoid physically restraining the child. Restraints can escalate the behaviors as well as endanger the child if not properly utilized. If your child has a lengthy history of aggressive behavior and frequently threatens or carries out harmful behaviors to others, then some parents may feel that restraints are the best option. If so, seek out specialized training from a professional.
  • Wait it out: One of the hardest parts of melt-downs for parents to come to terms with is the duration. Sometimes, it seems like the child is going through one forever. Melt-downs become especially more difficult when happening in public because now you have bystander attention and try rushing your child in order to avoid negative looks from others. As painful as it can be, parents should wait out the melt-down. Maintain your communication roles, continue to calmly observe the child. The child will let you know through verbal and non-verbal communication when they are ready for you to engage and to help.
  • Introduce calming techniques: The signs that a melt-down is coming to a close may include the following: pupils return to normal size, the child’s breathing starts to slow, and the child starts to cry in a different way (softer, as if remorseful). He or she may reach out to parent and caregivers for help. The leader can now slowly introduce calming techniques or items that the child finds soothing, which is different for each child (i.e. blankets, stuffed animals, water, food, etc.). It’s essential to move slowly and to not bombard the child with stuff and with words in order to avoid triggering another melt-down.

Melt-downs in children can last from several minutes to several hours and can happen multiple times throughout the day. Consult with a specialist about what approaches are right for you and your child in reducing incidences and de-escalating episodes.

Obsessive Compulsive Disorder in Children- OT’s Role and Recommendations

Some of us television connoisseurs may automatically think of the show "Monk" when the topic of OCD or obsessive compulsive disorder comes up. The character's tendency to wipe his hands, create an orderly household, and neurotically sterilize and control his environment are attempts to create humor and entertainment. However, outside of the Hollywood glamour are the functional disruptions that OCD can provide in someone's life and it can start in very young children.

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) lays out qualifying symptoms for a diagnosis of obsessive compulsive disorder:

  • A presence of obsessions, compulsions, or both. Obsessions are thoughts, impulses or urges that cause unwanted stress or anxiety.  Compulsions are actions that are repetitive in nature in order to alleviate obsessions or stress/anxiety that results from those obsessions. This is a very simplistic definition, so feel free to review the DSM-5 manual for yourself for greater detail.
  • Obsessions and/or compulsions end up being very time-consuming (at least one hour of time) and can take away from other important areas of occupational and social participation.
  • A true diagnosis of OCD is obtained if no other mental disorder can better explain the child's condition http://beyondocd.org/information-for-individuals/clinical-definition-of-ocd. For example, OCD is commonly mistaken for autism spectrum disorder because of repetitive or ritualistic behaviors. Sometimes, OCD can be diagnosed on top of autism but there are incidences in which both diagnoses are separately present.

OCD symptoms can start as early as 3 years old and affects up to 1 in 100 school-aged kids. The exact cause of OCD is unknown, but research shows that OCD may be triggered by stressful or traumatic events and have a genetic connection (Obsessive-Compulsive Foundation, 2006, https://adaa.org/sites/default/files/How-to-Help-Your-Child-A-Parents-Guide-to-OCD.pdf).

So in a realistic situation at home, what does OCD look like during childhood?  Common fears that turn into obsessions include fear of getting dirty or contaminated, fear of being harmed by others, or fear of doing something bad or violent (Child Mind Institute, 2018, https://childmind.org/guide/obsessive-compulsive-disorders/obsessive-compulsive-disorder-what-is-it/). As a result of these fears, children with OCD will often participate in compulsive behaviors that seem somewhat bizarre and take up a lot of their time.  Examples include excessive handwashing or other hygiene-related rituals, locking and unlocking the doors multiple times, touching and lining up objects, avoiding any time of activity that presents even the slightest risk of danger, hoarding objects, etc. When parents or loved ones attempt to correct or interrupt these rituals, it can further upset the child and add to a vicious cycle.

Pediatric occupational therapy has its place in addressing the functional deficits that can occur with OCD in children. Some of the following may be appropriate intervention approaches, depending on the child's individual needs:

Mindfulness and other relaxation techniques: Mindfulness and relaxation techniques are very popular for reducing stress and anxiety in adults as well as children. The goal would be to have the child adopt these strategies in order to provide a substitute for the compulsive behavior they frequently use to alleviate stress.

Use of purposeful activities: This would include engaging the child in activities of interest, whether that be current activities or activities they used to enjoy prior to obsessions and compulsions taking up their time. Purposeful activities include anything from self-care activities to hobbies, leisure, and social activities that bring the child joy. The idea is to introduce activities in a graded manner in order to effectively distract the child from obsessive and compulsive participation.

Time management skills: As mentioned earlier, obsessions and compulsions take up a lot of time in a child's day, and take away from the child's participation in other activities of importance. Time management interventions aim to reduce the child's time spent in unhealthy compulsive actions in order to have the child participate in other daily tasks that matter (i.e., self-care, school, social activities, etc.)

Desensitization techniques: If the child has any sensory-based needs that are fueling the obsessive-compulsive behaviors, then the OT may take this approach. Consult with an OT that specializes in sensory integration in order to get an appropriate assessment and treatment plan for your child.

class="g5-color-primary"Parent/caregiver education: Of course, a huge chunk of the OT's time spent with the child will also include education of parents and caregivers in order to carry out learned interventions at home.

Consult with a specialist if you believe your child may possibly exhibiting symptoms of OCD. Consult with a wide variety of professionals, including an occupational therapist in order to provide your child with all of the available options.

Dravet Syndrome: What is it and what can Pediatric OT do?

Approximately 0.0064% of the United States population has a disorder called Dravet syndrome, a devastating disorder for young children with used to be known as severe myoclonic epilepsy. According to the Dravet Foundation (2018), approximately 80% of infants diagnosed with Dravet syndrome have a present genetic mutation SCN1A (https://www.dravetfoundation.org/what-is-dravet-syndrome/). Unlike other genetic disorders, children do not have to have this mutation in order to be diagnosed with Dravet syndrome. What makes this disorder so damaging to a child's health and general function are the numerous seizures that occur during infancy.

Multiple types of seizures occur before the age of 15 months and can continue throughout a child's life in varying severity and timing. Often-times, a child will seem to develop quite normally before the age of 4; however, due to increasing seizure activity of the brain, the child's development starts to slow down. Depending on the area and extent of brain damage, children with Dravet syndrome may experience difficulty with walking (abnormal gait patterns), intellectual disabilities, behavioral and emotional issues, and speech or language impediments. Children with Dravet syndrome are also more prone to infections, continuing seizures, feeding problems, and sleep difficulties (Dravet Syndrome Foundation, 2018).

Many children with Dravet syndrome survive into adulthood but require lots of assistance from family and caregivers to meet daily needs. Approximately 10-20% of children with Dravet syndrome die due to a higher risk for sudden infant death syndrome (SIDS). Medications and intense clinical treatments are available in order for children and adults to better cope with the symptoms and to increase their quality of life. Pediatric occupational therapy is among the many services available, but what exactly can this profession do for these children and their families?

In 2015, the American Journal of Occupational Therapy recognized a study that captured the story of a family living with Dravet syndrome. Breland et al. (2015) relayed how the family was able to thrive while caring for a family member with Dravet syndrome, focusing on occupation-based activities in the home. In other words, as rare as Dravet syndrome is the occupational therapy world knows about the condition and has intervention ideas for those affected as well as their family members/caregivers.

Here are some example intervention approaches that pediatric OT may use depending on the child's individual needs:

  • Cognitive intervention: Seizure activity in Dravet syndrome frequently results in cognitive damage ranging from mild to severe. This can negatively impact a child's behavior, attention reasoning skills, memory, and so on. Such cognitive deficits affect the child's ability to do anything and everything including activities at home, academics, building relationships, etc. The OT would have to conduct an extensive evaluation to target what areas of cognition the child has trouble with, and then introduce interventions to address the problems.
  • Sensory integration: A handful of children with Dravet syndrome may exhibit sensory processing disorders, which should be thoroughly assessed by a pediatric OT with sensory integration training.
  • ADL (activities of daily living management): A pediatric OT may introduce ways to modify a child's ability to feed, dress, and bath themselves more independently. This could mean introducing specialized therapy equipment or adaptive equipment for the child or parents to use.
  • Functional mobility: Gross and fine motor skills can be impacted as well, which means the child may display challenges with picking things up like a fork or walking across the room. OT can implement therapeutic exercise programs, manual therapy, and other muscle-working protocols to strengthen the child.
  • Orthopedic interventions: Some children may require bracing or splinting programs to assist with movements. This could be braces that assist with weak muscles or braces that prevent a child's muscles and joints from tightening up, further restricting movements.
  • Family/caregiver education: Of course, the child's OT intervention will include family and caregiver education in order for loved ones to carry out therapy interventions at home with their child.

References

  1. Breland, H., Hoffart, A., McDonald, A., Owens, L., Zeigler, J (2015). Who do we live with a chronic condition without expectations? A family's story of thriving with Dravet syndrome.  American Journal of Occupational Therapy, 69, doi:10.5014/ajot.2015.69S1-PO5103.