Pediatric Home Health

Early Onset Schizophrenia and its Impact on Child Development and Function

When we think about the term schizophrenia, we reasonably picture an adult exhibiting bizarre or unexplainable behaviors. However, there is a very rare condition called early onset schizophrenia in which children under the age of 18 experience a break down in mental health. What is early onset schizophrenia? According to the Mayo Clinic (2019), this type of schizophrenia can present with the typical symptoms of hallucinations and delusions in teenagers:

  • Hallucinations: Hearing or seeing things that do not exist (i.e. hearing voices, seeing people who others can’t see).
  • Delusions: Holding false beliefs (i.e. believing that you are famous when you are not, believing you have superpowers, etc.).

Other symptoms of typical schizophrenia include disorganized thinking or disorganized speech (i.e. word salad or reciprocating inappropriate or odd conversation) as well as negative symptoms with is a reduced capacity to function normally (i.e. lack of hygiene, social withdrawal, disinterest in activities, lack of emotion, monotone speaking, etc.). These symptoms can present in teenagers, but may not yet come to light in children with early onset schizophrenia under the age of 13.

In extremely rare cases, children between the ages of 7 and 13 years can be diagnosed with early onset schizophrenia but the symptomology presents a little differently. The following may or may not be symptoms of schizophrenia in early childhood, according to the Mayo Clinic (2019):

  • Language delays
  • Late or unusual crawling
  • Late walking

Other abnormal motor behaviors — for example, rocking or arm flapping https://www.mayoclinic.org/diseases-conditions/childhood-schizophrenia/symptoms-causes/syc-20354483. The American Academy of Child and Adolescent Psychiatry (2013) states that the following symptoms are often found in children with early onset schizophrenia as the approach the teen years:

Schizophrenia is still being heavily researched regarding its etiology. Researchers believe that there are both genetic and environmental explanations for why schizophrenia is triggered in some individuals. As far as function is concerned, schizophrenia left untreated can have a detrimental impact on a person’s ability to carry out day-to-day living tasks. Imagine how hard it would be on a child who is just starting to get used to the requirements of life.

Pediatric occupational therapy has a place in the world of mental health, including any affected individual across the age span. When it comes to early onset schizophrenia for a very young child, an OT’s work may include the following:

  • Consultation and Evaluation: The OT will want to complete a detailed evaluation of the child, whether that is in the home or in a clinical setting. Assessments will include testing the child’s developmental milestones, tracking strengths and weakness, and how delays are impacting a child’s ability to participate in activities typical of their age.

  • Interdisciplinary communication and collaboration: Schizophrenia is a very complex disorder, no matter how old the individual. Thus, it would be wise of the OT to collaborate with relevant clinicians who may also be working with the child. This will include pediatricians, mental health counselors, and/or psychiatrists. The OT will need to review the child’s medication schedule, if there is in fact one that has been recommended by a doctor already. The medications schedule will need to be coordinated with the OT intervention in order to help the child participate in the most optimal way possible. Intervention planning: After the evaluation period, the OT will then plan out interventions and goals with the parents and the child. Goals are related to developmental milestones as well as to what area the child or parent’s find the most important. Examples include hygiene, dressing, motor activities (crawling, walking), social participation, academics, play, self-feeding, dressing, sleeping, and community activities just to name a few.

  • Caregiver/parent education: Of course, all interventions need to be followed up with education for the parents and caregivers of the child. This includes providing handouts and information that proves helpful for parents and caregivers to carry out interventions in the absence of the OT.

What Parents can do at home with their Child to Prepare for Airline Travel

Airports are giant vessels for stress and anxiety, even for full-grown adults. Climbing into a compact, metal bird with dozens of other people certainly doesn’t ease any of that tension. Thus, it is reasonable to ascertain that young children often do not take well to this set-up either. How many parents are limited in their travels because their children do not tolerate airplane rides? How many parents absolutely refuse to bring their child on a plane because their special needs far outweigh the benefits of a trip through the skies? It should come as no shock that there is a significant number of families who will choose ground travel or no travel at all.

However, a time will come where walking aboard a plane with a young child (or several) becomes inevitable for some families. You are weeks out from your trip and you are sweating about all of the possible scenarios in which this trip can go terribly wrong because of your child’s behaviors. There are some things you can do several days or weeks before your trip begins in order to prepare your child for the long haul:

  1. Call the airport regarding special needs and accommodations: If your child has a clear history of behavioral issues or developmental concerns that will impede travel, call the airline ahead of time to arrange for accommodations. By law, airlines in the U.S. must make reasonable efforts to accommodate for a passenger’s special needs. This includes wheelchair and other durable medical equipment accessibility, shortening wait times at security, etc. If you are lucky, you might be able to arrange a tour of the aircraft where your child can check out the plane and get comfortable with the seating arrangements.
  2. Warn and mentally prepare your child: If this is the first time that your child has flown on an airplane, you will want to inform them of the trip (especially if they are old enough to grasp the concept). Give them a daily countdown until the trip using a visual calendar. If you think it will help, show them Youtube videos of airplanes (interior and exterior) taking off and landing at airports. Let them participate in packing their own luggage.
  3. If you can, spring for first class seats: If you are financially able, spring for the first class seats. First class has a ton of leg room, less people, recliner seats, and faster flight attendant services.
  4. Consider sensory triggers that may aggravate your child: Before you trip, organize and assess all of the triggers that set your child off: noises, lighting, foods, medications, touch and proximity to others, lack of sleep, hunger, dehydration, bodily pains or discomforts, certain activities, etc.
  5. Bring items that will alleviate or stall behavioral problems: Account for and bring any toys, games, books, blankets, snacks, or other items that you frequently use at home to calm your child. Call and confirm with the airport that said items are appropriate and will be allowed in carry-on luggage.
  6. Practice long waiting periods at home or in other community settings: Find opportunities to practice and to work up to long waiting periods in sitting. Practice according to how your child will be seated on the plan (i.e. parent’s lap or an individual seat). Using a public transit bus is effective because you can increase waiting periods per stop or you can get off of the bus at any stop if your child is having trouble. Some children struggle with wearing a seatbelt on the plane, which can be difficult for flight attendants to work around. If that’s the case, find time to go on long car rides with the child wearing their seatbelt and incrementally work your way up.
  7. Have a plan when something does go wrong: If you are going on a long flight, face the fact that your child will most likely have a melt-down despite your best efforts. Have a game plan for how you will handle it and whether or not you will be recruiting flight attendants for help. Let the airline know ahead of time what these meltdowns look like for your child and what kind of space and accommodations will help ease the problem.

Not all parents with children have to be limited to ground travel, but it’s also safe to assume that airline travel will not always go smoothly. Prepare now, well in advance so that you and your child can manage a waiting period in the sky.

Childhood Obesity and its impact on Daily Function

When children are still in their infancy, round tummies and pudgy legs are cute and even encouraged. Pediatricians and other childhood clinicians emphasize the importance of providing children with plenty of nourishment including healthy fats in order to foster development. However, there comes a time in a child's life when fat rolls are no longer cute but are in fact dangerous to the child's health and ability to function.

According to the CDC (2018), 13.7 million children and adolescents in the United States between the ages of 2 and 19 years old are obese. Roughly 14% of children in the U.S. between the ages of 2 and 5 as well as 18% of 6 to 11 year-olds are considered obese (Centers for Disease Control). This leads us to an obvious question: What exactly does it mean when a child is considered obese?

A parent or clinician can determine if a child (or anyone for that matter) is overweight by using the Body Mass Index, which is calculated using weight and height measurements in order to determine body fat percentage. This percentage can be compared against charts (Centers for Disease Control) that reflect BMI readings of children across the U.S. in order to gauge a child's weight. Children whose BMI percentile is at or above 85 are considered overweight.

Obesity-related medical conditions are highly talked about and dangerous among the adult population, so what does this mean for children? According to the CDC, the negative consequences to a child's health are really not that much different from an adult. Immediate health risks from childhood obesity include: glucose-insulin imbalances and Type II diabetes, cardiovascular problems, asthma, anxiety, depression, joint and musculoskeletal problems, sleep apnea, high blood pressure, high cholesterol, esophageal reflux, liver diseases, and gallstones to name a few (Centers for Disease Control).

According to the Childhood Obesity Foundation (2015), some children run a higher risk for obesity because of some of the following reasons:

  • Consume food and drinks that are high in sugar and fat on a regular basis such as fast food, candy, baked goods, and ESPECIALLY pop and other sugar-sweetened beverages
  • Are not physically active each day
  • Watch a lot of TV and play a lot of video games, activities that don't burn calories (sedentary time)
  • Live in an environment where healthy eating and physical activity are not encouraged
  • Eat to help deal with stress or social problems
  • Come from a family of overweight people where genetics may be a factor, especially if healthy eating and physical activity are not a priority in the family
  • Come from a low-income family who do not have the resources or time to make healthy eating and active living a priority
  • Are exposed to the aggressive marketing of energy-dense foods and beverages to children and families
  • Have a lack of information about sound approaches to nutrition
  • Have a lack of access, availability and affordability to healthy foods
  • Have a genetic disease or hormone disorder such as Prader-Willi syndrome or Cushing's syndrome (Childhood Obesity Foundation)

Childhood obesity can drastically hinder a child's ability to perform daily tasks, ranging from tasks that need to be done (i.e., schoolwork, chores, daily hygiene routines, sleep, etc.) and tasks that they may want to participate in (sports, playing with friends, etc.). While there are some legit medical reasons for childhood obesity, many cases can be prevented or changed if a child and their immediate caregivers are willing to make some lifestyle transformations.

Occupational therapy can play a relevant role in a child's life if obesity is the major barrier to functional participation.  Approaches would include:

  • A full evaluation of the child including medical conditions, barriers to functional performance, the child's daily routine, the child's favorite activities and preferences, etc.
  • Therapeutic exercise routines and schedules that would match the child's interest and engage them in regular movement.
  • Lifestyle redesign which would include reducing or eliminating maladaptive behaviors and habits that contribute to the child's obesity (i.e., screen time, food choices, etc.).
  • Cognitive or behavioral intervention which would be helpful for children who struggle with hidden issues that could be negatively impacting their ability to participate in healthy routines (i.e., anxiety, depression, stress, developmental or mental disorders, etc.)
  • Caregiver or family education in order to assist the child in staying consistent with their intervention plan. Parents or immediate caregivers have a lot of say and more power in determining whether or not the child sticks with healthy changes.

Consult with a pediatrician today if you think that your child is at risk for obesity. Proactively prevent medical and functional problems that your child would go through now and in the near future.

Spatial Awareness in Children: What it is and its Impact on Daily Participation

Before we hop into the basic definitions of “spatial awareness”, let’s also define some similar terms and determine how those terms are related. If you google the word “spatial awareness” just for the sake of your own research, several similar terms pop up: spatial cognition, spatial perception, and visual spatial awareness. What do these words actually mean?

  • Spatial cognition: This refers to a branch of cognitive psychology that focuses on assessing people regarding how the use and gain knowledge about their environment in order to get around and to survive. (https://www.apa.org/pubs/books/4318108.aspx)
  • Spatial perception: According to Britannica.com (2018), spatial perception is:

    “[the] process through which humans and other organisms become aware of the relative positions of their own bodies and objects around them. Space perception provides cues, such as depth and distance, that are important for movement and orientation to the environment.” (https://www.britannica.com/science/space-perception).
    Visual spatial skills: This refers to a person’s ability to orient themselves to space around them using objects and other items in their environment through eye sight and to organize that information into meaningful patterns. (https://www.britannica.com/science/space-perception)

  • Spatial awareness: According to Hohmann, Weikart, & Epstein (n.d.), as referenced by Kathuria of the Plainfield Public School District, spatial awareness is "an awareness of the body in space, and the child's relationship to the objects in the space." Additionally, spatial awareness includes two main factors: orientation and visualization. (https://www.state.nj.us/education/ece/pd/spatial/PresSection1.pdf)

Don’t get too caught up in the technical information. In simplest terms, spatial awareness is what we are focusing on, but it should be noted that “spatial perception” and “visual spatial skills” are encompassed in the whole idea of spatial awareness. So, what does this have to do with your child?

Spatial awareness is a process sourcing from your child’s brain. As they develop after birth and are exposed to all sorts of things in their environment, they are fine-tuning their spatial awareness in order to participate in all daily tasks. Kids have to have good spatial awareness skills in order to navigate the stairs, walk around furniture in the house, sit down on a chair, jump over toys, etc. Aside from movement, spatial awareness is crucial in the less obvious activities such as handwriting, eating, drawing, navigating a school setting or a neighborhood, using a pair of scissors to cut paper, and so on.

Some children may experience delays or deficits in spatial awareness skills, which can have a long-lasting impacting on their ability to function day to day. What makes it so difficult is that, like many cognitive functions, spatial awareness is not physically visible to the untrained eye and so parents/caregivers may not even recognize that there is a problem. Children with developmental delays and certain diagnosable conditions may have spatial awareness issues: autism, Down syndrome, unspecified learning disabilities, dyslexia, Turner syndrome, blindness, developmental coordination disorder, and cerebral palsy to name a few.

If you suspect that your child is struggling with some underlying issues that you find challenging to identify, especially if those issues are hindering movement or their overall participation in tasks that are most meaningful to them (i.e. school, community sports, playing with friends, home activities and responsibilities, etc.), consult with a pediatrician as soon as possible. Spatial awareness deficits can be identified through testing administered by a professional.

Pediatric occupational therapists can also help parents and children identify whether or not limited spatial awareness skills is a concern. Although OTs can’t make medical diagnoses, they can utilize standardized tests to see if a child is in fact struggling with tasks that require spatial awareness skills.

After testing, OT can also provide skilled interventions to improve or to compensate for spatial awareness challenges. Such interventions can be provided in the home or in an outpatient, pediatric setting. Consult with a doctor today, and conduct your own research about spatial awareness and what can be done today.

Reference
Educating Young Children, Chapter 16, Space (p.428) by Author(s), Mary Hohmann, David P. Weikart, and Ann S. Epstein- 3rd Edition, Ypsilanti, MI: High Scope Press, High Scope Educational Research Foundation.

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.