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.

Predictability in Childhood: The Importance of Creating a Daily Routine with Flexibility

There are hundreds if not thousands of research articles and blogs available online that tout the necessity of having established, daily routines for young children. The Center on the Developing Child at Harvard University explains how creating steady, daily routines for a child can assist in normal brain development. Along with having supportive family relationships, a child needs to participate in structured routines in order to develop what is called executive function, which the Center defines as "skills [that] are the mental processes that enable us to plan, focus attention, remember instructions, and juggle multiple tasks successfully" (https://developingchild.harvard.edu/science/key-concepts/executive-function/). Developing a child's executive function early on and in a healthy manner sets them up nicely for things they have to do later in life such as attend school, hold jobs, create friendships or relationships, run a household, etc.

Some children thrive off of overly, predictable routines in their schedule, including those on the autism spectrum. Behavioral problems seem to decrease when these children know exactly what's going to happen next going from the transition to transition. However, predictable routines are not necessary for many children to develop in a healthy manner. In fact, routines that are completely foreseeable come with some negative consequences for both children and parents:

  • Parents and other family members just might go crazy: Stringent routines impact everything about the day for everyone in the house: bed-times, TV shows, food preferences, outdoor play, chores schedule, school, homework, sports, lessons, etc. The child may be the one participating in these tasks, but the parent has to be around to enforce the schedule. There is nothing wrong with having a plan. On the other hand, a routine can be too rigorous to the point where the child will not know how to react if something in the day gets canceled or switched.
  • Children will lack development in flexibility: Unexpected changes in the schedule should be expected. Sometimes the electricity goes out, and your child will not be watching their favorite morning shows before school. Sometimes, mommy can't get to the grocery store on time to get all of the child's favorite foods at the beginning of the week. Sometimes, bedtime will be late because the family is out and about doing other activities at night. A child needs to be exposed to opportunities that make them flexible in the event that unexpected things happen. Flexibility means a much easier time coping with the changes instead of melting down the moment something goes awry.
  • Activities outside of the house are limited or greatly disrupted: Having a tight home-based routine means makes out-of-the-house activities more complicated. The child now expects routines to specifically impose on community activities to make them more comfortable: bringing favorite toys, bringing favorite snacks, knowing EXACTLY where they are going and what they are doing before going, and making sure that the parent does everything in their power to make sure that activity isn't unexpectedly canceled.
  • Children lack the ability to learn or to try anything new: A predictable routine that incorporates all of the child's preferences that make them happy might create barriers for new learning and exploration: trying new foods, watching new movies, wearing different clothes, playing with new friends, etc.

Make-shifting a flexible routine for your child doesn't have to be hard. Of course, having structure is very healthy but there is always room to change it up for the sake of your child's development:

  • Expose your child to choices: Save yourself some near-future problems and have Plan B on the back-burner. If an activity, a favorite toy, a favorite food, or a favorite anything falls through fill your arsenal with some additional choices that your child could still enjoy.
  • Give them some warning: Your child is young, but not dumb. No matter how young, you can start giving them some verbal warnings like "Honey, it might rain today. If it does rain, we might not get to go to the park". Verbal warnings early give a child a chance to develop their language skills anyway.
  • Handle behavioral reactions one at a time: You will never be able to please your child 100% and tantrums are inevitable. Your child will tolerate some changes and hate others. Handle those tantrums accordingly and one at a time.
  • Provide opportunities for new learning: Be willing to introduce new activities, new toys, or new foods to your child on a regular basis. Foreign opportunities enhance their flexibility and ability to learn, despite whatever reservations or discomforts they may have to begin with.

Positive and Negative Reinforcement for Children in the Screen-time Age: An OT’s Perspective

At times, parents get desperate and the reasons behind it are totally relatable to others in a similar situation. Your child has a major melt-down in the grocery store, usually in the check-out line and a typically swift procedure turns into a grueling crisis that holds up the rest of the line. Maybe your child decides the best time to freak out is in the middle of church where even a minor disruption among the reverence earns your family everyone’s eyes and ears. Or, your child is at home and you are at your wits end because he/she has been screaming for the last 6 hours. So, as a parent, what do you do? You give your child something that usually shuts them up immediately: your phone, your tablet, or whatever small device with a screen will grab their attention and silence the evil noises penetrating the house.

Today, many kids and adults in the U.S. have unlimited access to these devices that harbor endless forms of entertainment. As a result, phones, I-pads, and tablets have become the new candy for children. Parents just merely have to hand over a device to a young child and there is an immediate change in their behavior. Those changes appear good to parents because it provides a period of quiet time absent of difficult behavior… for now.

Before we dive into the repercussions of handing over the phone to a young child, let’s get a couple of definitions clarified:

Operant conditioning: B.F. Skinner, a behaviorist who is well-known in the psychology field, defined operant conditioning as a method of learning that occurs through punishment and reward of human behavior. Such a punishment and reward system occurs through positive and negative reinforcement.

Positive reinforcement: Positive reinforcement strengthens a person’s behavior by providing a consequence that the person finds appealing or rewarding. In the case of a phone, a child may figure out that they need to behave a certain way in order to earn time on the phone.

Negative reinforcement: Negative reinforcement occurs when an unappealing or unpleasant consequence is removed from the situation causing a strengthening in a human’s behavior. https://www.simplypsychology.org/operant-conditioning.html. A child may attempt to behave in a good way in order to avoid getting the phone taken away from them or having their time on the phone reduced.

If used correctly by parents, positive and negative reinforcement strategies could be very effective for shaping their child’s behavior over the lifespan. However, here are some ways in which parents take the wrong turn:

  • Giving the child the phone in order to stifle a temper tantrum: It has become common practice amongst parents to hand over the phone to a screaming child in order to silence them. This isn’t much different from other examples such as handing them a piece of candy or a favorite toy in order to produce immediate results. This practice will often worsen behaviors in the future, making it more difficult for parents in the years to come because the child automatically believes that they just have to drive their parents insane in order to get what they want.
  • Giving the child the phone to reduce boredom: If a child is bored, this often leads to some exploratory behavior that drives the parents up the wall: getting into things that don’t belong to the child, breaking stuff, harassing siblings, etc. So, once again the parent hands over the phone which gets the child to sit in one place for longer than 5 minutes. Similarly to handling temper tantrums, this teaches the child that it is alright to destroy things out of boredom in order to earn time on the phone.
  • Giving the child the phone as a substitute for all forms of entertainment: Putting your child on a phone or a tablet for entertainment purposes will eliminate their awareness or desire to occupy their time with other engaging things (i.e., playing with friends and family, going outside, completing schoolwork, playing sports, etc.).

In short, giving your child the phone doesn’t have to be a bad thing in the end if you know the tricks of the trade behind operant conditioning. Develop a system with your child, including positive ways they can earn the phone and specific minutes earned for certain behaviors. Don’t let the phone become the all-encompassing reward either. Take charge and keep time on the phone very limited so that the child knows that there is more to the world than a screen.

Oppositional Defiant Disorder (ODD) in Children: Can OT help parents with managing difficult behaviors?

Oppositional defiant disorder (ODD) is not and should not be such an easy condition to diagnose. Young children, especially as they develop and learn, will at many times exhibit problematic behaviors. They will fight with, yell at, and maybe even hit family members when things don’t go their way and it is just part of growing up. What sets these typical childhood behaviors apart from symptoms of ODD is persistence and severity of the behaviors as well as the negative impact such behaviors have on other family members or relevant relationships.

According to the Child Mind Institute (2018), children with ODD will display some of or all of the following symptoms that will occur for six consecutive months and longer:

These behaviors tear at families and make schooling and community interactions incredibly difficult. A few examples may include continuous fights and principal’s office visits at school, horrible tantrums at the store or other public setting, and poor adherence to house rules such as chores and treating family members with respect. More often than not, children with ODD may find themselves in legal trouble as they get older and are at risk for their condition morphing into other disorders such as conduct disorder.

So, where does OT’s role come into play with children with ODD? Psychotherapy and medication management (for when the child has other coexisting disorders such as ADD, anxiety, or depression) are not within the OT’s realm of practice, but are common approaches for ODD through other disciplines (Mayo Clinic, 2018). With that in mind, it is essential for parents to embrace a multi-disciplinary approach and to consult with various professionals. Pediatric OT may introduce and apply some of the following intervention approaches when working with children with ODD:

  • In-depth initial evaluation: An OT can’t diagnose a child with ODD, nor can they provide additional diagnoses like a psychiatrist or medical doctors. OT evaluations sift out functional problems and patterns. In other words, they zero in on the activities in which the child has trouble with due to difficult behaviors. As a result, OTs may be able to provide a more holistic picture for the parents and possible causations for escalating behavior.
  • Social Skills Training: Pediatric OTs often provide social skills training for children with difficult behaviors who have trouble with making and keeping friends. Furthermore, social skills training teaches a child to reciprocate healthy conversations with friends and family by teaching them how to appropriately react in social scenarios.
  • Cognitive/Problem Solving Training Techniques: ODD is considered to be a neurological disorder, or a condition of the brain in which the cause is unknown. Therefore, it would make sense to use cognitive approaches. OT can teach the child specific problem-solving techniques where they have to work with difficult situations that may cause them to lash out inappropriately. Enhanced problem-solving skills are used to reduce negative behavior in order for the child to participate in daily tasks successfully.
  • Family-based interventions and education: OTs can also help target challenging interactions between children and their parents/caregivers. By doing so, the OT may use interventions that heavily involve positive communication between parents and the child. Improving interactions will reduce the child’s capacity to test and push parents’ authority through tantrums and manipulation.

There is no cure for ODD, thus a parent’s influence and approach is a daily process. At times, some of the best parents will start to question themselves and their parenting skills when raising a child with ODD. This is heart-breaking, but normal. Like any child with unique needs, a parent who has a child with ODD will be using different styles that best work for them and their family. Do not hesitate to consult with professionals as soon as possible. No parent is ever expected to know everything about raising a child, so expand your knowledge and get the help now.

Deep Pressure Activities for Your Child: Why?

For parents of children with autism, you are probably already familiar with the concept of deep pressure activities from a sensory integration standpoint. Some children with autism seem to crave that pressure stimulation, and the results are immediate and calming for their entire body. Why does this work and are deep pressure activities something that other children can benefit from?

Deep pressure techniques or activities are based on the sensory integration theory developed by Dr. Jean Ayres in the 1960’s, and the activities are widely used and apply by occupational therapists. Deep pressure, according to Krauss (1987), is defined as “the sensation produced when an individual is hugged, squeezed, stroked, or held”. Deep pressure activities are often used in a therapy setting in order to alleviate stress, anxiety, over stimulation, and low stimulation. Carefully tailored sensory diets can be purposefully laced with deep pressure activities by a certified SI occupational therapist in order to assist children with very complex conditions.

Children outside of the autism spectrum can also benefit from less formal deep pressure activities such as regular hugs, pillow squeezes, weighted blankets, wrestling with siblings, etc. Every child is susceptible to stress, anxiety, and over-stimulation. Sensory integration is a constant process for everyone and not just children on the autism spectrum. For parents who are at a loss for how to manage their children while they are bouncing off of the walls or while they are experiencing a relentless melt down, deep pressure activities might be the way to go.

Try some of the following methods. Keep in mind that deep pressure activities can be dangerous if not used correctly. Avoid covering your child’s mouth and nose and avoid squeezing their chest or stomach too hard. If you decide to wrestle with your child or squish them with a large pillow, never put your full body weight on top of your child:

Daily hugs: Some families might be surprised to hear this, but there are many people and families who do not practice regularly hugging children. According to the American College of Pediatricians (2018), hugging your child provides multiple health benefits. Hugs are shown to reduce your child’ stress and anxiety levels, increase their immune system, and enhance their relationship with their parents or whoever is hugging them (https://www.acpeds.org/do-you-hug-your-child-enough).

Pillow squeezes: Grab a few pillows off of your bed and have your child climb into the pile. Gently push the pillows into their body without placing your full weight onto your child. This produces similar effects that hugs would, but may provide a fuller long-lasting deep pressure. This is a good go-to activity for a child who craves or asks for hugs constantly.

Weighted blankets: Blankets with sand or other material inserts have become more increasingly available to parents as autism awareness has grown in recent years. Parents have also found ways to make their own weighted blankets for a fraction of the cost of sensory-related blankets. Additionally, there are weighted jackets and vests available in kid sizes that produce similar calming effects. Having the extra weight provides enough deep pressure to calm the child’s body, especially during times in which their over-stimulated and show signs of increasing anxiety or stress.

Blanket Burritos: Roll your child up in a blanket to provide that deep pressure sensation. Monitor and supervise your child, especially if they are too small to figure out how to get out of the blanket by themselves. Again, avoid covering their face to allow for them to breathe properly.

Massages: Massages aren’t just reserved for adults. Gentle rubbing of muscles and joints can be very soothing for a child as well. This would be a useful technique for a child who doesn’t mind holding still for a few minutes to enjoy a massage from a parent or a caregiver.

The therapy world is still heavily researching the benefits behind deep pressure activities and why they work for children. If your child has abnormally difficult behaviors that indicate certain diagnoses (i.e. autism, ADHD, Down syndrome, etc.), consult with an occupational therapist and/or a pediatrician prior to starting regular deep pressure activities. Your child’s symptoms may either stagnate or worsen with casually applied deep pressure techniques.


References:

K. E. Krauss, “The effects of deep pressure touch on anxiety,” The American Journal of Occupational Therapy, vol. 41, no. 6, pp. 366–373, 1987