Tuesday, September 23, 2008

Does My Child Need Therapy?

I was recently asked by a parent, "How do I know if my kid needs therapy?"

Your daughter may need support if she is struggling with relating and engaging with you.

Your son may need help if he is unable to play well with other children, including siblings.

Your toddler may need assistance if he is exhibiting behaviors such as a high level of aggressiveness, explosive rage, or if he does not listen to you and repeatedly tests the limits you set for him (and you feel that it is beyond what might be age-appropriate).

If your child is unable to soothe himself; is frequently sad, angry, or anxious; or is going through a transition that is difficult for him (such as going to daycare or school for the first time), he or she may benefit from therapy.

Or, you may feel concerned that after a long period of growth, your child has regressed in her behaviors.

Therapy can help address these types of concerns.

Parents can often also benefit from consultation or "coaching." Coaching sessions focus on helping parents to improve their care giving skills and ability to interact positively with their child.

Some of my goals in coaching parents are to help them feel more confident, more in control, and to ultimately enjoy their child in a full and rich way.

Coaching may include helping parents with issues such as implementing discipline, teaching ways to help co-regulate and calm the child, learning about the developmental milestones for their child's age, recognizing their child's strengths, and improving the parents’ overall relationships with their child.

Monday, September 22, 2008

How to Spend Quality Time with Your Child

1. Turn off the TV, put down that magazine article you were reading, get off the internet. Finish the laundry a little later.

2. Set aside twenty minutes a day to play whatever your child wants, not what you want. And remember, no video or computer games, please!

3. Let your child take the lead. If your son wants to run around the yard wearing his favorite tablecloth "cape" playing superhero, join him! Offer to be his side kick. Ask him what role you are supposed to play. Ask him to show you what his superpowers are.

4. Remember that it is through play that children are able to express and work out diverse emotions, from being scared and helpless to powerful and omnipotent. By trying out different types of feelings and roles, children develop a better sense of self and how they fit into the world.

5. Play also teaches your child specific skills such as creative problem solving and logical thinking. Help him to build bridges within the play. A simple way to do that is by asking, "And then what?" or "Now what's gonna happen?" or "What do we do now?" But, let him be the one to determine what, exactly, that should be: "Show me!"

6. Be willing to enter your child's world according to the rules governing the play he has initiated. By doing so, you demonstrate that you know how to honor him and his internal world, including the full range of his emotions and creativity.

Bottom line: By spending time in child-centered activity each day with your son or daughter, you will build a better, more loving and respectful relationship with your child.

And who doesn't want that?

Sunday, September 21, 2008

Isn't That Fitting?

One of the most gratifying things for me is when I see parents enjoying interactions with their children.

This is especially true when a mom or dad has been struggling to have good interactions with their child, whether this is due to the child's behavioral problems or a difficult child-parent "fit."

In our society, we expect that when babies are born, mothers should automatically bond with them. But, this just isn't always so. Just as in any relationship, there has to be a compatibility or "fit."

An example of a poor "fit" is when a parent is extroverted and enjoys a lot of different interactions but has a baby who is highly sensitive to stimuli.

The baby may turn away from sound or visual cues, including the smiling, loving face of mommy. This can be disheartening -- and even devastating -- for the mom, who may keep trying to connect by making her voice louder, putting her face closer, kissing or stroking the baby, or rocking baby harder, which only overstimulates the child even more.

Mommy may feel that due to her baby not responding to her, crying, or actually recoiling from her, she is not a good mother. She may even feel that she is a terrible mother.

She isn't; they just aren't a "fit."

The good news is that this is an issue we can work on. Infant-mother therapy sessions can help mom to be better able to read her baby's cues. Sessions can teach mom to understand what her child is sensitive to as well as what gives the baby pleasure.

Through helping mom and baby to achieve a better "fit," they can experience truly joyful and loving interactions together.

Saturday, September 20, 2008

Let the Band Play On!

Charlie is four years old and I have been working with him for 15 months now. He is one of the children I see who was prenatally exposed to methamphetamine (and possibly alcohol).

This means that like many other children with prenatal exposure, he has some major challenges, including poor impulse control, aggressiveness, resistance to limits, problems understanding social cues, and difficulty tolerating frustration.

What this often looks like is Charlie pushing his younger brother over, kicking his sister, yelling at everyone around him (myself included), and throwing things at us before attempting to run out of the room and down the stairs.

Children use their senses to form emotional bonds with others. Together with his father, we've incorporated a number of ways to help Charlie "regulate," or soothe himself so that he can return to a calmer, more organized state and ultimately be able to relate appropriately to another person.

In addition to weekly occupational therapy sessions, where Charlie can roll, tumble, swing, jump, and so forth, we have incorporated music into our play, which also helps him to feel better.

This week, Charlie and his sister collected toy instruments including a drum, a horn, and an accordian from the cabinet in our play room and decided that they would form a band. Each family member was assigned an instrument, including dad on the tambourine.

Charlie led the band in playing various songs such as "Twinkle Twinkle Little Star," and directed everyone to join in and sing. The play at that moment was remarkably joyful and robust. Everyone seemed to be having a good time, a smiling Charlie included. And, he was able to stay focused, calm, and organized for a much longer period of time than is usual for him.

As he continued in this activity with his family during this particular session, it was plain that what Charlie was experiencing with them was a sense of competency, togetherness, and simple fun.

So let the band play on!

A Note: I play a lot of different CD's during sessions with Charlie. A new one that we are enjoying a lot is Dan Zanes and Friends' Spanish language "Nueva York!" For lots of singing and fun, please check it out -- my personal favorite on the CD is "Pollito," which is a great way for kids and grownups alike to learn some new Spanish words.

Saturday, September 13, 2008

The Miracle of Occupational Therapy

A year ago, we were very fortunate to have wonderful USC-trained pediatric occupational therapist (OT) come to our clinic to start an OT program.

This is unusual in a traditional mental health setting such as ours, as OT is typically used for children with issues such as autism and feeding and eating problems.

Occupational therapy is essentially focused on helping a person to engage in meaningful and purposeful activities throughout his or her daily life. For a child, this would cover areas such as playing, learning, and engaging in relationships. A child can have difficulties with any of these areas for emotional or biological reasons, such as the trauma of loss or problems with brain development.

Since the arrival of OT at our clinic and its use with a number of the children I see with mental health and behavioral issues, the way I think about how to treat the young children who come into our clinic has changed dramatically.

Now, in addition to looking at what's happening in the family, the school, the child's relationships, the child's developmental history, and losses and separations, I also think about what is going on with the child's ability to self-soothe and manage incoming stimuli. This stimuli may include sound, touch, taste, movement, and pressure. I consider how we can use this additional sensory-related information to help the child to feel better emotionally.

For example, if a child is calmed by a rocking movement and the deep pressure of massage on the arms and back, then I encourage parents to use this at home, especially if the child becomes upset or tantrums. We might also use this in session.

I believe strongly that OT has the potential to help children with emotional problems to learn how to manage their feelings better. Through helping them manage their sensory experiences, we provide them with the miraculous beginnings of being able to handle difficult feeling states.

Wednesday, September 10, 2008

Sensory Awareness: Looking At the Whole Picture

As human beings, we are hopefully constantly learning and experiencing new things, which we can then incorporate into our senses of who we are and how we move through the world.

The same can be said for child therapists. Every day we have contact with children and parents in the clinical setting means the chance for a moment of learning. It can mean another opportunity for a eye-opening and unexpected experience, which can then enrich the work we do moving forward.

The way that I work as a child therapist has changed and evolved tremendously in the past year. I attribute this in large part to the learning that I’ve been doing about the brain, the central nervous system, and sensory issues.

This past year, we were fortunate to have an occupational therapist come to our clinic, set up an OT program, and help us to incorporate an understanding of these areas -- including how a child regulates, or manages, his or her sensory input (sound, touch, gravity, taste, balance). Our occupational therapist taught me to understand the deep influence this has on a child’s emotions and behaviors.

Take 4-year-old Dylan. He is constantly moving, running, bumping into furniture, climbing up on the table, and jumping off things like the arms of the sofa. If he lands on his head, he just gets up again without seeming hurt at all. He has a very hard time following directions. He also gets frustrated very easily and quickly, to the point of catastrophe – and then, inevitably, there’s a meltdown. We (the caring grownups) then have to help scoop it all up and put back together into the shape of a little boy.

Using a traditional mental health model, Dylan’s symptoms could very easily be chalked up to ADHD. That’s Attention-Deficit Hyperactivity Disorder. For Dylan, the subtype that would apply to him would be “Predominantly Hyperactive-Impulsive Type.” The parent might be coached to provide increased structure and routine at home, use repetition, or use behavioral charts (which might include one sticker for every episode of “good” behavior, as outlined on the chart) and rewards.

I’m not saying any of that is bad or wrong. It’s just not looking at the whole picture. I’m not saying it’s not doing enough. I’m saying we could be doing more.

The whole picture, if you look at Dylan from a sensory perspective, would include consideration of the fact that Dylan is sensory seeking and sensory craving. He wants movement. He wants pressure against his body, the bottom of his feet. He wants to touch a lot of different textures.

Dylan wants the inner-ear stimulation of swinging which allows him to feel calmer. He wants the deep pressure of a hug from grandma that makes him feel more organized and allows him to actually pay attention when she asks him to put his shoes on. And, Dylan wants all of this now.

So, I’ve learned, why not give him what he needs if it helps him to actually feel better and prevent a tantrum or another “catastrophe?”

I’ve incorporated this way of thinking into my work and collaborated with Dylan’s grandmother to give him the stimulation that he needs. If she sees that Dylan is becoming frustrated and upset (or “dysregulated”), she can now recognize it and give him some calming pressure, like squeezing his arms, or giving him a big bear hug while also reassuring him.

And, it works!

I’m just touching on the tip of the iceberg here about looking at the whole picture. I'll be talking more about sensory integration, regulation issues, inner motivation, and ways to help a child improve the way he deals with people and the world outside of himself.

Monday, September 8, 2008

Yes We Can: Collaborating with Parents

By the time parents walk into our clinic, they are often feeling confused and uncertain, helpless and exhausted, and sometimes, quite desperate.

It's my job not only to help their child but to help them too. I do this by listening to them. I acknowledge that though they may not have all (or even some) of the answers, they know their child better than I ever probably could or will.

After all, they have been there from the beginning. Each day, they are the ones who spend time with their child, dropping her off at school, making her dinner, tucking her into bed and reading to her at night.

I inform parents that I need their help to get to know their child's history and issues and to understand their family's problems. I also explain that while I may not always have the answers, I will do my very best to support them and be present to what they are going through.

Along the way, through the treatment process, I constantly seek out their input and feedback. How did the past week go? Tell me about the ups and downs and how that made you feel. What happened to make your daughter cry almost every day? What did you do to help her feel better?

Really, this is the best way to do it. By working together hand-in-hand, through collaboration, we slowly begin to see improvements in a child -- and in the family.

Yes, together, we can make change happen.

Sunday, September 7, 2008

Change We Can Believe In

When it comes to aggressiveness or other behavioral problems, I want to remind you that sometimes change takes time.

Four-year-old Alex was brought into our clinic by his young parents, who were at their wits' end. Alex had just started pre-school after spending most of his years thus far at home with his grandma and mom.

Recently, Alex had begun kicking, scratching, and pinching other children, including his older brother, in a very aggressive way. The parents had been spoken to by the teacher and informed that Alex might have to leave the preschool if his behaviors didn't improve.

Alex was very angry and letting everyone know. He didn't like being sent to school one bit.

In working with Alex and his parents over a period of nearly a year, there were times when mom and dad came in believing that nothing in their son's behaviors and their relationships with him had changed at all. They also would dip into believing that his behaviors would never get better.

"So he got in a fight with his brother this week?" I asked one day after several months of seeing Alex.

"Yes," Mom replied.

"And he pinched one girl this week?" I asked to confirm.

"Yes, I don't know what to do...he's not getting better!" Mom said, becoming tearful.

"Well, let's think about this," I offered. "Remember when you first came in here. How often was he fighting with his brother?"

"Every day...and lots of times every day."

"So this week he started a fight with him one time?"


"And how many times did he used to hit or pinch the other kids in class?"

"Almost every day?" Her expression told me she knew now where I was going with this.

I then emphasized that Alex was actually doing a lot better than before, and that although it seemed, at times, like he wasn't making any progress at all, it was important to look back at the whole picture and remember where he was starting from. I also stressed that although we all want instant improvement and success, sometimes change just takes time.

This is especially true when it comes to behaviors in young children which are tied to very strong emotions and issues such as separation, loss, moving, or starting at a new school.

After the conversation with this particular mom, in which I also reinforced that she and her husband were obviously working hard and doing something right since their son was improving, a look of relief came over her face.

Improvements that take time...now that's change we can believe in.

Saturday, September 6, 2008

Eavesdropping On A Phone Conversation

Me: I've spent the past two years specializing in working with children zero to five.

Marilyn K. (68 years young): "Aren't we all really just zero to five?"

Friday, September 5, 2008

What's Respect Got to Do With It?

[Today's post is a response to comments on my September 3rd post about the "Time In" versus the "Time Out." The comments: When does "Time In" cross over into "giving in" and "spoiling" the child? Will it set a precedent that the child will recognize tantrumming as a way to get what he or she wants?]

Part One:
"Time Outs" should not be used with young children under six. And, a "Time In" should not be viewed as "giving in."

When parents respond to a crying, upset, or tantrumming child by soothing him and helping him to calm down (what I call a "Time In") instead of by punishing him, parents are helping the child to manage his emotional state. This process is called "co-regulation."

Co-regulation is a key skill that will allow a child to be successful in different settings including, eventually, the classroom. This is certainly not giving in.

Co-regulation can happen in a number of ways, including by reflecting back what the child feels, empathizing with him, simply holding him, or giving him a hug. The result is that the child feels safe, calm, and contained, which makes it easier for him to then respond to mommy or daddy's directions.

All young children need parents to help them return to a calm, regulated state. Children learn to eventually soothe themselves and manage anger, frustration, and disappointment on their own. But even the most exceptional children can't do this until they get older. And even then, it can sometimes be difficult.

Part Two:
Many of you are familiar with TV shows such as "Nanny 911" and "SuperNanny." I myself watch them on occasion as they do offer insight into the types of struggles that many parents face in raising their children.

The single reason why parents seek out the Nannys' help is simple: their children aren't behaving. Not only are these children not responding to their parents appropriately; they are running the show. These parents are worn down and feeling helpless and desperate.

While "behavioral interventionists" like "SuperNanny," Jo Frost, utilize time outs (or "Naughty Step," as she calls it) and teach parents how to implement them, they actually do something that is even more crucial. In nearly every episode of "SuperNanny" I've watched, Jo points out to the parents that at the heart of things, their children don't respect them and that is why they are acting out.

Jo makes a good point. We have to gain our children's respect in order for them to respond to us and behave as we'd like. And, this needs to happen from day one.

So how do you do this?

Show your child that you love and honor all aspects of who he is, including the little guy who feels that the world is ending because you have to step away to prepare dinner. Don't just praise the part of him that listens to you when he is supposed to listen. Showing him that you can tolerate all parts of him: the good, the silly, and even the "bad," creates a sense of security that fosters love, respect, and the powerful feeling that "mommy and daddy love me -- no matter what."

So what's respect (and co-regulation) got to do with "Time Ins" and "Time Outs?"


Hey, keep those comments and questions coming!

Thursday, September 4, 2008

Baby's Play

Recently, I went to visit my friend, Amy, and her new son, Sven, who was just seven weeks old. Amy was adjusting well, had her Excel sheets to track Sven's sleeping and eating cycles, and was thinking about the days when she would be able to get back to her Ironman training again.

Most of all, she was trying to get used to being a mom for the first time.

Amy held Sven confidently and chatted with me about the little things she was noticing about him -- how he had long arms and legs like her but his dad's nose and eyes, that he seemed to usually hold one arm up whenever he was feeding, and that he tended to prefer leaning against her on his left side.

She also told me that she heard that you were supposed to play with your baby but that because he was still so "little," she wasn't sure how to go about doing it.

Playing with a baby even seven weeks old is wonderful fun and not that difficult. It's about cooing back when baby coos, smiling at him, laughing, and making silly faces. It's about making sounds that he responds to with a gurgle, another coo, or a slight wiggle. Then you gurgle, coo, and wiggle your fingers back, both of you filled with mutual delight.

These kinds of interactions are so important for a child to have from his earliest weeks on.

A child develops a sense of self and of the world through his relationships. The back-and-forth between baby and mom or baby and whomever else is of importance to him helps baby learn to recognize different types of facial expressions, stimulates his brain growth, allows him to develop the ability to engage with another person, and lets him try out all the fancy new tricks that his little body can now perform -- like smile, hold up his hand in a fist, and let out a startlingly loud fart.

As Amy and I watched, played with Sven, and realized that day, it's also just pure fun.

Wednesday, September 3, 2008

Take Time In

I'll just come out and say it: I don't believe in time outs.

Yet, when I ask parents how they manage their child's behavior, the number one response is, "I give him time outs."

They commonly go on to explain scenarios such as "He was crying and wouldn't listen, so I put him in his room and told him to stay there."

I ask, "Did it work?"

They answer, "No, not really."

Time outs can work for some parents when used judiciously and when the reasons for the time outs are explained and tied to the behaviors. They tend to be less effective when used with younger children, however.

Let's take Steven for example. He is three years old and constantly moving, including jumping out of the car once he's unbuckled from the car seat, jumping off the arms of the sofa, and so forth. It's hard for him to pay attention to his dad (his primary caregiver) or any adult for that matter. It takes a tremendous amount of repetition, including "I need you to walk, use your walking feet!...Walking feet, Steven! Walking feet!" to get him to respond.

One day, a few weeks ago, Steven did not want to leave our therapy play room after his session ended. He began crying and did not respond to soothing as we left the room. In the hallway, he planted himself on the floor and began tantrumming. He was inconsolable.

Some parents might have given him a time out at such a moment. His dad and I did not.

Instead, we took the time to take him into the education center, a room where we keep books, computers, and an art table, and sat together with him on the bean bag chairs.

"I know, I know you don't want to leave," we each told him. As we acknowledged his feelings and let him know we were fully there with him, he began to calm down. Steven stopped crying and asked to pick a book. Then, he asked for the small picture book to be read to him. So, we did just that.

After the book was read, Steven was calm and we were able to let him know that it was time to go home. He got up from the beanbag with dad and hand-in-hand, they began walking.

Bottom line: Try using a "Time In" instead of a "Time Out."

Take time to acknowledge your child's upset feelings and reflect this back to show that you are there with him, you feel what he feels. Staying with him until he can calm down shows him that you love all sides of who he is. Ultimately, this will help you to build a more positive relationship with your child. And, that means a child who is more likely to respond to you when you ask him to please behave.

Tuesday, September 2, 2008

Children Know Best

Two days ago, I was at Annie's sixth birthday party next door. The theme was "Perry," meaning my dog. Pictures that her dad had taken of her and Perry were posted up on the gazebo as decorations. A "doggy obstacle course" was set up. Snacks included dog-bone shaped quesadillas. Yes, Annie officially loves Perry.

In the midst of the festivities (lots of excitement), Annie was swinging hard and fast on the swingset, then running and jumping up and down. She had to be persuaded over and over again to join in the structured activities. At times she became irritated (because she wanted to do her own thing and swing!).

At one point when she was swinging, she shouted over at me to "help me push." I went to push her from the back, but she corrected me and shouted, "No, push my feet! Push my feet!"

For a child like Annie, all that movement, especially the swinging and the pressure on her feet, is not only fun; it's calming and organizing both physically and emotionally.

When it comes to movement, children always know best about what they need. So, follow their leads.

If you have a child who is "on the go," loves to spin, swing, and jump, give her activities and opportunities to experience that kind of movement. Try setting up a "crash pad" (a pile of pillows and stuffed animals) she can jump on. Add a big exercise ball she can lie stomach down on and help her roll -- then jump. Swinging and jumping especially stimulate the part of the inner ear that affects balance and can be very calming for certain children.

I'll be writing a lot more about movement, self-regulation, and emotions in the posts to come, so stay tuned! Happy Birthday, Annie!

Monday, September 1, 2008

Meditating on Self Care

When parents are stressed out about their child's behaviors and issues, one of the most important things I emphasize is self care.

This means making the time to take a walk and exercise, making sure to have some alone (and/or couples time), eating right, getting enough sleep, or calling a friend for support. They're commonsense things that often get thrown out when a family is in crisis or feeling stressed.

Self care is also crucial for all therapists, especially those working with young children. This work can be highly challenging and triggering, such as when a child is screaming, tantrumming, throwing things, and kicking or hitting you. It can bring up a wave of feelings about your own early childhood challenges.

One of the best ways I've found to take care of myself is to meditate every morning. This means sitting quietly, focusing on my breath, and letting thoughts come and go without focusing on them. It's like building a protective cushion around myself for the rest of the day.

There are a lot of different styles of meditation out there, but simply sitting quietly with your eyes closed can often be helpful enough. Research shows that meditation aids in the formation of nitric oxide, which helps blood vessels to open up and lowers your blood pressure.

To Lower Blood Pressure, Open Up and Say 'Om': http://www.npr.org/templates/story/story.php?storyId=93796200