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Entries in Development and Learning (28)

Sunday
09Oct2005

Screening for Autism in Toddlers

The Modified Checklist for Autism in Toddlers (M-CHAT) is "designed to screen for Autism Spectrum Disorders in toddlers (i.e., over the age of 12 months, and ideally over the age of 18 months). A parent can complete the items independently. The M-CHAT does not allow a clinician to make a diagnosis of an Autism Spectrum Disorder, but is a very useful clinical tool that has excellent sensitivity and specificity. Positive results suggest a high risk for an Autism Spectrum Disorder, and may necessitate referral."

This checklist was not designed for post-institutionalized children, and in fact, distinguishing "post-institutional autism" from "ordinary" autism can be quite challenging, and may require a period of observation. Many of the institutional features (repetitive self-stimulating/self-soothing behaviors and lack of appropriate spontaneous social interactions) do show dramatic improvement with time, in contrast to the autistic spectrum disorders.

Sunday
09Oct2005

Developmental Milestones

Here are some resources to help understand the order and timing of typical developmental milestones. Remember that institutionalized children are often delayed by up to 1 month for every 3 months in that setting, that there's a wide age-range of "typical" even in family-raised children, and that it's usually more useful to focus on the sequence and tempo of developmental achievement rather than strict timing of milestones. If you do have concerns about your child's development, please share them with your child's providers, and consider an Early Intervention evaluation.

Friday
07Oct2005

Tools for Assessing and Managing ADHD

The National Initiative for Children's Healthcare Quality (NICHQ) has developed a free toolkit for providers to help with standardized assessment and monitoring of ADHD (attention deficit/hyperactivity disorder) in children ages 6 and up, available at the UTHSC website (below) or as a downloadable zipped folder from NICHQ.

ADHD is not a do-it-yourself-at-home sort of diagnosis, but I thought it would be helpful to make these available for completing before appointments, and there are excellent handouts here as well. You should not be filling these out if your child is less than school-age, or if you have a child who was only recently adopted in the past few months. Please bring these in to discuss with your health care provider if you have any concerns about ADHD, learning, or behavior.

Thursday
01Sep2005

Parenting by Temperament

If you are raising a child aged 4 months to 5 years old, get thee to the "Preventive Ounce" website. I'll let their blurb do the talking ...

"No child is average.

Unfortunately, most parenting advice is written for the average child.

This interactive web site lets you see more clearly your child's temperament, and find parenting tactics that work for your child.

Developed by the Preventive Ounce over the past ten years, this program has been used by more than 20,000 parents in health maintenance organizations in the Western United States.

Outcome studies show that parents who use this service avoid the anxiety, frustration and guilt that comes when they can't understand why their child acts "that way". They also avoid escalations into behavioral problems, conflicts with spouses and relatives, and unnecessary doctor visits.

As a community service, we now offer this preventive program free to all parents. To start using this program, click on Image Of Your Child. You can then:

  • Complete a short, temperament questionnaire and see immediately on-line a profile of your child's temperament.
  • Learn general strategies for managing the highs or lows of your child's temperament.
  • Discover what specific behavioral issues are normal for your child's temperament.
  • See when and how often these issues are likely to occur in the next year.
  • Get information, tailored to your child's temperament, for managing each issue you are likely to encounter. See what other parents of similar children say works well, and what doesn't."

What more can I say? It works as advertised, and it's free. You'll learn where your child is on scales of Sensitivity, Movement, Reactivity, Frustration Tolerance, Adaptability, Regularity, and Soothability. Make sure you click on the scale/subscale links first to learn what these scales mean. Then check out a wealth of sound, temperament specific parenting advice on issues that your child is likely to encounter in the next year. Some of the advice is mildly out-of-date (1990s, so not that ancient, but playpens are less common these days, for example), so use your parental "sniff test" for what's right for you and your kids, as always.

Monday
11Jul2005

Culture for Kids

There apparently was a day and time when a Korean adoptee in a small homogenous American hamlet could grow up with most everyone pretending they were just as all-American, assimilated, and, well, white as the rest of their adoptive family and town.

Well, it's getting harder and harder to do that these days. The good revolutionaries of Adoption Nation have taken care of that ... But now that the importance of celebrating a child's culture of origin is widely acknowledged, where oh where does one turn to find appropriate bilingual and multicultural items, especially if you don't live in a big multiculti cornucopia like Seattle?

One great adoption-friendly catalog is available from Culture for Kids, who also produce Asia for Kids. The print catalogs are easier to browse than the website, in part because they carry so many bilingual and multicultural books, videos, dolls, and toys - picture dictionaries, translated children's classics from Guess How Much I Love You to Harry Potter (in 8 different languages!), immigrant stories, factbooks, the Language Little bilingual talking dolls, and more ...

Region-specific adoptive family organizations like Families for Russian and Ukrainian Adoption (FRUA) and Families with Children from China (FCC) are also good places to turn to for ideas on raising children from other cultures, meetings of local adoptive families, local language classes, and activities like culture camps.

Thursday
23Jun2005

The "Difficult" Child

Some children, whether we blame temperament, genetics, neurochemistry, prenatal exposures, and/or early childhood experiences, are just plain difficult to parent - intense, needy, easily frustrated, inflexible, inattentive, hyperactive, impulsive, and so on. Or, if you prefer to look on the bright side of life ... spirited, sensitive, perceptive, persistent, and energetic.

If you're nodding your head, read on ... there are effective ways to parent, and perhaps even embrace these traits. The good news is, kids can change - but often we need to change our understanding and approach first. A good place to start would be with one or more of these resources. But bring it up with your doc as well, and consider a specialized parenting class, family counseling, "positive behavior support", or consultation with a developmental/behavioral specialist if you find yourself out of ideas or optimism.

You and your providers may also consider diagnoses such as ADHD, RAD, SPD, ODD, OCD, FASD, and other 3- and 4-letter-words. I'm not label-happy, and agree that it's easy to get lost in this "alphabet soup", but I am a believer in early, accurate diagnosis and treatment when neurologic and mental health disorders are involved. One way to start evaluating concerns about emotions, behavior, attention, and peer difficulties is with a screening tool like the Strengths & Difficulties Questionnaire.

Transforming the Difficult Child, by Howard Glasser and Jennifer Easley, is my favorite book for parenting, and yes, transforming, older children (over 5-6yo) who are difficult to parent, including kids with ADHD. It's also a lovely, positive parenting approach for "easier" kids. If you want a sample, check their website, and I've posted the first 2 chapters on our site as well. Glasser's belief is that normal parenting and teaching methods are designed for the "average child", and that the harder normal methods are applied to difficult children, the worse the situation can get, despite the best of intentions.

I really think this approach has arrived at a simple, but essential truth about parenting ANY child - we need to reverse our typical, inadvertent pattern of paying more attention to misbehavior than to good behavior. Instead of making a big deal over negativity ("why water the weeds?"), make a big fuss over the good stuff. Their Nurtured Heart approach has 3 basic aspects:

  • Super-energizing experiences of success
  • Refusing to energize or accidentally reward negativity
  • While still providing an ideal level of limit-setting and consequences

In Glasser's words, this approach helps therapeutically shift intense children to using their intensity in wonderful ways, and creates a world of first-hand experiences of prosocial behavior: "Here you are being successful ..." This is more than "catching kids being good", it's about having powerful ways to make any moment an opportunity to create success, by finding the good in what IS happening, but also in what ISN'T happening.

Do I love this approach? Yes indeed. You're very likely to find something useful, if not transformative, in this resource. As for his take on medications, I find it to be provocative, but not as much in line with our experience. The "energy" that kids with significant ADHD or FAS have is not always a gift to be cherished, and medications can be invaluable, as part of a comprehensive plan like the Nurtured Heart approach and school accommodations. But I am increasingly recommending a dedicated trial of this approach, plus the therapeutic parenting ideas in Gabor Mate's Scattered, before prescribing medications.

Another book that folks have liked is The Difficult Child: Expanded and Revised Edition by Stanley Turecki, which focuses on nine particularly difficult temperaments: high activity level, distractibility, high intensity, irregularity, negative persistence, low sensory threshold, initial withdrawal, poor adaptability, and negative mood.

A classic in the "insert-euphemism-here" child literature is Raising Your Spirited Child: A Guide for Parents Whose Child Is More Intense, Sensitive, Perceptive, Persistent, Energetic by Mary Sheedy Kurcinka, and her Raising Your Spirited Child Workbook.

"Inflexible, intolerant, and explosive" child? Try The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children by Ross Greene.

"Challenging" child? See The Challenging Child: Understanding, Raising, and Enjoying the Five "Difficult" Types of Children, by child development guru Stanley Greenspan, for positive parenting insights into "the sensitive child, the self-absorbed child, the defiant child, the inattentive child, and the active/aggressive child".

A website that draws on a number of these books, as well as her own experience parenting and running groups, is Elaine Gibson's The Challenge of Difficult Children. Lots of good, opinionated, from-the-trenches advice to be found here.

My favorite temperament resource is the "Preventive Ounce" website, for children up to 5 years old.  Learn where your child is on scales of Sensitivity, Movement, Reactivity, Frustration Tolerance, Adaptability, Regularity, and Soothability. Then check out a wealth of sound, temperament-specific parenting advice on issues that your child is likely to encounter in the next year. A good temperament site for school-aged children is INSIGHTS, with its online temperament profile.

Finally, a brief note on The Strong-Willed Child. James Dobson and his "embrace-your-inner-bully" theories are emphatically NOT RECOMMENDED, particularly for a child who has already experienced lack of attuned caregiving, violence, or other trauma.  The man beats his pet daschund with a belt on page 3 ... this is the guy you want helping you raise your kids? There are much better Christian parenting books out there that don't involve spanking your children into submission. The research on corporal punishment is overwhelmingly against it, and no amount of "folksy take-charge wisdom" or selective Bible interpretations should convince you to hit your kids.

Thursday
23Jun2005

Home Biofeedback

True confessions - both Dr Bledsoe and I have something at home called "Journey to Wild Divine". It's a home biofeedback system and "Myst-style" computer game that uses the same biofeedback technology (finger sensors measuring heart rate variability and skin conductance) that our local hospital's adolescent clinic uses to help with headaches, pain syndromes, self-regulation, and chronic stress.

We think it's an engaging and remarkably effective way to learn self-calming, better emotional control, and alertness, and have been recommending it to our older school-age patients with low frustration tolerance, poor self-regulation, ADHD, anxiety, and stress-related issues like headaches and chronic abdominal pain. The sensors measure signs of your nervous system's balance between sympathetic tone (energized, agitated, "fight-or-flight") and parasympathetic tone (calm, relaxed, "rest-and-digest"). Children who've experienced early stress and neglect tend to be chock-full of the former, with precious little of the latter. With practice, you and your kids can learn to calm yourselves much more quickly and effectively.

In the game, you move through an idyllic landscape, performing various tasks using your developing abilities to become calmer or more alert and energized. Levitating and gently lowering rocks, juggling balls, building stairways, and other nifty activities let you hone these skills until they become effortless. This game is begging for a Star Wars version, since it's really all about the Force, and Yoda would be quite at home with the game's collection of gurus ...

It's not cheap ($159), but that's about what one biofeedback clinic session would cost, and you can do it at home whenever you want. It's actually quite a good deal compared to other home biofeedback devices like HeartMath's emWavePC, handheld emWave (excellent portable device) and StressEraser, which I also like. You will need a fairly modern PC or MAC, since it uses a lot of processing and graphics power. You will also need a modicum of tolerance for SNAG's (Sensitive New Age Guys/Gals) and "what's my mantra?" mysticalisms.

I also recommend their followup game, "Wisdom Quest", which uses the same software but has 30 new biofeedback activities, which are easy to access through a new "Guided Activity Mode". You should also download a free update for their first game that enables a similar "Chapter Tour", so that you can revisit favorite activities without having to load saved games.

Another device that we have no experience with whatsoever but is appealing to my inner geek is S.M.A.R.T. Brain Games, a home neurofeedback device that uses actual brain wave sensors (instead of heart and sweat sensors) mounted in a bike helmet to help control Playstation (or Xbox) video games with your mental states. They use the ratio of beta to theta brain waves (a measure of focussed alertness and concentration) to control your speed and progress in off-the-shelf Playstation games, especially racing and jumping games.

The cost of this "brain training system"? $600 for the helmet, neurosensors, processor, and modified Playstation controller. Yowzah! But again, possibly cost-effective if you were planning on paying out-of-pocket for actual neurofeedback clinic sessions. For folks desiring neurofeedback treatment for a specific condition (like ADHD), you'd probably be best off starting, at least, with an experienced neurofeedback provider ... EEG Spectrum is a good place to start for general information and local providers.

The research on neurobiofeedback and ADHD is quite promising, if not yet definitive; see this "Play Attention!" article for a favorable take on this particular system, and The Role of Neurofeedback in the Treatment of ADHD for a review of the latest research. My opinion is that neurofeedback may well be a useful adjunct to other medical or behavioral treatments for ADHD. My hope is that it will be more broadly helpful for my patients with anxiety, dysregulation, PTSD, and perhaps even aspects of attachment difficulties. I'll keep you posted as I learn more ...

 

Tuesday
21Jun2005

Language Development In Internationally Adopted Children

Initial delays in speech and language are almost universal in children adopted from institutions, with expressive language (talking) usually more delayed than nonverbal social interaction skills. Those of us who work with a lot of adopted children develop a rough sense of what are "typical" orphanage delays, but fortunately, we're also seeing some useful research data on what actually is "normal" language development in internationally adopted children.

The thing to remember (and remind your pediatrician, school district, mother-in-law, etc ...) is that this is not just an ESL or bilingual issue. Internationally adopted children from backgrounds of neglect or inadequate stimulation are usually delayed in their native language.  When they are adopted, they have "arrested" development of that 1st language (unless you happen to be fluent in Russian, Mandarin, etc). They then rapidly lose what abilities they had in their native language, before their "new first language" (English) has time to develop. This leaves them in the "language lurch" for awhile, without functional abilities in either their 1st or 2nd languages.  Not an easy place to be ... this may be partly responsible for those "the honeymoon is over!" behavioral issues that many families experience several months post-adoption.

Sharon Glennen, Ph.D., CCC-SLP, has done a lot of the research on this topic, including a longitudinal study of language development in children adopted as infants and toddlers from Eastern Europe. On her website, she reviews the effects of orphanage care on language development, presents some very useful tables of typical language development in international adoptees, as well as pre-adoption language questions for parents to ask.

Other Resources:

Friday
17Jun2005

Sensory Integration and Sensory Processing Disorder

Sensory integration dysfunction (DSI), or as it is currently known, sensory processing disorder (SPD) is a complicated, somewhat controversial disorder of "sensory processing" - the ability to take in, filter, and respond appropriately to sensory input (touch, movement, vision, hearing, taste, and smell). Some children are felt to be "sensory-avoiding", or "sensory-defensive" - feeling bombarded by overly intense experiences of touch, lights, sound, and so on. Some children are "sensory-seeking", or "sensory under-responsive" - seeking intense stimulation, bashing and crashing around, and seeming less aware of pain and touch. Some children have trouble using sensory inputs to plan and perform gross and fine motor tasks ("dyspraxia", or motor planning disorder).

SPD is one of those diagnoses where definitive research on prevalence, validation of diagnostic tools, and effective therapy is lacking. It's especially hard to know when normal developmental, temperamental, and other individual differences in sensory responsiveness becomes a "disorder". It's underdiagnosed in many arenas, and overdiagnosed in others, just like any disorder where convenient but unvalidated checklists proliferate on the web, and where "cottage industries" marketing products and treatments are competing for your parental attention and money.

Having worked with a lot of post-institutionalized and alcohol-exposed children (two populations that are at higher risk for SPD), I am convinced that there are many such children for whom SPD is a real disorder - one that significantly impairs their function in home, social, and school environments. And I've seen children respond well to occupational therapy (OT) sensory interventions, especially functional approaches that integrate sensory work with the child's needs in motor skills and social interactions.

Even if your child's issues are more reflective of developmental immaturity or individual temperament than a definitive disorder, the sensory approaches can be fun, stimulating, and helpful with self-regulation and self-soothing. It's still hard to convince insurers and schools to fund such interventions, and depending on your situation, sensory-based therapy may not be the most pressing use of your time and money ... but here are some good resources on the topic. A lot of interventions are ones that you can do at home, and while there are scads of nifty products marketed for SPD, you can get a lot done with simple, cheap, or home-made tools and toys.

Sensory Processing Disorder Resources:

 

Tuesday
31May2005

Café-au-lait Spots and Neurofibromatosis

There is a group of genetic neurologic conditions called neurocutaneous syndromes where skin findings can be the first clue to a broader syndrome. One of the most common is neurofibromatosis type 1 (NF1), which occurs in up to 1 in 3000 individuals. This is a condition where benign tumors grow on nerve tissue, causing skin, bone, and sometimes brain issues.

One of the first signs of NF1 can be "café-au-lait spots", which are typically light to dark-brown flat, discrete, round or oval skin patches. These spots become more common with age, and can be more common in African-Americans, but most of us have 3 or less. If more than 5 café-au-lait spots (>5mm each) are seen, this should be considered NF1 until proven otherwise. Other findings like freckling in the armpits or groin, or firm, rubbery neurofibromas typically show up later, in preadolescence. Many with NF1 only develop a few fibromas, but they can be quite cosmetically significant for some.

Mental retardation is rare with NF1, but attentional and specific learning issues are common in this disorder. While fibromas are benign, there is a somewhat increased risk of malignancy (3-5%), and brain fibromas can be associated with epilepsy. Short stature and large head are common in NF1.

The majority of folks with NF1 have mild disease, and complications are often correctable to some degree. Treatment focusses on surgery for painful or cosmetically significant fibromas, and addressing learning issues through early intervention and school supports.

Here are the diagnostic criteria for NF1 (2 or more are required for the diagnosis), from GeneReviews:

  • Six or more café au lait macules over 5 mm in greatest diameter in prepubertal individuals and over 15 mm in greatest diameter in postpubertal individuals
  • Two or more neurofibromas of any type or one plexiform neurofibroma
  • Freckling in the axillary or inguinal regions
  • Optic glioma (tumor of the optic pathway)
  • Two or more Lisch nodules (iris hamartomas)
  • A distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with or without pseudarthrosis (related orthopedic issues)
  • A first-degree relative (parent, sib, or offspring) with NF1 as defined by the above criteria

Additional Resources: