Praise

The abilities to give and receive praise are often taken for granted. All successful parents know giving praise in the right way and at the right time are amazing tools. As a parent you must also understand learning how to receive and respond to praise is a neglected skill that is often taken for granted.

Praise is the name given to any behavior or activity that validates and informs a child they have tried hard or done something right. It supports the development of a child’s self-esteem and allows a parent to focus on building their child’s strengths and self-confidence. In order for you to provide appropriate praise you must pay attention to your child and determine what your child is trying to do. You do not want to reward them for something they did not work at.

Praise should focus on effort and not outcome. It should be an unconditional affirmation of a genuine strength of your child. The role of praise is to guide your child to positive appropriate behavior. Praise is age specific. In infants praise is generally a facial expression or high pitched tones that express your pleasure. For toddlers you show praise in both your actions and words when they show curiosity and an interest in exploring the world. For the pre-school and older child praise is given when they accomplish a purposeful developmentally appropriate task.

Praise may be a positive reinforcement that makes your child feel “good” and hence more likely to repeat a behavior or action (“Thank-you for making your bed!”). It may be descriptive and provide information to the child about what they did right (I liked the way you put your shoes on!”). Another type of praise is when you praise the effort your child showed (“You tried so hard to put that Lego tower together!”). Effort praise should be carefully used since it can reward a child for not completing a task the child really wanted to perform. The last type of praise is robotic praise. This type should be avoided. It is too general and your child will be confused because they really wanted to perform the task they were unable to perform (Your child receives a pass from a teammate and is in front of the goal and tries to kick the soccer ball into the goal but misses the ball and you call out: “Nice try!”).

The long term goal of praise is to help children focus on effort and action and not results. Praise will help your child learn how to deal with emotion and accept the emotions that are attached to various behaviors. It is one of the first steps in learning how feelings lead to thoughts which in turn lead to words and actions.

Environment and Brain Growth

A recent study published in the May 2012, Annals of Neurology supports the finding that the structure of the adult brain is associated with adverse childhood experiences. Recent studies suggest childhood socioeconomic status has long term effects on the structure and function of brain development.

Possible causes include diet, low quality parental health care, impoverished environment, under stimulating environment and prenatal exposure to toxic substances. Prior reports have shown adverse childhood experiences are associated with adult psychiatric disorders and cognitive deficits. Additional studies support the role stress plays in reducing the size of a part of the brain called the hippocampus. Chronic stress in childhood causes a decrease in hippocampal development. The hippocampus is involved in many cognitive processes including the storage and processing of memories.

The environment a child is exposed to plays a major role in long term brain development and cognitive and emotional competence.

Common Questions About Temperament

When is a child spoiled?

When a child has excessive self-centered and immature behavior for his age he is considered “spoiled.” Spoiled children frequently display a lack of consideration for others and demand to have their own way. They have difficulty delaying gratification, and are prone to temper outburst, tantrums or excessive crying spells, if they do not feel they get what they want. Overall, they are difficult to satisfy and very demanding. Such behavior may be expected at times with all children, but by age three they should begin to gain control of their emotions.

How does spoiling happen?

The most common cause is the failure of parents and caretakers to set and enforce age appropriate limits. By discussing these with their child and being consistent among all care givers for the child.

Do healthy infants cry?

Average healthy infants cry for an average of 2 ¼ hours per day in the first seven weeks of life. Such crying should be expected. However, by the time they can communicate their needs verbally, crying behavior should become less and less.

What should I do when my baby cries?

Try to find out what she is trying to tell you. Go through a series of steps to see what she wants. After making sure that she is not uncomfortable due to wet or soiled diaper, or is too hot or cold, try feeding. If unsuccessful, then try to holding and mildly stimulating the infant. Always provide the opportunity for her to go to sleep.

When does the meaning of a child’s cry change?

After four to six months of age, an infant’s cry starts to be used in a way to get attention. After this age he is trying to communicate. Remember, children who are tired, sleepy, hungry or ill are most easily frustrated and most apt to cry.

What is temperament?

The inborn behavioral response style which children are born with is known as their temperament.

Are there any patterns of temperament more difficult to deal with?

Yes. There are certain patterns which cause parents’ problems, particularly, if the parents attempt to suddenly and drastically change their child’s behavior.

Why is it important to know my child’s temperament?

You must not overrespond to your child’s behavior. Often it is the temperament which you are seeing rather than “spoiled behavior.” Instead, set limits and rules which are reasonable for your child. Be detached enough not to take your child’s action and behavior personally. Do not overact to troublesome behaviors.

Do infants have temperament?

Yes. All infants are different, but we see three general patterns, plus combinations of these (see below).

Can you describe some temperament patterns?

Some infants are “difficult” and settle slowly. They do not adapt to change well and frequently overreact to stimulation. They accept schedules poorly. On the other extreme are the “easy-going” infants who are less moody and more easily satisfied and remain satisfied longer. Their eating, sleeping and stooling pattern are also more regular. They tend to react less severely and more consistently to caretakers, foods, and various situations without “bad” moods. Lastly, there is a group of children best described as “slow to warm up,” who have characteristics of both groups, but become more satisfiable as they become comfortable with the surroundings and the care taker.

How do I respond to my child?

Determine your child’s developmental level and you will then know what behaviors to expect from your child. Remember, a toddler’s curiosity is normal and the best way to handle it is to “child proof” the house rather saying “no” all the time. Do not try to “correct” or change watch and every behavior that does not meet your standard. Work patiently and discuss your standards with other experienced mothers.

The Past Does Not Need to be Your Future

Your emotional state has a direct effect on your health and well being. Your body responds to stress with activation of the sympathetic nervous system. Structures within the brain serve as control panels for these functions. One of these control panels is in your hypothalamus. It overrides the parasympathetic nervous system which calms emotions. Activation of the posterior hypothalamus intiates a “flight or fight” response. This is the same “freeze” response you have when you are suddenly startled by something you did not expect. You may fall to your knees or drop a glass you are holding when someone jumps out and startles you.

When you are startled arteries thoughout your body constrict and other vessels dilate to increase the flow of blood back to your heart. Your adrenal glands release chemicals that tell your body there is a threat. If the stress continues cortisol is released. Cortisol has both short term benefits and long term negative effects. This complex response is part of a new field called psychoneuroimmunology and is part of the mind-body connection.

When you perceive and experience stress your body logs the experiences. It is important you recognize stress and pursue strategies to alter these responses. The first step is to seek the balance of satisfaction rather than the state of happiness which is all to often clouded by judgement and perception. Satisfaction, on the other hand, is tethered to pleasure, engagement and gratification. When you are satisfied you have found a state where there is the sense of fullness, fit and flow. Every parent can recall events that embody satisfaction. Your memories could include your child’s first steps, the swing of a home run, a soccer goal, a dance recital or their word. When these experiences happen time stops and your feelings in the present allow past feelings and emotional responses to be rewritten.  In this act the past has changed. satisfaction mediates this change.
 
Parenting is filled with experiences that evoke fear, worry and concern. By seeking satisfaction in your life you will learn to mediate these negative responses and thereby control your hormonally mediated responses that damage your body and shorten your life. Protect yourself by throwing away this concept of immutability of the past. Every day seek satisfaction in your words and actions. Your life will be filled with unlimited opportunities and your child will see how you live life and will learn by watching you. You are your child’s best teacher.
 

Newborn Nursery

I love rounding in the newborn nursery.

It was dark as I drove to the hospital. The birds were beginning to sing and traces of shade hidden snow reflected in my headlights. In the nursery a nurse wheeled in a bassinet with a newborn for me to examine. She looked up at me with an engulfing gaze filled with wonder and amazement. I wondered what future sights those eyes would behold and who she would choose to become.  Her breathing was soft, measured and smooth. Her arms held close to her chest with her fingers delicately resting on a soft receiving blanket. As I raised her in my hands her lips seemed to move slightly as if trying to speak. I held her softly and felt her warmth as she settled on my shoulder. Time stood still as she joined a parade of other infants I had held over so many years.  Infants are our greatest gifts.

After finishing my exam I talked to several new parents. Tired and excited, each was radiant with a mixture of joy and fearful expectations of what was to come.  We talked about infants and how parent self-care is the most neglected part of newborn care. We talked about car seats, hand washing, infant carriers, sleep patterns and feeding options but mostly we talked about nurturing, intuition and trust. We discussed how perfect parenting practices are a mirage since every child is born ready to engage life.

Our society is increasingly portrayed as a violent culture devoid of trust and founded on selfish individual desires. We are bombarded with media reports telling us what we as parents must do if our child is to grow up healthy, smart, strong and protected. This fear is based on lack not plenty. By instilling helplessness and anxiety in parents such fear hides endless opportunity that is within each of us.  I believe such actions steal life from every child no matter what challenges their physical life might demand. Our love, affection, attention and encouragement provide the foundation for freedom, respect and the power of choice that lives within every child. We are temporary guardians who hold and protect each child waiting for the real fun to begin.

When was the last time you looked into the eyes of a newborn?

ASD Treatments

  • Behavior and Communication Therapies
  • Education Therapies focused on social skills, communication and behavior
  • Parent Training (PT) focuses on the transfer of knowledge and information to parents to provide the skills needed to care for their child at home and in the community. Topics include: behavioral principles, behavior management techniques, play activities, social skills, augmentative communication strategies and visual communication techniques. Role playing, homework assignments and ongoing review and feedback are key components to the training
  • Medication is used to manipulate chemicals in the brain (Dopamine System: attention/ planning/ deep subcortical structures. Serotonin System: involved in almost every part of the brain)

 

Alternative Medicine

  • creative therapies (art/ music/ sensory integration)
  • special diets: food allergens/ probiotics/ yeast free diet/ gluten free diet/ casein free diet/ supplements: A,C, B-6, Magnesium, Folate, B-12, omega-3 fatty acids.
  • Chelation therapy

 

Why So Many Dead Ends?

  • ASD Rx has not been a priority for psychopharmacologic research.
  • Complex ASD population
  • Inadequate tools to determine mental health comorbidity
  • Scarce outcome studies
  • Disorganized multicenter approach
  • Short history of ASD medication Rx

 

General Rules for Medication Use:

Start low and go slow/ beware of medications in combination/ simpler is almost always better.

“When there is no cure there are always many proposed treatments”

Medication does not cure any psychiatric disorder.

Medication is never a substitute for psychosocial or educational therapies.

Focus on a child’s profile and symptoms.

Target the symptoms.

Seek a balance between efficacy and tolerance and periodically re-adjust your medication plan.

Improved quality of life for your child in and out of your home is the goal.

Risperdol (risperidone)/ Abilify (aripiprazole): Irritability/ hyperactivity/ stereotypy/aggressive behavior/SIB/ ritualistic behavior/ sleep problems. FDA has approved Risperdal for the treatment of irritability and mood instability associated with autism in children ages 5-16 years (aggression/ self injury/ temper tantrums).

Dosing for Risperidol: Children weighing 14 to 20 kg started on 0.25 mg/day with gradual increases to a maximum of 1.75 mg.

For youngsters weighing 20 to 45 kg, dosing started at 0.5 mg/day and graduated to a maximum of 2.5 mg/day; for children weighing > 45 kg, dosing started at 0.5 mg/day with gradual increases to a maximum of 3.5 mg.

If fail on Risperdol consider off label use of Abilify.

Consider off label use of Geodon (ziprasidone) for refractory

Self injurious behavior (SIB) that does not respond to the other medication.

Ritalin (methylphenidate): improved inattention and overactivity (Increased SE profile: tics/ social withdrawal/ irritability/ decreased appetite).

Non-stimulant medication: clonidine/ tenex/ intuniv. Alpha 2 agonists. Possible benefits in hyperactivity/ inattention/ insomnia/ tics. SE: BP change/ drowsy/ dry mouth/ constipation/ HA/ dizziness/ vomiting/ GI upset/ rashes/ nervousness. Strattera (atmoxetine): improved hyperactivity.

Antidepressant medications: potential benefits for repetitive behaviors, mood and anxiety. (decrease in outbursts/ rituals/ repetitive thoughts/ anxiety/ depression leading to potential benefits of improved social relatedness, language usage and eye contact.

SSRI: Appears to be reasonable due to anxiety and repetitive OC-like behaviors/ used for repetitive behavior and anxiety: not proven. Study in 2009: Celexa (citalopram) no better than placebo/1/3 of patients from placebo and celexa improved/ higher rates of SE’s/ disinhibition syndromes: HA/ impulsivity/ insomnia/ decreased concentration/ increased energy levels/ stereotopies/ diarrhea.

Mood Stabilizers: commonly used in BPD/ lithium/ AED (VPA/ Tegretol/ Lamictal/ Topomax/ Keppra). Many potential side effects.

What to do if you have an Aggressive Child?

The initial step to deal with aggressive behavior is to assist parents in obtaining evidence based parent and child skills. These skills need to be age and developmental specific. Cognitive, behavioral and affective patterns of the child need to be integrated into the types of services and intervention provided. These services can be provided by any professional with expertise in the skills necessary for your child.
The engagement of families and children improves success and compliance. This can be done through supportive services and information available in the office and through online resources, including social media.
The importance of identifying and choosing target behaviors with parents is vital for short and long term success. If a primary issue or antecedent can be identified then this should be addressed first. In doing so the goal is to avoid the use of medication if the cause of the aggression can be identified and eliminated.
Antipsychotic medication is effective in treating aggressive behavior. The use of medication can protect and revitalize families who are in severe and often dangerous discord. Studies and information about comparative use of antipsychotic medications in pediatric populations is limited. Information suggests there are more adverse metabolic outcomes for clozapine and olanzapine than for quetiapine and risperidone. No matter what medication is chosen close follow-up and dose titration is needed and caution used when tracking behavioral responses which are highly variable and may be independent of ongoing issues. Target symptoms and monitoring parameters need to be chosen and closely followed.
When antipsychotic medication and psychosocial interventions are inadequate the use of a mood stabilizer should be considered. Although the use of the “fewest medications possible” is the golden rule, children with complex conditions may require multiple medications to deal with specific symptoms. At all times every chosen medication must be selected with the individual patient in mind. Lower risk medications with potential sustained benefits and known patterns of positive compliance should be chosen first, if possible.
During every step in this treatment process parents and family members need to be engaged and involved in observation and decision making. A therapeutic alliance with the family will foster success.

Adolescents with ASDs

Adolescents who have an autism spectrum disorder (ASD) commonly have difficulty initiating and maintaining friendships. Peer interactions often are limited and this leads to frustration, anger and social isolation. Bullying can also occur as does acting out and challenging behaviors. These adolescents have difficulty recognizing and following accepted social norms. This lack of awareness leads to the adolescent with an ASD being identified by peers as being “different” and further social isolation that is peer and not self- induced often occurs.

Adolescents with ASDs have difficulty matching their interests to others. This pattern of special interests leads to further social isolation and decreased peer commonality. They may also have associated problems including auditory processing, executive function, anxiety and ADHD that further complicate social interaction and limits reciprocal social communication.

How do you recognize an adolescent who may have an ASD? The first step is to look for a longstanding pattern of preference for solitary activities. A recent pattern of separation would suggest depression. Look for difficulty with recognition of nonverbal social cues that limits the adolescent’s ability to understand the intent, purpose and meaning of others. Do they have difficulty making or keeping friends? Do they have highly developed or specialized interests that are appropriate for younger children or are excessive for their age? Is their eye contact limited? Do they have repetitive mannerisms of their hands or fingers? These are all signs to suspect and ASD.

You must recognize adolescents with an ASD and adjust your interaction style to meet their needs. The goal is to support healthy lifestyle behaviors including healthy diet, exercise and adequate sleep. Stress must be managed and the integration of physical activity into every day is essential. Focus on safety and security issues that place the adolescent at risk. Discuss sexuality and bullying issues openly and support age and socially appropriate peer activities.

Adolescents with an ASD have the same puberty onset patterns as neurotypical adolescents. They also have the same interests in sexuality. A difference, however, is they may have an inadequate understanding of issues relating to friendship and social cues relating to relationships. Often language for these adolescents is concrete and rigid and increases misunderstandings. These responses lead to an interpersonal disconnect and unsettling behaviors and responses often develop. If there are associated intellectual delays there can also be difficulty with self-care, personal hygiene, safety and birth control.

Maternal Obesity Risk for ASD

Every parent knows there are multiple risk factors for autism spectrum disorders (ASDs). The specific causes have not been determined. Reviews have been performed and the following patterns have been found to be associated with an increased risk for autism: advanced maternal age, maternal prenatal medication use, gestational diabetes, being the first-born vs. the third child or later and having a mother born abroad are all associated with an increased risk for autism.

Recent reports support metabolic conditions in women being associated with an increased risk of that mother having a child diagnosed as having an ASD. The primary metabolic conditions are diabetes, hypertension and obesity. Not only are these women at greater risk for having a child with an ASD but also having a child with developmental delays without autism. Obese mothers are 1.6 times more likely to have a child with an ASD and twice as likely to have a child with developmental delay.

It is unclear what role these conditions play and whether it may be similar to other non-specific risk factors like prematurity and birth complications. There appears to be an association especially when the obesity risk factor was included but causality was not suggested or proven. Research on the causes of ASDs is ongoing but answers will come slowly. If you have any of the above conditions it is important to address your concerns with your doctor. By opening a two way conversation you will be better able to deal with any fears these reports cause and help you begin a successful collaborative treatment program. Certainly, this information may encourage women to address weight issues and that is helpful for a healthy pregnancy and a healthy newborn.

Maternal health is important not just for the increased risk of having a child with an ASD. It is vital that maternal self-care be integrated into the life of every mother. Each mother must take care of her own needs first if she is to have the best opportunity to be able to take care of the needs of her child when issues arise.

Speech Services

Children with autism spectrum disorders (ASDs) have  a wide range of speech capabilities. This can range from little or no expressive language to highly developed language skills with some associated pragmatic language impairments. As a parent you are in the best position to work with your child to improve attention, communication interest, language intent and language skills. This is done in conjunction with a Speech Language Pathologist (SLP) and is incorporated into home and school settings.

Individual and group support is determined by the needs an capabilities of each child. Some children with ASDs are overwhelmed by sensory and environmental stimuli and respond best to small or individual settings. The focus is on the integration, acceleration and expansion of imitation and social communication. Treatment by a speech-language pathologist is appropriate for all children with an ASD. Useful or communicative speech can be achieved by most children with ASDs. No child should be excluded due to age, lack of prior speech service gains, lack of prerequisite skills, or low IQ scores. The focus must be on services based on intense close collaboration and subsequent extension to group intervention for social skill training when appropriate. Traditional pull out services are often ineffective due to the lack of frequency, intensity and the limited environmental integration of services to natural settings throughout the day. Training for parents, teachers, peers and all caretakers must be integrated into the speech services. The goal is to promote functional communication in natural settings both in and out of the home.

Augmentative communication strategies can be very effective in increasing functional communication. This often involves a Picture Exchange Communication System (PECS) and the use of gestures, signs and alternative communication techniques. Let no stone unturned. Find the type of interaction your child enjoys and prefers and utilize it to facilitate communication. Initially the communication may be unidirectional about what your child wants but the goal is reciprocal communication where there is sharing of feelings, thoughts, words and actions. Augmentative strategies do not hinder the long or short term ability to talk. By increasing symbolic language they increase future ability to speak and communicate.