Author: Dr. Tobing-Puente

Like many other people, I was happy to move past 2020 and welcome in a new year. My new calendar arrived with this bold quote (above; photo credit) for the month of January. It certainly reframes how we might think about winter. As a figure skating coach whose family comes from Norway, I’d like to be able to summon my inner “Elsa” and say that “the cold never bothered me anyway.” But for those of us without Disney magic, cold weather is often unpleasant, to say the least.

Last January, if anyone asked me whether I was conducting outdoor therapy sessions, I would definitely have assumed they were joking and/or I would have looked for some hidden cameras. Of course, that was before the COVID-19 pandemic. The pandemic has led to many modifications in our routines to reduce the spread of infection, the most prominent being a major increase in virtual interaction—Zoom calls for work, Zoom for remote school, Zoom calls for Thanksgiving family gatherings, etc.  Needless to say, our collective screen time has gone up exponentially. And although this method has helped keep infection rates lower, many people have been making efforts to minimize screen time when possible. Which brings us to another pandemic-prompted change—increased time spent outdoors.

The benefits of being outdoors have been widely documented (see here, for example). The fresh air, the change of scenery, the increased vitamin D, are all alluring reasons to head outside. In fact, some schools (see here, for example) have successfully implemented 100% outdoor education. Thus, Dr. Lauren, Dr. Jaime, and I have recommended outdoor psychotherapy sessions for many of our clients, including for children whose developmental or regulatory needs make it very difficult to successfully engage in teletherapy (psychotherapy via video). We have been excited to engage in therapy sessions with children and families in parks, backyards, and courtyards, while maintaining safety guidelines and wearing masks during the past several months. Thinking outside the frame, and adjusting our expectations of what therapy “should” look like, has led to unique learning opportunities for ourselves and our clients.

Together with our clients, we have learned many important new things through outdoor psychotherapy sessions, including:

• How slowly we need to walk if we want to get a closer look at some winter birds (great real-life practice for modulating our movements)
• How far we can walk in the park and still get back to the bench where a parent is waiting by the end time of the session (time management)
• How our bodies feel (increasing body awareness) and what kind of movement we can do in order to stay warm (promoting motor planning; coping skills)
• How much distance we should keep from others in the park (social awareness; health and safety)
• How much louder our voices need to be in larger, noisier spaces (voice modulation)
• How the sun sets a little later each day in January than it did in December (science; safety awareness).
• Outdoor psychotherapy sessions also provide more space to move around, which is essential for children with diagnoses of ADHD, autism spectrum disorder, and related challenges, as well as for all children.

In the past, I typically spent a lot less time outdoors once the cold weather arrived. Outdoor therapy in January was a totally bizarre concept to me. But this winter, I’ve found myself thinking more flexibly about the kinds of activities that I can do outside. I’ve been taking walks to the grocery store, for example. I went on a 2-mile jog last week. And I haven’t  been the only one out there! I’ve seen several friends’ posts on social media from hikes they’ve taken with their children this month. As long as I am wearing “suitable clothing,” that is, my gloves, head warmer, sunglasses, and mask, the cold temperature is manageable. So, I encourage clinicians and caregivers alike to bundle up and head outside to discover all that winter has to offer!

As discussed in the previous blog the COVID-19 pandemic has impacted families and our practice in many ways.  I described the (many unexpected) positive of our use of telehealth in the previous blog, while here I delve into the challenges we have encountered and how we have addressed them.

Cons/Challenges of Conducting Remote Psychotherapy Sessions and How We Have Addressed Them:

1. Fewer materials: It goes without saying that one of the biggest challenges of conducting virtual sessions is the lack of therapeutic “stuff” readily at hand for our clients. For our practice, this ranges from our sensory gym space (in Bayside) where children are able to get the movement and/or sensory input they need to regulate, communicate, interact (or just plain have fun) during sessions, to our therapeutic play materials, such as people figures, doll houses, play kitchen sets, blocks, balls, and various games.
   • Solution/Tip: Get creative!  Sometimes I ask the child to take me on a tour of their home (with parental permission) to see if I can encourage them to engage with materials that would lend themselves to a virtual interaction. For some of my older clients, we have engaged in problem-solving around this together, and some of my favorite ideas have been virtual Chess, Boggle, and other games that truly rely on our interaction, rather than materials.
2. Technology issues: Of course, tech glitches will always be a factor to consider during virtual sessions.
   • Solution/Tip: Do your best to prepare. Make sure that your own device is charged and free of issues (to the best of your ability) prior to session, and provide some expectations and guidance ahead of time for how your client or family can do the same.
3. Some kids are not very responsive “through the screen:” Depending on developmental level and a variety of other factors, some clients may not be as engaged this way.
   • Solution/Tip: Again, get creative! Think ahead and perhaps engage some family members to brainstorm preferred activities that may be translated on screen. And/or, consider shifting the approach and take on more of a coaching role with parents (as discussed in the previous blog), which will likely elicit important information to use in treatment overall.
   • Please note that this “barrier” may work in the opposite direction as well. We have a number of child clients who have been MORE engaged virtually than during in-office sessions. Although this may seem, and sometimes certainly can be, a “pro” of virtual sessions, it is important to consider this as meaningful information about the client (and to explore why this may be the case.)
4. Less privacy: This applies to both the child/family, and the professional. In most cases, concerns about privacy have not been an issue for families that we treat and it has rather proved a benefit (discussed above) as more family members become involved. However, this is important to consider for preteens, adolescents, and young adults, and people who live in smaller or more crowded homes.  Likewise, virtual sessions often provide more of a window into the clinician’s personal life, which clients typically have limited knowledge of. For example, children or pets may come into the frame of the video or be heard in the background.  Some parts of the clinician’s living space may be visible.
   • Solutions/Tips: Prepare ahead of time for yourself and your clients. Be mindful about your background space, and encourage clients to do the same. Discuss limits to confidentiality and privacy with clients before the first virtual session.

Taken together, we all know how difficult the COVID-19 pandemic has been on all people, including personally and professionally.   We are glad to have experienced many positives in our work, as well as our ability to think outside of the box to address the challenges we have encountered.  All that said, while we look forward to being back in the offices “as usual” as soon as possible, we have a feeling that we will incorporate many of these new strategies when we do to create another “new normal.”  After all, evolution and development are valuable for us all!

Welcome back!  As the pandemic continues, we are continuing with our “Ch-Ch-Ch-Changes” blog series.  This blog highlights the positive impact that we have found of COVID-19 related restrictions and changes on our intervention with our clients.  The next blog will detail the challenges we have encountered and how we have addressed them.  

To briefly reflect, we as a society have now been dealing with the impact of the pandemic for more than 7 months.  Many employees continue to work from home, schools vary between using “blended” models of remote and in-person learning, full-time remote-only, and full-time in-person models with COVID-19 precautions in place.  Thus, families are continuing to navigate and adapt to a number of challenges that have presented based on these logistics and disruptions in typical routines.  In our group practice, we, too, have continued to navigate and adapt to these changes, mostly by providing psychotherapy (and aspects of evaluations) virtually through a HIPAA-secure video platform.  We have found many benefits and challenges for remote sessions.   Many of these have been unexpected, but all have provided us with opportunities to reflect, learn, and grow as a practice.

Pros/Benefits of Conducting Remote Psychotherapy Sessions:

1. Increased involvement from other family members, and a better understanding of family dynamics: As families have become more comfortable engaging in virtual sessions, we have often been better able to observe and understand family dynamics than we have in the office. Family members have been more often present in the home (and therefore during sessions) than there would be in the office. It is thus often easy to incorporate siblings and other family members, even if only for a few minutes at a time. This has allowed us as clinicians to develop deeper relationships with the entire family, which we strongly believe promotes the therapeutic process overall for all family members. 
2. Live coaching: Remote sessions allow for in-vivo problem-solving and coaching in a family’s natural environment. Very often, parents report struggles at home that do not occur in the office setting. With virtual sessions taking place “in the home,” we are  able to observe and then coach families through challenging moments.  Regularly seeing the family’s natural environment provides a much greater understanding of what strategies will be effective and we can fine-tune them on a more individualized basis.
3. Natural generalization: We often tell parents how little it matters if a child demonstrates a skill or capacity during our sessions in the office once a week, but does not do so in other environments/with other people. Without generalization, gains are much less meaningful and impactful in terms of the child’s overall functioning. What a child does (or does not do) in their home, with their family, or at school, than I do about in my session is much more important, because that is where and with whom they spend the most of their time. Enter virtual sessions! These sessions provide increased opportunities for generalization, because we are working on skills (virtually) in the home, with their family members, in their everyday interactions.

While we deeply miss working in the office “as usual” during this pandemic, it is wonderful to see how virtual treatment has positively impacted so many of our clients and families. Stay tuned for the next blog on the challenges of virtual treatment and how we have addressed them. Stay safe and be well!

1. More flexible scheduling: Sessions typically occur once per week for 45 minutes and require transportation to the office, amongst other logistical factors (e.g., child care for another sibling). Since the onset of the pandemic, many of these previously limiting factors no longer applied and have led to greater variation in session duration and frequency.  For example, increasing frequency (once weekly to twice weekly) and decreasing duration (from 45 minutes to 30 minutes) is often appropriate for children working at more foundation developmental capacities.  This has been helpful in supporting sustained attention and engagement throughout the session, as well as providing increased consistency for the family to address their goals.  

In Part 3 of the Ch-Ch-Ch-Changes blog series, I will focus on our adaptation to the concept of “Social Distancing.”  This term, which many of us never heard before March 2020, is so prevalent within our vocabulary, the media, and our mindset in recent months.   This term may have brought about many emotions in us: fear (“What if I can’t buy my necessities if shopping in stores is not safe?”), sadness (“I miss giving people hugs”), or frustration (“What will I do if I can’t see my friends, family, or coworkers?).  However, many of us have adapted to this concept during the past few months.  As we have discussed in the earlier posts in this series, this time of pandemic has shown how we have adapted and (hopefully) allowed us time to promote our self-care and well-being.  My hope is that adapting to distancing has allowed for new ways of interacting and skills that can be used in the future.  For kids, this may mean having more meaningful connections with family members who moved far away; for adults this may mean having new ways of working and “going” to doctors appointments, for example.

Before we go further, we need to ensure that we change our thinking about “social distancing” and consider the more appropriate term, “physical distancing.”  Social distancing implies that we are maintaining distance from our social networks, which is very much the opposite of what is needed during a time of so much stress, anxiety and new routines.  Positive social interactions are excellent coping strategies.  It is crucial to remember that humans are wired for relationships.  Even people who struggle to maintain relationships with others need relationships, despite the factors that make it difficult.

During the past few months, you likely have found yourself, or your child on a Zoom call, a Google Meets or, in our case for our practice, a Doxy.me session once, twice or several times per week.  I am so grateful for these video platforms, while not the same as being in person, it enables us to provide the visual aspect of social interactions.  Many young children are not great at speaking on the phone, but may have already learned how to Facetime with faraway family members prior to this pandemic.  That all said, you may be finding it difficult to maintain virtual social interactions for your children.  This may not be a skill that comes easily for you or your child. 

Here are some tips to help facilitate virtual social interactions for kids:

• Especially for younger (chronologically or developmentally) children: organize and schedule virtual get-togethers for them.  Younger children are less likely to ask for them and are less able to schedule them independently.  Do this with grandparents, cousins, and other family members, and especially with classmates and other friends.
• Remember, kids interact more physically than adults do; so, expect that their video chats will be more active, too.  They are less likely to just sit and look at their friends’/family members’ faces.  Here are some ideas for virtual activities:
  • Have them give a tour of their bedroom or their house and reciprocate
  • Hula hoop contest, dribble a basketball contest
  • Scavenger hunt (e.g. Surprise each other with a funny hat; find something that starts with the letter ___)
  • Online interactive games  (e.g, Scribbl.io, Scattegories, Hangman).  You can make some of these up as well.

• It may help to plan activities for video chats ahead of time so they know ahead of time that they will be doing something of interest or motivating.
• Remember that just because kids may not be talking or looking at the video screen does not mean they are not invested in the interaction.  They may enjoy having their aunt, for example, watch them draw a picture or build a Lego structure, as the aunt comments and validates their ideas.

Tips for Caregivers

• Think about how often you socially interacted during the day pre-pandemic  (e.g., a couple of quick pleasantries in the elevator or at the front desk; morning fitness walk with a friend; lunch with a colleague).  The interactions may have been brief and routine, but meaningful.  Be sure to engage at the same frequency or more now.  It may be with different people (family member at home rather than co-worker) or in a different format (text message versus in-person) but will provide you with some drops in the proverbial cup of social interaction.
• Virtual get-togethers: with friends, family, co-workers, etc.  Again, the visual component to video interactions is quite meaningful.  In our practice, we now hold our weekly group meetings via video, rather than by phone conference.
• Consider your comfort level for live, in-person visits, as the pandemic eases.  With better weather these days, there are greater opportunities for outdoor activities (which the CDC says are safer).  Meeting at a park or backyard with masks while maintaining distancing guidelines is quite feasible.  With kids, consider their understanding of physical distance rules and use of masks.  

I hope these tips and strategies help to prioritize social relationships during this pandemic.  Although we are likely to be missing many of our routine social events, it is crucial to maintain our, and our children’s, relationships with friends and family.  You may find that relationships deepen and/or grow using these new tools.  And if not, they will hopefully help us cope with the pandemic until it is safe to resume regular activities again.

Stay tuned for our next blog on maximizing the benefits for time at home with your child.

This is Part 1 of the Ch-Ch-Ch-Changes Blog series. Click here for the Introduction to the series.

First, take a moment to thank yourself for clicking on this link! The past few months have placed so many new burdens on caregivers, and just as some may have subsided a bit, we are faced with additional stressors this week. Last week, Dr. Jaime’s blog addressed how families are adapting to distance learning. This second part of our blog series focuses on a few practical ways to promote well-being for the entire family. Finding even just a few minutes of the day to devote to your own wants or interests can be very challenging. Children who used to spend anywhere from 7-10 hours a day across school, extracurricular activities, and playdates, have now been spending all of those hours at home, with family. Prior to the COVID-19 pandemic, the tasks of providing education, opportunities for movement and exercise, socialization, and stimulation in the form of playtime were addressed by a much larger support network. Now, these responsibilities have largely fallen to primary caregivers, many of whom are also expected to work from home. Teachers, coaches, babysitters, service providers, or extended family members who would usually spend time with children in person have been unable to. Parents have reported high levels of stress, anxiety, frustration, and exhaustion. The good news is, there are some quick and simple strategies that can make this situation a bit easier on children and caregivers alike.

Self-care is, quite literally, taking care of oneself – that is, one’s body and mind. Just as we take time to eat during the day, taking time to check in with our physical and emotional state is just as important. You’ve likely heard of the analogy of the oxygen mask on an airplane – put yours on first so that you can be available to help your child with theirs. Much in the same way, if the adults in a household prioritize their own self-care, they will be more regulated and better equipped to help their children use these same skills. In an effort to avoid bombarding families with even more Things To Do, I’ve provided three key words that can be easily recalled during the day – an “ABC” of self-care. These are by no means the only ways to engage in self-care, but a good starting point to keep things manageable. We welcome any other suggestions that you may find helpful!

1. Awareness: Asking oneself, “What do I need right now? Does my body need to move or stretch? How long have I been working without a break? What am I feeling?”
   • Name what you are feeling and express it out loud. Modeling emotional expression for children helps them develop a wider emotional vocabulary and can also help them organize some of the confusing feelings they may be experiencing internally.
   • If you check in with yourself and answer yes to “Does my body need to move or stretch?” Fantastic! There are so many ways to build in a small movement break: walking to the kitchen to get a drink of water, standing and reaching your arms over your head, twisting from side to side. The Openfit app has a wide variety of live exercise classes throughout the day, including a few 5-minute classes consisting only of stretching. There is also a wonderful child-friendly book called Mindful Movements by Thich Nhat Hanh, featuring ten easy movements designed to bring the awareness back into the body in a fun way. Breaks that involve movement and getting outside are even better. Our bodies love getting fresh air! Kids can plan ahead with their families to make outside time into a game (e.g., “What should we look for while we’re outside today? How many birds do you see?” Caregivers can scaffold this and add visuals for children with language difficulties).
2. Breathe, mindfully: It seems like I see the reminder “Just Breathe” all over social media, even on t-shirts or mugs available for purchase. But what does it actually mean? Research shows that taking a few deep breaths can help refocus the mind and allow us to relax. Paying attention on purpose to the physical sequence of an inhale-exhale also puts us back in touch with the body. The free version of the Calm app has a breathing exercise tab, with timed prompts to inhale and exhale. The duration of the exercise can be adjusted for as many minutes as you have (even one minute). This is another great exercise to model for kids – you can invite them to try it with you, or they can watch and “coach” you through it. Letting children take the lead and announce when it is time to breathe in and breathe out helps give them a sense of efficacy and control, in an appropriate way.
3. Connect: With restrictions on our ability to socialize with others in person, it can be easy to neglect our social networks. Send a quick text during the day to a close friend – sharing something positive (e.g., “The kids are playing nicely together right now”) or simply sharing how you are feeling in the moment. Invite the children in your household to connect with their peers, too: “Daddy’s going to call Grandma today to say hello; which friend would you like to say hello to today?” Scheduling a video call with a babysitter or coach that your child hasn’t seen can also be a great way to maintain those relationships. Finally, connecting with new peers and instructors is another possibility. Outschool offers online classes for children, grouped by age, with subjects ranging from “Intro to Card Magic” to “Introduction to Veterinary Medicine.” Varsity Tutors also offers online classes by subject and grade level, at no charge.

Keep in mind: you are doing your best and expectations should be adjusted during times of high stress. On a final note, I have a version of “Self-Care Bingo” at home. I often check the sheet and send a text to a family member or friend when I reach “bingo” during the day. There are several self-care bingo visuals available online for those who are interested in printing out a version to use with their family.

Wishing you all lots of success on your daily journeys of well-being!

Stay tuned next week for our next blog!

This is Part 1 of the Ch-Ch-Ch-Changes Blog series. Click here for the Introduction to the series.

In a matter of mere days, maybe even hours, we learned that schools were closed, jobs became mostly remote, and life as we knew it was coming to a complete halt.  Old challenges remained unsolved or put on the back burner, new challenges arose.  We felt shock. Frustration. Anger. Sadness. Boredom. Helplessness. Pain. And more. That being said, I have witnessed a remarkable ability for people- parents and children alike- to demonstrate one of the most important skillsets and predictors of success in life.  And yet, it is not a skill that you explicitly learn in school.  That is, the ability to adapt.  I have found myself thinking about that concept and skill a lot lately, and through my professional lens as a clinical psychologist, the importance of developing this skill in children and parents.  “Adaptability” is even a subscale on a social-emotional/behavioral assessment measure that we commonly administer to  parents and teachers when we conduct psychological evaluations.  There is also a well-established research base regarding adaptability in the workplace and in business.  Needless to say, we have all done A LOT of adapting lately, probably both consciously and subconsciously.  In this blog, I will focus on adapting to distance learning and various strategies that families can use at home.

As part of a recent workshop that Dr. Jennifer, Dr. Lauren and I provided to parents regarding special education and the IEP process during the times of COVID-19, we gathered information from various local schools to gain a better understanding of how schools were adapting and implementing distance learning.  Overall, we learned that there is a lot of variability where distance learning is concerned, and even in the few weeks since our presentation, it seems that these plans and programs are continually evolving.  Some schools are having regularly occurring “Morning Meetings” via Zoom or another video platform, some have teachers and related service providers assign activities online, and for others, teachers conduct whole lessons via video.  Much of this variability is dependent on students’ age, developmental level, and school setting.  As part of our ongoing work with clients and their families in psychotherapy, we have been helping them to adapt to such approaches for their particular child. 

Adaptations to remote learning are likely to vary by family, child’s developmental level, and schools’ expectations.  On an initial more global scale (and for children who are developmentally able and ready to engage in academic work), adaptations include implementing concrete strategies such as:

1. Creating a work space that is free from distractions, is comfortable to work at (i.e., with a chair and desk rather than on a bed), and has all the necessary work materials.
2. Creating a schedule and daily routine to provide structure and set times for academic work and free time.
3. Supporting organization and time management skills, including creating to-do lists, visual schedules, and calendars to track long-term assignments.
4. Determining priorities and planning accordingly.  Don’t forget to give yourself and your child a break- you do not “need” to complete ALL tasks, assignments, and activities just because they are available.  Your safety and well-being, including your and your child’s mental health is a priority (more on that in a later post!).   

For other families and their children with special needs, work may be less academically focused, and therefore may be more challenging to adapt for home-based learning.  I have heard from many families that it is often challenging and overwhelming to comb through the lists of activities or assignments provided by schools and related services providers, and then how to adapt them based on their child’s developmental level.  Many families that I work with have children who attend specialized schools in classrooms of students with mixed developmental levels.  It is difficult and quite time-consuming for teachers to provide remote activities and assignments for each individual student or developmental level.  It is equally, if not more distressing, for parents to grapple with how their child could participate in these activities at home. An additional stressor may arise when families are expected to document progress, or “show” a child’s work or completion of activities (often the case for parents seeking reimbursement for non-public  schools).  Here are a few ideas and strategies that have been helpful for some of our families:

1. First, consult your teachers and providers. You should not and do not have to do this alone. Reach out to your child’s teachers and ask how you might adapt an activity for his/her developmental level. Specify your concerns or what did/did not work in previous attempts. Similarly, engage them in brainstorming regarding what and how to document progress (examples may include a short video of your child completing an activity, a picture of a completed activity, or a quick written note describing what he/she worked on and how).
2. Get the general idea. That is, your child does not likely have to complete an activity/assignment exactly how it is being presented, but rather, participate at a level that is appropriate for them.  For example, one of my clients was assigned to “go on a scavenger hunt for winter clothes,” which she would not be able to do independently, nor likely understand.  I helped her parents brainstorm the objectives behind such a task, and how we could adapt it so that she is working on similar goals.  We came up with helping her to sort laundry, feeling “cold” versus “warm” by placing her hand in the freezer versus under warm water, and looking at books and videos about “winter.”
3. For children in NYC, ensure that your child has a Special Education Remote Learning Plan (for children with IEPs), and discuss it with teachers and providers accordingly.  A Remote Learning Plan is a live document akin to and based on a child’s IEP (see letter from NYC DOE’s Chancellor below) and the strategies that are helpful for that child.

I wish you all the best as you continue to adapt to the continued evolution of distance learning.  Feel free to share some of your own tips as well.   Stay tuned next week for our next blog.

References/Resources:

Helpful Links for COVID-19 from NYC DOE: https://www.schools.nyc.gov/learn-at-home/activities-for-students/diverse-learning-for-special-populations/helpful-links-for-covid-19  

Letter from Chancellor Carranza to Parents of Students with Disabilities:

https://www.schools.nyc.gov/learn-at-home/chancellor-s-message-for-families/message-to-parents-of-children-with-disabilities

During the more than two months of this COVID-19 pandemic (including, NY stay-at-home orders, “social distancing,” and remote learning), Dr. Jaime, Dr. Jennifer and I have spent much time discussing and reflecting about what families, including special needs families, need most, and how we can best support them.  We have smoothly transitioned to telepsychology for ongoing and new clients, and for evaluations, as appropriate.  I have increased the frequency of the free support group for parents of children with ASD.  We have offered several virtual webinars for parents on topics related to parenting during this pandemic.

We continue this mission to support families with a series of blogs ripe with strategies and information for families as this time of uncertainty and “new norms” continues to evolve and pose challenges.  Hence, the title of the series is: Ch-Ch-Ch-Changes (a reference to the great David Bowie song), as we continue to be faced with changes during this time.  This series will include:

Part 1: Adapting to Distance Learning During COVID-19

Part 2: Self-care and Family Well-being

Part 3: Safely Maintaining Relationships: Physically, Not Socially, Distancing

We hope you enjoy these blogs and find that they are useful in some ways.  If you have additional ideas for topics, please let us know.

Collaboration is crucial when working clinically with children in any setting to ensure generalization and carryover of skills to their everyday routines.  That is, the transference of skills across different environments.  One standard method to promote this is having parents actively involved in a child’s psychotherapy, whether that be through parent-child sessions, separate parent meetings with the clinician, or, ideally, both.  I always note that although our office has a waiting room, it is rarely ever used!  Parents are almost always involved in their child’s sessions in some way, and this provides them with the opportunity to learn strategies from the clinician’s modeling as well as more overt conversation to promote carryover to the home setting. 

Similarly, we need to ensure collaboration with the school team.  I often find myself encouraging and supporting parents in initiating more and more communication with their child’s teacher and school team.  Depending on the school setting (e.g., public, private, general education, special education), the teacher(s) and related service providers have various ways of communicating with families (e.g., communication notebooks; team meetings; phone calls).  Depending on the developmental level of the child, their own understanding of communication between their parents and teachers may have an impact on their behavior and functioning.  For example, knowing that their teacher is going to tell their parents about a really wonderful job they did on a project or a kindness they showed a classmate will likely lead to feelings of pride, validation, and excitement (and increase the likelihood of their demonstrating this positive behavior again).  Similarly, awareness of open communication between their parents and teachers when a challenging or perceived “negative” situation or behavior occurs may lead to a variety of feelings for a child as well.  In both cases, it is highly important for children to know and feel that all relevant parties are on the same page. 

It is ESPECIALLY important for children with developmental differences that parents, teachers, and clinicians are on that same page.  In her article, “Working resourcefully with parents of children who have severe disorders of relating and communicating,” Dr. Rebecca Shahmoon-Shanok wrote, “… how parents understand their child’s problem—is crucial to the eventual outcome.”  I would like to expand upon this notion to include the school team (and other providers)— that is, how EVERYONE in the child’s life understands the child’s challenge is an important factor to progress and outcome; so for children, who spend most of their time in school, it is essential for all parties—parents, teachers, providers—to be on the same page in terms of their understanding of a child’s strengths and weaknesses.  Dr. Shamoon-Shanok stated, “Frequent discussions, with every person learning and swapping ideas and support, are a cornerstone of [a] careful, intensive, and synthesizing approach,” which will only serve to promote progress for the child, and, just as importantly, comfort for the family.  It is a particular challenge for children with difficulties with forming relationships with others (e.g., children with autism spectrum disorder) to understand varying methodologies by their various supports and caregivers; we must decrease the fragmentation that may occur for these children and families.

So, how do we do this?  How do we create and nurture the family-school-clinician relationship?  I acknowledge this is no simple task, as it is often wrought with logistical challenges.  However, here are some ideas for parents to consider:

1. Provide consent for collaboration.  Giving your consent for a clinician to contact the child’s teacher will allow for the first step in this process.  To facilitate clinician-school contact, it is always helpful to send an e-mail to both parties indicating your consent (along with signing any necessary authorization forms) as well as an idea of what you hope to achieve by making this connection.  Schools are often more open to such collaboration when such communication gets off on the right foot and they understand that the clinician is seeking their impressions and observations of the child, with the understanding that the child spends so much of his/her time in school.  (maybe sounds better?)
2. Consider who would be the right person for this job. Is it the teacher? The school social worker? Guidance counselor? Psychologist on staff? Director/Principal?  Who is the person that will be best able to provide an understanding of your child’s functioning at school as well as take in and apply recommendations and strategies posed by an outside clinician?
3. Schedule a school observation for the clinician.  School observations do not have to be limited to an evaluation process.  It is often very helpful for clinicians to observe a child in their school setting (again, where they spend the majority of their time) in order to inform their treatment plan.  Similarly, it can be helpful for the school team to learn successful strategies and ideas from the outside clinician to apply to their interactions with the child in school.  I was recently conducting a school observation for an ongoing client when, in the middle of conversing with the child’s speech-language pathologist, the child appeared to notice my presence and initiated eye contact and big smiles in my direction.  She looked back at what she was doing, and then referenced me in the same way again. The teachers were so impressed by this connection between us—one that they reportedly had not experienced with the child themselves.  Their witness to this moment provides a great jumping off point for me to begin speaking with them about what they may be able to learn from and apply from my style to the child in school.
4. Ask whether the clinician can be included on pertinent emails between the school and parents.
5. Include regular consultation meetings (via telephone and/or confidential video conferencing) between clinician and school.

Reference: Shahmoon-Shanok, R. (1997). Giving back future’s promise: Working resourcefully with parents of children who have severe disorders of relating and communicating. In Greenspan, G.I, Kalmanson, B., Shahmoon-Shanok, R., Wieder, S., Williamson, G.G., & Anzalone, M. (Eds.). Zero to Three: National Center for Infants, Toddlers, and Families (37-48). Washington, D.C.: Zero to Three: National Center for Infants, Toddlers, and Families.

Families often seek help because they are concerned about their children’s behaviors.  As psychologists, we are frequently asked questions such as:

• What should I do when my child is disruptive in his/her classroom?
• Why does my child have trouble sharing?
• How can I get my child to stop screaming at a restaurant?

In the above situations, these behaviors are often presumed to be “oppositional” or “defiant” in nature, and as a result, the children are described using these terms. In fact, many parents say that doctors or teachers have mentioned the possibility of Oppositional Defiant Disorder (ODD), and they ask if this diagnosis applies to their child’s behavior.  It is common for adults to feel frustrated when a child does not comply with their requests, or when efforts to change a child’s behavior seem unsuccessful: “I’ve tried yelling, taking away toys, using rewards, even crying… Why don’t they listen?!  Why don’t they follow the rules?!”

These seemingly desperate questions are actually a large part of the solution. The moment we really begin to examine why the behavior might be happening, we become curious about a child’s experiences instead of acting punitive or blaming.

The most important thing to keep in mind is that uncooperative behavior is often an outward display of internal distress. In her blog, psychologist Mona Delahooke, Ph.D., urges us to pay attention to a child’s emotional and physiological experiences when they display defiant behaviors:

“We need to become investigators as to the range of individual differences that contribute to children’s emotional vulnerability, and help them construct new meanings from the sensations they experience leading to the challenging behaviors.”

This opens the door to so many possibilities to explore! So, let’s become investigators…the behavior is probably not happening because your child gets pleasure out of annoying you or because “they just don’t want to follow the rules.” There are probably several other whys if we look a little closer.

A common cause of internal distress is an overabundance of sensory input. Think about commuting home from work on a crowded train in the summer – you’re hot, tired, hungry, and likely have a low tolerance for people who are standing close to you (sounds, smells of others will make many folks feel annoyed or even outright angry at their fellow commuters). Most adults, thanks to their brain having fully developed its prefrontal cortex, are able to inhibit angry or aggressive impulses in this situation. But children, especially those with neurodevelopmental delays, are not as well equipped to handle these environmental stressors, as they are likely to be overly sensitive to such stimuli. Sharon Heller, Ph.D., writes eloquently about this sensory imbalance in her book, Too Loud, Too Bright, Too Fast, Too Tight.  While some children seem over-reactive to sensory input, there are also those for whom the opposite is true –those who need a higher amount of movement in order to stay regulated. These “under-reactive” children frequently get out of their chairs, run down hallways, or may look to “jump” from the second or third step at the bottom of a staircase. Whether a child shows more over- or under- reactivity, their unmet sensory needs can lead to dysregulation, which often in turn leads to “not following the rules.”

Behaviors of children with autism spectrum disorder (ASD) are often interpreted as being “oppositional” or “defiant” in nature rather than understood from the perspective of their developmental and individual differences.  For example, disruptions to normal routines can be triggering for children with ASD. When things don’t go as planned or expected in the environment, this can lead to increased anxiety, which often presents as irritability or as a full-on meltdown. Further, one of the hallmark symptoms of ASD is difficulty reading social cues. That means a child can’t always tell when their behavior is bothering someone else. Children with ASD typically need more help tuning into the social world around them, and they can miss the nuances that their peers pick up on. They are not annoying others just for their own entertainment or to receive attention, as is often presumed in the case of diagnoses of ODD.

Social communication difficulties play a large role in “defiant” behavior as well. A child with ASD or with a language delay may not have the expressive vocabulary needed to properly convey their feelings. Thus, hiding under a desk or trying to leave the room may be the best way a child knows how to say “I don’t understand what you’re asking me to do” or “I need to take a break.”  For example, I recently evaluated a child who repeatedly said, “No blocks!” when I presented him with a task.  On the surface, this phrase sounds oppositional, but given his very limited expressive language level (primarily consisted of requests and refusals), he was unable to explain what he needed (e.g., adults decreasing their level of language; a movement break) or what he was feeling (e.g., overwhelmed; distracted).

So, while we often may find ourselves asking, “Why isn’t this child following directions?” it is best to consider what the child’s needs are in that moment.  A child’s behavior is an attempt to communicate something, and we as the adults have the responsibility to uncover what our children are trying to say. The times when parents ask, “Why isn’t my child listening?” are crucial opportunities for attunement and co-regulation. Children feel just as frustrated as adults if their needs are unmet or if demands are too high. They may be asking the very same thing, “Why aren’t (the adults) listening to me?” Understanding a child’s behavior from this perspective, and learning how to meet them where they are at developmentally, can help caregivers and providers to respond in an appropriate, strength-based manner that promotes a child’s development.

Let’s all continue to be investigators and strive to understand children’s internal experiences and developmental differences to promote their development!