Collaboration is the key to growth: How to facilitate the school-home-therapeutic relationship. By Jaime Marrus, PhD

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.

“Why Doesn’t My Child Follow the Rules?” by Jennifer Andersen, PsyD

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!

Parenting Practices: Back to School: How to Support Our Kids

By Dr. Jaime Marrus

I thought it would only be appropriate for this month’s installment of the Parenting Practices series to highlight strategies to support our kids as they transition to a new school year.  The end of summer brings about many feelings in all of us.   Especially during the last few weeks of August, I personally start to feel a push-pull sense of ambivalence… The measured excitement of waiting for some new things (e.g., schedule) to begin, combined with the longing for continued summer vacation and relaxing vibes.

It is natural for children to feel similarly, with the potential added stress (depending on how your child responds to transitions) of thinking about new teachers, new routines, new classmates, new classrooms, and maybe even a new school.  They may worry about having friends in their class, getting a lot of homework, higher expectations of a new grade, and whether or not their teacher will feel like a good fit for them. 

Below is a list of ways to support children through the August to September (and October…) transition, with ideas for both informal and formal supports.

1. Establish a healthy routine prior to the first day/week of school.

This may seem tough because we all want to squeeze the last bit of summer out of August by staying out all day in the nice weather, seeing family and friends more often than you might be able to during the school year, and naturally, letting our children stay up later and wake up whenever they want.  It is important to begin reestablishing routines at least one week before the start of school.  This includes regular bedtimes and wake-ups (that are as close to a “school year” routines as possible), healthy meals, and likely more limited screen time than is the case during the summer.

2. Attune to and validate your child’s emotions.

As discussed above, emotions may run high in anticipation of the transition from summer to school.  Let your child know that however he/she feels is “okay.”  Some validating statements include:  “I understand you are a little nervous about meeting your new teacher.”  “I remember feeling worried about the beginning of the year, too.” “I know you’re wondering which of your friends will be in your class again this year.”

3. Prepare for and review the logistics.

Some children may feel stressed about the transition because it is difficult for them to picture or get a sense of what the changes may be like.  If your child is going to a new school, it is often helpful (if possible) to take your child on a tour before the first day.  Sometimes teachers may even be open to saying a quick “hello” if they are available- reach out to them!  If getting inside the school is not possible, even driving by and walking around the outside can go a long way in easing your child’s nerves.  Show him/her where he will arrive (and how- by bus? Will you be dropping off?) and where he/she can expect to go at the end of the day.  You can also check out the school’s website for pictures and information.  For some children, creating a social story (to be read on their own, and/or with you) including short sentences and visuals about the new routine is very helpful.   It’s fun to include pictures of the child outside the school building or with his/her backpack and school supplies.  You can also include a “countdown calendar” to the first day, and cross of each day that goes by. 

4. Do your best to ensure carryover from one provider or therapist to the next (if applicable).

If your child will be transitioning between therapists, think about reaching out to your child’s previous provider (e.g., speech therapist, occupational therapist, etc.) to ask if they can think of two or three “tips” to pass on to the next therapist about working with your child.  (This is also an idea to keep in your back pocket and ask for prior to the end of the school year next June).

5. Reach out to teachers and providers regarding your child’s IEP.

For children receiving supports at school via their IEP, it is a good idea to call and/or send an e-mail to the teachers and support staff to ensure your child’s services will be provided as mandated.  Do not hesitate to follow-up on this throughout the first few weeks of school.  It is very helpful to let your child’s team know that you are interested in connecting and collaborating with them.

Best wishes to you and your children for a smooth and successful start to the new school year!

Parenting Practices: Validating Feelings

By: Dr. Jaime Marrus

Welcome back to the Parenting Practices blog series on Supporting Children’s Emotional Development! We hope you found last month’s tips helpful (https://drtobingpuente.com/2019/04/15/supporting-childrens-emotional-development-starts-with-accepting-their-feelings/) and have gotten a chance to take notice and practice “accepting” your child’s feelings.

This month’s focus is on validation.

All people seek validation from others in a number of ways.  We may wear an outfit that we know our partner loves in hopes of a compliment or a loving gaze. At work, we often want to ensure that the boss knows of our particular contributions to a project and enjoy receiving accolades. Children may seek validation through obtaining “good grades” and being praised for them, or telling their friends about a really cool new toy they have.  What is often missed by parents, however, is the idea of validating our children’s feelings (rather than “good” behaviors or concrete results).

For some perspective, think about a time you may have felt upset or scared and shared those feelings with someone close to you (a friend, partner, colleague, etc.), and may have received one of the following possible responses:

  • You: I’ve been having this same argument with my husband for a week… I am so upset, I don’t know what to do!
  • Response 1: Maybe you can try a different approach with him?
  • Response 2: That is frustrating. I would be upset too.
  • You: I am just so nervous about this deadline at work.
  • Response 1: Oh, don’t worry about it! I’m sure it will be fine!
  • Response 2: Yeah, deadlines are nerve-racking, that’s tough.

While there may not necessarily be anything “wrong” with Response 1 in both examples, you may have noticed that Response 2, although not providing you with any solution or reassurance, just feels better; it feels like you were being heard.  That feeling is a feeling of validation.  It’s that person communicating: “You have a right to feel that way. If it happened to me, I probably would feel the same way.”  For some of you, you may have felt like Response 1 felt INvalidating.

We want to do this same thing with our children. We want to accept their feelings and then send the message conveying, “Hey that’s ok to feel that way, I get it!”  This is important for overall emotional development and mental health.  Acknowledgement of children’s feelings is an important step in supporting them to move through the feeling in order to work towards a solution to whatever may be causing it.  Children will feel worthy and dignified in their experiences, which leads to positive outcomes such as healthy self-esteem and self-efficacy skills.

As I continued to comb through my bookshelf this month, I came across this example from Dr. Daniel Siegel’s and Mary Hartzell’s Parenting from the Inside Out:

A child comes in from playing outside and excitedly shows his mother some beetles he has collected in an open jar.  He says, “Look, Mommy, look what I found, aren’t they pretty?” All the mother sees is the possibility of bugs getting loose in the house and responds, “Get those out of here right now…”  Although at first consideration, this example does not even have to do with emotions and feelings, it is important to see how the child’s emotional experience was missed by the mother.  He likely felt quite excited and “good” about his discovery, and clearly wanted to share it with his mother.  Instead, the mother communicated a message more likely to be associated with “wrongdoing,” thus missing the meaningful emotional connection that could have given value to this experience.

So, we want to validate our children’s experiences, as well as their emotions.  In this way, we send a message of acknowledgement, acceptance, and understanding.  Validation can take many forms, including reflection, normalization, empathic responses (i.e., “I’ve had that happen to me too.”).  Below are examples of some validating parent responses:

  • Child: This homework is so hard! I hate my teacher for giving this to us.
  • Parent: Hmm, yes, it is tough to get through it tonight.
  • Child: My friend was so mean at recess today.
  • Parent: It sounds like you’re still upset about it, I’m sorry that happened.

Try to start thinking about the language you use to respond to your child when he/she is expressing an experience or a feeling.

Stay tuned for the next post in the Parenting Practices series!

Reference:

Siegel, D. J. & Hartzell, M. (2003) Parenting From the Inside Out. New York, NY: Penguin Group (USA) Inc:


Supporting Children’s Emotional Development… Starts With Accepting Their Feelings

By Dr. Jaime Marrus

Recently, many parents that I work with (either independently or in conjunction with working with their children), have asked me for “parenting strategies.” My first instinct is to reassure them: “You are wonderful parents!” (as this undoubtedly applies to the families with whom I currently work). First and foremost, my goal is to empower them to feel confident in their own techniques and relationships with their children. They often smile and look a bit embarrassed, and say something like, “Well, thank you, but… maybe there are strategies to help me be better.” I am so touched to be in a position in which parents turn to me (not yet a parent myself) in these moments to glean information and suggestions to promote more effective interactions in their own homes.

So, I have taken some time to reflect on more concrete “strategies” and conceptualizations to impart upon parents, and began combing through my dusty bookshelf that I should remember to consult with more regularly.

While there are a seemingly infinite number of wonderful resources that I could “assign” parents to read, I view it as my job to scour these resources myself in order to share the “take home (literally) points” with clients– “THP’s,” as an old professor of mine called them.

In the rest of this post and those that follow in the coming months in this Parenting Practices series, I will provide you with some bullet-point strategies to consider and practice in your own home. You can find resources at the end for further reading.

This month’s strategy: Accept your children’s feelings!

Ideally, everyone (including and especially children) wants their feelings to be recognized and heard.  However, as a parent you may find yourself, now that you think about it, “denying” your child’s feelings from time to time.  The renowned book, How To Talk So Kids Will Listen & Listen So Kids Will Talk, include some great examples.  The authors, Faber and Mazlish discuss how natural it is for us to respond to something as straightforward as “Mom, I’m hot, I want to take off my sweater.” with “It’s cold in here, keep it on.” The same tendency is often true for emotional expressions.  For example, “I hate the new baby!” is likely (and even understandably) met with “No, you don’t! Don’t say such a thing, that’s not nice, you don’t mean it.”  But, let’s think about what we are really communicating here with such responses. The broader message that is likely unintentionally communicated may be a denial of the possibility that children just may have different feelings from us, the adults. So, the first step to accepting our children’s feelings is to accept them as they are- and that they may be (or are even likely to be) different from our own.


To practice this technique, take some time to consider how you can respond to your child in an accepting way in the following scenarios (as you may encounter them in the not-so-distant future). I included examples of some accepting parent responses:

1.         Child: I hate school!  I am terrible at math.

           Parent: Wow, you are feeling terribly about math and school right now.  I wonder why.

2.         Child: My big sister is the meanest in the whole world!

            Parent: Wow, she is so mean?  What happened?

3.         Child: (crying, tantruming) I don’t want to leave the playground!

            Parent: Yes, I know how hard it is to leave the (slide, swings, friends, etc).

Take some time to recognize opportunities to accept your child’s feelings, rather than (likely accidentally) deny them. This is a great first step in attuning to your child and setting yourself up for additional techniques to build emotional connections and understanding in your child.

Stay tuned for next month’s post in the Parenting Practices series on validation

References:

Faber, A. & Mazlish, E. (2012) How To Talk So Kids Will Listen & Listen So Kids Will Talk. New York, NY: Scribner


Free Parent Workshop: Transitioning to Kindergarten 4/10/2019

We are pleased to announce that Dr. Lauren and Dr. Jaime will be presenting their annual FREE parent workshop on Ensuring a Successful Transition to Kindergarten on April 10, 2019. Please forward to any parents of children of children with special needs who are navigating the “Turning Five” process and preparing for kindergarten starting September 2019. RSVP to: jmarrus@drtobingpuente.com

Signs of Love: A closer look

I recently came upon a posting from a joyous new mother citing an article on “signs your babies love you.”  I soon found that many websites that cater to new parents have articles listing the ways parents can determine that their babies love them.  I was appalled.

First, the title of such articles is not accurate.  The “signs” that these articles list are not indications of “love,” but actually signs of appropriate social-emotional development (in Western culture).  Of course, “signs of love” is a much catchier title than “developmental milestones,” but the distinction is a very important one to make.  The following are some examples of behaviors included in these articles:

  • Eye contact
  • Smiling at you
  • Noticing when you enter a room; showing an eagerness for your attention
  • Coos at you
  • Reaches his/her arms at you to signal that he/she wants to be picked up
  • Showing distress when you leave

These behaviors should most certainly be celebrated; not as signs of “love,” but rather as signs that the baby is developing fundamental developmental capacities, such as the capacity to share attention and relate and engage with their caregivers.  These foundation skills are essential in developing self-regulation, socialization, emotional processing, play skills, and many, many other developmental milestones.

Second, and more disconcerting to me is the impact of such articles on parents of babies who may not be showing these signs. There are many parents whose children with special needs do not display these signs, but under no circumstance does that mean these children do not love their parents, or that this should be questioned by the parents themselves or anyone else. It is important for parents of children with neurodevelopmental differences in relating and communicating to know that just because their children do not look at them or engage with them as expected, they still do love them. These parents and children may need the support of professionals who are specifically trained in helping parents and children attune to one another.  Stanley Greenspan, MD’s DIR (Developmental Individual Differences Relationship-based) model and related Floortime approach1 specifically addresses this. Such support may include identifying and developing expressions of love in unique and wonderful ways.

Third, and probably most alarming to me is the impact of such articles on the babies themselves.  Imagine a child who is born with developmental differences.  Maybe he has difficulties coordinating his eye gaze because his visual system is not well-integrated with other sensory systems, which impacts his ability to make eye contact.  Maybe her sensory system is overloaded and cannot process a combination of stimuli in loud and busy environments.  Maybe he doesn’t register that his parent entered the room because his auditory system has trouble quieting and ignoring the extraneous buzz and brightness of the fluorescent lights.  Maybe she needs so much swaddling and rocking to feel regulated that she has not yet mastered (or have time to master) attending to her mother’s face.  How sad for such babies that their developmental differences may be misinterpreted as a lack of love or affection for their parents.

The last thing children who are born with developmental challenges need are caregivers who think that they do not love them.  From my experience working with autistic self-advocates, they are glad to express and explain their unwavering love for their parents, even though they may never had made eye contact with them when they were babies or displayed other signs listed in the aforementioned articles.

Thinking again about the parents, giving them the false idea that their babies do not love them is far more likely to dishearten, sadden, worry, and possibly depress parents, rather than spur them to reach out for support, ask questions of their pediatrician, or initiate a developmental screening.  Thinking or feeling that your baby does not love you is likely to be embarrassing, which may even be an impediment to seeking help.  Further, I shudder while wondering if such parents may subconsciously change their behavior toward their babies if they do not think their babies love them, rather than understanding that they may need support in developing these social-emotional behaviors.

I am thrilled with the anecdotes often shared by parents of children with autism spectrum disorders (ASD) and other neurodevelopmental challenges who have learned to attune to their children and develop more robust relationships with them.  I have heard numerous accounts of how those parents recognize the, often unconventional, signs that their children love them:

  • “He (five year old) never used to look at me, but when I swing him around fast the way he likes me to, he looks right at me.”
  • “She (three year old) presses her chin into my knees, which prompts me to squeeze her tightly.  That’s when I know she is with me.”
  • “The more I join in with his (10 year old’s) interests, the closer he stays to me, and the more he wants to be around me.”

These expressions of love are reflections of the beauty of parent-child relationships among those with a range of developmental differences, and are worthy of celebration.  Lets remind ourselves that the signs most commonly listed in the general media should be celebrated as signs of social-emotional milestones in Western culture.  Suggesting that they are signs of love can be dangerous to those with developmental differences or special needs and their families.

 

1 For information on DIR/Floortime, see:  Greenspan, S. & Wieder, S. (1997). The Child with Special Needs. Perseus Books, and http://www.icdl.com.