Understanding Your Child’s Behavior: Reading Your Child’s Cues from Birth to Age Two

The Center on the Social and Emotional Foundations for Early Learning (CSEFEL) has released a new resource to help parents better understand their children’s behavior cues and respond in ways that support healthy social and communication development. Understanding Your Child’s Behavior: Reading Your Child’s Cues from Birth to Age Two is available online at http://csefel.vanderbilt.edu/documents/reading_cues.pdf

Diagnosis and Treatment

Apraxia: Speech Therapy in Toddlers and Young Children by Sharon Gretz, M.Ed. Apraxia: Speech Therapy and Treatment for Toddlers and Young Children By Sharon Gretz, M.Ed. (Note: Members of the Childhood Apraxia of Speech Association Professional Advisory Board have reviewed this article.) Introduction There is great concern among speech-language pathologists and others regarding the overdiagnosis or misdiagnosis of childhood apraxia of speech (CAS). Specifically, it is questioned as to whether children under age 3 should be given the diagnosis of apraxia of speech and if so when.Once the diagnosis is either made or suspected, the question of how to treat such a young child arises. It is recognized that many children who go on to be diagnosed with CAS will have additional speech and language therapy goals in addition to those targeting speech production. The purpose of this article is twofold: to communicate initial diagnostic procedures for identifying young children who may have CAS and to discuss speech therapy techniques that may benefit the speech production and expressive language skills of young children suspected to have CAS. Diagnostic indicators Strand (2003) argues that there are five key potential diagnostic characteristics of apraxia in young children. The five characteristics identified by Strand are: Difficulty in achieving and maintaining articulatory configurations Presence of vowel distortions Limited consonant and vowel repertoire Use of simple syllable shapes Difficulty completing a movement gesture for a phoneme easily produced in a simple context but not in a longer one (Strand, 2003, p. 77) The complexity of diagnosis in young children under age 3, according to Strand, is that the child must be able to participate sufficiently in the assessment. Unless the child can attempt to imitate utterances that vary in length and/or phonetic complexity (such as imitating /i/, then /mi/, then /mit/ or /o/, then /no/ then /nope/), it is very difficult to make a definitive diagnosis (Strand, 2003, p. 78). If a child is not able to participate with verbal attempts in this way, it is possible that the presence of certain characteristics can trigger a close watch of the child over the upcoming months. Characteristics such as restricted sound inventories and especially distorted vowels or a single centralized vowel sound might be indicative of motor planning and motor programming difficulties. Motor planning treatment principles such as those used for a child diagnosed with apraxia of speech can be instituted early, based on the presence of such symptoms. Others advocate a long-term history with a child suspected to have CAS prior to such a label being applied. Davis and Velleman write that, clinicians should have at least a 6-12 month therapy history for an infant or toddler before a DAS label is appropriately applied. (Davis and Velleman, 2000). The characteristics which Davis and Velleman feel are most descriptive of CAS in very young children include: Restrictions and gaps in sound repertoire (both consonant and vowel), including the possibility that the child may have acquired some later developing sounds while be missing earlier developing sounds. These children may demonstrate very limited use of syllables, possible use of an extended single sound or few vocalizations at all. The children may have difficulty combining the sounds that they do have. Limited variation of vowels and the use of a centralized vowel in a multipurpose way. Vocalizations may have speech-like melody but syllables or discernable words may not be present. Words may seem to disappear from use more than would be expected for a typically developing child of the same age. Predictable utterances may be easier than novel utterances (Davis and Velleman, 2000, p.182) Additional nonspeech characteristics identified by Davis and Velleman that possibly combine to indicate apraxia of speech in the young child include: homemade gestures or signs, some feeding difficulties such as eating mixed textures, drooling, late development of motor skills overall, and oral motor incoordination. (Davis and Velleman, 2000). Speech Therapy and the young child with possible apraxia There is very little literature about treatment for apraxia or diagnostic intervention for very young children with apraxia of speech. Davis and Velleman (2000), however, have described the overarching need to initially establish two primary goals when working with young children suspected to have apraxia of speech. First, the child needs to establish a consistent form of communication and secondly the child needs to develop and consistently use oral communication. The authors encourage making communication the top priority. Clinicians should watch for attempts to communicate appropriately and respond to any appropriate mode of communication.This strategy includes responding to gestures and other attempts. Communication attempts should not be ignored with the rationale that the child is willfully refusing to talk.Davis and Velleman, also offer that, One message the child should receive (although not to the extent that it interferes with communication exchanges) is that communication is conventional. Unless there is agreement on which gesture, sound or picture will represent which meaning, communication will not be successful. (Davis and Velleman, 2000) So, for example, a child can use gestures or sign that are not correct if they use the same gesture for the same meaning consistently. Setting Expectations: Parents as Collaborators From the very first meeting, clinicians need to involve parents in therapy opportunities for children with apraxia; to the greatest extent they are able and willing. Parents are able to share important information from the home and community environments. Parents are important informants on the likes, dislikes, and personality characteristics of their children. Additionally, because many repetitions of speech movement patterns are necessary for motor learning to occur, parents are valuable speech practice partners for their children in their everyday life experiences together. (Stoeckel, 2001) Hammer and Stoeckel listed the following responsibilities for the speech-language pathologist in working with parents of children with apraxia of speech: Educate parents re: CAS and intervention Educate parents re: networking/support availability Teach child needed skills in a flexible, productive manner Assure high expectations from the child Be able to explain goals and changes in therapy strategies Assure periodic observations either on-line or via videotape Work with parents to motivate and reinforce childs learning (Hammer and Stoeckel, 2001) Setting Expectations: Children as Risk-takers While in typically developing children, early sound play and communication attempts bring a great deal of fun and excitement, by the time a young child with suspected apraxia of speech arrives in speech therapy treatment, he or she may already have experienced a great deal of failure in efforts to communicate orally. Additionally, families may also feel somewhat like failures in helping their child to communicate. (Hammer, 2003).Clinicians can help by crafting very carefully planned small steps toward success in the earliest phase of therapy.Additionally, it is important for SLPs to set early boundaries and expectations around communication exchanges as well as teach these skills to parents if necessary. For most of us, and especially for children with severe speech production disorders, risk taking requires trusting that the situation or person to whom we are communicating is safe and predictable. It also generally requires that the effort be worth the risk. If these conditions are met most children will attempt to use what speech or communication they have to interact. The major issue, however, is how to create this environment? One proposition is the creation of boundaries. Boundaries, in this context, refer to the physical, mental, and emotional conditions that surround the child and are based upon realistic expectations for performance. Hayden, 2002 Children with apraxia of speech need to feel as if they can trust in the therapeutic process and have success. Reasonable expectations, based on the capability of the childs speech motor system, need to be implemented and reinforced so that the child also uses what they can produce orally in communication exchanges. (Hayden, 2002) Oral Communication Goals Depending on the child, Velleman and Davis state that increasing vocalizations of any kind may be the place to start.Some suggestions they have that reduce communication pressure on the child are: Speech in conjunction with movement ("whee" while sliding down a slide, as example) Sound effects Verbal routines with songs, predictable books, rhymes, etc. Speech in unison with another person Props such as puppets, little people, stuffed animals, etc. (Davis and Velleman, 2000) Velleman adds additional ideas of where to start with very young children: Words with distinctive pitch patterns (e.g.: uh-oh, wow, whee, yay) Words with strong emotional meaning Words that can be paired with actions (e.g.: whee, hi, oops, Words with very early consonants (e.g.: [h], glides) and simple syllable shapes (e.g.: hi, uh-oh, wow, whee, yay) Sound effects: animal noises, vehicle sounds, etc. (Velleman, 2002, page 66) Also, sounds that may be in the childs current repertoire can be used to expand oral communication: words beginning with a sound in the repertoire that also have functional meanings such as "more" "mine" if the child can make an /m/ are examples. Expanding Sounds and Syllables Velleman and Davis (2000) discuss adding two goals when a child has begun to consistently use vocalization to communicate: Expansion of sounds Expansion of syllable structures They further suggest, in the beginning, that the use of the sounds and structures is more important than accuracy. Suggestions for expansion of sounds: Expand to include more diverse consonant and vowel sounds produced in different parts of the mouth Sounds with varied pitch and loudness levels Short and long utterances Suggestions for expanding structures: Syllables rather than individual phonemes should be the focus Be systematic with teaching sounds and syllables in word structures. (as an example; Davis and Velleman recommend, "New word shapes, e.g., CVC "bag" when a child produces mostly CV words such as 'moo', the clinician should include ONLY sounds that the child can already produce, in some word position" (Davis and Velleman, 2000, p. 185) This strategy is described as the, "Old forms, new function - old functions, new forms" rule. Goals should target EITHER new structure or a new sound, not both at the same time. Speech Movement Goals and Training The above goals will improve the child's need for communication, but do not yet address the underlying nature of the problem of apraxia in children - which is speech in motion or the ability to plan accurate, well timed speech movements sound to sound, syllable to syllable, in order to produce old and new words. Clinicians need to keep in mind therapy opportunities that allow young children to build flexibility and reliability into their motor systems. Activities that use the same syllable but with a change at the end can help, according to Davis and Velleman (2000). The recommended strategy for practice is to first work on the same syllable repeated, (e.g.: ma ma ma ma). Next, introduce one change at the end of the repeated syllables, e.g.: ma ma ma moo or moo moo moo do. Alternating the syllables takes the activity one step further, i.e.: ma, moo, ma, moo or moo, do, moo, do, moo. As competence is built with these activities the most complex practice with syllables moves further so that the child produces varied syllables/sounds: ma, moo, may, my, mow. (Davis and Velleman, 2000) Further, in young children the approach will need to be fun, silly, engaging in order to elicit the childs attention, involvement and effort. In clinical practice, it is suggested that SLPs incorporate principles of motor learning: the need for many repetitions and practice, distributed vs. massed practice opportunities, appropriate use of feedback to the child to enhance motor learning etc. Even toddlers can be involved in therapy opportunities maximizing conditions for motor learning but adapted to their needs as very young children. (Strand and Skinder, 1999; Davis and Velleman, 2000) Ideas for gaining multiple repetitions, presented by Velleman and Davis, for children who are in the toddler age range include: Use of counting books but instead of counting the objects on a page, simply point to the object and repeat its "name" each time it appears on the page. For example, a counting book of animals has 4 dogs on the page for the number 4. Instead of counting "1, 2, 3, 4", you can guide the child to point to each dog and say "pup, pup, pup, pup" or depending on their skill, "doggie, doggie, doggie, doggie". While playing "house" and setting the table, each time a cup is put down saying "cup, cup, cup". Pretending to eat: "yum, yum, yum" (Davis and Velleman, 2000, p. 187) Core vocabulary books are another way to elicit practice from the child and can also incorporate parents or other communication partners. According to Hammer, The photos should consistof meaningful people, toys, and objects in the child's life as well as words that contain initially targeted sound sequences. This book often serves as a child's first success at expansion of functional communication interactions with significant others. (Hammer, Apraxia-kids website) Providing Motivation/Keeping the Childs Attention Play presents many opportunities for these repetitive sequences and parents and therapists can be creative in this way.The idea is to trick the child into practice by making their therapy experience not just fun but also successful for them.Even very young children with apraxia have gained the understanding that speech is difficult for them and may avoid or resist expressing themselves with oral communication. An astute, engaging clinician can use low-pressure opportunities and engaging play to help children with apraxia take risks with their speech attempts. (Hammer, 2003) Strand and Skinder offer the following ideas for providing motivation and keeping attention of young children with apraxia: Change positions after every 10 20 practice trials (stand up, sit backward, put hands on head, sit under the table, march, swing arms, etc) Change inflection (most helpful when child has some accuracy; place stress on different words, use low pitch, high pitch, exaggerate the target word or phrase) Use various dolls, puppets, animals that the child can speak for and change the selection after a number of practice trials. (Strand and Skinder, 1999, p. 128) Remember that while clinicians must make therapy fun and engaging, it is not sufficient to be able to say the child enjoyed the therapy session or that the session went well because the child cooperated. That alone will not effectively provide what the child needs, which is the opportunity for a high number of repetitions of speech targets and the clinicians thoughtful feedback about performance and results. Therapy for children with apraxia of all ages is designed to shape speech motor skill. If the child isnt saying much in the therapy session, the clinician is not going to be able to achieve this goal. (Strand and Skinder, 1999) Other "take home" points about speech therapy for toddlers with suspected apraxia of speech include: The idea that children with apraxia may not follow the typical "developmental" sequence for acquiring new sounds. (Hammer, 2003; Davis and Velleman, 2000) Children with apraxia of speech need some early success with speech. They need to know it is worth it to trust and cooperate with the clinician. (Hammer, 2003) Children with apraxia seem to have periods where sometimes they seem to 'plateau'. (Davis and Velleman, 2000) Play is the medium for these young children with apraxia to provide activity that builds in speech movement training. (Hammer, 2003) Parents need help and direct mentoring to understand their role and how they can effectively practice with the young child at home. (Hammer and Stoeckel, 2001) Break up sessions into several activities that have repetitive practice vs. one long activity (Davis and Velleman, 2000, Strand and Skinder 1999) Just as with older children with apraxia, younger children need feedback about their performance such as knowledge of results (did they get the word right) and more specific knowledge about performance (for example, "you need your lips out for that"). (Davis and Velleman, 2000; Hammer, 2003; Strand and Skinder 1999) Apraxia or Something Else? Once a period of therapy has commenced and the SLP has experience with a particular child suspected to have apraxia of speech, it may become clearer as to whether or not the childs primary difficulty is with speech motor planning and programming. Even if a child does not receive the apraxia diagnosis, the therapy recommendations outlined above may play a role in the treatment plan. Some have noted the possibility of a continuum of severity in childrens speech motor planning ability (McCauley, 2002). According to McCauley, A child's failure to respond to treatment methods in which the goal is to teach the child phonologic patterns (e.g., the Cycles Approach or minimal pairs) would also suggest the possibility that greater attention to motor factors in speech learning could prove beneficial. (McCauley, 2002). Conclusion In summary, while it is difficult to diagnose children with apraxia of speech at very young ages, it is still possible to provide speech therapy to them in a manner that meets the needs of children who may have a motor-planning component to their speech production difficulties. In early phases, attention to increasing overall communication and oral communication in particular, expanding sounds and syllable shapes, gaining multiple repetitions of syllables and words for speech movement practice, functional communication, and solid parent involvement can assist young children suspected to have apraxia of speech. References Davis, B and Velleman, SL. Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers". The Transdisciplinary Journal. Volume 10, No. 3, pp. 177 - 192, 2000. Hammer, D.Apraxia of Speech in Young Children. Presented at the Childhood Apraxia of Speech Association/Hendrix Foundation workshop.Houston, Texas. February 2003 Hammer, D. Brief thoughts about therapy.Apraxia-Kids website. http://www.apraxia-kids.org/slps/hammer.html Accessed January 12, 2004. Hayden, D. "How do we help children with apraxia become 'risk-takers' with their speech and communication?" The Apraxia-Kids Monthly. Volume 3, Number 10. December 2002. Hammer, D and Stoeckel, R. Teaching and Talking Together: Building a Treatment Team. Presentation at the annual convention of the American Speech Language Hearing Association, New Orleans, Louisiana, November 2001. McCauley, R. "What if a child isnt formally diagnosed with Childhood Apraxia of Speech (CAS), but appears to be having motor planning difficulties similar to children who are? The Apraxia-Kids Monthly, Volume 3, Number 7. August/September2002. Stoeckel, R. Why is it important for parents of children with Childhood Apraxia of Speech (CAS) to be involved in their child's speech therapy? Apraxia-Kids Monthly, Vol.2; No. 9, November 2001. Strand, EA. Childhood apraxia of speech: suggested diagnostic markers for the young child. In Shriberg, LD and Campbell, TF (Eds) Proceedings of the 2002 childhood apraxia of speech research symposium. Carlsbad, CA: Hendrix Foundation. 2003. Strand, EA, and Skinder, A. Treatment of developmental apraxia of speech: integral stimulation methods. In Caruso, AJ and Strand, EA (Eds.), Clinical management of motor speech disorders in children. New York: Thieme. 1999. Velleman, S.L. Childhood Apraxia of Speech Resource Guide. Clifton Park, New York: Delmar Learning. 2003 Page Last Updated: January 23, 2006 © Apraxia-KIDSSM - a program of The Childhood Apraxia of Speech Association (CASANA) www.apraxia-kids.org Date: 2/24/2005 Date Last Modified: 12/20/2008 9:16:36 PM Date Created: 2/24/2005 3:12:45 PM

Parent as Collaborative Leaders

Parents as Collaborative Leaders

A FREE TRAINING FOR PARENTS OF
YOUNG CHILDREN WITH DISABILITIES OR SPECIAL NEEDS
Whether you consider yourself a “leader” or not, your experiences as a parent of a
child with special needs are unique and important. This training will provide you
with an opportunity to gain the knowledge and skills needed to become more
actively involved in issues concerning programs and services for young children with
disabilities.

Space is limited to 20 participants – Call today!
800-782-2094 t o l l f r e e
The details:
June 11-12th
12:00 noon on Friday, June 11th
through 4:00 pm on June 12th
Greenville, NC
All materials, lodging and meals will be provided
AT NO COST!
Mileage will be reimbursed.
Seating is limited!
Register by: May 28th
~ Funding for this program is provided through the NC Division of Public Health/ Early Intervention Branch ~
~

Temperament Characteristics: Low Reactors to Big Reactors

Temperament Characteristics:
From Low Reactors to Big Reactors

Low Reactors are children who seem less demanding than others. Low Reactors tend to:

• be quiet and rarely fuss;
  
  
• sleep more than average;
  
  
• show their emotions with only slight changes in facial expression, tone of voice, or body posture; and
  
  
• tolerate a lot of stimulation.
  

The fact that these children are less demanding, however, doesn’t necessarily mean that they require less effort on the part of parents. On the contrary, you may have to work harder to attract and hold their attention.

At the other end of the spectrum are Big Reactors who tell the world how they feel in a voice that’s loud and clear. Big Reactors tend to:

• express their feelings with great intensity (for example, showing supreme happiness by squealing with delight and maybe expressing anger by shouting, throwing things, hitting, and biting); and
  
  
• react to physical stimulation intensely (for example, perhaps being unable to tolerate itchy tag on a T-shirt, the wrinkle in a sock, or an unpleasant smell).
  

For many children, intensity isn’t an issue at all. Their reactions fall somewhere between Low and Big Reactors, and they tend to take things in stride. Their moods are fairly even. They smile when they’re happy and complain, in a reasonable way, when they’re not.

Thinking About Your Child
Here are some questions to think about when considering your own child's temperament:

• How does my child react to sensory stimulation (sights, sounds, textures, smells, and tastes)?
  
  
• How much stimulation can my child handle? Does he react to the slightest bit of stimulation, does it take a lot to get him to respond, or are his reactions somewhere in between?
  
  
• Does my child express her feelings with high, moderate, or low intensity?
  
  
• How often do I find myself helping my child calm down?
  
  
• Is he a cuddly child or does he prefer protecting his physical space? What kinds of touch does he prefer or dislike? Does he react positively or negatively to specific clothing materials/fabrics, clothing tags, wrinkles in his socks?
  
  
• Is he a picky eater or will he eat anything? Will he only eat foods with certain textures or tastes? Does he seem sensitive to certain odors?
  
  
• What kinds of sounds does your child like? Is there particular music or tone of voice he prefers? Does he get easily distracted by, and perhaps startle or cry at sudden noises? Does he respond when you talk with him by making eye contact and vocalizing back?
  
  
• What does your child like to look at? Does he enjoy looking at lights, or do bright lights seem to upset him? Does he make eye contact when you are playing together?
  
  

Parenting Strategies for Low Reactors

• Tune things up to attract her attention. Watch your child’s reactions to make sure she in engaged but not overexcited. Choose music with a dynamic beat. Engage your child in safe, rough-and-tumble play. Use a dramatic voice while reading. Be silly and creative.
  
  
• Create interactive games. Try activities that involve taking turns so your child remains engaged, such as rolling a ball or passing a rattle back-and-forth.
  
  
• Get her body moving. Low-intensity children may be more responsive if they’re physically engaged.
  
  
• Find out what interests him. If your child sings, join in for a duet. If he dances, become his partner.
  
  
  

Parenting Strategies for Big Reactors

• Tune things down. Music and lighting should be soft. Clothing should also be soft. And play should be fun, but not overstimulating.
  
  
• Offer physical comfort when your child is distressed. Hold her close, massage her back, rock her.
  
  
• Show that you understand him by validating his feelings. For example, use expressions such as I know it’s hard for you to be in crowded, noisy places. Or, I know your feelings get so-o-o hurt.
  
  
• Help your child problem-solve. Say: Tyler’s birthday is probably going to be very noisy and crowded today. What can we do to make it more comfortable for you?
  
  
• Don’t punish your child for who she is. Your child is not overreacting. Holding her close and validating her feelings can help your child calm down and feel safe and secure. When you have strong reactions, it is tough to learn how to manage them. But with your support, your child will learn good coping skills.

Temperament Characteristics: Activity Level

A child’s temperament describes the way that she approaches and reacts to the world. It is her personal "style." Temperament influences a child’s behavior and the way she interacts with others.

When we understand our child’s temperament, we can begin to anticipate what situations may be easy or more difficult for her. We can nurture her strengths and help her learn to cope with challenges. And we can change how we parent based on our child’s temperament—for example, some children just need “the look” to stop an off-limits behavior, while other children may need more help from us to shift to another, more appropriate activity. Understanding temperament is one important way of nurturing a strong parent-child bond.

We are going to be running a series on Temperament. The first in the series is the Active child!!! Enjoy !!



Some children are not action-oriented—they tend to be "sitters." They are happy to sit and play quietly. They prefer to:

• take the world in by looking or listening; and
  
  
• prefer exploring with their hands (using their fine motor skills) instead of their large muscles (arms and legs).
  

They can often focus their attention for long periods, working on a problem such as how to get the puzzle piece to fit or how to make the clown pop up. Their interest in the things around them can be every bit as intense as an active baby, but they don’t feel the same need to be up and about.

Other children are movers and shakers. Even as babies, they are quick to roll over, squirm, and crawl. They like to reach out, grab, and bat at the dangling toys hanging from their mobile. They often develop into toddlers who are always on the go, exploring the world around them by crawling, running, and climbing. These movers and shakers:

• love spaces that offer lots of opportunity for movement;
  
  
• often need a lot of supervision;
  
  
• are likely to keep moving until they drop; and
  
  
• tend to reach out for and touch anything they can get their hands on.

Their activity level doesn't mean there is a problem; it’s just how they prefer to interact, explore, and learn. Their parents may be exhausted, but they definitely stay in shape!

Most kids fall somewhere in the middle. They enjoy running, climbing, and jumping, but they are also happy sitting with a puzzle or a book. They move easily from a quiet activity to a more active one.

Parenting Strategies for a Less Active Child

• Respect his pace and style. Offer your child lots of opportunities to play with the things that he enjoys—for example, books, dress-up clothes, puzzles, building blocks, toy figures, etc. (And remember, you still need to baby-proof the house, even if he is not moving around a lot!)
  
  
• Add movement to things she already enjoys. Entice your child to move by holding a favorite toy a little beyond her easy reach or by starting to play with an interesting toy a little beyond where she can easily move.
  
  
• Let your child look before he leaps. If your child prefers watching kids on the climbing gym, let him watch. Then suggest trying something together—like going down the slide on your lap. But always remember to follow your child’s lead, and take it slowly.
  
  
• Play hide-and-seek. When one of you is “found,” entice your child into a chasing game.
  
  
• Listen to music together. It’s easy to shift from listening to dancing if the music moves you!
  
  
• Remember, there’s nothing wrong with being a “sitter.” As long as your child gets the exercise he needs and can enjoy a range of activities, then he can be happy and healthy.
  

Parenting Strategies for an Active Child

• Offer lots of opportunities for safe, active exploration. Baby-proof your entire home. (Of course, you need to baby-proof no matter your child’s activity level!) Create obstacle courses with pillows on the floor. Play hide-and-seek, freeze tag, and other active games.
  
  
• Don’t expect your child to lie or sit still for long. Let her stand for a diaper change, give her permission to leave the high chair as soon as she is done eating, and allow her to turn the pages or act out the story when you read a book.
  
  
• Engage your child’s help with everyday activities. Ask him to carry spoons to the table, help pick up leaves, and put all of the clean socks in a pile.
  
  
• Recognize that your child will need extra time to wind down. Start limiting active play at least an hour before bedtime and perhaps 30 minutes before naptime to help her slow down.
  
  
• Remember, active children aren’t wild or out of control. They just need to move.

Potty Training Resistance

While most children show signs of physical readiness to begin using the toilet as toddlers, usually between 18 months and 3 years of age, not all children have the intellectual and/or psychological readiness to be potty trained at this age. Signs of physical readiness can include your being able to tell when your child is about to urinate or have a bowel movement by his facial expressions, posture or by what he says, staying dry for at least 2 hours at a time, and having regular bowel movements. Signs of intellectual and psychological readiness include being able to follow simple instructions and being cooperative, being uncomfortable with dirty diapers and wanting them to be changed, recognizing when he has a full bladder or needs to have a bowel movement, being able to tell you when he needs to urinate or have a bowel movement, asking to use the potty chair, or asking to wear regular underwear. Things to avoid when toilet training your child, and help prevent resistance, are beginning during a stressful time or period of change in the family (moving, new baby, etc.), pushing your child too fast, and punishing mistakes (treat accidents and mistakes lightly). Be sure to go at your child's pace and show strong encouragement and praise when he is successful. Even after he begins to use the potty, it is normal to have accidents and for him to regress or relapse at times and refuse to use the potty. The process of being fully potty trained, with your child recognizing when he has to go to the potty, physically goes to the bathroom and pulls down his pants, urinates or has a bowel movement in the potty, and dresses himself, can take time, often up to three to six months for most children. Having accidents or occasionally refusing to use the potty is normal and not considered resistance. While it is recommended that you don't insist that he sits on the potty and you should be prepared to delay training if he shows resistance, at some point if his resistance to using the potty persists, especially after he is 3 -3 1/2 years old, then you should consider him resistant to potty training and you will need to change your methods. Early on in the training, especially if your child is less than 3 - 3 1/2 years old, resistance should be treated by just discontinuing training for a few weeks or a month and then trying again. At this age (18 months to 3 years), resistance is usually because your child just isn't ready to begin training. Potty training resistance usually occurs because your child has had a bad experience at some point during potty training, especially if he was started before he was intellectually or psycholgoically ready. Other times, especially with strong willed or stubborn children, it may have nothing to do with your technique or timing, and you may have done nothing wrong. Reasons for developing a resistance to potty training can include: being scared to sit on the potty chair flushing the toilet may have scared him from wanting to sit on the toilet being pushed too early or fast before he was ready severe punishment for not using the potty or being forced to sit on the potty inconsistant training, especially among different caregivers he may have had a painful bowel movement from being constipated. If this is the case, treat his constipation and wait until he is having regular, soft bowel movements before you begin training again. or he may just be stubborn and is involved in a power struggle with his parents and is using his control over where he has a bowel movement he may enjoy the negative attention he gets from not using the potty or from having accidents although rare, there are medical conditions that can make it difficult for your child to hold in or delay urinating or having a bowel movement. Discuss with your Pediatrician if there are any medical reasons why you may be having a hard time teaching your child to use potty, especially if he seems to have other delays in his development. At this point, if your child is totally resistant to being potty trained, then it is best to just make him responsible for when he wants to use the toilet. This includes not punishing him for mistakes and not reminding him to use the potty. If he seems fearful, you can try and discuss calmly what it is about using the potty that scares him. While you may get a lot of negative feedback from friends or family members about not being more aggressive with getting your child potty trained, you should be firm and let them know that you are working on it and remind them that not all children potty train at the same time. In addition, it can be helpful if you: establish a reward or incentive for using the potty. This should include lots of praise and attention when he uses the potty. It can also include a star or reward chart on which you child can place stickers whenever he uses the potty. After a certain number of days that he has stickers, then he can get a reward, such as toy, etc. have your child be involved in changing himself when he wets or soils himself. This can include getting a new diaper, taking the dirty diaper off, cleaning himself (although he will probably need help after bowel movements), and throwing the dirty diaper away. At some point you can change him into regular underware. You can talk about it beforehand and maybe have a ceremony where he throws away the left over diapers or you may just decide not to buy any new ones. Now, when he does wet or soil himself, you can have him help to clean out his underware in the sink or bathtub. You may even have him put them in the washing machine and wait with you while they are getting washed and dried. He should then dress himself. This method is not for everyone, but is usually very effective. You can also have him clean up after himself if he wet or soiled the floor. Limit him to having BMs in the bathroom. This isn't always possible, but is easy if he always asks for a diaper just to have a bowel movement. Next, have him sit on the potty to have a bowel movement, even if he continues to wear his diaper. Then work on getting his diaper off by opening it and eventually taking it off. During this process, you should give lots of praise and rewards during each step. If he is having a hard time learning to use the potty, but isn't necessarily resistant to the idea, then developing a regular daily routine of sitting on the potty for five or ten minutes every few hours may be helpful. Most importantly, avoid physical punishment for not using the potty, even in an older child. It can be appropriate to verbally let him know that you disapprove of his not using the potty, but this should not get to the point of yelling, shaming or nagging.

Potty Training Resistance

While most children show signs of physical readiness to begin using the toilet as toddlers, usually between 18 months and 3 years of age, not all children have the intellectual and/or psychological readiness to be potty trained at this age. Signs of physical readiness can include your being able to tell when your child is about to urinate or have a bowel movement by his facial expressions, posture or by what he says, staying dry for at least 2 hours at a time, and having regular bowel movements. Signs of intellectual and psychological readiness include being able to follow simple instructions and being cooperative, being uncomfortable with dirty diapers and wanting them to be changed, recognizing when he has a full bladder or needs to have a bowel movement, being able to tell you when he needs to urinate or have a bowel movement, asking to use the potty chair, or asking to wear regular underwear. Things to avoid when toilet training your child, and help prevent resistance, are beginning during a stressful time or period of change in the family (moving, new baby, etc.), pushing your child too fast, and punishing mistakes (treat accidents and mistakes lightly). Be sure to go at your child's pace and show strong encouragement and praise when he is successful. Even after he begins to use the potty, it is normal to have accidents and for him to regress or relapse at times and refuse to use the potty. The process of being fully potty trained, with your child recognizing when he has to go to the potty, physically goes to the bathroom and pulls down his pants, urinates or has a bowel movement in the potty, and dresses himself, can take time, often up to three to six months for most children. Having accidents or occasionally refusing to use the potty is normal and not considered resistance. While it is recommended that you don't insist that he sits on the potty and you should be prepared to delay training if he shows resistance, at some point if his resistance to using the potty persists, especially after he is 3 -3 1/2 years old, then you should consider him resistant to potty training and you will need to change your methods. Early on in the training, especially if your child is less than 3 - 3 1/2 years old, resistance should be treated by just discontinuing training for a few weeks or a month and then trying again. At this age (18 months to 3 years), resistance is usually because your child just isn't ready to begin training. Potty training resistance usually occurs because your child has had a bad experience at some point during potty training, especially if he was started before he was intellectually or psycholgoically ready. Other times, especially with strong willed or stubborn children, it may have nothing to do with your technique or timing, and you may have done nothing wrong. Reasons for developing a resistance to potty training can include: being scared to sit on the potty chair flushing the toilet may have scared him from wanting to sit on the toilet being pushed too early or fast before he was ready severe punishment for not using the potty or being forced to sit on the potty inconsistant training, especially among different caregivers he may have had a painful bowel movement from being constipated. If this is the case, treat his constipation and wait until he is having regular, soft bowel movements before you begin training again. or he may just be stubborn and is involved in a power struggle with his parents and is using his control over where he has a bowel movement he may enjoy the negative attention he gets from not using the potty or from having accidents although rare, there are medical conditions that can make it difficult for your child to hold in or delay urinating or having a bowel movement. Discuss with your Pediatrician if there are any medical reasons why you may be having a hard time teaching your child to use potty, especially if he seems to have other delays in his development. At this point, if your child is totally resistant to being potty trained, then it is best to just make him responsible for when he wants to use the toilet. This includes not punishing him for mistakes and not reminding him to use the potty. If he seems fearful, you can try and discuss calmly what it is about using the potty that scares him. While you may get a lot of negative feedback from friends or family members about not being more aggressive with getting your child potty trained, you should be firm and let them know that you are working on it and remind them that not all children potty train at the same time. In addition, it can be helpful if you: establish a reward or incentive for using the potty. This should include lots of praise and attention when he uses the potty. It can also include a star or reward chart on which you child can place stickers whenever he uses the potty. After a certain number of days that he has stickers, then he can get a reward, such as toy, etc. have your child be involved in changing himself when he wets or soils himself. This can include getting a new diaper, taking the dirty diaper off, cleaning himself (although he will probably need help after bowel movements), and throwing the dirty diaper away. At some point you can change him into regular underware. You can talk about it beforehand and maybe have a ceremony where he throws away the left over diapers or you may just decide not to buy any new ones. Now, when he does wet or soil himself, you can have him help to clean out his underware in the sink or bathtub. You may even have him put them in the washing machine and wait with you while they are getting washed and dried. He should then dress himself. This method is not for everyone, but is usually very effective. You can also have him clean up after himself if he wet or soiled the floor. Limit him to having BMs in the bathroom. This isn't always possible, but is easy if he always asks for a diaper just to have a bowel movement. Next, have him sit on the potty to have a bowel movement, even if he continues to wear his diaper. Then work on getting his diaper off by opening it and eventually taking it off. During this process, you should give lots of praise and rewards during each step. If he is having a hard time learning to use the potty, but isn't necessarily resistant to the idea, then developing a regular daily routine of sitting on the potty for five or ten minutes every few hours may be helpful. Most importantly, avoid physical punishment for not using the potty, even in an older child. It can be appropriate to verbally let him know that you disapprove of his not using the potty, but this should not get to the point of yelling, shaming or nagging.

Potty Training 2

Starting Potty Training II

by Belinda Chou, MD

OK! We're ready to start toilet training! By the time you've finished with the preparation (discussions, videos, books), purchasing the potty chair and underwear/pull-ups, most children will have started making some associations between peeing/pooping and the potty. For some it may be peeing in his/her diaper, announcing that she needs to pee and running to the potty after the fact. For others, it may be actual successes on the potty. And yet, for others it may be the mere recognition of peeing in his/her diaper. This is the time to start watching your child's body signals closely. Most children will have a tell tale stance, facial expression ("the look"), or routine (running to another room) when having a bowel movement. When you notice that your child is about to have a bowel movement (especially helpful if there is a particular time of day your child does it) this is the time to say "Shall we go sit on the potty?" If willing, take your child to the potty. Sometimes reading books will help your child relax while sitting on the potty. However, this may also end up being a "reading fest" so I would try to limit the book reading to only what's necessary. Additionally, some children may want "privacy" and helping them sit on the potty and then leaving (letting them know that when they are done they should let you know) may prove the most successful. Recognizing when your child is urinating is a bit harder. Some children, especially as they get older and are voiding less frequently, will stop momentarily to pee. Some will even squat. Frequently watching their fluid intake is more helpful. If your child has had a large amount of fluid, taking him/her to the potty 30 minutes to an hour after drinking will maximize success, and help your child recognize the connection between bladder fullness and peeing. Every child is different, and some children will be "bowel" trained before being "bladder" trained and vice versa. Whichever may be first, keep in mind that it is usually one before the other and not both simultaneously. Additionally, day-time dryness almost always comes before night-time dryness and may precede it by several months. Now that the process has started, here are some additional things to keep in mind: Patience! Patience! Patience! Toilet training is a big process. Some experts feel that it is the first and biggest developmental step your child will take. The process generally takes several weeks to several months to complete. Two steps forward, one step back. Don't be discouraged if you have a few good days followed by a few bad. Again, it's a process that's going to take time. Also keep in mind that when your child is tired or upset this is the most common time for accidents or setbacks to occur. Know when to back off If you are pushing too hard, your child may "push" back with more accidents and/or resistance. Take the control out of the issue and step back. It is ok to take a few days or even few weeks "off" . Your child will recognize the power struggle is gone and relax and respond to it. A final word: As hard as it may be to admit or realize, toilet training is truly in the control of your child. All you can do is be supportive and encouraging and set the stage for success. Keep in mind that your child will probably be toilet trained when she is ready, NOT necessarily when you are ready. If you are experiencing major difficulties, it may be time to sit back, re-examine the situation and ask yourself if your child is truly ready (see article on readiness). If you are meeting up with a lot of resistance in a child that is ready, it is time to examine those issues.

Potty Training

As children approach 2 years of age, parents frequently start thinking about toilet training. What is the "right" age? Depending on whom you ask, the "right" age may range from as young as 6 months to 3 years. While age can be used as a determining factor, there are several others to address. The most important factors are not necessarily age, but rather physiologic, physical and psychological readiness.

Before a child can be "toilet trained", she must have attained a certain amount of physiologically readiness, namely "bladder readiness". In infancy, babies frequently are unable to hold large amounts of urine in their bladder and void small amounts. As a child grows older, her bladder becomes more mature, and is able over time to hold larger amounts of urine between voids. This comes hand in hand then with the additional ability to be able to increase the interval between voids. When you notice that your child is dry at longer intervals (i.e. dry after a nap or for at least 2 hours) and is voiding large amounts at a time, then that is a sign that your child may be physiologically ready for toilet training.

Another component, which overlaps with psychological readiness, is the ability of your child to recognize that she is voiding (i.e. if your child does not recognize when she is voiding, toilet training is virtually impossible). Some children start showing some signs of "bladder readiness" around 2 years of age. Most will attain it by three years of age.

Another component of readiness is physical readiness. This includes the ability to walk well (to and from the bathroom), to be able to pull pants up and down, and the ability to get on and off the toilet/potty chair fairly independently. While this may seem like a "given", think about grandmas who claim their children were toilet trained at 6 months or a year of age. Some kids are not even walking at a year, how could they be toilet trained?

The last component is probably the most important: psychological readiness. Or what I like to call willingness! If a child is not bothered by a wet or dirty diaper, if she is uninterested or unwilling to sit on the potty, believe me, you are not going to get very far. As the saying goes, you can place a toddler on a potty, but you can't make her pee. Toddlers quickly learn that they can control their bodily functions.

Once your child is showing all these components of toilet training readiness, most experts recommend waiting at least three months before you start toilet training to ensure that all is set. This is a good time to "set the stage" for toilet training as well (letting her observe others using the toilet, introducing books or videos on the subject, starting to talk about them using the potty soon).

Last but not least, look at yourself and your family situation. In order for toilet training to be as painless and smooth as possible, make sure that you AND your child are ready. Some kids toilet train quite easily, while for others it becomes what seems like a long drawn out battle. If you are incredibly busy at work, moving to a new house or a new baby is due soon, it's ok to wait a few months to let things settle down. This is probably one of the biggest steps for your child and it's worth it to wait.

Just remember, all good things come with time. Or as my then 3 and a half year old son said "You have to be patient, and then the pee will come".

Next week will follow up with Potty Training 2

Happy New Year

Happy New Year! I hope this year has started off well for all the families.. This article is about Playing with your Child. I hope you find it interesting and I would love to hear what other activities you and your children do.

Playtime Adults and children alike love to play. For children, play is more than fun- it is essential for learning. Through play, children learn about their world, how to get along with people, test their muscles and strength, gain language, problem solving skills and self-esteem. Sometimes children will play by themselves, or near other children. Sometimes, they prefer to play with others. You can lay the foundation for learning early in your child's life, by giving them opportunities and time for play. Here are some fun activities to try with your child. For babies: Talk and sing to your baby, so he knows your voice well. Rock your baby gently and cuddle him, as you sing "Rock-A-Bye Baby" to soothe him and just for the pleasure of being with your baby. Hang toys where your baby can bat at them. Put your baby on a blanket on the floor to exercise her muscles. Place your baby in a chair or carseat or prop her up with pillows. Play with a flowing scarf or large bouncing ball. Move it slowly up, then down, then to the side, and watch your baby as she follows the movement with her eyes. Play games with your voice. Talk in a high pitched or low pitched voice. Make noises with your tongue. Whisper. Take turns with your baby. Repeat any sounds he makes. Put your baby close to you, so he can seen your face as you make the different sounds. Let your baby look into a mirror. Place an unbreakable mirror on the side of your baby's crib or changing table so he can watch. Look in the mirror with your baby, too. Smile and wave at your baby. As your baby gets a little older: Babies love banging objects to make noise. Give your baby blocks to bang, rattles to shake or wooden spoons to bang on containers. Show her how to bang the objects together. Put some music on the radio or stereo and "dance" with your baby- place him in a standing position and let him bounce and dance. If your baby can stand with a little support, hold his hands and dance together. Make a simple puzzle for your child by putting blocks or ping-pong balls inside a muffin pan or egg carton. Play hide-and-seek with objects. Let your baby see you "hide" an object under a blanket, scarf or diaper. If your baby doesn't uncover the object, cover only part of it. Help her to find the object. Play "peek-a-boo", "pat-a-cake" or "this little piggy went to market". Try playing the games different ways. Hide behind furniture and "peek-a-boo" or clap pan lids or blocks in rhythm with "pat-a-cake". Make an obstacle course with boxes and furniture, so that your baby can climb in, on, over, under and through. Play the name game. Name body parts, common objects and people. This helps your baby to know that everything has a name, and to begin to learn what those names are. For your toddler: Water play is lots of fun. Put "squeeze toys", such as sponges, squeeze bottles, and "dump-and-pour toys", such as cups and bowls, in water in the bathtub for your child to play with. Toddlers love to try blowing bubbles. Or you can blow the bubbles and your child can have fun chasing them and popping them. Play "pretend" using a doll or stuffed animal. Encourage your child to have the doll do what he does- eat, sleep, walk, dance and jump. You can have the doll join in with any activities or games you and your child play. Make a picture book by cutting out pictures from magazines or by using photos of family members and pets. Read the book together and let your child point to the picture as you say what it is, or ask your child to identify the picture you are pointing to. Toddlers love playing with balls. Use a beach ball to roll, throw or kick. "Dress up" clothes provide practice opportunities for children to learn to put on & take off shirts, pants, shoes & socks. They can fasten big buttons and zippers. For children 2-3 years old: Going to the library to find books for special reading time or bedtime. Libraries often have story time sessions, that are appropriate for children this age. The playground offers lots of opportunities for play- on swings, rocking toys and small slides. A trip to the playground or park is a good way to have your child begin practicing interacting with other children. Put an old blanket over a table to make a tent or house. Then have a picnic or snack in the "tent'. Your toddler may even want to have a pillow & flashlight for a nap in the "tent". Get out the paper and crayons. Draw large shapes and let your child color them in. Take turns. Have your child help around the house. She can help you set the table or wash the dishes or fold the laundry. Get a large piece of butcher paper. Have your child lie on the paper and draw an outline around your child's body. Then talk about parts of the body and print the words on the paper. Your child can then color the poster and hang it in his room.