Monday, August 20, 2012

Therapy Secrets: How temperament affects therapy-Part 2

Eating things that stick to the spoon

 How does temperament affect reaching milestones? 

Most babies learn to roll when they are trying to reach for their favored toy.  However, there are different ways to accomplish this desire. 

Laid back baby
The laid back baby will see the toy, try to reach it, decide it's too hard, see a closer toy, pick that up instead, and is very happy to play with this toy instead.  Both toys are cool! 

In general, a super laid back, typical developing baby may reach their milestones a little later than their same age peers because their enjoying themselves and aren't really in a hurry to "grow up".  Many people tend to describe these babies as "good" babies because they are easily comforted, aren't very particular about what they want, and just seem to roll with the punches. 

Physical baby
The physical baby will see his desired toy, try to reach it, try to scoot, try to pull his body with his arm, try to reach it with his leg, try to reach it with both his leg and arm, starts to play by rocking back and forth, and suddenly finds himself on his stomach.  This is so much fun!  He rocks again and rolls to his back.  Surprised, but delighted, he keeps practicing this knew skill until he's tired!  What toy?  Rolling was so much fun!

A baby who is super physically oriented, may reach all their gross motor milestones sooner than their same age peers, but may be a little later reaching their fine motor milestones.  They love to move and they may focus most of their energy on becoming mobile.

The verbal baby
The verbal baby will see the toy, try to reach it, make a cooing sound, try to reach it, make a frustrated sound, try to reach it, keep making frustrated sounds or cry until mom figures out what she wants and brings the toy to her.  Then she cries in delight...making sounds worked!

A very verbal baby may be a little later in reaching their gross motor milestones, but may begin to "communicate" sooner than their same age peers. 

The thinking baby
The thinking baby sees the toy, tries to reach for it, tries to reach with the other hand, takes time to think, tries to reach with his legs, takes time to think, he lunges with his whole body and rocks towards the toy without enough strength, then he leers at the toy.  Finally, he scoots closer using his legs against the floor.  He still can't reach the toy!  In his frustration, he flails his limbs and somehow ends up on his stomach.  It takes a moment to orient to his knew position.  He's not sure what happened, but he sees the toy, reaches for it and grabs it with delight!

A thinking baby may develop their cognitive skills a little faster than their peers, but may have more difficulty developing their physical milestones at the same pace as their cognition.  This often leads to a very frustrated baby who may be more fussy in the beginning.

Every baby can display some aspect of all these behaviors, but most will show a tendency towards certain behaviors over others.  Just like the adults they become, children are all different and their corresponding areas of interests are also different. 

Using laughter to encourage

What temperament is my baby?

I have used the Myers Briggs method of assessing personality for over 10 years.  I was originally introduced to it when I read "Do What You Are" by Paul D. Tieger and Barbara Barron-Tieger, a book about finding your perfect career or job based on your personality.  It shows you how to assess your own temperament and match it to a career or job situation.  Then I found the book, "Please Understand Me II" by David Keirsey.  It's a much more detailed book about the same personality descriptions. 

The above baby descriptions are somewhat based on these personality descriptions, only simplified for clarity.  "Please Understand Me" has a great section describing what these temperaments look like in children, but I also bought "Nurture by Nature", written by Barbara Barron-Tieger. 

It would take too long to go into detail on this post.  If there is interest, I may write a separate post.  In summary, there are four basic types of personalities: Guardians, Artisans, Idealists, and Rationals.  Then there are four subtypes in each main group, which makes 16 different personalities.  It sounds too simple, but there many things to consider and in the end everyone is a unique individual.  However, these descriptions can help us understand some general tendencies, especially if they are very different from our own. 

I really use these descriptions more as a guide, not as a definite description of a person or child.  It's only there to help me understand, not to replace my observations of the real person.  For everyone is affected by their life experiences and choices, making us all very unique.  However, as the examples of the different baby temperament shows, this general guide can help you understand your child and help you find the key to their inner motivations.

My son is definitely a Rational (see thinking baby description).  It's not always easy to figure out a baby's personality, but he is an extremely opinionated little guy, making his preferences and personality quite clear.  I am also pretty sure that he is an INTJ: introverted, intuitive, thinker, and judger (the words have different meanings than popular definitions). 

In general, INTJ's are super independent, innovative little thinkers, who tend to be socially awkward.  They are super competitive with themselves and refuse to accept anything less than their own expectations of themselves.  They are the quintessential nerds, who tend to be lovers of technology all their lives.  They are super intuitive and are great people readers. 

So I try to take his temperament into consideration, when I set up his environment.  If you look at my previous post on setting up the environment, you can see that there are places for independent play, technology toys, blocks, and a private zone.  Rationals seek autonomy all their lives and they have a great need to experiment and achieve their visions.  So I give him plenty of freedom to try things at his own pace and I try to give him space even when I'm right next to him.  He's very sensitive to "failure", so I make sure to set things up for success whenever possible and try to show him through example that it's okay when things don't turn out the way we planned. 

Why is this important?  When we work with a child's temperament, they feel honored and accepted for who they are inside.  This increases their confidence and their willingness to be courageous and try new things.  This translates well into therapeutic goals because we frequently ask the child to try things differently.  If they feel confident to try things without falling apart, they are going to be more willing, not only to try it but keep practicing until they succeed.  As their experience of success increases, they're willingness to practice outside of therapy increases.  Then this leads to a child to practice skills in a variety of settings and situations, making reaching milestones a smoother process.

Learning to balance, while discovering the new

How does this fit into therapeutic goals?

Though we make very specific goals to measure progress, progress is really an organic process, especially in children whose condition affects their function overall.  In my experience, when I'm finally able to motivate my client intrinsically, they seem to suddenly make progress in many areas.  It seems like something finally clicks and they are excited to reach goals and try new things.  This process can be quick for some and longer in others, especially if they are not using words to communicate.

The light-bulb moment is amazing to see.  Some of these moments happened right in front of me and they stay with me forever. 

One moment that comes to mind happened with an 11 year old boy, diagnosed on the Autism Spectrum.  He was considered non-verbal and also suffered from severe sensory issues that prevented him from participating in social gatherings.  After 6 months of therapy twice a week, he seemed more relaxed and even began to smile and giggle in response to appropriate stimulus.  One day, I was playing around with paint in a silly way, just to make him laugh.  He kept giggling and watching my "amazing" painting skills.  When I finally stopped, he slowly looked up at me with a huge smile and a look of happiness and said, "funny!". I was floored!  Not only did he say something appropriate, he was describing my a qualitative action!  It was the day that changed everything.  He began trying to communicate more, he had fun at parties, he began to cuddle with his family, and he made amazing strides in his academic skills.

This young guy was a cautious, quite, thinker.  He preferred and needed to observe first, before he could trust.  He didn't like being rushed and he learned best on visual mode.  He really liked art and being silly tickled his sense of humor.  I used this knowledge to set up the treatment sessions progressively.  It started with the swing and providing plenty of vestibular (movement) therapy.  It was a slow progression, but it was worth every moment. 

Taking temperament into consideration when setting goals and setting up treatment can lead to success.  This process tailors treatment to an individual and creates the opportunity to motivate the person from within themselves.  This can really affect their ability to generalize their skills from one setting to another and can also lead to progress in many areas.

How do I take temperament into consideration?

Many parents automatically start learning the preferences of their children and may begin to take a child's preferences into consideration before making decisions on everyday activities.  For example, you might realize your baby loves being around a lot of people, so you sign up for a mommy/baby class.  Or your child may prefer quieter occasions, so you make a play date with a mom and another gentle baby.  Your child may prefer being outside, so you go walking everyday.  We are naturally affected by our baby's temperament and we adjust our lives to make things smoother. 

Well, this consideration can be taken to the next level.  You can begin to actively use the knowledge about their temperament to encourage progress towards their goals.  Notice I emphasize "their goals".   As you're observing your child, try to figure out what they are trying to do.  Are they trying to roll?  Are they trying to put the peg in the hole?  Are they trying to talk?  Then figure out how you can help them succeed by making the task just hard enough to be interesting and easy enough to accomplish.  If you need some ideas, this is a great question for your OT. 

Then set up the activity and wait.  Let your child take the lead.  This will make them feel more independent and it will give them time to figure out the task on their own, a very good cognitive exercise. Don't worry if they don't do the activity "the right way".  If your child asks for help, show them how to do it, but let them finish the last step.  This will make them feel accomplished, despite needing help.  Plus they will begin to learn the activity.  If they end up needing a lot of help, it may mean the task was still too hard, so next time set it up with fewer steps.

Remember to consider your child's strengths.  If they are good at sitting, but have difficulty standing, set up a sitting task that is challenging.  If they want to stand, make the task easy, so they're mainly working on standing.  Make sure to give positive reinforcement on the actual goal.  (You can do that standing!  Amazing!).

What if my child doesn't use words to communicate?

Observation is important with all children, but is especially useful, when your child is not using words to communicate.  When your child isn't using words to communicate, observing their behavior can tell you a lot about what's going on inside.  Try to take time to observe without speaking.  Communicate on their terms.  If they're using gestures, use gestures.  If they use eye contact, use eye contact.  If they aren't really communicating, use silence with action. 

It's important to balance their communication style, with our talking.  Yes.  It's important that they learn language, but it's also important that they feel understood.  When a child feels understood, it opens the door to try and communicate with us, using "our language". 

When I first immigrated to the US, I didn't speak English.  Not only did I not understand English, I didn't understand the accompanying gestures or cultural nuances of people's actions.  The more they talked, the more everything sounded like gibberish.  I usually felt confused and ended up with a headache.  But as soon, as people stopped talking to me, I was able to focus, observe, and understand.

So, it's important to give someone plenty of speaking breaks, so that they can observe and learn while you're spending time together.  Learn to speak less and do more.  Give them time to process what you're trying to communicate.

A place of his own

What does this look like everyday?

As a parent of a special needs child, I can honestly say that it's hard to be "on" all the time.  In fact, it's impossible.  I'm a therapist, but being a mom is my primary role with my child.  That means I have to fit therapy in little 15 minute spurts throughout the day.  I try to think of what I can fit into our day, then decide what goal I'm working on that day.  At most I have, one structured activity per day.  Then I try to fit in as much "physical" activity as I can.  Then I do one session of the Masgutova Method per day.  I also try to give Baba the opportunity to do things on his own when possible, as therapy.  Honestly, some days one therapeutic thing may be the only thing I can do that day.  I try not to go longer than three days of zero therapy, though that's not always possible.   But this is really okay.  I know that we're looking at the long term, not just the short term goals.  We are creating our own pathway.  One that works for us, and so far it's been successful. 

Every family must find their own rhythm.  It's best if the whole family can be involved, sharing the load is so much better.  Even if the person can only be a supportive helper, it can really help the main caregiver.  It's also okay to take short to two weeks.  Everyone needs to be refreshed and have time to just be a family doing "family" things.  Though if you're feeling loaded down, it's also a good opportunity to see if things can be re-arranged or re-organized.  Most of the therapy should be fun, not difficult work.  Be sure to enlist the help of your OT and request for ideas on how to make things easier and what to focus on.

Most importantly, remember that having loving family support is the most important thing for your child.  They are children first.  Their diagnosis does not define who they are.  It just something they deal with, just like everyone deals with some sort of difficulty. 

Easy next to hard activities


The act of trying to figure out your child's temperament will have another important effect.  It will help you to see your child first, his diagnosis will fade into the background.  It will also help you help support your child, they way they would like to be supported.  In this arena of special needs, it's often easy to forget our children are unique individuals that have preferences that may not fit into nice little "diagnosis" molds.  Their temperament has a huge effect on how they will navigate their lives.  Their temperament may hold the key to what will motivate them to push through whatever obstacles lie in their path.  Setting fire to this intrinsic motivation will also reduce the pressure on the main caregiver to provide extrinsic motivation, since the child will be motivated to try things on their own.  In the end, this motivation will help them create a path to their maximum potential...whatever that may look like. 

Wednesday, August 15, 2012

Therapy Secrets: How temperament affects therapy-Part 1

Therapy on new ground

My son's temperament

He is not a giggly, cuddly, extroverted "Gerber" baby.  He is a serious, intellectual, and very observant little man.  He is more interested in achievement and autonomy, than playing and relaxing.  He can spend an hour trying to figure out how something works and gets really disappointed when he can't figure it out.  Unlike some children, he is hard to distract from his current activity, unless you pull out the iPad. 

He is constantly seeking intellectual stimulation and will start sighing really loudly when he's bored.  Most of the time, his play time looks more like work time.  He can't wait to be old enough to do everything mommy can do.  When we go to the playground, he watches the older kids and gets overwhelmed by all the things he wishes he could do too.  He doesn't know that he's a baby and compares himself to the big kids.  It's obviously disappointing.  He uses his O-ball to test new surfaces before walking on it and also uses it to console himself when he's disappointed with himself. 

When he is finally able to achieve something, he squeals with delight and struts around like he won a gold medal.  He is internally motivated.  He is not as affected by praise, though he appreciates my encouragement.  He gets very upset when I miss his cues or if I'm distracted by some activity when he wants my attention.  On the other hand, he gets over being upset quickly and seems quite satisfied with my apologies.  He is very intuitive and frequently responds appropriately when I explain things.

Sometimes it's really hard to figure out how to set up an activity so that it is challenging, but not overwhelming.  He has a small threshold of things that excite him or bore him or overwhelm him.  He likes some regularity in his schedule, but needs some flexibility for possible intellectual pursuits or other exciting activities.  He hates the mundane and loves new experiences.

Learning how things work

How does temperament affect behavior?

Have you really thought about your child's temperament?  Temperament can play a huge part in your child's development.  Your child's temperament can affect when they reach their milestones, how they overcome obstacles, and how they interact with the world.  It can affect therapy by how you set up the environment, how you set up therapeutic activities, what activities you choose, how you present them, etc.

My little guy has sensory issues that can overwhelm him in crowds, but his intense desire to experience new things can help him overcome his inclination to run from crowds.  For example, he will often refuse to go to a small crowded familiar playground, but he is willing to go into crowds if it is a new place.  His curiosity helps him tolerate the discomfort of being in a crowd.  However, on a bad sensory day, this method may fail because he's not feeling well enough to override the discomfort.

If your child likes people, they may tolerate crowds better than a child who prefers intimate settings.  I know that my little guy may tolerate doing easy tasks in a crowded place, but he will most likely refuse to do anything that he has not yet learned how to do.  Unless the activity has sparked his curiosity or his intense desire to accomplish a task.  I know not to push him because it will only push him away.  However, if I expose him to the task and wait, his own curiosity will force him to try the activity.

I also know that he prefers new experiences more than socializing with people.  He's young and true cooperative play doesn't start until much later, but some baby's are interested in other people.  My baby is more interested in things.  He is quite wary of strangers, except other babies and some children.  He is very social with me and with his aunt (Most likely because she lives with us).  Eventually, he will socialize more, but right now I'm focusing on his strengths.  I know this will build his self confidence, while I expose him to social events slowly.  As he slowly gets used to other people, I know that he will find the courage and interest to tolerate social events more.

A place of his own

How does temperament affect therapy?

Why is the consideration of temperament important for success in reaching therapeutic goals?  It's important because intrinsic motivation works better than extrinsic motivation.  What does that mean?  When a person or child is motivated from within themselves, they are more likely to reach their goals than if they are only being motivated by an outside source: therapist, parent, or other...saying, "Good job!"

When a child is motivated from within themselves, feel good chemicals flood the body and these help to decrease sensory defensiveness, fear, or any other negative emotion.  You may recognize this when your child does something you never thought they would do.  Some parents feel confused by this because "He won't do that at home".  Why won't he do that at home?  If he's motivated by the behavior of other children, then he may "not do that" at home.  Or perhaps he's motivated by the mats on the floor, he's not afraid to fall on the mats.  Or he's motivated by the swing.  It usually takes a lot of observation with trial and error, before we can really see our children's personalities and figure out what motivates them.

Whenever I started to work with a new client, I spent the first sessions observing their behavior and building trust.  Depending on the child's personality, this process may take between 1 session to 16 sessions.  I accomplished most of the therapy by setting up appropriate activities, but I usually follow the child's motivation.  Each session was set up to build on the last session.  The goal was to find out what motivated my client and to build enough trust so that they would be willing to try things that feel uncomfortable. 

As a parent, this process is slightly more complicated, as my own son has taught me.  Your child is more comfortable with you and will be more likely to complain and generally be a more difficult client.  For the first time in my therapy career, I have to use an iPad to bribe my son into therapeutic exercise!  It's so much harder to be a therapy parent!

Placing the easy one closer

What is intrinsic motivation?

When I say intrinsic motivation, I mean that a child is motivated to succeed from within themselves.  In a therapy session, there is usually a combination of intrinsic and extrinsic motivations.  I believe a session is the most successful when there is more intrinsic motivation.

The ultimate goal is a child who is self motivated and also motivated by you.  This is where the parents have the upper hand.  Your child already wants to please you.  They may complain, but they feel very accomplished when they make you proud.  As therapists, we have have to build that kind of relationship.  So being the parent has some perks!

When your child is self motivated, she will practice tasks without prompting.  The feel good chemicals are helping her to keep trying despite the repeated misses and fatigue.  She's excited by the little progress she makes and feels good about the effort she's putting in.  Even if she doesn't completely succeed with the task, she is happy about what she's done.  She can't wait to try again!  This is where extrinsic motivation by the parent or therapist can cement the feeling that she is making progress and she will accomplish this task soon!

If your child is dependent on extrinsic motivation during therapy, the feel good chemicals aren't providing the extra boost.  The misses make him feel bored and exhausted.  Each effort seems a monumental task and he feels like he'll never accomplish this task.  He may want constant praise, food rewards, or other rewards to help him feel accomplished.  This isn't to say all kids who want these rewards are not motivated.  Kids want rewards all the the time.  The difference is realizing if these rewards are the only things making him feel good or if these rewards are a bonus for how good he already feels about his accomplishments.

This theory applies to all kids, including typically developing kids.  However, for children with special needs, motivation is even more important.  Special needs kids have to push through a variety of obstacles that are much harder than the average kid.  Either physical, mental, emotional, or medical problems make reaching milestones difficult and challenging.  It's easier to feel discouraged and defeated, especially when it seems easier for everyone else. 

Easy to learn when you're interested

What is the Occupational Therapist's role?

It's my belief that an occupational therapist (OT) is the facilitator, the professional who finds a way to help your child achieve their goals.  OT's have two basic ways of treating: improving deficits (i.e. strength, coordination, cognitive skills, etc.) and teaching compensatory skills (i.e. using equipment, alternative methods, etc.).  However, without instilling motivation, the child may only do well in therapy and have a hard time generalizing their skills into other areas of their lives. 

Most people don't realize that OT's are trained to work with psychiatric diagnoses, as well as physical ones.  Occupational Therapy is based on holistic health.  OT can only be successful when you are treating the whole person from a mental, emotional, physical, and social perspective.  Modern medicine has been splitting the person into parts for different specialties, but OT is about putting the person back into one whole being. 

This is why it's appropriate to take temperament into consideration when making a treatment plan.  A child's temperament affects every part of their recovery.  It affects what goals are made and how they are reached.  It affects which tasks are used to practice their skills.  When a treatment plan is tailored to the child's temperament, it can instill motivation and really bring out their potential.

Parents are the key in this process.  When a parent is able to define their child's temperament for the therapist, the therapist can tailor their treatment and progress can be observed sooner!  This can also improve the likelihood that treatment will be successful. 

So how do we increase motivation and use it to reach therapeutic goals?  Children are naturally motivated to reach their milestones.  However, this motivation can be affected by their temperament and their experiences.

How does temperament affect reaching milestones?  How do you take temperament into consideration?  What if my child doesn't use words to communicate?  Learn the answers in Part 2!

Thursday, August 2, 2012

Leaving Babyhood Behind

Change is hard.  Before motherhood, change was easy for me.  In fact, I looked forward to change.  I got bored easily and change was a refreshing way to make things interesting.  Then...then, I became a mother.

A very serious baby

 Now, I can't wait to get back "on schedule" and keep things as similar as possible.  I feel scatterbrained and I can't remember where anything is!  Is that normal?  Is it the lack of sleep?  Well, I guess it's all a package.  At least, it's a very cute package!

I used to jeer...yes, jeer at the mother's who obviously cut their own child's hair.  Why don't they take them to a professional?  It looks awful!  Then...I cut my own son's hair.


Why?  I am deathly afraid of taking him to get his haircut.  He is very weary of strangers, he's sensitive to being touched, and I'm afraid of a full out tantrum...when everything is already hard.  So...I cut his bangs, while he was watching Youtube.  It was hard.  It was really hard.  How do the pros do it?  At least, the hair is not poking his eyes anymore...the only reason I was "persuaded" to cut the offending hair.  Otherwise, it's just going to be long.  It's going to stay long!  Even if everyone keeps thinking he's a girl.  A girl wearing very boy clothes. 

For now, our house has 4 pieces of furniture...a table, two chairs, and a highchair.  Unless, you count the boxes and a couple mattresses on the floor.

Ikea table and two chairs

Studying the Alphabet

Baba thinks this is his playroom...since his toys dominate the living area.  There's no place to put the toys.  So they have taken over.

Ikea train set

It's fun to see how he figures out the toys.  I like how he experiments with them.  Stepping on them, moving them, trying to build using different toys together.  He's really becoming a boy...slowly leaving babyhood behind.

He seems to understand more and he seems to want to communicate, but his words are mostly vowel sounds.  He can't seem to imitate sound when he wants, though sometimes he's able to imitate when it's automatic. 

He recognizes the difference between letters and numbers.  He knows what they look like.  When he holds his "letters or numbers", he corrects their orientation correctly.  He can correctly point to "0, 1, 2, 3, 4, 7, 8, 9, and 10".  He knows some of his letters, especially "A, E, O, U, H, B, M, P, Z, S". 

But, he really doesn't seem to know words.  He asks me to repeat the same word...over and over.  It seems like he's having a hard time, processing all the sounds together. 

Yet, he seems to understand things...intuitively.  He is very sensitive to emotions.  My emotions seem to affect him the most.  He will start to whimper, if he thinks I'm hurt.  If I'm anxious, he gets anxious too.  So I do everything possible to control my emotions.  To regulate them and not spend too long on negative emotions.  It's actually been therapeutic for me.  For the first time, in a long time, I'm more positive than negative.  I owe it to him.

Learning to walk on a hill

He's slowly becoming less cautious and a little more willing to explore new places, new obstacles.  I hold back my fears of seeing him fall and I encourage him to make a new pathway for himself.  I let him know that he can be independent...even if he should fall...because he can always get up.  Most of all, I'm always nearby...just in case he needs me to reassure him.


Sometimes, I'm so close to saying "no".  But I take a deep breath, shut my mouth and watch.  Most of the time, he's careful.  Most of the time, he will ask for help...if he really needs it.  So, I am just a guide.  I am here to help him find his way into this world.  So that he can have the confidence to overcome the obstacles that are looming in the way. 

If he can find his independence...even if he's never able to use his voice...he will succeed in finding his own way. 

My only to not get in his way.