Tuesday, November 11, 2008


Anticipation is something that is important to all people. It means thinking about something before it happens. Some of us are a lot better at it than others. The youngest children often can't wait for things, so anticipation is difficult for them. Anticipation can be a good thing. This happens when we think of some positive events that can happen in the future. It also happens when we have had an experience with some event or person and become excited in a happy way, or nervous in a bad sort of way. It also happens when we do something that might be wrong in the eyes of another person or other persons, and we anticipate a response or consequence. Telling a lie or a fib is something that involves an incredible amount of anticipation once the fib or lie has been told. The anticipation is the tremendous amount of anxiety that exists from the time the lie has been told until the time it is discovered. Discovery, oddly enough, can be such a relief that it functions as a reward for telling another lie.

Planning for something that has a good chance of happening helps take the edge off the anxiety particularly if the future event has a chance of repeating something unpleasant that has happened in the past. Many people approach a holiday with anxiety because they plan on being with family members that they both love and fear. They recall all of the good times that they have had with those family members, but some things just get in the way of making them comfortable about being together with them. The more intense prior events were, the more conflicted people are about having something social with those family members. What can be done? What would you want to do? What family members are most harmed by doing nothing at all, and chancing a repetition of prior events?

Those people who are planners have the potential of being good behavior engineers. Behavior engineers set up situations to minimize negative things. They are good at anticipating. Suppose, for example, we know that some family members don't like being near others. Planned seating arrangements are a really great way to reduce potential problems with that one. Suppose we know that some guests have the potential for breaking family heirlooms. Moving those to a safer location prior to their arrival is a great idea. Now, here is the difficult one. Suppose we are having company, and one or more of the guests is a person who has gotten into trouble because of alcohol.

There is NOTHING wrong with eliminating all alcoholic beverages from the home prior to the arrival of alcoholic family members. They might even thank the host for doing it. This might mean moving liquor bottles from the home to places like an office, or a storage facility. Serving non-alcoholic facsimiles at dinner might be a reasonable addition to moving all alcoholic beverages, or it might cause a reaction. Actually doing it (serving non-alcoholic beer or wine/fancy grape juice) might send a great non-verbal message. Plan for any verbal response to the non-verbal message that you are sending with a good deflection or positive response such as, "We have planned for a loving and positive family gathering this year." A repeated (though different) negative response should result in the same response, "We have planned for a loving and positive family gathering this year." Keep saying the same thing until the negativism stops, or make a non-alcoholic toast, "A happy, and healthy year for all, until we get together again." Many alcoholics bring a bottle of an alcoholic beverage to family gatherings as a "gift." This should be accepted gracefully and quickly brought to the place outside of the home where the other beverages are hidden. Never hide the alcohol at the home where the event is taking place. Alcoholics are good at finding it. They might even go so far as drinking cooking extracts (vanilla extract, almond extract, etc. all contain alcoholic - true alcoholics know this and will empty them), mouthwash, aftershave (yes, even though the alcohol in that is poison), cough syrup, etc.

Involving all members of the host family in planning can help reduce anxiety. Remember to have one last meeting before the arrival of guests to go through a checklist of the plan. Scripting or anticipating what might be said in various circumstances might be a good idea. One anticipated remark from a guest might be, "I am sorry about what happened. Can we please have fun?" The response might be, "We accept your apology. We love our family. That is why we have planned to have a loving family event this year." Repeat as necessary.

Another form of anticipation has to do with punishment. Anticipation can be used a part of a program of consequences. This is part of the Love and Logic behavior management system (refer to http://www.loveandlogic.com/). Suppose a child has done something, and there is a need for some kind of organized punishment from ALL caregivers (both parents, grandparents, extended family, etc.). It is perfectly reasonable to say, "You know that we love you. What you have done has caused me to have discuss your consequence with (family members). We will let you know what we have decided. Until then, don't worry about it." That last part is what creates the anticipatory anxiety that serves as punishment.

Wednesday, October 15, 2008


There are a fair number of different kinds of headaches. First, many people recognize that it is not the brain that aches. It has no pain receptors in it. However, the head, outside of the brain can hurt, and this can be disabling.

Muscle tension headaches are among the easiest to treat without medication. Learning to tense and relax muscles is an important skill for people who have this variety of headache. Muscle tension headaches can also be relieved by progressive relaxation, by hypnosis, or by meditation.

Vasoconstrictive headaches are caused by increased blood flow to the vessels around the head. Roughly two thirds of these can be stopped by reversing that blood flow in a simple way without medication. The idea is to move blood away from the head. This is done by dilating (opening) the blood vessels in parts of the body that are away from the head. Taking a warm bath is a good idea. Running warm water over the hands is another. Make a cup of hot herbal tea (non-caffeine) and wrap your hands around it.

The psychologist was working at a secondary school in eastern North Carolina. The child stopped taking a test, complaining of a headache. He took a chance that it might be a vasoconstrictive headache (a good chance/guess because of the circumstances). The student and the psychologist went to the only nearby place with warm water, a sink in the teacher's lounge. The student held her hands under warm running water for a few minutes and her headache disappeared!!! She completed the testing without a complaint of head pain.

Wednesday, October 1, 2008

How To Drop-Out of School

All of the United States have a law that defines the acceptable age for children to drop-out of school. It's easy for a child who reaches this magical age to go to school sign some papers and, >>>Booooom<<< their education is finished. Many never sign out. They just stop going to school. School systems almost never go after them to sign the paper work. What a shame.

Children who drop out have no liability for just walking away. They can get public assistance and put a burden on tax-payers who support them. They usually get menial jobs and end up having kids who don't do well either. I'm not just talking about drop-outs who have learning problems. I am not going to get into the extended argument about school contributions to drop-out such as multiple grade retentions that have been researched and repeatedly demonstrated to be a failed way to improve student performance (in the long run). The process that allows children to drop-out needs to change.

Rule 1. Never refuse a child the opportunity to make the choice.
Rule 2. Require the child to learn what the choice means.

Every child who wants to drop out must be required to complete an assignment as a part of the process. The completed assignment is signed by the child, and placed in the child's record. The school reviews the assignment to make certain that every aspect of it is complete, interviews the child to make certain that he or she actually wrote it by asking the questions that were answered in the report, returning it to the child if it has been determined that they did not complete it and having them "try again" until they actually do it, and, finally, a school administrator signs it.

The assignment:

Part 1.

1. Read the newspaper "Help Wanted" section and find a job that they could get without a high school diploma. The salary must be listed in the advertisement or they must get a written copy of the salary offer from the potential employer. This must be included with the report.
2. Using math skills that they have learned in school, they must calculate their monthly salary after taxes and social security are taken out.
3. Read the newspaper again. Go to the advertisements for places to live. Find a place to live that costs the least, leaving them enough money to pay for the extras such as electric, heat (oil or gas, for example), and cell phone service.
4. Add together the rent, and the extras. Subtract that amount from the monthly income from the job after taxes. How much is left? That is the amount needed to buy food.
5. Forget about cable television, eating out, going on dates, etc.
6. Go shopping for food but don't buy anything. Add up the prices of what you might eat in a week. Multiply it by 4 or 5 (the number of weeks in a month). Subtract that from the remains of your monthly wages.
7. Now, think about how you are going to get to work. Add up the cost of transportation. Do you have any money left after buying food?

Part II

Determine how much money you can get from public assistance (aka, Welfare, Food Stamps, etc.). Complete the above task using the total amount of money that this turns out to be.

Part III

Go to the newspaper, and find the salaries of jobs requiring a high school diploma, or more education. Determine everything from Part I above. Make a choice.

Final question: If everyone was receiving public assistance (welfare, food stamps, etc.), who would pay for it?

How much is it costing to PAY Attention?

Back in August 2000 or 2001 Dr. Adrian Angold and others at Duke University published an epidemiological study of the rate of diagnosis of Attention Deficit Hyperactivity Disorder in the western part of North Carolina in the Journal of the American Academy of Child and Adolescent Psychiatry. That study discovered that thousands of school aged children had been misdiagnosed and NEVER should have been medicated at all. Few people reference that article.

I have four important true stories about real children to tell you.

More recently than the next post, I saw a 7 year old from another county. This boy was clearly terrorizing his class and his teacher. He would never sit still. He grabbed a scissors whenever he could and would cut his own clothes, hair, and the hair of other students. The referral was for an evaluation of ADHD and other behavior, as you could well imagine. One of my favorite developmental questions is frequently left out of routine interviews concerning child development. It needs to be included. I always ask when a child first began to sleep through the night. This case was one of only a few where a child had never slept through the night. His nightly sleep was always interrupted, and not for using the bathroom. The simplest way to treat sleep problems is to establish a nightly sleep routine. This child had one. I strongly recommended that the parents try giving him Melatonin. He slept the night through for the first time. The next day he brought home his first "A" for behavior. The teacher thought that he had certainly been given a stimulant like Ritalin. The problem with any stimulant medication is that it would have bypassed the sleep deprivation/interruption and delayed correct treatment. Follow-up reports have indicated continued good behavior as the result of a complete night of rest.

I recently saw a 6 year old boy who had significant behavior problems in school that included biting one teacher, hitting another teacher, kicking a child, and punching another child. This boy was often out of his seat to the point where one note described him as doing cartwheels in class. One of my more recent concerns about small children displaying behavior and attention problems has been sleep. This boy was going to sleep at 11 PM and waking up at 6 AM to go to school. His teacher also reported that he would fall asleep at school. We know from research that 6 year old children need 11 hours of sleep per night. We also know that sleep deprived children are inattentive, active, and aggressive. I recommended that he get more sleep, and provided suggestions. His mom called back recently (12-4-08) and told me that he had two consecutive days of on task, appropriate behavior after going to sleep at 8:30 PM rather than 11 PM. It is likely that most psychiatrists would have put him on medication that kept him up, rather than working on the sleep problem

One child, a boy, attended a Christian school. His physician thought that he had ADHD, so he prescribed Cylert (Pemoline Magnesium), a very dangerous drug, despite published articles warning that it was harmful, in addition to an FDA warning. The boy also had Celiac Sprue, a digestive disorder in the same category as a cluster of irritable bowel disorders. He was not permitted to consume wheat products. The school psychologist that saw him three years earlier had warned his parents that Cylert was dangerous and gave them literature about its harmful effects on the liver. The physician did not change the medication despite the parents conveying the concerns to him. I was told, when I got to the school, that the teachers wanted him to take more medication. I saw a boy with yellow tinged skin. The "whites" of his eyes were yellow. I gave the parents a computer print out of an article that listed the dangers of Cylert, with the parts describing liver damage and potentially fatal results highlighted. I told them what I saw, without diagnosing anything else ("Your child has yellow skin and yellow eye whites"). I told them that it was critical to give the boy's physician the information. I tested the boy.

I went back to the school three months later. The parents of the boy saw me. They ran over to give me a hug. They exclaimed that I had saved their child's life. They also told me that their son's teachers congratulated them on increasing his medication after it had, in fact, been stopped, because he was paying attention and working harder at school than ever before.

A young girl's grandmother called me and begged me to test the child. The school in Texas had claimed that she had ADHD. The parents gave permission for the assessment. The principal at the school had called them once too often. They told of how often their child got out of her seat without permission. Her mother described how her daughter began to tap her feet while standing outside of the principal's office, with principal saying something like, "Will you look at that! I told you she has ADHD!" I accepted the case. The grandmother paid for her granddaughter's airfare. I saw an active, busy nine-year old. She had to use the bathroom twice while I tested her for about an hour and a half. My interview also revealed that this child's hand hurt after writing for a short time. I advised the mother to obtain a complete physical, being certain to give the physician a copy of my report (which explained the physical problems that I - a psychologist, not a physician - observed). The child had an arterio-venous (blood vessel) jumble that was causing her significant kidney problems - resulting in a frequent need to use the bathroom. The teacher, who limited bathroom breaks for students, was very concerned about how fidgety she was, and thought that this child had ADHD. It also turned out that the child had a bone malformation in her writing hand that caused pain. The symptoms of ADHD magically disappeared after the appropriate medical treatment of both problems. Ask yourself this: How many psychiatrists request a complete physical before they prescribe medication for ADHD? Think about it. See if you can obtain a copy of a book written by a psychiatrist about the usual failure to check for medical explanations of active behavior. The Hyperactivity Hoax is the book written by Dr. Sydney Walker, III. I hope that you find it and read it.

There are many drug-free programs to treat attention problems. The drug companies (they like to be called pharmaceutical manufacturers) have much more money to publicize their products than authors of drug-free treatment programs.

You could also check out something that I've written as a suggested program for all children:


Tuesday, September 30, 2008

Join the association

A Russian discovered something interesting about 110 years ago. He was studying the salivary (spit) glands of dogs. Pavlov noticed that his dogs would start producing saliva way before they saw or smelled food. This happened because the dogs heard the very distinct (to them) boot sounds of the lab assistant that brought them their food. This somehow became distorted in the pages of history to the ringing of a bell. The same boot sounds at other times would also produce the saliva. The dogs learned that boot sounds meant food and made a connection. That connection stayed even when there was no food forthcoming. How could this ever be useful to people?

A professional journal article described a developmentally challenged person would only eat for one particular staff member. This became a problem when the staff member took off for the weekend, a holiday, or a vacation. A clever psychologist paired a succession of staff members with the preferred staff person, and the developmentally challenged person soon accepted a bunch of staff persons to provide food.

Certain levels of spinal cord injuries cause paraplegia and a loss of bladder control. Someone discovered that these paraplegics could empty their own bladders before they had accidents by applying a mild electric shock on the area outside the body that was above the bladder. These folks carried a small device that applied the shock. Before long, many paraplegics discovered that all they had to do was move their hand to area of their body above the bladder, and they would urinate without using the electric shock. There was an association between the movement and emptying of the bladder. Now, think about association learning and education.

One problem with learning to read is learning the sounds that go with letters. Some letters have multiple sounds that change depending on the other letters nearby. Thinking about the rules for word sounds might make an educated person become tongue-tied. Few of us think about the rules after a solid reading education. Some folks find it difficult or impossible to learn the rules involved in the sounds that letters make. Whole word reading may be a way to overcome it, even though some phonological dictators (nice double entendre there) would disagree.

Many less able children at the appropriate age can identify a picture of a dog, and say dog. Learning to read the word dog is an altogether different story. Suppose you repeatedly pair the printed word with the picture? What happens if you fade the picture (progressively make it less and less clearly visible)? It can be done by copying it, then copying the copy until it becomes almost unrecognizable, while maintaining the visible "strength" of the printed word beneath it. You can even use action pictures to teach action words. Sure the technique has its limitations. It also has the potential for teaching something that might have otherwise been "unteachable."

Another important skill that can be taught by association is multiplication facts. A bunch of teachers do not approve of this. You can do it at home and they will never know. Produce pages that contain basic math facts from multiplication tables. Mix up the calculations so that the children do not learn them in order. Now, give them a calculator. That is correct, a calculator. Few things equal a calculator for teaching math facts. Have them use the calculator to solve the problems. Do it over and over again with different pages and problems in different order. Give them a break every 30 to 45 minutes to stand-up and walk around. Set a timer for about five minutes, and then get them back to work. Work on it all weekend. They use the calculator on the first weekend day (Saturday). On Sunday start them with the pages and without the calculator. Check their work. Note the ones that they got wrong, and use them on new pages of problems to work with the calculator. Do it again next weekend. Be certain to provide some fun activities like a trip to the movies on the second weekend. You child has a great chance of learning the multiplication tables (multiplication facts) without stress this way and it is all because you joined the association.

Sunday, September 28, 2008

Silent Arguing

Some folks allow loud arguments to get in the way of having a functioning marriage. A therapist who does not do family therapy suggested to a patient that she and her husband might argue silently in the following way:

Get a notebook for arguing. Go to the bedroom when you want to have a disagreement. Sit on the floor, on the opposite sides of the bed with your back against the bed. Bring the notebook. Each side has a pen or pencil. The person carrying the notebook into the room goes first. That person writes their first comment, question, diatribe, whatever concerning the issue at hand and passes the notebook across the bed to the person on the other side. Never throw the notebook. pass the notebook so that the other person can reach it. The other person sits with back against the bed until the first person has turned around with their back against the bed. The receiving person gets the note book, reads the first statement, skips a line, and responds in writing. No talking is allowed. The second person passes the notebook back after writing, and the process continues until a peaceful agreement is reached.

The first time the therapist's patient tried this, the total silence made the children curious. They timidly knocked on the door to find out what their mother and father were doing. The only thing that they were allowed to do is tell them that they were having an argument. The puzzled children left the room.

Another therapist told the therapist that this technique was also used by the well known psychologist, Dr. Stella Chess.

Friday, September 26, 2008

Run Away Tots in Stores

So many parents have experienced the horror of a small child leaving their side and getting lost in a very big store. There are parents who purchase a harness and a sort of leash for their child to prevent the problem. Then there are those who think, "I'm not going to treat my child like a dog." Still others have clever children who figure out how to remove the harness or leash and get away. This last one is one that I've seen.

I love Google because you can search for answers quickly and easily. I did a search and read a number of the answers. I found a parent who taught her child the old fashioned game of "Red Light, Green Light." I mentioned this to the mom of the child who was always running away, and she liked the idea. She taught the game to her very clever little girl. The idea, is to practice the game in several settings, starting at home, then working in a park, moving on to small stores, and working up to the larger ones. After the child learns to stop on mom saying "Red Light" you can make the game more entertaining by throwing in a different color with something else to do. For example, "Blue Light" could mean "jump up and down" or "dance." Be aware or beware of stores that have "Blue Light Specials" though. Some food stores might resort to an overhead page, "Child jumping/dancing in Aisle 5" when you yell "Blue Light. You will be able to find your child that way.

Another parent that I know professionally, has stopped her child with another solution. They have a fish tank/bowl in their home that has a high turnover in residents. Every time the little girl goes to a big department store, they make the first stop to buy a fish (for a very low price) in a plastic bag. The child has to hold the bag without running or she might drop it. This mom has never lost her child while she was holding a fish in a bag.

Monday, September 22, 2008

Cheap Thrills - Low cost fun to have with toddlers

Television and electronic games have all but stopped parents from engaging in some of the older types of activities with their children. One of my greatest joys occurs when I draw a smiling face on my thumb and show it to a toddler. I have not met one who does not want me to draw a face on his thumb. Then, my thumb "looks" at his/her thumb and starts having a conversation. What a great way to teach social interaction! You could even draw them on his/her other fingers so that they can have a play group. One possible secondary benefit to this thumb person is the possible resistance to thumb sucking, because he/she would not want to "eat" the thumb person. Be certain to use nontoxic markers when you draw them.

Drinking straws make really cool musical instruments. You flatten one end. You really have to work at flattening one of those plastic straws, unless the plastic is really thin. Then, cut off the corners to leave a near point (leave a little bit of a straight edge at the front). Continue to work on flattening that tip. Insert the cut end in your mouth so that you lips are on the round part. You may have to work a bit to get the flat part just right. Blow. The shorter the straw, the higher pitch sound you'll produce.

Paper airplanes are a lot of fun. You can have distance contests with them.

Mood Swings in Infants and Toddlers

Disclaimer: This is not intended to be either a comprehensive review or a diagnostic rubric. The purpose of this paper is to present alternative hypotheses to a consideration of the reasons for mood swings and their treatment. The final decision about treatment and diagnosis depends on professionals having direct contact with the children and their families.

There are many causes of mood swings. The moods of children can change because of physical illnesses and environmental factors. Some children develop a “temperament” that may be perceived as being extreme. Unexplained mood swings in children might be termed idiopathic. It is this author’s experience that idiopathic expressions of an emotional nature are often given psychiatric or psychological labels. Thus, we see increasing numbers of small children being labeled as Bipolar or Manic-Depressive because of unexplained mood swings.

A brief list of physical causes of mood swings (not comprehensive):
Environmental allergens or toxins
Food allergies – manifested by low blood histamines, idiosyncratic food preferences.
Sleep disturbances that may or may not be related to environmental or physical causation
Headache that may or may not be related to environmental or physical causation
Child abuse (physical, sexual, or neglect)
Medications used to treat allergies - added 1-30-2010 - Montelukast (generic for Singulair) has numerous postmarket reports from consumers that children have severe mood changes while taking this medication - consider www.drugs.com/sfx/montelukast-side-effects.html
Ear infections
Endocrine (hormone) problems including juvenile diabetes/hypoglycemia
Vitamin deficiencies
Scoliosis (undetected spinal torsion – even of a mild nature)
Autoimmune disorders including HIV, PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus).
Coeliac Sprue
Yeast Syndrome – infantile seborrheic dermatitis
Seitelberger Disease (Infantile Neuroaxonal Dystrophy) – rare, autosomal recessive disorder.
Polycystic Kidney Disease – rare
Prader-Willi Sundrome – rare, and marked by obesity and food craving.

The New York Times Sunday magazine recently (September 21, 2008?) had a long article about the "Puzzle of Bipolar Disorder In Children." The article mentioned sections of the book The Bipolar Child by Papalos and Papalos, but left out critical information, some from the book, and some that was absent. Dr. Andrew Stoll, Massachusetts General Hospital, has done research comparing the effectiveness of Omega-3 Fish Oil with that of standard prescription drugs for treating Bipolar Disorder. I have had success with recommending it for my patients. They even discuss the success of parents using flavored, chewable fish oil capsules to treat the bipolar symptoms of children. There is a big question here. If it works, why haven't more psychiatrists recommended it? We might have a fairly good guess about that. Perhaps a side-bar might help.

I worked in a prison as a psychologist for about 17 months, and once attended a mental health conference for the Department of Corrections in my state. Drug companies (they prefer to be called Pharmaceutical Manufacturers) paid folks big bucks to speak, and brought out bunches of little gimmick hand-outs for attendees. One speaker discusses the benefits of a form of "hard drug" to treat Bipolar Disorder. I raised my hand and asked about the success with using fish oil (citing the research of Andrew Stoll, MD). His response was an inappropriately sarcastic, "You don't want a bunch of inmates running around with fish breath, do you?" Money makes people dumber than they really are.

There is research that also strongly suggests that a young child’s mood is often dependent on the mood of their caregiver. This means that mood swings of any kind expressed by a caregiver can result in having a child express similar mood swings as a reaction.

Being in two places at the same time.

Billy was a child who was identified as being brain blind. That just means that his eyes worked fine, but his brain wouldn’t tell him what he was seeing. Billy did not walk. He was about 12 years old. We worried about him because he would use his hands to punch himself in the head. The home that he stayed at thought that they had tried everything. They placed his hands into large plastic soda bottle with big holes in them so that he would not hurt himself as much when he punched his own head. We had a meeting with his parents.

Mr. and Mrs. Jones would sometimes take Billy home for weekends. They loved their profoundly retarded son. Mrs. Jones told the team at the meeting that Billy did not have a problem at home. I asked how they stopped him when he started to punch himself. Mrs. Jones said that she simply tells him to stop. I said that they needed to stay at the home so that Billy wouldn’t hurt himself. The rest of the team appeared either amused or angry. I explained that I wanted the parents to create an endless loop audiotape that played their voices telling Billy to not hit himself in the same way that they did at home. We had the tape in less than a week. The cassette tape player went where Billy went. Staff simply played the tape when Billy started to hit himself. It worked and kept on working.

The Magic Interview

Let’s talk about magic.

If I gave you any magic power right now, talk about what you would do.

Supposing you had the magic power to travel through time. Go back to a time that you want to visit. Talk about it.

Go ahead to a time that you would want to visit in the future. Talk about it.

Sometimes magicians meet up with others that can do stronger magic. Supposing there was an evil/mean magician who wanted to send you back to a time that you did not want to visit. When would that be? Talk about it.

That same evil/mean magician wants to send you to a bad time in the future. When do think that would be? Talk about it.

Another type of magic involves changing into other things, like people or animals. Lets talk about people. Who would you like to trade places with?
How would things be different if you did that?

What would that person say about being you?

Suppose you traded places with an animal. What animal would you pick? Talk about the reasons for trading with it.

What would the animal think about being you? Talk about it.

Supposing you could change your size. Would you become bigger or smaller? What would you do after you have changed, that you could not do now? Talk about it.

(Gender change). Supposing you could become a man/woman. The change would be temporary. Would you do it? Why or why not? What would be good about the change? Talk about it.

What would be bad about the change? Talk about it.

Talk about being invisible. This means that no one could see you or feel your presence. You could walk through walls, but you could not touch anything or any one. What would that be like?

Is there something magic that we have not talked about? Talk about it.

What's In a Reward? A reward by any other name. . .

With apologies to Shakespeare, the concept of reward has been restricted, much as the definition of a flower has been restricted to those colorful parts of plant anatomy that assure generational propagation. Some flowers are clearly not roses, dahlias, daffodils, etc.

Negative reinforcement or reward is something that psychologists learn about in school but hardly ever apply. Those who are not trained, or those who forget their training often make the error of thinking that negative reinforcement equals punishment. Here's the boring definition, "Negative reinforcement is anything (an event or object) which, by its removal, increases the likelihood that the behavior which it follows will happen again."

Darlene was an adolescent with Trisomy 21 (Langdon-Down Syndrome). She was not doing her work at school, saying "No" each time that she was given a task. Many times, she would push the person offering her a task. Few people would guess that she had rewarding "Nos." The task given to the paraprofessional (1975 to 1977) was to get her to do anything. We started with something simple, a board having large easy to grasp pegs. Sitting together, with Darlene saying "No" many times, the therapist takes her hand places a peg in it, and rapidly guides the hand to place the peg in the board. He then moves to the far end of the table. Darlene laughs.

Within two weeks Darlene was completing an entire pegboard in order to get the therapist to move away. This was negative reinforcement in action. There are obvious ways to enhance the negative reinforcing value in cases like this. One would be to work out heavily in a fitness center, getting all full of perspiration. Don't shower. Perhaps your Darlene will work twice as hard to move you away. Another way makes use of the negative reinforcement value of garlic breath, ordinarily an occupational hazard for psychologists and therapists.

Let's consider the case of Jean. This 19 year old loved to shake his hand in front of his face. Way back in 1978, he was a resident of a facility for severely and profoundly developmentally delayed people. He had a goal to be able to work at a sheltered workshop task or tasks. The psychologist, Dr. Paul, was a well trained behaviorist. He tried every thing that he could think of to get Jean to stop shaking his hand in front of his face in order to work. His attempts included rewarding competing behavior (actions that could not be completed unless he used his hands), rewarding progressively lower rates of hand shaking, and others. Nothing worked. Paul ate lunch with the psychologist and informed him of the bad news. He was discharging Jean to his living unit where he would spend his days shaking his hand in front of his face. I asked Paul if he had tried to put gloves on Jean's hands. It did not make sense to him. It did not make sense to any one at the facility. However, they reluctantly agreed to a trial run.

A large number of staff members gathered in the dayroom of Jean's living unit. Jean came in, accompanied by staff members. He leaned against the wall shaking his hand in front of his face. The only time that this did not happen for more than a few minutes was when he slept. A staff member brought in a pair of gloves. As soon as the gloves were placed on his hands, he stopped shaking them in front of his face.

It did not take long for Jean's improvement to become dramatic. He was soon at the work training facility assembling pens. The gloves sat on the table in front of him. He never needed them as long as they were visible.

A parent of a recently evaluated adolescent revealed a similar treatment for head banging. Her adopted son used to bang his head against the same place on the wall near his bead. Bucky was profoundly visually impaired. His mother desperately wanted him to stop hitting his head on the wall. She came up with the idea of gluing foam ceiling tiles over the area around the bed. The ceiling tiles glued to the wall stopped the way that the head banging sounded and felt to Bucky. He stopped banging. What is more surprising, he never tried a different area of wall for the head banging activity.

Within the past few months (2009), I had the chance to evaluate a 2 - 3 year old boy who lived in a very rural part of the state. His home was the only one on the narrow road. The little fellow was born with some problems that interfere with swallowing and with breathing, so he continues to survive with a tracheotomy tube. He is fed through a tube in his stomach wall. There is a full time nurse in his home to suction fluid accumulation from the trache.
One of the problems that I needed to address with Rocko was his hand biting behavior. He bit his hand so hard on several occasions that it bled. One of the major university medical hospitals solved the problem with prevention. They have his arms in removal, semi-flexible restraints that keep his hands away from his mouth. I observed that Rocko would bang his hands on surfaces. Sometimes, he would strike flat surfaces with the palms of his hands. Sometimes, he would strike the surfaces with the heel of his hand. He also held his fingers pointing downward and struck his finger tips on flat surfaces. It seemed to me that this indicated that his hand biting was not at all related to oral stimulation. His goal was to stimulate his hands. I recommended providing hand stimulation and pressure along with a consultation with an Occupational Therapist. I'll let you know what happens.

This is all about thinking in ways that are different. There is an old saying, "If you keep doing what you've always done, you'll get what you've always gotten." That much is true for behavior change. If you use the same way of thinking, without trying to change it, you may never be a person who changes behavior.

Sunday, September 21, 2008

Control Issues with Children

One of the major issues between children and parents is control. Children want it, and depending on the age of the child, parents do not want to give it up.

There is a way to control certain aspects of living with children by giving them the illusion of control. This is where Hobson's Choice comes in as a handy tool. The best way to illustrate it, is by the example of bedtime.

Suppose you want your six year old child to go to bed at 9:00 PM. You go into his/her room, where s/he is happily watching a cartoon show on television at 8:55 PM. You offer the following choice: "You can go to bed now, or at the end of the show (which will be 9:00 PM). What is your choice?" I don't know of many children who will immediately stop to go to bed. The child almost invariably picks the end of the show. Your child gets a bit of control, while you achieve your goal.

This type of behavior management tool stops being useful when the child reaches 8 or 9 years old. That's when they figure out that you have not given them a choice at all. Smile, because you used the tool for all those years before they "got smart."

Thursday, September 18, 2008

Understanding Time Out

Time-out. No, really, TIME OUT. This is probably one of the most misused and least understood forms of behavior management (behind spanking - get the double entendre?). Please stop it, read this, and then decide whether you want to use it.

The original name of the procedure defines it much better than the shortened name: "Time-out from positive reinforcement." This literally means that a person who is in time-out must be deprived of anything that is rewarding. This is no joke, because using Time-Out (TO) in the wrong way can end up rewarding behavior that you want to reduce or stop. Pause and think about the kinds of TO that you use, and how they might be rewarding your child.

Varieties of TO
Baby, you send me.
Parents often use a child's room as a place for TO. This is absolutely the worst thing that you can do. A child's room contains multiple opportunities for reward. Most children can rapidly find ways to amuse thenselves in their room even when you make them sit on their bed. The problem here is the way that parents think. They think that when they leave, the child will remain on the bed. They go back to check on the child and find him/her on the bed, concluding that s/he must have stayed there in their absence. I often wonder if the parents can silently and invisibly transport themselves into the child's room, or install a camera/monitor to keep an eye (or two) on them during TO. Staying in child's room during the one or two hours of TO might be a solution. Why don't you try it? Don't talk or answer the telephone while you wait.

Smart parents might think that they can overcome the reward factors of the child's room by sending him/her to a bathroom, parent bedroom, or other location. Does anyone know how many things can be used for fun experiments in bathrooms? My personal favorite is finding out how much toilet paper it takes to make the commode flood. Bathrooms are great places for children to practice their interior designs skills. Parent bedrooms are great because of a supply of perfume, jewelry, and clothing. Those are wonderful opportunities for creative play.

How many folks want to put their child into TO when their behavior becomes inappropriate at the park, supermarket, or shopping mall? Try sending them to their room then. This is not a portable form of TO, is it? Most, but not all, forms of TO suffer from the problem of only being able to be applied in certain settings. There are parents who attempt to apply TO in Walmart by making the child sit on the floor in toy aisle. Nice Try. The selves are not empty at the bottom. A child can be rewarded by being allowed to fantasize about having the toy in front of him/her, or s/he can simply reach for the toy while mom/dad isn't looking. Never leave your child locked in your car as a form of TO, particularly if they know how to start it without a key, and can figure out how to drive.

Some people think that a corner is a great place for TO. It is great if you can temporarily glue the child's head to the corner (don't take me literally). Does anyone have a child who does not look away from the corner during this attempt at TO? Be honest now. Some folks simply put a child on the couch in the Living Room while they (the parent) watch television. There is no reward there, right? There was this one mom who put her child on the floor for TO and handed him a cup of his favorite juice (I'm serious here). By the way, how portable are corners? Some places don't have corners (for example, the park).

The novel.
One problem with TO is the struggle to get a child to go. This is a "no struggle" variety of TO. The parent simply removes himself/herself to a room of their choice, locks the door, and reads a novel (hence the name). Children (especially fighting siblings) notice the absence, stop fighting, and hunt down the parent. They (or one) find the location and do one or more of the following:
1. Resume the bad behavior outside the door. This clearly demonstrates how rewarding your attention has been to them. Any attention is better than no attention.
2. Beg you to come out with a typical voice characterized as a whine.
3. Break down the door of the room you are in.
You can respond by repeatedly saying (as if you are a scratched CD), "I will come out when you have quiet for as long as I want." The child pauses for 5 seconds, and asks, "Was that long enough?" Don't answer. Wait at least ten seconds (preferably eleven seconds or until you have finished reading a chapter).
The problem, as previously noted, is that you cannot abandon your child at Walmart in order to go to their restroom and read a novel.

It comes with the territory
Carpet squares make handy dandy portable forms of TO. You can put them anywhere and tell a child to get on it and not move. You can takes those almost any place to use for your very own TO spot. The presence of one that has been used before is known to strike fear in the hearts of most kids. People love it because of that. Children love it because they still get the reward of seeing their parent being aggravated. That really is rewarding to many children - I promise. Keeping the child on the square can also be a problem unless you have a way to put up a fence around the carpet square (just joking here).

You won the blue (or any other color) ribbon.
A simple ribbon or button can be designed to signal that child is in TO. Heck, you can even have a t-shirt made that says, "I'm in Time-Out. Don't speak to me" on the front and back. Yeah, that'll work. Ever see a kid approach another and say, "What did you do?" Does anyone remember those signs that kids put on other's backs that say, "Kick me?"

Try the silence of the lambs.
I wish that I had a dollar for every school that has used silent lunch as a punishment. This form of TO is particularly bad for so many reasons that I might miss one. People who really know about changing behavior know that it is best to apply a consequence (like reward, TO, etc.) close (in time) to the behavior. Just saying that the child is going to get the consequence is not enough. Kids who are rambunctious at 8:30 AM get silent lunch. Big deal! Many kids forget the reason for silent lunch, so the teacher has to remind them. Can you hear it? "You were so bad at 8:30 this morning, you have to eat in silence now." What about little Suzy who was not doing anything wrong? Well, she is part of the class so she has to get punished as well. How many teachers actually consider the behavior that happens between 8:30 AM and lunch? What happens if a kid passes gas loudly during silent lunch? How many schools serve beans (more than once a month) at lunch? Everyone laughs and the class gets more punishment. The kids who have silent lunch get to throw their peas and stick straws up their noses in total silence. They get to see other kids enjoying conversation. They get to raise their hand to use the bathroom, where they talk and have fun.

Let's get grounded here.
Grounding is a form of semi-TO. "Semi" means "partial" in more ways than one. A kid gets to be deprived of certain privileges. For example, they can't go out on weekends, but they can still talk to, and see the same friends at school. That's effective, eh? Grounding is often done for so long that a child (even a teenager) forgets the reason for it. Have you every heard of a parent telling a child that he/she is grounded for life? Some kids become experts at begging, so that the grounding ends sooner than originally planned, enabling them to think (and believe) that they have "gotten over" on mom and/or dad. Indeterminate grounding is one way to stop the problem. Why is it so hard to say to a kid, "You are grounded until further notice." You define what grounding entails (all limitations) except for the time. "They'll keep on asking, "Is it done yet?" That sort of anxiety is a priceless form of punishment. Tell them not to worry about it, and that you'll make you mind up soon. By the way, if you ground a child from television, for example, be certain that they can't get to one.

The eyes have it.
One of the best forms of TO that I know is literally within your hands. The origin comes from having done therapy with a pre-school teacher. She complained that she was unable to quiet her pre-school class after lunch. She learned, from the therapist, about having them close their eyes for a matter of seconds. The teacher reported that it worked. The children remained still and quiet while their eyes were closed, and most miraculously, they were calm afterward. The psychologist periodically asked about the ongoing effectiveness of the technique. It worked for the entire school year. Whenever the class was rambunctious, the students eyes closed for seconds. This technique is easily applied individually. Place the small child (you can't do this with child much over seven or eight years old) on your lap with their back toward you. Cross your legs over theirs. Position one hand on the back of their head, and taking care not to poke their eyes, cover their eyes with the other hand. Hold for only ten seconds. You can apply this technique anywhere that you can take your hands. It works great while the child is seated in a shopping cart.

Understanding rules about TO and punishment
1. Never use negative consequences/punishment without rewarding the desirable behavior that you want to increase.
2. Never keep a child in TO for so long that he/she cannot remember the reason for TO.
3. Understand the "Punishment Burst." Punished behavior gets worse before it gets better, leading people to believe that the consequence is not working. Persist a while longer.
4. Apply any consequence (reward or punishment) immediately after the target behavior.
5. Avoid using group consequences unless you are certain that all members of the group engaged in the problem behavior.

Think about the special case of attachment disordered children.
Most children with attachment disorder have abandonment issues. Most forms of TO represent another type of abandonment and bring back very bad memories. The technique of covering the eyes with your hands allows for physical contact as well as a consequence. The holding reduces the abandonment issues, while the darkness provides a TO consequence (take care about the darkness as well - you may have to stop covering the eyes and just position the child with his her back to you).

Positively Time-Out

Some forms of TO can be a reward.

Finding the recesses of the mind.
TO can actually be a break that gives children the energy to continue. There was a teacher who wanted to stop the loss of attention that his middle school students experienced about half way through class. Recess does not happen in American middle schools. We came up with a guided, in seat recess. The entire class, with eyes closed, was guided through imagining their activities at home after school. They were told to continue imagining. The TO lasted only a minute. His students were much more focused on their school work after the pause that refreshed them.

Playing non-musical chairs.
Half way through a class period, have your students put their books (all of them) on their desk. Move the front row to the back, and have the other rows move up one row. Vary this with moving the back row to the front, and the others move back one row, the left column of seats to the extreme right, the righ colmn of seats to the extreme left, etc. The movement is a positive form of TO.

A game for most ages

This is a very simple game that teaches turn taking to small children. The marvelous thing about the game is that everyone who plays wins.

This is a game that toddlers and adults can play as a family. Military deployed parents can even play it with their child. Each player needs a crayon or a colored pencil. Play the game on a piece of paper. The first play makes a mark/scribble. The next player also makes a mark/scribble that has to touch or cross the mark of the previous play (this rule can be suspended for very small children who might not understand it). In the case of a deployed parent, the paper is sent to him/her, the parent makes the mark, and then sends it back home. Everyone decides when to stop. Each player then gets to say what the created conglomeration of marks looks like. They have to say why it looks like that. Be certain to encourage paper turning (lengthwise, sideways, etc.) or use a round piece of paper for the game. say what the thing looks like in each orientation. Put the every participants name on the finished creation and write the date. Hang it someplace so that people who visit can see it. The child can practice their conversation skills by telling all about the "picture."

One more thought about the activity. Wouldn't it be great if one of these fell into enemy hands? Think of the resources that Al Qaeda would have to devote to breaking the "code!"

Wednesday, September 17, 2008

Baby Attention and Activity

Infants and toddlers are naturally more active and seemingly inattentive than older children. They are for the most part inquisitive and want to learn about their enviornment. Sometimes they seem more active and inattentive than we, as adults, would like them to be. The best advice is sometimes easier said than done. That easy to say, harder to do advice is, "Get over it!"

Don't hate me for this next part. Television is a very, very poor babysitter/parent. For one thing, a television does not provide the warm, secure, physical, safe base that a baby/toddler needs to have. The second part of this is even harder to understand.

Babies/toddlers who watch too much television end up having a tough time paying attention. Read it again - Babies/toddlers who watch too much television end up having a tough time paying attention. Check this link out: http://www.sciencedaily.com/releases/2008/07/080715071452.htm The internet is full of information about this (pro and con). Read it after your child is asleep. Think this way, though: If it is true, and I let my child watch television too much as a baby and toddler it may be difficult or impossible to fix their inattentiveness when they are older. Best advice - no more than one hour per day of television for a child. Give up your soap operas, game shows, talk-shows, and movies for your child, or record them so you can see them when they are asleep.

Why does television harm the ability of a child to pay attention? Because it moves (shifts attention for them. They don't have to turn pages. They can't operate the devices that pause television action so that they can look at things that interest them. Their brains, in essence, become lazy. They stop moving to explore their surroundings because it does this for them. This, believe it or not, can be a terrible thing.

How do you acquire the attention of your baby/toddler for table activities (such as eating at a restaurant or with the family, or playing to learn)? There is research on this. Make several (as many as you can) placemats with very "busy" designs (paisley, multi-color, abstract with small details). Laminate different designs on each side of an identically shaped, sized piece of cardboard board. Circular shaped mats are best because turning them makes the mat into something new. Place the mat on the table where you want to work with your baby, get some blocks (smooth sides - no linking blocks like Leggos (tm)), crayons and paper, etc. Have fun! Change the mat every few minutes.

What is the best color of block/crayon for your child? Red.

Tantrum Episodes

Every child has tantrums at one time or another. Parents are often frustrated about stopping tantrums. some children tantrum because they are not getting what they want. In those cases parents try to wait until the tantrum ends. Giving in, even once, rewards the tantrum so that the child will be likely to use it as way to obtain something again and again and again. This is how parents can end up having 16 year old children who have tantrums. Perhaps it would be helpful to share a few tales of tantrum busting.

A parent tells me that she has stopped her child's tantrums. I asked how she did it, and I was told about a wonderful technique with mirrors. The child has a tantrum, and the parent takes out a mirror and holds it in front of them. It shows the child what they are doing and how awful they look while they are doing it. Using a mirror put a rapid end to any tantrum that her child had. The idea of a reflection of undesirable behavior to stop it is good. People ought to try it.

The 7 or 8 year old girl was on the floor outside of her second grade classroom. Three teachers, two women and a man were standing around her telling her to get up and go to class. The girl just kept on screaming. No amount of talking (by the teachers) worked. One teacher bent over and gave a gentle touch to the girl's shoulder. She kept screaming. The psychologist was walking down the hall.
He stops and says, "I can get her back to class in under a minute. Would you like me to try?" The three teachers look amused. The girl does not know the psychologist. The three teachers agree to let him try.
We all know how cold it is on the bare hallway floors of many schools. The psychologist gets on the floor and lies down facing the girl. The teachers are watching. The girl looks at the psychologist. At that moment, the psychologist puts his thumb in his mouth and sucks on it. No, the psychologist does not make it habit to suck his thumb. The girl does the same. It is very difficult to scream with a thumb in your mouth. The psychologist removes his thumb from his mouth and says, "Mine's chocolate. What's yours?" The girl takes her thumb out of her mouth and quietly says, "Strawberry." The girl and the man (50 year old psychologist) suck their thumbs a few seconds more. The psychologist stops, and says, "Is everything okay?" The girl nods, and says, "Yes." The psychologist asks, "Are you ready to go back to class?" The girl smiles and says that she is. The psychologist says quietly, "You can go to class now." The girl gets up and walks into class. The three teachers are speechless.

Baby tantrums leave parents feeling hopeless when it appears that there is just no way to stop them. The center of a tantrum is the head. Babies scream and cry. Some tantrums include other behaviors that go beyond the head, like flailing arms and kicking feet. Some babies have worse tantrums than others. Most tantrums last for less than thirty minutes. There are serious problems present when a tantrum lasts longer than that. Babies who have spend an extended period of time having their needs neglected tend to have extremely long and intense tantrums. Baby Ben was an example. The police found eight-month old baby Ben in a filty room with a mattress on the floor. There was a half eaten bowl of macaroni and cheese on the mattress. His face was caked with dried macaroni and cheese. There was a bottle of sour, spoiled milk. There was no telling when he last had his diaper changed. His great grandfather took temporary custody. Two and a half year old baby Ben had become a tantrum champion. He could tantrum for eight hours straight for no apparent reason.
Ben was up for adoption. The potential parents knew him, and about his behavior. They wanted him evaluated. The assessment team met with the great-grandfather, Ben, and his social worker.
The tantrum started within the first minute of the team meeting to plan Ben's assessment. The psychologist asked to work with Ben immediately, in front of the team. A kicking and screaming Ben crossed the table into the waiting arms of the psychologist. The psychologist removed one shoe. Ben did not stop. He took off Ben's other shoe. Ben was still screaming. The psychologist eventually went through two complete cycles of removing AND putting on Ben's shoes and socks, one item at a time. Ben did not hear one word from the psychologist. He stopped screaming and raging. The next tantrum began almost fifteen minutes later. Ben, in the arms of the psychologist, had to endure only one cycle of sock and shoe removal because he calmed down so quickly.
The team took Ben to a room to do the assessment. Poor Ben was confronted by a team of three professionals assessing him at the same time. He started to scream. The psychologist picked him up. Ben looked the psychologist directly in the eyes and said, "Feet." Ben did not tantrum again during his visit to our diagnostic center!

Tuesday, September 16, 2008

Asperger Teen Wearing Baby Brother's Diapers

Many parts of this article have been changed to protect identity.
There are some parts of this article that should be rated PG-13 because they discuss human sexuality.

Roger was a 12 year boy who was diagnosed with Asperger Disorder. His father worked for UPS and was away from home frequently. His step-mother was a devout Episcopalian, who believed in following religious teaching closely.

Roger had a distinctive voice problem. It sounded like he was whining all of the time. He also had some unusual habits that were consistent with his diagnosis. The family had to lock food storage cabinets and the refrigerator because of his unusual food preferences (he liked to eat sticks of butter or margarine, dry drink mix powder, and the liquid from pickle jars). The behaviors that caused him to come to my attention were his wearing of his infant brother's diapers, and the fact that he refused to take showers. He would also become angry because his step-mother would yell at him for wearing the diapers. They attempted to solve the problem by locking up the clean diapers. Roger solved that problem by wearing the wet/soiled diapers that he took out of the trash. He was smart enough not wear diapers to school.

Roger never talked about his reason for wearing the diaper. I did not know of a medication for diaper wearing, so I did not refer him to a psychiatrist. I'd bet that most psychiatrists would figure out a medication to use.

Ms. Wanatoast came in about a month after therapy started. She was in a tiff. She had discovered why Roger was wearing diapers. This proper lady found him seated on the bathroom floor with a diaper under his bottom, masturbating. She told me that he was going to hell because he was masturbating, and she did not care what my beliefs were about that. I had to stop him from doing that. My first thought on the matter was that Roger's masturbation had actually caused a vision impairment - her's. I told her that I would work on the problem.

She went into the waiting room, and Roger came in. He looked very dejected. "Roger, you are not going to hell because of what you did. I cannot stop you from doing what you did. I can help you solve your problem and improve your situation." He looked up and smiled. "Let me guess, Roger. You were using your brother's diapers as a way to get rid of the mess." He smiled and shook his head in the affirmative. "Are you interested in learning about a way to get rid of the mess without your mother finding out?" Of course he was. I told him that if he masturbated in the shower, the water would wash the mess down the drain. He liked the idea.

Ms. Wanatoast came in for the next session. She was smiling as she came in to the office and said, "You are a genius! Roger is not wearing diapers anymore. He stopped masturbating, and he is taking a shower every day. Sometimes he takes two showers a day." It was difficult to keep myself from laughing, but I thanked her for her praise."

Roger and I worked on his mother's anger. We figured out a way to keep him from responding to it. It worked. Do you want to know how? Ask in a comment, and I'll tell you.

Monday, September 15, 2008

Culture, Adolescent "Depression," and Nonverbal Signals

This 17 year old boy was brought to my office by his parents because they were concerned that he might be depressed. Tom (not his real name) came in looking very flat and listless.

His parents said that he had lost all interest in the things that he normally enjoyed doing. He did not want to go out, and stopped talking to his friends. His appetite was down to nibbles.

Tom was a solidly built, attractive looking teenage male who, I think, should have been enjoying life. His voice tone was flat, and he looked very sad. I took a history, and checked for suicidal ideation or actions (none on either count). There were no recent deaths in the family. He was appropriately oriented, and there was no psychotic process. The family history was generally negative for a history of emotional problems and learning problems.

I sent them home with a promise to speak to Tom alone during our next visit.

Tom arrived on time for his next visit. He looked as depressed as he had the week before and slumped down in his chair. I asked him if he had a girl friend (I assumed, correctly, that he was heterosexual). Tom had an unusual response, "How do you get one around here?"

I asked where he was living the last time he had a girlfriend and he said it was California. It was important to find out how one got a girlfriend in California, because large parts of that state are vastly different, culturally, from the Deep South where Tom was now living.

Tom reported that many girls would approach him in the street and put notes in his pocket with their name and phone number. Tom clearly did not have to work to find girlfriends where he lived. This was a time when the behavior that Tom described was not acceptable in Fayetteville, North Carolina.

He learned that girls here behaved differently at the time. He was concerned that if he approached a girl for a conversation and their phone number that they might reject him. Tom was unaware of the signs that he was being admired by a girl or girls.

We discussed some of the nonverbal cues that girls give when they are interested in someone. I then suggested a typical teen hangout (The Mall) and asked him to try out the "education" that I gave him. He made another appointment.

The following week Tom was a changed adolescent. He was smiling, laughing and generally his old self. His parents were happy. Tom came into my office. I didn't have to ask what happened, he announced, "It worked. I got hooked up." I told him to come back if he ever needed to talk again, and he promised that he would.

Sunday, September 14, 2008

Rumination in Children

This was a problem that I first saw at the institution in Brooklyn. It happens too frequently in developmentally delayed children. Some of them find a way to regurgitate what they have eaten and then reconsume it. The behavior is disgusting and dangerous. People, you know, are not anatomically configured like cows. Bovines, it seems, functionally ruminate without harming themselves because of the structure of their digestive system. People do not have that structure. Vomiting brings up stomach acid. The stomach has a lining to protect against the acid which aids in digesting. The lining of the esophagus was never meant to be repeatedly in contact with stomach acid over a short period of time. The teeth are also harmed. There is danger of aspirating the vomit into the lungs causing other sorts of damage.

This is a long story, because it took me almost 15 years to come up with a solution. First, I went along with the most current treatment methods. These included paced feeding, which was continuous feeding of very small amounts of food that would be difficult to regurgitate. This sometimes worked, but required huge amounts of staff time and work. Another method involved using physical food characteristics to make rumination difficult. These kids were fed loads of peanut butter, which was sticky, heavy, and difficult to regurgitate. Kids can't live on peanut butter, not to mention the problems it would cause to someone with an allergy. That was in 1976.

In 1985, I found myself in the position of Director of Psychological Services at a small private institution in North Carolina. There was a 19 year old patient there who had Moebius Syndrome. This disorder involved the dysgenesis or agenesis of a portion of the 8th cranial nerve, and no innervation to the face. This guy could not cry, smile, or frown. His face looked like an unchanging mask. One thing that this guy could do was ruminate. He would eat, then sit in his rocking chair and ruminate. It was made even more disgusting by the fact that he would open his mouth so that the emesis was visible. The smell was awful, no one wanted to be near him to work with him, and he was really harming himself (his teeth were already severely damaged). I took a very brief baseline of his rumination, and then went to work. I had watched him a number of times, and noticed that his rocking had something to do with his ability to ruminate. I stopped his rocking in the chair, and his rates of rumination nearly disappeared. I thought that the rumination worked by making himself "sea sick."

Fast forward to 1991. I was working at a group home when I was asked to check on a six-year old girl who was ruminating. She would eat, and then engage in some very subtle movements that made me think back to 1985 and the young man with Moebius Syndrome. I did some research on motion sickness, and found something odd in an aerospace journal. The early space flights attempted by the Russians with dogs as passengers crashed because the animals got motion sickness, threw up, and damaged the wiring. The Russians solved the problem by removing the vestibular mechanism inside the dogs ears prior to flying into space. That worked. The dogs without vestibular mechanisms did not become sick during launch or in space. We could not do the same surgery on this little girl.

I thought, "What if we gave this kid some Dramamine (tm)?" I put in a request to accompany her to her next physical. I proposed the idea to her physician (a Medical Resident) who referred me to his supervisor. The supervisor and I had a brief discussion about space dogs, Moebius Syndrome and rumination. He decided to give it a try. Twenty minutes before eating breakfast, the girl took an appropriate dose of Dramamine (tm). She stopped ruminating for the whole day. The success lasted until I left and no longer had contact with the case. I don't think that this would work for every case. There are also more powerful anti-emetics to try (with more side effects).

This is an update. Recently saw a child between 1 and 2 years old (closer to 2) who was engaging in voluntary vomiting. I asked the mother to describe what he does before the vomit comes out. She described it: "First, he puts his hands down to grab the bottom of his seat. Then he shakes his head up and down (like indicating 'yes'). The vomit comes." Her instructions were to hold his head still (gently) from behind. This, by report of mother, paternal grandmother (reporting when her daughter in law was not home), resulted in a 100% cessation of voluntary vomiting. I recently came across a reference on line that might help to understand how the control of movement works: www.sciencedaily.com/videos/2007/0509-science_of_motion_sickness.htm

Saturday, September 13, 2008

Paper Airplane Therapy

There is an institution in Brooklyn for developmentally delayed children. It was pretty new in 1975. They looked for Psychology Assistants. That's how I got started. I passed the Civil Service test for the position. They ranked those who took the examiner in order of their scores. There would be about 130 jobs for the 3000 or so who took the exam. It was my good fortune to have scored well enough, with my undergraduate major in Political Science and my 12 credits in Psychology to get a job. I then went to graduate school in Psychology.

My first task was to somehow get a 20 year old, visually impaired young man whose measured intelligence was somewhere between 20 and 30 (IQ or standard score) to go to school. He was staying in his room and refusing to go. Nothing had worked to entice him to walk across the campus to the school building. My supervisor told me to get together some games, paper and crayons to make friends with him so that I could entice him to go to school.

The first day was a total failure. I took out some material that was appropriate for his functional level, sat at a table in his room and invited him over. He just said, "No." I stayed for the required time and left.

Benjy was a friendly fellow with thick eyeglasses and a winning smile. He eventually sat across the table from me smiling. Every effort to get him to play that first week was met with the same response, "No."

Friday could not come quickly enough. I sat across from Benjy, and I must confess that I was bored. Benjy was not bored. He just would not work, and would not go to school. My boredom resulted in taking a piece of paper and folding it into a paper airplane. I took it and gently flew it toward him, where it bounced off of his tummy. Benjy smiled, stood up with the paper plane, and threw it.

Now, I had a plan for Monday. I arrived with a fresh paper airplane (the latest model). Benjy was there waiting for me. I faced him toward the door of his room, and handed him the white paper airplane. Benjy threw it toward the door. He ran to it. I was right behind. When he got the plane I turned him toward the opening of the doorway. The plane went out of his room and so did Benjy. That morning, Benjy threw the plane across campus and into school. He sat at his desk with that plane on it, and did his work.

The paper airplane took him took school and back home every day after that. It was so weird that I became known as the person who changed a resident's behavior with a paper airplane!


My psychologist friends have said that I've used some unusual interventions during my career. Many have asked me to publish them in professional journals. I rarely have done so. A blog is an interesting way of publishing. It is available to anyone, and can be read by anyone. It does not have to follow a format or style sheet.

One has to be careful though. I am going to hide the identities of the people who have been treated to keep within the bounds of professional ethics. All of the things discussed are real, and happened during my more than 30 year career.