Monday, June 29, 2015

Pacifier Mistakes

Dear Melissa,
Should my child use a pacifier?

I think pacifiers are great...when used correctly. There are times such as car rides, church, etc..., where the pacifier is your best friend at trying to keep a child happy, quiet, and calm when you have few alternatives. However, a pacifier is not always the best option. Try to avoid common mistakes parents often make. 

1. Do not let your child form a bad pacifier habit.
I sometimes see an infant/young child happily and fully engaged in an activity, but still have a pacifier in his/her mouth. In this case, the pacifier is simply a bad habit. I have been at the park a lot lately with my own kiddos, and I am amazed at the number of children running, climbing, and playing on the equipment that are still using a pacifier. Yes, a child that is this old is probably too old for a pacifier, but that is beside the point. If a child is getting all of that fantastic sensory input from running, jumping and playing, then the pacifier is probably not necessary for calming, and is just a bad habit.

2. Do not offer a pacifier without regard for the child's actual needs.
Listen to and observe your child. Respond to their need for a hug, play, attention, etc... When you respond to your child's actual need, you will likely find the child is more content than they would be with a pacifier.

3. Do not offer a pacifier while your child is talking.
Now, I’m not a speech therapist. For that perspective, please see TEAM Speech Therapist Connie Clark's comments on pacifiers in my blog from last week. However, my experience has been that whenever a child is trying to speak to me with a pacifier in their mouth, they are nearly impossible to understand. If a child is old enough to talk, then he probably shouldn’t be using a pacifier during the day. If the child is still using a pacifier during the day (and you are an Auntie or family friend), have the child spit the pacifier out at least while talking so you can understand them more clearly. 

4. Don't allow an older child to continue use a pacifier.
Weaning a child from a pacifier is hard. Pacifiers are calming! If you take away what calms him down, you will have a cranky child, and who wants that? I agree with the pediatricians, dentists, and speech therapists that its ideal for babies to stop pacifier use by 1 year of age. I prefer to gently start weaning from the pacifier at 1 year of age, and slowly take away more and more environments in which the pacifier is used, until the pacifier is completely eliminated by 2-2 ½ years of age. In my experience working with children with sensory processing disorders, I know that children sometimes find other, less desirable, calming methods when their pacifier is taken away. So, a gradual approach to weaning is highly recommended.

Finally, my take as a pediatric occupational therapist is that babies use “non-nutritive” sucking (that is sucking without eating or obtaining nutrition) even before they are born. It is probably an infant’s first “occupation”. I remember my daughter sucking on her hands in the delivery room when she was only minutes old. Given correct use, I recommend pacifiers as I would much rather a child use a pacifier to calm themselves, instead of sucking on their hands (which are often germy) or over using the bottle/breast.

So, there you have it. I have provided a multidisciplinary approach to the question “should my child use a pacifier?” I have discussed a dentist's concern about orthodontic problems. A speech therapist's concern about articulation problems. And finally, my sensory-based OT perspective.

Related to this topic, in next week's post I will tackle this parent question, "Whenever my 10 month old cries at night I respond by giving him a pacifier. The problem is he cries 4 or 5 times a nights until a pacifier magically reappears in his mouth again. Help, I'm sleep deprived. How do I wean this child from his pacifier?"

Do you have questions you would like me to explore on my weekly blog? 


Monday, June 22, 2015

Pacifier Time vs. Language Development

Dear Melissa,
Thanks for your pacifier post last week. Should I be concerned about pacifier use impacting my child’s speech development?

To respond to your question I have reached out to one of our Children's Therapy TEAM's Pediatric Speech/Language Pathologist, Connie Clark.

Melissa:  Should infants be allowed to use pacifiers?  Why or why not?
Connie:  I think pacifiers are OK if the infant wants it. It should not be forced, but they are perfectly fine for helping to learn a coordinated sucking pattern before feeding. Also, pacifiers are certainly helpful if they help to comfort the baby.

Melissa: Are certain pacifiers better than others from a speech/language pathology perspective? 
Connie: I prefer for a child to use pacifiers with a smaller nipple. Unless the child uses a pacifier for an extended period of time and until they are older, it should not effect dentition or tongue placement. However, it is generally a good idea to limit the time an infant uses a pacifier, particularly if the child is not actually requesting it. 

Melissa: At what age do you recommend weaning/eliminating use of a pacifier?
Connie:  Generally, I feel that babies should start weaning from a pacifier when their teeth start to come in, or before 1 year of age. 

Melissa: What specific problems might occur if an infant continues to use a pacifier well into toddler-hood?
Connie: There is some mixed literature as to what extent prolonged pacifier use will impact language skills. We do know that there is some correlation between pacifier use and an increased risk of ear infections in infants (Nimela, Uhari, & Mottonen, 1995) and this can cause temporary disturbances in hearing. We also know that prolonged pacifier use can cause dental anomalies such as cross bites, open bites, and dental arches (Larsson, 1994).  These dental anomalies can then in turn impact articulation (Boshart, 2001) as well as create a tongue thrust which will also distort articulation (Van Norman, 2001). 

Melissa: What literature supports the efficacy of prolonged pacifier use?
Connie: Shotts et al (2008) found no real difference between children who never used a pacifier, children who stopped pacifier use by 15 months, and children who continued to use a pacifier past 18 months. This said, while not every child who uses a pacifier past the age of 1 year will develop problems, I think it is still a good idea to begin to eliminate the use of pacifiers at this time to help make sure that the young child’s speech can develop as normally as possible. 

Melissa: What is your biggest concern regarding pacifier use?
Connie:  If a child is old enough to communicate with words, phrases and sentences, it is very difficult to speak clearly with a pacifier in your mouth. So whether there are long term effects or not, communication can definitely be interrupted by constant and prolonged use of a pacifier.    

Thank you Connie Clark! Also, thank you to TEAM Speech Therapist Amy Love-Smith for your consultation. Next week I will offer my own thoughts on this from an occupational therapy perspective. 

 What are your thoughts on the risks/benefits of pacifier use? 
 We would love to hear from you! Also if you have a questions that you would like me to address in my weekly blog please don't hesitate to reach out to me.


Monday, June 15, 2015

Are pacifiers OK? A Dentist's Take

Dear Melissa: 
I am pregnant and due next month with my first child. What are your thoughts on the use of pacifiers? If I do choose to use a pacifier, which ones are best? 

First of all, congratulations!  There are so many choices to make with a new baby that can be a bit overwhelming all at once. Which doctors should you use, disposable or cloth diapers, which crib to buy, etc... The use of a pacifier is one of those decisions that is often tricky for new parents. Many medical professionals as well as parents have very strong opinions as to whether to use a pacifier or not. 

The American Academy of Pediatrics reports that there is no harm in the use of pacifiers and that pacifiers may actually have a preventative effect for SIDS. However, the La Leche League strongly discourages the use of pacifiers and wants infants to solely breastfeed. Personally, I have always been curious to see the different medical perspectives on this controversial pacifier topic. So, first we will explore the issue from a dental perspective. So I'm reaching out to my favorite local pediatric dentist, Dr. Karen Green from Pediatric Dental Associates:

Melissa:  Should infants be allowed pacifiers? 
Dr. Green:  Babies have a natural reflex called non-nutritive sucking, and will try to suck on objects even when they are not hungry. Some babies even suck on their fingers or thumbs before they are born. In this respect, a pacifier is not a bad option and can soothe the baby.  It may even be a better option than the child using a finger or thumb to suck on. A pacifier would likely be more hygienic than sucking on a finger/hand that was also used to touch everything else! In addition, a pacifier habit is much more easily broken than a thumb/finger habit. 

Melissa:  I have noticed that some pacifiers are labeled “orthodontic”. Are some pacifiers better than others?
Dr. Green:  Yes, some pacifiers carry the label “orthodontic”. Basically, the flatter the pacifier is at the roof of the mouth, the less it may affect the palate (or roof of the mouth) and it is less likely to cause orthodontic problems with prolonged use. 

Melissa: If an infant/child does enjoy using a pacifier, at what age to you recommend weaning/eliminating it?
Dr. Green:  I recommend weaning/eliminating by 2 years of age to avoid long term bite complications. If a child repeatedly sucks on a finger, thumb, or pacifier over long periods of time, the upper front teeth may tip outward and create an open space in the front of the mouth where the top teeth and the bottom teeth no longer meet. 

A special thanks to Dr. Karen Green for her opinions on pacifier use!  We will also be interviewing her in a few weeks regarding her opinions on bottles and sippy cups.  

front office area at Pediatric Dental Associates and Orthodontics
Do you have questions you would like me to explore on my weekly blog? 
Pacifiers, American Academy of Pediatrics (accessed May 2015)
Pacifier Overuse May Harm Speech SkillsAmerican Speech-Language-Hearing Association (Downloaded May 2015)
Pediatric Dental Associates, Northwest Arkansas
Sudden Infant Death Syndrome (SIDS), Mayo Clinic (accessed May 2015) 
Thumb Sucking and Pacifier UseAmerican Dental Association (Downloaded May 2015)
10 Tips to Breastfeeding for a YearLa Leche League (Downloaded May 2015)

Monday, June 8, 2015

Redshirt Kindergartner?

Dear Melissa,
My son will turn 5 in June. I am torn between starting Kindergarten this fall, or waiting another year. Your thoughts? 

As a pediatric occupational therapist, this is a question I'm often asked. Quite frankly, many parents of children who have summer birthdays begin asking me this question when their child is only 2 or 3 years old. When college athletes choose to "redshirt" a year before fully joining the team, they benefit from having an extra year to become stronger and more skilled in his/her sport. Similarly, some parents choose to "redshirt" their 5 year olds, holding them back from attending kindergarten even when they are old enough to attend. But, is having this extra year to mature and strengthen academic skills always the best choice? There are arguments on both sides of this debate. Here are a few of them.

An Argument for NOT Redshirting 
According to Dr. Elizabeth Graue, professor of early childhood education at the University of Wisconsin at Madison, "The oldest kids in a class aren't always the ones who third grade it all evens out. The difference of a year between two youngsters isn't noticeable at all." Additionally, the National Association for Education of Young Children (NAEYC) strongly recommends that all children should enter school when their school district says that the child is chronologically ready. The NAEYC further states that it is the job of the school to create an environment conducive to learning for each and every child, no matter what their developmental level is upon entering kindergarten. 

An Argument for Redshirting
Unfortunately we don’t live in a perfect world. While I understand the NAEYC's perspective, I'm concerned that some schools just don’t have resources to provide the extra support that some children need. AND, the demands of kindergarten keep getting greater and greater. Some expect children to be reading before they even start the first day of school, and they certainly must know all of their letters, sounds, and numbers. These expectations can be even more challenging for boys. Fred Brown, former president of the National Association of Elementary School Principals, reports that  "Generally, there is a developmental delay of at least six months between boys and girls, so a boy with a late birthday may be at even more of a disadvantage.”  

Key questions to consider
When helping families over the years there are certain questions I consider before giving the green light for kindergarten. It is certainly not necessary to respond, "yes" to all of the questions below. But, it is a good place to start. 
  • Can the child color a picture and cut it out, including consistently using his/her dominant hand?
  • Can the child write (not copy) his/her name with reasonable legibility. This counts even if it is just the first name in upper case letters. 
  • Can the child sit at the table for at least 20 minutes at a time. This could be for meals, playing legos, coloring, etc.? 
  • Can the child generally follow verbal directions? Not only does your child comprehend verbal directions, but does he generally want to follow directions?
  • Can the child use the bathroom independently?  This includes generally being independent with clothing management, wiping, flushing, and washing hands.
  • Does the child generally get along with other children?  Can your child share?  Is your child aggressive toward other children? Is your child always too shy to talk to another child? 
  • Does your child use materials appropriately. In general, can your child use various toys, eating utensils, art materials appropriately? After your child is finished with these materials, is she capable of putting them away properly?
  • Probably most importantly, is your child curious and ready to learn?
Consult with experts, then trust your gut
Ultimately parents have to trust their gut instincts. However, I applaud parents who try to fully inform themselves before making a decision. The professionals that regularly work with your child will likely each be able to offer advice. They may either alleviate unfounded concerns, or point out possible concerns given their area of expertise. Consider consulting with the following: 
  • Pre-K Teacher
  • Occupational therapist 
  • Physical therapist
  • Speech/language pathologist
  • ABA therapist 
  • Pediatrician
Do you have questions that you would like me to address in my weekly blog?

8 signs Your Child is Ready to Start Kindergarten, Amy Ettiger, (accessed May 2015)
Is Your Child Ready for Kindergarten?, Beth Levine,  (accessed May 2015) 
Is My Child Ready for Kindergarten? Ben Mardell and Melissa Tonachel, National Association for Education of Young Children (Accessed May 2015)
Children's Therapy TEAM, Offering individualized perdiatric therapies (OT, PT, ST and DT) in Northwest Arkansas

Monday, June 1, 2015

SUMMER! Water Safety

Dear Melissa,
This is your mother. I know last year you posted on your blog various excellent information on keeping kids safe around water this summer. However, BOTH of your children (my lovely grandchildren) had close calls with drowning last summer. Can you please remind your readers of water safety tips?  Love, Grandma Ro Ro

Yes, mother! So, my extended family was sitting at the dinner table this week and we were discussing various boating and swimming plans for this summer. I was reminded how close BOTH of my kiddos (aged 3 & 6 years) had come to drowning the summer before. Therefore, I figured that a water safety reminder was due. And, quite frankly, I might just make this a habit to re-research, re-write, and re-post this important information EVERY summer.

The CDC reports that drowning is the second leading cause of death for children aged 1-4 years (with the most common cause of death being birth defects).  For children under 14 years, drowning is also the second leading cause of death (behind motor vehicle crashes). 1 
A few reminders for keeping your kids safe!
Teach your kids to swim! 
Boys & Girls Club, American Red Cross, private pools/clubs (you don’t necessarily have to be a member), local colleges/universities, word of mouth private teachers, the options are limitless! Which reminds me, I need to sign my own kids up for swimming lessons this year!
Know your child’s personality/abilities. 
Does your child have Autism, ADHD, or is he impulsive? Know your child’s natural personality and if he tends to be a risk-taker or not. If he is the risky type, be even MORE vigilant than you would otherwise. Drowning is the #1 cause of death for children with Autism (Autism/Asperger’s Digest) However, don’t just assume that your very timid child who won’t even put his face in the water is automatically safe because he is timid. That is how my 6 year old who couldn’t swim a stroke ended up in the deep end of the public pool.
Underestimate your child’s swimming ability!
Yes, your child may have passed off the check list as a beginner swimmer, and yes, he may be able to swim across the deep end of the pool, but don’t then just assume that he can swim well enough to keep himself safe. When it comes to water safety, maintain extra vigilant with less than ideal swimming conditions such as the lake, swim parties, canoeing, the ocean, etc. It is also important to share your child’s swimming abilities (or lack there of) with any camp counselors, babysitters, or family friends who might be taking your child swimming. It is always a good idea to make your child wear a life jacket, just in case. Yes, many children will balk at the idea of continued use of the life jacket, but the rules are the rules!
It is easy to have a short lapse in supervision.
Again, true story. I was IN the water, sitting on the pool steps with my 3 year old within an arms reach. I turned my head to watch my niece doing a flip in the pool. I turn my head back, and my daughter is completely silent, under water, no splashing. Scary. Ninety percent of drowning deaths occur while the child is being supervised. 2  Unlike what you see in the movies, drowning is generally silent. No splashing. No screaming. Silent. Again, scary.
Make your home pool Fort Knox. 
Put up a barrier fence. Move pool furniture away from this fence so that it can’t be used as a step stool. Make sure pool toys are not left in the pool. Install a pool alarm to alert you if the pool water is disturbed. Lock back doors/gates to create additional barriers to the pool area. You get the idea. The more layers of protection you have surrounding the pool, the less likely a child will wander off and decide to go for a dip, alone.

Yes, swimming is excellent exercise and a great way to cool off in the summer. Just make sure your child is safe and supervised. And by the way, don’t forget the sun block!

Do you have questions that you would like me to address in my weekly blog?

Unintentional Drowning: Get the factsCenters for Disease Control:  (Accessed May 2015)
Water Safety: The Ultimate Life SkillAutism/Asperger’s Digest (Accessed May 2015)
Pool & Spa Safety, (Accessed May 2015)
Home Pool SafetyAmerican Red Cross (Accessed May 2015)
Water Safety at HomeSafe Kids Worldwide (Accessed May 2015)
Children's Therapy TEAM, Leading Pediatric Therapy Care in Northwest Arkansas

Monday, May 25, 2015

Bad School Behavior

Dear Melissa,
My 8-year-old had a lot of problems at school this year. He was impulsive, interrupted often, did not follow directions, and was often defiant with the teachers. He was frequently sent to the principal's office. The school called me 3 times during the last month of school to come pick him up. HELP! I really don't want to repeat this all over again next school year.

It sounds like it was really a difficult year for your child, you and likely your child's teachers as well. In my recent "Naughty - Bad - Misbehaving" Post, I stand firm that there are no bad kids! Rather, we must get to the root of the problem, take a closer look and see what is causing the bad behaviors.

Investigate what may be causing the problems. If school is on break because of summer vacation, observe whether the behaviors are still present at summer camps, vacation bible school, etc. Be prepared for the upcoming school year. Have a classroom observer ready to investigate. Regardless of the setting, it is better if the observer is someone other than a parent because children often behave quite differently when Mom or Dad are nearby. When the next school year starts, don't wait. Talk to the school and see if a counselor or school psychologist might be available to observe. Things to look for include:

  • Too much noise
  • Disorganized space
  • Other kids in his personal space
  • Other kids “picking” on him
Identify missing splinter skills
Over the years, I have seen over and over again that splinter skills are the root of bad behaviors. On a monthly basis a child is referred to me for “bad” behavior at school. I complete fine motor testing and determine that the child has significant delays in writing skills (and SO much of the school day is spent writing!). In addition, while I am testing, I see a very willing child misinterpreting my verbal directions. For example, I may say “sort” the cards, and he begins to “shuffle” the cards.  I say “stand” on the bench, and the child “sits” on the bench. When I repeat myself or correct the child, he is often confused. Poor guy!  He is trying, but he is not properly interpreting my words. This is where speech therapy can greatly help as well. The most common splinter skills I see missing include:

  • Social immaturity
  • Emotional immaturity
  • Inattention
  • Impulsivity
  • Decreased expressive/receptive language skills
  • Decreased handwriting skills
  • Decreased self-help skills
  • Poor motor planning skills
  • Sensory processing disorders

If these splinter skills are not addressed, all of the behavior modification skills in the world will be completely ineffective. As I have mentioned in the past, most children would rather be viewed as bad than stupid! The good news is that summer is a great time to target splinter skills (though this can be done any time of year). Talk to your pediatrician about your concerns. They may give you a referral for an Occupational Therapy and Speech Therapy evaluation. This is a great way to investigate the possibility of splinter skills. 

Set a behavior plan
This is where you can take proactive steps to address behavior concerns. Given all that you learn from taking a closer look at what has caused your child's misbehavior, be prepared to talk to your child’s teacher and principal when the new school year begins. Set up a meeting and create a behavior plan to meet your child’s needs. If your child works with an occupational therapist, speech therapist, behavior therapist, or psychologist, then they can assist with this process as well. If you don’t have these professionals for support, you can also ask for the assistance of Arkansas Support Network at this behavior meeting. They are a wonderful free service here in Northwest Arkansas which helps out families of children with various special needs. They can not only help you navigate the school process, but other services as well. 

Several components of a good behavior plan include:

  • A developmentally appropriate workload
  • Frequent breaks (It is great if these breaks involve physical exercise which will also help address attention, motor planning, and sensory processing skills)
  • Clear-cut expectations and consequences (consequences that do NOT involve calling the parents to pick up a child from school, except for the most extreme situations)
If this is still not working, then assemble the village! Gather parents, grandparents, occupational therapists, speech therapists, teachers, principals, psychologists, behavioral therapists, and anyone else who knows your child well, and create a new plan. As I said at the start, there are no bad kids...only kids that need extra help. 

How have you worked with your child’s school to create a plan that worked?  What worked for you and your school? What did NOT work? Again, it takes a village! Please share your ideas!

Aggressive, (accessed Feb 2015)
Arkansas Support Network, a local Northwest Arkansas support agency  
Children's Therapy TEAM, provides occupational therapy, speech therapy, physical therapy and developmental therapy to families in Northwest Arkansas
The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible ChildrenRoss W. Greene, (2014) 
The Out of Sync Child: Recognizing and Coping with Sensory Processing Disorder, Carol Kranowitz, (2006)
The Sensory Sensitive Child: Practical Solutions for Out of Bounds Behavior, Karen A. Smith and Karen R. Gouze, (2005)

Monday, May 18, 2015

Why we love our SLP's!

Dear Melissa,
Did you know that May is Better Hearing & Speech Month?  

Last month my "The Heart of an OT?" post inspired this question. So, this month it seemed appropriate to shed light on the work of pediatric Speech therapists, also known as pediatric Speech/Language Pathologists (SLP’s). For this, I turned to several members of our fabulous SLP team at Children's Therapy TEAM. They captured the "heart" of the discipline that is celebrating "BHSM", as our friends at the American Speech and Hearing Association like to refer to it. This is what they shared:

"There's nothing more rewarding than watching a parent see their child communicate with them for the first time. And that's just the beginning!" 
– Lynsey Decator

"Since I see a lot of babies and young children, I love the connection I get to make with the families. Parents that sit in on my sessions are eager to see their kids eat and be successful, and I love being part of that." 
– Connie Clark

"I have the coolest "office" ever, I laugh daily and get hugs frequently....and that cannot be beat! I think communication in any form is such a gift, and I love watching kids learn and grow. I also love that I can try to provide support and encouragement to parents as they navigate parenting along with special needs." 
– Amy Smith

"I love being able to give kids a way to communicate. It gives them some control in an environment that sometimes feels out of control for them. Even communication as simple as learning to point to make a choice, or learning to nod or shake your head for "yes/no" to make choices, is so powerful when you haven't had that control in your life." 
– Carmen Shumpert

"Kids have the need and the desire to learn. For me it's a cycle...I learn just as much from the kids on my caseload as they do from me. They keep me on my toes constantly. I enjoy being a positive and consistent role model in their lives. I assume when it comes to communicating that it's just one big or small puzzle that the kids and I are attempting to solve together. When the child is successful so am I. I also appreciate all the knowledge I gain from my fellow TEAM members." 
– Tabitha Mayberry

"I love being a speech therapist because I love helping kids and seeing them making progress toward their goals every week! Working with a diverse group of patients and diverse disorders is challenging to me. I love our clinic and how we are able to spend so much one-on-one time with each patient and their parents in order to provide the best treatment possible!"  
- Jill Goodwin

Speech Therapists help in more ways than you may think
When working with children, many people think that speech therapists simply work with stuttering, articulation problems, or with children who are not talking yet. But pediatric speech therapists do so much more! They also help children with eating, drinking and swallowing difficulties, conversational skills, social skills and understanding the meaning of language. 

The Last Word: Why I love my SLP’s!
As an occupational therapist working in a large multi-disciplinary pediatric team, I have the pleasure of frequently interacting with speech/language pathologists. I love my SLP’s because they are such fantastic collaborators and problem-solvers. My personal clientele includes many kiddos with speech delays which are contributing to frustration and ultimately behavior problems. I am so thankful to have a group of SLP’s that take the time to figure out the root of language delays and collaborate with fellow therapists, teachers, and the family to create a plan for communication improvement. This ultimately helps empower the child and contributes greatly to their peace and happiness. 

Why do you love speech therapists?  
What have they done to make a difference in your life or the life of your child?  
I would love to hear your stories!