Monday, March 2, 2015

Dentist's Tip: Keep helping kids brush!

credit: Envato
Dear Melissa,
I have a 4 year old son with a diagnosis of Autism. He has extreme defensiveness to touch, food textures and he gags easily. This oral sensitivity also makes brushing teeth a nightmare! He refuses to let me brush his teeth and refuses to brush them himself. I'm hoping that not brushing or flossing will be OK because he just has baby teeth. 

In responding to this question I have already addressed: 1) The importance of caring for baby teeth in the "Baby Teeth...Big Concern!" post; 2) The challenges of oral care in the "Help, my child refuses to brush!" post. Finally, 3) I address the all important topic of when and how children should begin to independently care for their own teeth at home. I'm again joining forces with Dr. Karen Green, a Board Certified Pediatric Dentist at Pediatric Dental Associates & Orthodontics

Melissa:  Until what age should the parent still help the child brush his/her teeth?
Dr. Green: A child should be allowed and encouraged to brush their teeth, but until the child is at least 8 years old (and often older depending on how effective brushing is) an adult should be helping the child brush.  

Melissa: I think some parents might be surprised by how much they need to still help a child who seemingly brushes independently?

Dr. Green: Think of it this way: Would you allow your 4 year old to wash your dishes and then expect that they have been thoroughly cleaned? The same goes for his/her teeth. At a young age, their manual dexterity is not sufficient to do a thorough job. 

Melissa: I just got a mental picture of my 4 year old daughter washing the dishes, and then the family eating dinner on them. Not pretty! I am officially helping her brush her teeth more! 
Dr. Green: If you start this practice early, the child will be more receptive. As soon as the first tooth cuts through the gums, the parent or guardian should be brushing the child's tooth/teeth twice a day. Even before the first tooth erupts, a baby's gums can be massaged with a baby toothbrush or a soft dampened washcloth.  

Melissa: For older kids a good compromise might be for the child to brush his teeth first, and then the parent provides a thorough, but gentle, scrubbing after the child is “finished”. How often should a child (and parent helper) brush his/her teeth?
Dr. Green: Brushing should be done at least twice a day, preferably after breakfast, and before bedtime. Flossing should be done once daily.

Melissa: Do all children need to floss?
Dr. Green: Most kids do need to floss. A toothbrush cannot reach between the teeth like floss can. If your child's teeth are crowded, flossing is really important. Look inside your child's mouth and if you can see space between all of their teeth, then flossing is not necessary at this point, but practicing and getting into the habit of daily flossing is always a good thing.

Thank you Dr. Green for your expert advice! Over the years I have helped many children with Autism and Sensory Processing Disorder learn to brush up their pearly whites. So, there is hope! I know it can be done. From my perspective as a Pediatric Occupational Therapist, here are just a few of the many components of brushing and flossing:
  • overcoming sensory defensiveness, 
  • developing body awareness,
  • "fine tuning" fine motor skills, 
  • working on sequencing skills, 
  • focusing attention on the task.
If your child finds any of these components difficult, COMMUNICATE! Talk to your dentist, occupational therapist, or speech therapist. Oral care can become a painless and simply part of your daily routine, but developing the foundational skills to make that happen may require consultation with professionals. Do a bit of research to find out which dentist in your community works best with children who are orally defensive. In Northwest Arkansas, don't hesitate to reach out to the Pediatric Dental Associates. I think they do a wonderful job with children who have challenges with sensory defensiveness.  

A special thanks to Dr. Karen Green for participating in this week’s blog!
front office area at Pediatric Dental Associates and Orthodontics
What has worked with your little ones to create a healthy home oral care routine?  
I would love your tips!  Please share! share@childrenstherapyteam.com
References:
"Dentist visits for kids with sensory defensiveness", Children's Therapy TEAM Dear Melissa Blog for Parents (February, 2015)
"Baby Teeth...Big Problem!", Children's Therapy TEAM Dear Melissa Blog for Parents (February, 2015)
"Help, my child refuses to brush his teeth!", Children's Therapy TEAM Dear Melissa Blog for Parents (February, 2015) 

Monday, February 23, 2015

Help, my child refuses to brush his teeth!

Credit: Envato
Dear Melissa,
I have a 4-year-old son with a diagnosis of Autism. He has extreme defensiveness to touch and food textures, and he gags easily. This oral sensitivity also makes brushing teeth a nightmare! He refuses to let me brush his teeth and refuses to brush them himself. I'm hoping that not brushing or flossing will be OK because he just has baby teeth. 

Following up from last week, yes baby teeth matter...a lot! To further respond to your question I'm again reaching out to Dr. Karen Green, a Board Certified Pediatric Dentist at Pediatric Dental Associates and Orthodontics. As I have mentioned before, I use her for my own kids, and I also recommend her to the families I work with. 

Melissa: What if a child cries and fights teeth brushing? Do you having any tips? 

Dr. Green: Some children fight brushing, while others are more compliant. It can vary depending on many factors such as oral sensitivity, gag reflex, and often stubbornness! The best time to get a routine established is in the first year of life. The earlier the better. 
  • You can try having the child sit in your lap while you brush, but this makes visualizing the teeth somewhat difficult.  
  • Another method is to have the child lay on the floor or on the couch/bed while you brush. It makes seeing the teeth much easier!  
  • If your child is aggressively fighting you while you are trying to brush, and you don't have another adult to help stabilize the child while you brush, you can use a towel to wrap the child while holding him in your lap.This will prevent his arms from reaching up to grab you. This works really well on younger children.
Melissa: As an occupational therapist, many of the kiddos with Autism that I work with are very orally defensive, and they perceive brushing teeth as very painful. What are your thoughts on the strategies I use to gently get a child more accustomed to more regular oral care? For example:
  • Using clear infant toothpaste (rather than fluoride toothpaste; the taste is more gentle)
  • Not using toothpaste
  • Using a toothette sponge rather than a toothbrush
  • Using a shortened time (while singing ABC’s x 2) 
Dr. Green: I like the techniques you have suggested. I think working up to optimal oral hygiene gradually is a great thing for those that need more time. 

Melissa: For parents with kids who are orally defensive, how important is diet?

Dr. Green:low sugar diet, especially things that are very retentive (think really sticky and sugary), is very important. Even gummy vitamins can be really bad on a child's teeth. The bacteria that cause cavities metabolize/eat sugars. So, if your child's diet is high in sugar, the bacteria are being fed often, producing more acid, which leads to cavities. The more orally defensive a the child is, the more attention needs to be placed on diet.  

Melissa: What are your feelings about drinking juice, soda, etc?

Dr. Green: Many parents don't realize how bad soft drinks are for their child's teeth. They are very acidic and often loaded with sugar, which can be very damaging to the teeth. A child should be drinking mainly water and unsweetened milk at meal times. 

Melissa: Any other tips for good oral care at home?

Dr. Green: Unfortunately, sometimes kids get cavities, and we have options based on the child's level of comfort and treatment needs. We try to make it as comfortable for both child and parent as possible, but prevention is always better! Plaque (a sticky film on the teeth where bacteria grow) forms on the teeth after eating or drinking. Brushing and flossing removes plaque. Establishing a good oral health care routine at home, where parents are actively involved, is critically important.  


A special thanks to Dr. Karen Green for participating in this month's Blogs!
front office area at Pediatric Dental Associates and Orthodontics
 Have you had particular difficulties or successes caring for your child's baby teeth?
Please share! share@childrenstherapyteam.com

References:
Pediatric Dental Associates & Orthodontics, Fayetteville, AR
Visiting the Dentist for kids with Sensory Defensiveness, Children's Therapy TEAM Dear Melissa Blog for Parents (February, 2015)
Baby Teeth...Big Concern, Children's Therapy TEAM Dear Melissa Blog for Parents (February, 2015)

Monday, February 16, 2015

Baby Teeth...Big Concern!

credit: Envato Images
Dear Melissa,
I have a 4-year-old son with a diagnosis of Autism. He has extreme defensiveness to touch, food textures, and he gags easily. This oral sensitivity also makes brushing teeth a nightmare! He refuses to let me brush his teeth and refuses to brush them himself. I'm hoping that not brushing or flossing will be OK because he just has baby teeth. 

I'm sorry to hear about your struggles! Learning tooth brushing skills is tricky for many kids, and for children with Autism the challenge can seem insurmountable. I will respond to your question fully over my next few posts.This week I will tackle your comment about brushing and flossing baby teeth.

We can certainly "hope" that not brushing or flossing will not cause any long term problems for our kids, but is this really the case? I respect the opinion of Dr. Karen Green, a local Board Certified Pediatric Dentist from Pediatric Dental Associates & Orthodontics. I'm again reaching out to her to respond to your comment.

Melissa: What is your response to the idea that not brushing baby teeth is OK because they are not permanent teeth?

Dr. Green: Even if your child does not like brushing, it is very important to brush the baby teeth. There will be some baby teeth in your child's mouth until around age 12. Not brushing can lead to cavities. Cavities are a bacterial infection in the mouth, which can cause severe pain and swelling if not treated. If a tooth gets infected, it may need to be taken out early. A baby tooth that is taken out early may lead to increased crowding with the permanent teeth.
painful, decayed baby teeth
image credit: Envato

Melissa: OK, so care for baby teeth is very important!
Dr. Green: Yes, and baby teeth are very susceptible to cavities, as the enamel (outer and strongest layer) of the tooth is much thinner than in an adult tooth. Good oral hygiene and a healthy low sugar diet are the best way to prevent cavities from forming! Children that have cavities in their baby teeth are also more likely to have cavities in their adult teeth. Protect those teeth from the start!



A special thanks to Dr. Karen Green for participating in this week’s blog!
front office area at Pediatric Dental Associates and Orthodontics
 Have you had particular difficulties or successes caring for your child's baby teeth?
Please share! share@childrenstherapyteam.com

References:
Pediatric Dental Associates & Orthodontics, Fayetteville, AR
Visiting the Dentist, Children's Therapy TEAM Dear Melissa Blog for Parents (February, 2015)

Monday, February 9, 2015

Dentist Visits for Kids with Sensory Defensiveness


image credit: envato
Dear Melissa,
I am worried about my son's first dentist appointment. It is scheduled next month! My son is 5 years old and has a diagnosis of Autism. He barely lets me brush his teeth due to his sensory defensiveness.

In my work as a pediatric occupational therapist, I help prepare my kiddos for the dentist by practicing ahead of time. I have them lie down on their backs while I gently “tap” their teeth. We gradually work towards me brushing their teeth with a regular then electric toothbrush. We also read and write stories about going to the dentist. However, as a mom and sensory-based occupational therapist, I know that the particular dentist and hygienist you choose really matters.

It is very common for children on the Autism Spectrum and children with Sensory Processing Disorder (SPD) to have various forms of oral defensiveness. Therefore, it should not surprise us that these children are often terrified of the dentist. When it comes to finding the right dentist, I use Dr. Karen Green for my own kids, and I also recommend her to the families I work with. She is a Board Certified Pediatric Dentist at Pediatric Dental Associates and Orthodontics. I have found the staff to be very calm and patient. I recently reached out to Dr. Green to gain her perspective on this subject. 


Melissa: What do you wish a parent would tell you (the dentist) before their child’s first dental visit if the parent thinks that the child will have a stressful time?
Dr. Green: If you are concerned that your child may have a stressful first visit, let us know. It is nice when the parent informs us as to how oral hygiene procedures usually go at home. Is the child is resistant to brushing? Do they scream at the sight of floss?

Melissa: What do you wish a parent would tell/do with their child before their first dental visit to make it less scary?
Dr. Green: It may be helpful to bring your child to the office for a "comfort visit" where you show the child the office and let them become comfortable in the environment. Books, pictures and/or videos about going to the dentist are often helpful. It also may be beneficial to practice brushing your child's teeth while they are laying down. Know that if you as the parent are overly anxious about the dental visit, the child will usually pick up on this anxiety and become more nervous.

Melissa: What can the dentist/dental office do to help alleviate fears of the child/parent?
Dr. Green: The dental home you choose for your child should be willing to help lessen the fears by providing an inviting atmosphere and using kid-friendly phrases for dental tools and procedures. We use phrases such as “train whistle” instead of drill,"silly nose" instead of gas mask, and "brave air" instead of nitrous oxide. We avoid the use of the word “shot”, we often describe it as “giving your tooth a little sleepy juice”.

Melissa: At what age should a child first see the dentist?
Dr. Green:The first dental visit should be scheduled after the eruption of the first tooth and no later than 12 months of age (as recommended by the American Academy of Pediatric Dentistry). Prevention is key. Dental problems often start early, and the sooner we catch a problem or potential problem the better! We address diet, hygiene, age-appropriate injury prevention, and counseling for nonnutritive oral habits (e.g., finger sucking, pacifier, blankets). We also provide anticipatory guidance (what to expect for your child's developing mouth).

Melissa: How often should most children see the dentist?
Dr. Green: For most children, we recommend seeing the dentist every 6 months. This is adjusted based on the needs of the child.

A special thanks to Dr. Karen Green for participating in this week’s blog!
front office area at Pediatric Dental Associates and Orthodontics
So here's the bottom line. If you think your child may have trouble visiting the dentist, COMMUNICATE! Talk to the dentist, talk to the dental hygienist, and talk to your child’s occupational therapist and speech therapist. They are all fabulous resources to help keep your little one happy and smiling!
What tricks have you used with your kiddos to help make dental 
appointments less stressful?  Please share! share@childrenstherapyteam.com

Monday, February 2, 2015

ADHD Treatment: Where do you start?

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Dear Melissa,
My daughter’s kindergarten teacher is concerned that she has ADHD. How do I know if she has ADHD or not? If she does have ADHD, what are the best treatment options?

Last week I tackled the first part of your question in my blog post, "ADHD or just being an active kid?" This week I'm addressing the second part of your question. 

How is ADHD treated?
According to the CDC, in most cases ADHD is best treated with a multifaceted approach. This can include medication, behavior therapy, parent training, and school accommodations. Because roughly 10% of American children have a diagnosis of ADHD, there have been many, many, MANY books written about additional treatment options. Some of these options are sound and have research to support them; others are no better than snake oil. Unfortunately, inappropriate treatments can actually cause harm. It is very important to discuss all of your child’s ADHD interventions, both pharmaceutical and non-pharmaceutical, with your child’s pediatrician or mental health professional.

Behavioral Interventions
With so many treatment options, where do you start? According to the American Academy of Pediatrics, treatment for preschool-aged children should start with evidence-based behavior interventions BEFORE any medications are considered. This is where many pediatric Occupational Therapists can help. By working with the child, their families and teachers, strategies are used to:

  • address impulsivity 
  • regulate emotional outbursts 
  • improve focus and attention

Also in my role as an OT, I help children with ADHD “catch up” on any splinter skills such as handwriting, making friends, and self-care. These are not developed properly due to difficulties attending to tasks.

Medication
Several different types of medications may be used to treat ADHD. Children can sometimes react differently to various ADHD medications. Because “trial and error” may be needed before the right combination is found, parents must work closely with the child’s prescribing physician. Any side effects need to be reported; you should not just stop a medication on your own.

Though it may seem counter-intuitive, stimulant drugs work well for many children with ADHD. Think of it this way. When the drug provides a child brain with sufficient stimulation, then the child is less likely to constantly seek out additional stimulation from his or her environment. Between 70-80% of children with ADHD respond positively to stimulant medications. 

Currently, stimulants are the best-known and most widely-used treatments. A recent study published by the American Academy of Pediatrics found that treating ADHD with stimulants is NOT associated with reduced growth patterns in children as they reach adulthood. However, decreased appetite and difficulty sleeping have been observed as possible side-effects. Non-stimulant drugs were approved for treating ADHD in 2003 and appear to have fewer side effects.

Importance of Treatment
Regardless of the treatment approaches you choose, the bottom line is simple: get your child’s symptoms under control. Children with unmanaged ADHD are at a higher risk for substance abuse, smoking, job loss, divorce, and driving accidents. Therefore, it is imperative to work with your child’s treatment team in order to find what works for YOUR child. 

What techniques have worked for you? Please share!
Resources:
What is ADHDNational Institutes of Health
ADHD or Not? Why a Diagnosis Matters, Web MD, Eric Metcalf (2012)
ADHDCenter for Disease Control & Prevention
Diagnosing ADHD in Children: Guidelines & Information for Parents, American Academy of Pediatrics, (updated January 2015) 
ADHD, Stimulant Treatment, and Growth: A Longitudinal Study, E. Hardstand, Weaver, Katusic, Colligan, Kumar, Chan, Voigt, Barbaresi, American Academy of Pediatrics, Pediatrics, Volume 134, (October 2014) 
Stimulant Treatment of ADHD and Cigarette Smoking: A Meta-Analysis, E. Schoenfelder, Faraone, Kollins, American Academy of Pediatrics, Pediatrics Volume 133, Number 6 (June, 2014)
ADHD Resource Center, American Academy of Child & Adolescent Psychiatry (updated October, 2014)

Monday, January 26, 2015

ADHD or just being an active kid?

credit: Envato Images
Dear Melissa,
My daughter’s kindergarten teacher is concerned that she has ADHD. How do I know if she has ADHD or not? If she does have ADHD, what are the best treatment options?

I frequently get this question from parents. The Centers for Disease Control and Prevention calculated that 11% of children in the U.S. had an ADHD diagnosis in 2011. That was up from 7.8% in 2003. Among all children in the U.S., 6.1% were taking an ADHD medication in 2011, such as Adderall and Ritalin, up from 4.8% in 2007. With rates this high, ADHD is a challenge that many families and every classroom teacher will have to face.

What is ADHD?
Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common childhood brain disorders and can continue through adolescence and into adulthood. Kids with ADHD struggle with focus and attention, have difficulty controlling behavior, and exhibit hyperactivity. Attention Deficit Disorder (ADD) is similar to ADHD in terms of deficits in focus and attention, but hyperactivity is not a problem.

ADHD or not?
Many young children have difficulty attending to classroom instruction. But does that mean they have ADHD? Certainly not! According to Dr. George Depaul, a 
psychology specialist in the field of ADHD research, upwards of 40% of elementary students are reported by their teachers to be easily distracted or lacking in focus (Metcalf, 2012). Considering the rise of academic demands in younger grades, combined with the decline in recess and other extracurricular time, no wonder there are problems! Other explanations for inattentiveness could be classroom chaos, boredom, a family crisis at home, or anxiety and depression problems. By working with your child's pediatrician, psychiatrist and/or psychologist, hopefully the right diagnosis (or non-diagnosis) is reached.

How is ADHD diagnosed?
If your child's teacher raises a concern or you suspect ADHD, a good first step is to talk to your child’s pediatrician. Some pediatricians perform ADHD assessments themselves. However, many will refer the family to a mental health specialist (such as a psychiatrist or psychologist) with a specialty in childhood mental health disorders such as ADHD. The pediatrician and mental health professional will also rule out other possible causes for the inattentive behaviors such as deficits in vision or hearing, seizures, insomnia, anxiety, Autism, depression, and learning disabilities.

Generally, the processes of diagnosis for ADHD include interviews with the parents and the child, as well as various standardized tests and questionnaires. In order to qualify for a diagnosis for ADHD, symptoms need to occur in more than one setting (such as both home and school), and they should also demonstrate a negative impact on an individual’s daily life.


What are Treatment Options?
There are MANY treatments for ADHD available. Stay tuned...I will discuss treatment options on my next post. 

Has your child been diagnosed with ADHD? How did you discover your child's diagnosis?
Please share! share@childrenstherapyteam.com
Resources:
What is ADHDNational Institutes of Health
ADHD or Not? Why a Diagnosis Matters, Web MD, Eric Metcalf (2012)
ADHDCenter for Disease Control & Prevention
Diagnosing ADHD in Children: Guidelines & Information for Parents, American Academy of Pediatrics, (updated January 2015) 
ADHD, Stimulant Treatment, and Growth: A Longitudinal Study, E. Hardstand, Weaver, Katusic, Colligan, Kumar, Chan, Voigt, Barbaresi, American Academy of Pediatrics, Pediatrics, Volume 134, (October 2014) 
Stimulant Treatment of ADHD and Cigarette Smoking: A Meta-Analysis, E. Schoenfelder, Faraone, Kollins, American Academy of Pediatrics, Pediatrics Volume 133, Number 6 (June, 2014)
ADHD Resource Center, American Academy of Child & Adolescent Psychiatry (updated October, 2014)

Monday, January 19, 2015

"because I said so!"

credit: envato
Dear Melissa,
When adults tell children to follow directions, “because I said so!” that should be enough of an explanation for any child.

The above statement actually comes from a discussion I had with a local child psychologist several months ago. If I thought saying, "because I said so!" provided children with opportunities to develop thoughtful self-discipline, then I would be all for it. However, it is difficult to make that argument. I strongly feel that every direction I give to a child is a little, two second teachable moment. It is my hope that if I provide enough of these tiny teachable moments, then I have given the child the tools he needs to make the best choices he can throughout his life. 
My trial and error approach 
I have gathered these ideas from lots of books and blogs then taken a trial and error approach over 7 years of being a mama and over a decade of being a pediatric occupational therapist. As a disclaimer, this blog is largely my opinion. This is simply me sharing my personal style of behavior modification and preferences in dealing with challenging behaviors. 

Teaching children...not programming robots
We want our children to learn how to make good choices rather than blindly following directions. If we don’t teach a child the reasoning behind our directions, then how will they know how to make good choices when we are not there? 
My formula for giving directions
Give a 5-7 word command followed by a 5-7 word explanation to describe the “cause and effect” nature of the situation. That’s it. My directions are not up for debate. Who has time for that? If the child starts to argue, I just repeat my directions.
Examples of cause and effect directions and natural consequences 
Direction: "Wash your hands. I don't want you to get sick."
If a child refuses to wash his hands, then I won’t let him touch any of the fun equipment in the clinic to keep him/others safe from germs.
Direction: "Hold my hand in the parking lot, so you don’t get squished by a car."
What if the child refuses to hold my hand in the parking lot? Then I will help him “practice” by pacing back in forth in the parking lot, holding my hand. My #1 job in life is to keep children safe.  

Direction: "Wear your coat. You will feel cold outside without one." 
No coat? Then no playing outside. We can sit at the table and work inside, because again, it is my #1 job to keep kids safe. 

Keep it simple
Children can’t process a 5 minute discussion over every command. Their language skills are simply not that advanced. After the first few words, your voice simply turns into “wah wah wah” like the teacher in the Peanuts cartoons.  
Give "the look"  
What about the child that keeps asking why?  Well, you have given your direction. You have already answered “why”.  This is when I throw in "the look” and simply say, “I have given you my explanation." 

Choices
Eons ago one our own TEAM OT's, Cara Duran, and I were roommates during OT school. It is from her that I picked up a phrase that I use daily: “Life’s all about choices.” Sometimes we have two good choices like cake or ice cream. Sometimes we have two bad choices like tooth pain or a root canal. By teaching children about causes and effects, we empower them to make good choices even when confronted with challenging options. 
I love, love, LOVE having fun and playing with kiddos and I hope they think of me as fun adult who loves them to pieces. However, it is not my job to be their best friend. It is my job to teach them how to make good choices. I will not always be there to look over their shoulder and prompt them. At some point, I need to be able to trust them to make their own choices.

Your thoughts? Please share!

Resources:
20 Things You Should Never Say To Your Child, Carla Field, WYFF News (2014)
The Explosive Child, Ross Greene (2014)
25 Ways to talk so children will listen, William Sears, www.askdrsears.com (2013)