SE Regional Breakfast Meetings

Pennsylvania Association for Infant Mental Health

SE Regional Breakfast Meetings

1/2/2014

After each meeting... Jean Mercer will provide updates and information from the meeting... Please feel to add comments or ask her questions... Thank you!

Jean Mercer

1/3/2014 01:23:01 am

"More Preemies, More Problems?

Dr. Hallam Hurt of CHOP provided a DVG-WAIMH breakfast presentation on Nov. 1, 2013, on the topic “More Preemies, More Problems?” In the course of this most interesting presentation, Dr. Hurt unpacked some of the complex information and complex interactions that combine to determine the outcome for a preterm baby-- and for full-term babies as well.

Dr. Hurt began her presentation by commenting on some of the reasons for preterm birth, and some of the changing factors that influence not only the timing of birth but outcomes, including both survival and good quality of life. Preterm birth can result from complications like the multiple gestations sometimes associated with technology-assisted reproduction, but may also occur when pre-eclampsia or heart disease make continued pregnancy dangerous to a mother, or when intrauterine growth retardation shows that an infant might develop better outside the uterus. Another factor, now becoming less frequent, is Caesarean delivery of babies who are mistakenly thought to be of higher gestational age than they are.

More of these babies are surviving than was true in the past, and even among extremely low birth-weight infants a third survive without impairments. But there is no question that preterm infants may suffer from brain injuries, lung injuries, and damage to the intestinal tract. In spite of treatment, many preterm babies still show in infancy that they are experiencing cognitive delays, cerebral palsy with its problems of motor control, and vision or hearing deficits. CHOP provides programs to treat these problems, but at school age, children who were born preterm may show learning disabilities, attention disorders, and poor executive function, all of which will interfere with their academic and vocational achievement.

Dr. Hurt commented that her early interest in infant development, beginning in 1989, had involved the question of gestational cocaine and its effect on development. The popular press at that time had essentially declared that “crack babies are broken” and that environmental factors could not facilitate good development for them. In Dr. Hurt’s research, comparing a group of low-SES, cocaine exposed babies to a similar group of low-SES, non-cocaine-exposed babies, it appeared that in fact there was very little difference between the exposed and non-exposed infants’ development, but that there were large differences between both and norms drawn from middle-class babies. (It’s notable that the cocaine-exposed babies had not been exposed to just one party, but to about a hundred days of cocaine use during gestation.) The point seemed to be that whatever happened in the hospital or before, the environment the infants went home to had a critical effect on facilitating or retarding developmental progress.

This insight led to further investigation of the home environments of other babies from low-SES groups. The families tended to have few resources, to have work and family problems, to use public transportation with all its associated difficulties, and to have limited parenting skills. The best predictor of a good IQ outcome for the children was the HOME Inventory, developed several decades ago by Bettye Caldwell-- an observational inventory that looks at positive interactions of parent and child, at interesting and stimulating aspects of the environment (like books, pot plants, pets), at experiences outside the home, and so on. High scores on the HOME Inventory went with higher scores on later child IQ tests (but, interestingly, the actual physical environment did not predict IQ.)

Based on understanding of the role of an enriched environment in preventing developmental lags, Dr. Hurt and CHOP created a program to encourage positive parenting and enriching, nurturing environments for children seen at the Special Babies Clinic. Reading to children is encouraged from the earliest infant days, and each family is given a copy of Goodnight, Moon when the baby is discharged. On subsequent clinic visits, more books are given, and both parents and children hear reading-aloud during their visits. The emphasis on reading emerges from the evidence of the 1995 Hart and Risley paper (and of a 2012 paper by Fernald) that low-SES children hear many fewer words spoken to them during their early years than middle-class children do, and that more of the words addressed to low-SES children are emotionally negative. Reading aloud is an activity that helps parents address more speech to their children and makes both parent and child associate speech with pleasant interactions rather than with scolding and disapproval.

Dr.Hurt’s presentation was much appreciated and was followed by a number of questions about working effectively with poor families

Jean Mercer

1/3/2014 01:34:40 am

"A Relational Approach to Toilet Training"

The DVGWAIMH Dec. 7 breakfast meeting presentation was by Dr. Christine Kodman-Jones of the Center for Family-Based Training, on the eternally important topic of toilet training—with an emphasis this time on the essential relationship basis of this developmental step. Dr. Kodman-Jones touched repeatedly on adult-child relationship issues, but also took time to address “techniques” and practical details of toilet training.
Toilet training is an area of unusual importance for parents, and becomes particularly complex when children attend day care or preschool. Coordination of efforts by parents and other caregivers is necessary, but can be difficult when parents are receiving conflicting advice from many directions. Parents of children cared for outside the home-- even those for whom relatives are the caregivers—are likely to be extremely anxious about difficulties or lapses in toilet training, which raise concerns about the child being “kicked out” of a care situation that enables the parent to work.
Dr. Kodman-Jones suggested a checklist of evidence that a particular child is ready to begin toilet training. This includes dry intervals of about two hours, daily and somewhat predictable bowel movements, the child’s awareness of the difference between wet and dry or soiled and clean diapers (more difficult with highly absorbent disposable diapers), and the child’s appropriate development of gross motor abilities like walking. Behaviorally, the child who is “ready” also shows the ability to participate by helping to take the diaper off, an interest in other people’s toilet activities, and visible signs of awareness of elimination such as stopping other activities briefly. Children with good language development can usually behave in more organized ways and display more self-control than those with language delays.
Although we often think of the child as the one who must be “ready” for toilet training, adult caregivers also need to be ready to do their parts. If there are multiple caregivers, their relationships and cooperation are essential to this “readiness”. Individual caregivers also need to be well-informed and capable of calm and self-control—which may be difficult to achieve for parents who are terrified of losing child care or are bombarded by family criticism.
Being well-informed includes knowing some facts about child development. For example, children under the age of 5 usually need to urinate about every two hours and have one or two bowel movements a day. If they are not hurried, most children will have a bowel movement soon after breakfast—but the fraught mornings of modern family life often delay this event until afternoon or even bedtime, whenever the first relaxed time occurs.
Whether children urinate and defecate regularly may depend in part on their food and liquid intake. Drinking plenty of water is helpful in both departments, but soda, fruit juices, and caffeinated drinks may make the bladder irritable and less predictable. For children who become constipated, raw fruits and vegetables, beans, grains, and so on are helpful. One of Dr. Kodman-Jones’ recommendations was the addition of psyllium powder to foods as a help to the many children who resist high-fiber foods.
One more useful point for caregivers’ information is the fact that staying dry at night is a different matter from daytime training. Given that a child is “ready”, the success of daytime training depends on a range of important steps and experiences. Night dryness, however, has a strong genetic component and does not correlate so much with training methods or the child’s motivation. It’s very common, especially for boys, for children to remain unreliably dry at night until age 5.
Dr. Kodman-Jones suggested that body awareness is a first and essential step in toilet training. She recommended that the child be encouraged to “help” in diaper changing as much as possible. Standing while being changed, lifting a foot as requested, undoing diaper tabs or pulling off pull-ups are examples. Children can also start early by helping to wipe themselves. Another important suggestion was the teaching of a good vocabulary for both body parts and processes-- a vocabulary that should be shared and understood by other caregivers as well as by parents.
Dr. Kodman-Jones suggested that adult calm is an essential factor in successful but relaxed toilet training. This point is important not only in quiet responses to “accidents”, but also in measured praise for successful steps toward training, such as asking for help, reporting a wet diaper, or cleaning up after lapses. Calm can be fostered by enlisting the child’s help when clean-up is needed-- not as a punishment but as a job that needs to be done—and preschool or day care sta

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