Karen Chesnutt, Ph.D

Author: Karen Chesnutt (Page 1 of 4)

Independent Living for Young Adults

June 1, 2017 /

Over the last few years, I have worked with patients who are aging out of the public school systems. Often, their families are planning to have that child continue to live with them, because they feel that their handicapped child is unable to live independently. Many of these children/young adults are not good candidates for group homes, because they are too high functioning, but they cannot live without support either. The problem becomes more complicated because as these young people get into their 20’s, their emotional development is similar to their non-handicapped peers—they want to be living out in the world, not in their parents’ homes.

As a result, many parents have worked to figure out an in-between arrangement where these young adults can live in apartments and have the staff come in to provide support. Some have joined together with other families so young adults can be sharing a house and support staff.

For young adults living at home or in one of these alternate settings, there are still concerns.  Here is a partial list:

  1. They continue to be isolated. They may live in the community, but many have very limited interaction with people in their neighborhoods or in their communities.
  2. Most do not have transportation except for their family members. This makes it difficult for them to be truly independent.
  3. The opportunities available in the community for recreation are somewhat limited. The opportunities for casual relationships and activities is very limited.

The parent of one of these young adults showed me a program in Florida that seemed to me to provide an answer to some of these concerns and I have been encouraging as many people as possible to begin a discussion of whether this may be an answer for the young people in this area.  Basically, the people at Noah’s Ark in Florida have built a community, with a community center in the middle. It is my understanding that there are a variety of housing options in the community—group homes, supported apartments, etc. Then, programs are developed at the community center that residents can participate in. I have learned since first hearing about this that there are several other similar programs in the country. In some ways, this looks similar to some of the models developed for senior citizens.

It would be interesting if this type of program could include a fitness center, where residents could swim. Or a café where they could go for coffee. I could see a number of possibilities for our young adults to live a more “normalized” life in a community that provided both safety and opportunities for independence.

Some have told me that one of the reasons not to support this type of program is that the emphasis should be on integration into the community. I would argue that we don’t really have integration at the present time; these young adults are very isolated. I think this model could be “integrated” by bringing in non-handicapped peers to staff the programs or possibly to participate in events.

My goal at this point is just to begin a dialogue about whether this type of program might be a possibility for handicapped young adults in this area. I hope that parents will begin to discuss this, because it has been my observation that parental input is crucial in developing new programs to meet their children’s needs.

Medical objects

A Strange Perspective on Strength

April 6, 2017 /

A number of years ago, I had two patients come into my office, one after another. The contrast between the two has remained with me for a number of years.  It helped me learn something about strength.

The first one was a young man who was tall and what we would call, “well built.” He had the size of a football player. What he didn’t have was much emotional strength.  Every time I suggested something to him as a way to cope with his problems, he had a reason not to do it. Sometimes he said that it was “too hard.”  Sometimes he complained that it would take too much effort. It quickly became clear to me that this young man was unable to face very much. Even though we would have regarded him as being strong and capable, which was true of his physical abilities, it was not true of his emotional abilities.

This become even clearer with my next patient. This was a girl who had struggled for years with a major medical problem. She had tolerated and survived many medical procedures. On the day she came to see me, she was having a spinal tap. She regarded that procedure as just something else that had to be done. I asked her how she tolerated the pain and her response was that, “it really didn’t last too long.” What a difference between these two people. He was physically strong, but had little emotional capacity to tolerate any discomfort. She was physically compromised but had the grit and tenacity to cope with the most painful of procedures.

It was interesting to me that she did not see herself as strong or brave. She just saw her treatment as what had to be done. He saw himself as being strong, and was insulted if I suggested that he had any kind of weakness.

I wish we could begin to value emotional strength. I wish we could understand how much value it has for our lives. I wish we could spend as much time and money developing this type of grit and of resilience. I also hope that we can begin to value it in others and in ourselves.

Why Do They Do That? Consistent Reinforcement

March 13, 2017 /

One of the best explanations for children’s behavioral issues is the concept of reinforcement. All of us have heard about the effects of positive reinforcement or “reward.” We have heard that one of the ways to get children to obey is to give them an immediate reward for specific behaviors. In the opposite way, people think that the way to change or eliminate a behavior is to give a negative reinforcement or a punishment.

The one thing that parents don’t often consider is something we call the “candy aisle phenomenon.”  For psychologists, this is the type of reinforcement that is most important. Here is how it works. A child is in the candy aisle and asks his/her mother for a piece of candy. Mom says, “no.”  In fact, Mom says “no” on every one of the next 5 times that her child asks. So far, so good. Unfortunately, the next time the child asks, the mother gives in. The child has learned to keep up with the questioning for a longer time. This is what we call “intermittent reinforcement.” The behavior in question is reinforced or rewarded sometimes, but sometimes it is not. What happens is that you child has learned to keep trying! After this type of reinforcement, the behavior is very difficult to change. In fact, it is the type of response that is the strongest in prolonging the behavior.

Many parents tell me that they don’t use this type of reinforcement, that it is not a problem for them. What I think happens is that parents don’t notice how frequently they engage in this type of reinforcement. In public, it is often easier to give in rather than have your child melt down, right in the middle of the candy aisle. And, as you have noticed, children do have the capacity to wear you down, even with the best of intentions!

What should a parent do?  First, be careful when you tell a child “no.” You must be really willing to enforce it. If you are not sure, then don’t give a response. This is true of situations that involve both major and minor issues. It is true of items in the candy aisle, of promises to go somewhere (“No, I will not take you to Target”), or of possibilities of major purchases. “No” needs to mean “No.”

So, what if you have told your child “No” but then find out the situation has changed. Can you change your mind?  Of course. But, (and this is an important “but,”) you change your mind because YOU choose to, not because he/she has relentlessly campaigned for it. This may sound like a minor distinction, but it really isn’t. It is quite important. It avoids the intermittent reinforcement (of his/her nagging behavior) and that is key!

Why Do they Do That? It’s Developmentally Appropriate

March 6, 2017 /

Often, parents ask me why children engage in certain behaviors.  We have looked at a variety of reasons—because the behavior achieves the intended purpose, because it meets some sensory needs or because it is because it is part of a cycle of behavior that is characteristic of children with Down’s Syndrome.  Are there other reasons?  Yes there are.

One reason that hasn’t been discussed is that the behavior is developmentally appropriate.  If you have ever wondered why your preschooler insists on throwing everything off his/her high chair tray, you will understand the developmental explanation.  Children at his/her age are just learning about object permanency, and he/she is experimenting.  Does a toy that is tossed off the tray continue to exist? When they see it on the floor, it is proof that it continues to exist, It takes a number of repetitions before a toddler can have the principle firmly established.  Unfortunately, the repetitions are usually very unpleasant for adults who are involved!

Similarly, there are many actions that are developmentally appropriate. “No!” from a two-year-old is hardly surprising.  Eye-rolling from a teenager is also developmentally appropriate.  I find that many four year old boys seem to develop a pattern of challenging authority, somewhat like we see in preadolescent males. This is not really “bad” behavior, but is a pattern that does present some challenges to caregivers. These elements of growth are developmental, but can also be difficult.

Children with special needs often show a similar pattern of developmentally appropriate behaviors even though their cognitive profile may not be the same. Some parents are surprised to have their impaired teenagers begin to show typical “push back” behaviors that are characteristic of non-handicapped teens. Disabled two year olds will also develop the “no” stage in spite of their handicapping conditions. Young adults with disabilities do develop a desire to have relationships with the opposite sex and often want to leave home to establish their own independent lives. Sometimes these behaviors are not understood and parents are often unprepared to deal with these “normal” types of behavior.  Interestingly, the types of parental response to these behaviors is usually the same—good limits, appropriate amounts of freedom and lots of teaching of appropriate behavior.

Why Do They Do That? Because They Have Sensory Needs!

February 16, 2017 /

#2. Children do what they do because they have sensory needs!

Often, children will engage in behaviors because they have some kind of sensory need. Children with a Sensory Processing Disorder often will engage in behaviors that will not necessarily seem sensible or reasonable to you, but these behaviors do meet a sensory need.

Here’s how I think about it.  Have you ever had one of those days when you were craving chocolate?  You might try eating chips or cheesecake, but truthfully, none of it works.  What you really need is chocolate.  Children’s sensory needs work in a similar way. They crave certain kinds of input. Some have a high need for strong sensory inputs. These are children who seem to engage in “rough” play, who jump down stairs or run into walls. The one thing that these types of children can’t tolerate is very mild stimuli (like tags or seams on their socks.) The rough play behaviors serve to give them the sensory input they need. Many parents will describe this type of behavior as “hyperactive”. It really isn’t related to ADD or hyperactivity. Actually, it is sensory seeking. They need the sensory input. If you try to punish or discipline this activity, it won’t work. It is not “bad” behavior.

So, how can you treat this type of behavior?  The specialists are Occupational Therapists, who can both diagnose and treat this type of behavior. In general, what we try to do is to give them the input they need.  Basically, we give them “chocolate.” This meets their sensory need and prevents some of the behaviors that are problematic. If you are in a public place, you don’t want your child running around, seeking sensory input (while you are both embarrassed and frustrated!). Instead, you would want to give him/her the input they need before going out.

There are a number of different types of Sensory Processing Disorder.  I cannot diagnose those, but I do like to help parents understand some of the general principles that may be involved in treatment. One of the main reasons I like to do this is so that sensory issues do not become labeled as behavior problems.

Here is a brief list of some types of behavior that may be related to sensory issues:

  • Dislike of specific textures, including in certain foods
  • Tantrums when their hair is being washed or brushed
  • Can’t tolerate shoes or socks; sometimes they have sensitivity to seams on socks
  • Pain response to loud, unexpected sounds (vacuum cleaners, motorcycles, etc)
  • Everything in the mouth—need for oral stimulation
  • Shutting down in the presence of large amounts of visual information

There is a more extensive list, but these should give you an idea of whether you may want to seek out an assessment for a sensory processing disorder.

Why Do They Do That? Because It Works!

February 9, 2017 /

Very often, parents ask me why their children engage in specific behaviors.  Many times, these are children with special needs, but many of these suggestions apply to all children.  I have a list of seven things that can explain why children do what they do.  Here’s the beginning of my list.

#1.  Children do what they do because IT WORKS!

They get what they want, they get attention, they get control of the whole household.  It works.  Let’s look first at the attention part, because I think parents generally don’t think about the power of their attention.  Here are some general principles.

  • Good attention (praise) and bad attention (yelling, punishing) serve the same function. You see them differently, but your child does not.  In fact, negative attention is often much stronger than positive attention.  Think about it.  When you praise your child, you may focus about 10 percent of your attention on him/her.  When you are angry, it is like a laser, with 150% of your attention directed to your child.  As a result, negative attention may be more reinforcing than positive attention.
  • In addition, when you are focused on one child, no one else is getting attention. Other members of the family are not getting their needs met.

In addition, you will need to consider the essential question—“Who is in control?” If one child is able to act in such a way that he/she is in control of the family, then the behavior has “worked”. It accomplished the goal of controlling everything.

The final reason that the behavior “worked”, is that the child got what he/she wanted. If it was a tantrum about a toy, a TV show or her/his own way, then if the end result was getting what was wanted, the behavior worked.

For Parents

  • Make sure that you are not inadvertently reinforcing behavior by your attention (negative or positive)
  • Make sure that behaviors only “work” if they are ones that are acceptable to you.
  • This is another reminder that parents need to be in control of the household, not children!!

If you decide to placate your children just to keep peace, you will NEVER have peace!  It will never be enough. It is much more important to have parents in charge, even though children may complain, tantrum or act out!  In the long run, parents who are authoritative (not authoritarian) will have the best success with their children.

Do we Ever Test Adults?

January 17, 2017 /

Most of the time, when we think about testing, we think about testing children.  In fact, we often have opportunities to test adults. There are many reasons that adults need to have an IQ test done.  Here are a few of them:

  • We often use IQ tests as part of a battery when there are medical problems that are being explored.  For example, when there is a question of dementia or memory loss.  After strokes or head injuries, adult IQ tests can be very helpful in determining deficits but also in identifying strengths.
  • When adults return to college or when they are exploring the possibility of a new career path, they often want to get a good picture of their skills.  Sometimes testing will help them make a decision about what kinds of supports they may need or about their ability to pursue a particular vocational path.
  • Sometimes people come in just to have some of their own personal questions answered.  They want to know if they have ADD/ADHD for example, or whether they have an undiagnosed learning disability.
  • This type of testing is often useful when people are concerned about whether they are showing cognitive change.

We usually use a test called the Weschler Adult Intelligence Scale (WAIS) for this type of testing.  It takes about 1 ½ hours to complete and involves a number of subtests. Some of the subtests are verbally based and measure vocabulary. Others are visual and look at how we you can copy block patterns or how well you can make designs. There are some memory scales as well.

After all the data has been collected, the psychologist will look for patterns in the scores to help describe your cognitive profile.  Because these tests have been given to thousands of other adults, we have some idea of the “normal” pattern of scores.  Your pattern is then compared to this norm and we look for differences. A little bit of difference is expected—we all are different!  But when there is a large discrepancy, we want to look at it more closely. Sometimes more testing is suggested so that we can get more information about why your scores are so different (Don’t forget, they could be both higher or lower than we expect!).

The next step always is to apply the results to the “real world.”  How do these scores impact your daily life?  Should you use different strategies to help you remember? Should you “talk yourself through” a difficult task so you can use your best skills in that area? Sometimes people find that they have lived their lives feeling that they weren’t “smart enough,” only to find out that they have one small area of weakness but that otherwise, they are fine!  For some of the patients I have worked with, this revelation has been very freeing for them, allowing them to try new things or move in new life directions.

Remember, though, that IQ tests only measure certain types of tasks. They NEVER should be used to judge your value as a person, or your ability to be successful.  They just give us a snapshot of specific tasks; our lives a so much more complex than that. So don’t overvalue IQ scores! Use them for what they are intended to do.

When your Child is Worrying (Part 2)

January 12, 2017 /

In an earlier blog, I discussed anxiety in children.  Most of us don’t want to think about the fact that children can worry. It’s not our idea of childhood.  Parents’ innate responses are to comfort and protect.  The way to handle childhood fears is actually the opposite of that.  As I explained earlier, firm parenting is key to addressing your child’s fears.

Here are some more suggestions about what to do:

  • It is important to remember that anxiety often has a ruminating quality to it and it can dominate your child’s thoughts. You should not foster this by constantly talking with him/her about it.  Put limits on the conversation,  so you can help your child learn how to do that.  You might say, “I understand that you are worried about flying, but that is not happening for two months, so I will not talk with you about it now” and then don’t.
  • Our general treatment for specific fears is to have children face these fears. That is the only way they can get past them, so the fears don’t have an ongoing impact on their lives. Since this is a stressful process, I usually suggest that you only use this technique when other areas of your child’s life are relatively stable. And you will want to do it in a step-wise fashion. For example, for children who are afraid to go upstairs by themselves, I have them practice walking upstairs first with a parent present. They start with 5 steps and then increase daily. When they finally get upstairs, I have a parent at the bottom of the stairs. The child starts by staying upstairs and counting to five. Then I have parents increase the task until the fear is totally overcome. The important thing is to do only a small step at a time.  In this way, your child can overcome a specific fear, but at the same time feel very successful.
  • Obviously, using punishment or shaming will make anxiety worse, not better.
  • If your child’s sleep is disrupted for more than 2 weeks, I recommend seeing a therapist soon.  For my patients, I use this as a red flag that the anxiety is reaching a point where a  professional opinion is needed.

 

Your Child is Worrying! What Should a Parent Do? (Part 1)

January 10, 2017 /

All of us worry at some point in our lives. Most of the time, parents are surprised when their children, even preschoolers start worrying. We have this idea that childhood should be carefree, but that isn’t the reality for some children.

So where does this anxiety come from?  We inherit a predisposition to how we respond to stress. Some of the tendency to be anxious may run in the family and then be triggered by some kind of stress. In other children, it can be a direct result of trauma. We usually don’t think about trauma as occurring in children, but we are becoming much more aware of it. Things such as accidents, medical procedures, family disputes and obviously abuse all can trigger anxiety in children.

You can see anxiety in your children for a number of reasons. Sometimes, specific events are frightening for them, like thunderstorms or having to ride in an elevator. Other children are shy and have difficulty in new or public situations. Some worry about everything, starting most sentences with, “What if…” I often find that a bright child can come up with many “What ifs.”  They also can develop fears as a result of news coverage of a tragedy or natural disaster. Some develop stomachaches, some have difficulty leaving home, some are clingy to adults and others have problems sleeping.

My concern is that the family response is often the opposite of what needs to happen. Parents feel sorry when they see their child suffering so much. They want to comfort and protect their child. This is a natural response, but one that will not help stop the cycle of anxiety. In fact, it will make it worse.

Parents want their child to understand that there is nothing to worry about, so they spend a great deal of time discussing why thunderstorms or elevators aren’t dangerous. Sometimes, parents try to avoid the frightening situation or try to protect their child (“It’s OK, you don’t have to talk to the waiter. I’ll order your meal”).

Children who are afraid don’t need explanations. Fears are emotional, not rational. No rational explanation will help. The first step for parents is to realize that indulging their child’s fears will not help at all. In fact, it just reinforces them. A child might think, “If Mom thinks there is a reason to be afraid and we avoid the elevator, it must be really dangerous.”

Here’s the first step to take:

  • The most important thing you can do is to establish firm parenting. Your child needs to realize that you are stronger than his/her thoughts. You are the one who is in charge of life. For example, your child does not need to worry about someone breaking into the house, because security is your job and you are quite good at it.  You, as parents, are the ones who decide if a weather situation is dangerous or not. Basically, you relieve their fears by being the ones in charge and making the decisions.

This firm parental presence is the best way to reduce a child’s anxiety. It should not just occur in a specific situation but should be an overall approach to parenting.

In my next blog, I will review some other ways to help your child cope with anxiety but strong parenting is the foundation of all the rest.

Psychological Testing—All tests are NOT created equal

January 5, 2017 /

One of my favorite parts of my practice was when I could do evaluations. I liked trying to figure out ways to get good data, even when the situations were complicated. It was like solving a puzzle, putting all the parts together to get a picture of how someone worked with information. Then, I could start to figure out what could be done to help.

Many times, parents would bring in reports to me that had received from other psychologists. Even though the results were clear to me, many parents said they had no understanding of what all the numbers meant. They also didn’t know how to use the information to help with planning for their child. So, I decided to write a series of blogs to help sort out the confusion.

There are many kinds of tests and more are coming out every day. Psychologists sort through all these and usually use only the ones that have two important characteristics.

First, it is important to be sure that the results are consistent.  If a child is tested one day, will the results be similar the next time. The question is, can we count on the test results. One way to be sure about this is to have given the test many times, to many different groups of students. Even though this kind of research is not interesting to non-psychologists, it is crucial if you are going to base treatments on the results.

Second, does the test really assess what it says it does. If a test is developed to identify the presence of an Attention Deficit Disorder, for example, is it really able to sort out what is ADD behavior from what is “squirmy boy” behavior, or sensory seeking behavior, or just normal behavior for that age. How can we be sure? They all can look similar. So, research is needed on a large number of children, from different areas, different backgrounds to make sure that the test is really valid. In general, the more children in the sample groups and the more care in studies, the more accurate we can be.

I know many parents don’t worry too much about these factors, but in my opinion, they should. I have seen tests used to label or categorize children when the tests themselves were of questionable value. Unfortunately, I have also seen times when the choice of tests was made to give a desired result, usually to deny services to a child.

So, I have written a series of blogs where I try to outline to variety of tests available so that parents can be sure that they are getting the best assessment possible for their child. In defense of the testors, it is important for parents to know that buying the test kits is extremely expensive so most independent psychologists don’t have a wide variety. Instead, they choose the ones that they have the most use for.

What should a parent do either when testing is recommended or when you feel your child needs an assessment?  

  • Make sure the questions to be answered are clear.  Do you need to know about your child’s overall ability or are their specific questions about his/her vocabulary development, for example.
  • Look at the lists of tests in the next blogs to be knowledgeable when you talk to the psychologist.  Ask what tests will be used.
  • Carefully review the results, to be sure you understand what the results indicate about your child.
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