Graduates

Charlotte graduated from Occupational Therapy (OT) at the end of November with little fanfare which is a good thing and Happy is wrapping up her time with Minneapolis Public School birth to three special education team.

We told Charlotte at the beginning of November that she only had to go to OT three more times and she was super excited.  She had a lot of fun at OT but she said she was excited to be with her friends at Edgecumbe Montessori all day.  While in OT she was showing up at school around 9:30 am once a week rather than her usual 7:30 a.m. where I think she liked being there before everyone but one kid rather than just being dropped in a full classroom in full swing.  I think we all can relate and appreciate easing into things.

But the OT really helped her get control of her sensory issues and fears.  At the end of October we were at Fireroast, Charlotte's favorite and my favorite coffee shop, eating outside when some two ton trucks rolled down 38th street on separate occasions and Charlotte didn't even notice.

And then at school, her teacher at Montessori did little nothing to hide her skepticism of Charlotte's need for OT and freely reminded me time and time again of all the times that Charlotte would hear loud noises and not react.  So clearly, in the teacher's eyes, Charlotte was just playing us for the fool and playing up her fears around us.  Rather than argue my alternate theory,  I just let her teachers think that because it really isn't a battle worth having.

But I think about all the kids I used to work with who would hold their speech together all day at school and then go home and stutter like crazy in front of mom and dad.  Or all kids who behave in school and come home and throw temper tantrums.  It's kind of like if I went to the beach and walked around shirtless, I would be trying like crazy to keep my belly sucked in.  That's a lot of work over the course of the day.  And when I got home, I would put on some pajama pants an old t-shirt and let my belly relax and go wherever it wants.  Kids do the same thing.  They have to perform at school and when they get home they just can't hold it all together anymore because it is so much work.  That's why the OT was so important for Charlotte so she didn't have to work so hard to keep her sensory self together.

Before OT, she'd suppress her out-of-whack sensory system to try to act like all the other kids.  Only it wasn't working as well as she hoped.  Over the summer she had daily to weekly behaviors with other kids and her teachers.  Pushing past kids.  Refusing to transition or follow directions.  Regular old three year old meltdowns, but way more than usual for her.  The teachers held her accountable as they should and we did too.  But... we never saw those behaviors at home.  I think Charlotte was overstimulated at school with light and noise and tried to hide her outbursts (because no other kid was freaking out about noise), but the energy and anxiety was pent up and had to come come out, only it came out sideways.  So she pushed kids, cried, yelled, refused to share.... like any other three year old at his or her worst, only the source was sensory based.  In the end it doesn't matter, but I do find it telling that all of these behaviors went away as Charlotte got better and better at tuning out irrelevant environmental noises.

And part of all this is to give a shout out to all the PTs, OTs, and my fellow SLPs, and the select teachers who can see the child holistically and not just focus on the one thing they are paid to work on, be it learning walk, read, or improve language skills.  Charlotte's PTs and OTs were able to connect the dots in ways that Charlotte's teachers at Edgecumbe, as great as they are, are not specifically trained to do.

Regarding Happy, her walking and talking coming along.  She has this super funny way of walking where her arms are like noodles that just hang down and flop around while her legs and tummy do all the work.  I am not sure if that is an issue or not and she is actually starting to use her upper body more.  Her PT will come out soon to check up on her.  But she is as happy as can be, climbing and walking and following Charlotte around or just doing her own thing.

Happy certainly has a mind with a heart of its own.  Charlotte and she are similar in that they are both very aware of what they can and cannot do and will do the hard things only when they are good and ready.  But they approach that line so differently.  Charlotte approaches with trepidation and meditation and then reflection, and Happy is more straight up defiant.  She knows exactly what the PT wants her to do and she just walks away from her as if to say, "Nope.  Not going to do that.  End of story" and acts like the PT doesn't exist.  But then.... that night there is Happy all by herself practicing independently whatever activity or exercise it is the PT wanted her to do earlier in the day (usually it's squats of some kind).  And at her age that's all we want, is for her to do the exercises.  The defiance, well, that's a streak I'm proud to say both my girls have, even if it manifests itself differently.  Charlotte is more of a "No thank you" about it all while Haps is more like "No and I don't care about you."

It's like my friend said about having two kids: one is pizza and the other is tacos.  They're totally different and you love them both the same.

Along those lines, Happy's language development is interesting.  She is finally willing to imitate and attempt sounds.  She'd imitate every nonspeech sound you can think of and laugh and smile the whole time.  But the second you did something as simple as an "m" for "more" she would just ignore that and do her own thing.  But now she is feeling better at taking risks with her speech and has tried to say Charlotte's name in imitation few times as well as a slew of other easier words all the time.  She probably has about ten words so a language boon should happen in about six months.  If not, well someone else can speech therapize her because that's going to be my role.  But she is finally interested in talking, just like her PT and special ed teacher told us: once she gets walking down she will be more interested in trying out speech.

So things are progressing.  Charlotte is eager to take responsibility for her learning and digested every second of OT, and Haps is eager to take responsibility for herself and doing things on her terms.

Tacos and pizza.  I love them both.

Busman's Holiday

For a change I will be on an IEP team and not have to do any of the paperwork.  Happy was assessed by the Minneapolis Public Schools birth to three team on Wednesday and yesterday and she does indeed qualify for special ed services.  The concerns are not huge, but enough to warrant a little extra help from a physical therapist and a teacher will help monitor her language, feeding, and other cognitive development.  Obviously I can handle the speech and language aspect but that is not the role I want to play with my own child, yet I find myself wanting to analyze and work on it anyway.

It will be awhile before we get the full report from the team, but basically Happy's adaptive, functional, social, and non verbal skills are developing just fine.  She is 1.4 standard deviations below the mean with her language development and further behind in her motor development (the teacher said 1st percentile but that can't be right because Charlotte wasn't that low and Happy is further than long than she was).  So we will have a teacher and physical therapist come to our house around once a month to monitor her progress and give us things to work on at home.

Regarding the motor aspect, Happy is personally focussed on walking and standing.  You can tell she wants to walk like her sister more than she wants to learn how to do anything else.  I would say 75% of her play is motor based: climbing, cruising furniture, crawling, moving, trying to stand.... So we might see some nice gains over the next few months.  Happy's IEP goal is to walk in a stable fashion.

In terms of feeding, her tolerance of textures is improving.  Emily has a good theory.  Happy's teeth emerged in an unusual order.  The top four teeth came in  months ago and the bottom two just came in over the last two weeks.  It seems like now that she has her lower teeth she is much more comfortable eating different textures besides puree.  But she still cannot drink from any kind of a cup.  The physical therapist said this is likely due to her low muscle tone.  Charlotte had the same problem with cups and her physical therapist said the same thing.  So we will have an IEP goal for Happy to drink from a cup independently.

For communication, we all want Happy to communicate with sign, gesture, and words.  Well, except Charlotte and Happy could care less about this.  They are quite content babbling back and forth to each other.  So Happy's motivation to talk is not as strong as her desire to walk.  Oftentimes a kid like Happy will appear to behind in many areas when really they are only behind in one.  This is because the kid is so busy working on the one thing she can't do that she will ignore the other things she could also be working on.  In other words, a little 14 month old brain can really only focus on one area of development.  And because motor development is slow-going, she has no cognitive resources left to work on her speech and language development at the same time so she lags in that area.

At the risk of going too far down the clinical path, this is the distinction between a disorder and a delay.  The gross motor is a disorder and Happy will not catch up to her peers without intervention from a specialist.  The communication issues are a delay and once Happy gets to working on it, she will take off on her own.  The teacher assessing Happy basically suggested this in not so many words.

Kind of an interesting distinction between Happy and Charlotte.  Charlotte's language skills and fine-motor skills are, frankly, well above average and always have been.  For the first 18 months of Charlotte's life she had little to no interest in walking or any gross motor.  She was quite content to sit in one place and look at books or play with one toy, or sit with us and look at books.  So of course her language and fine motor took off.  Meanwhile, Happy really wants to walk and is focussed on that.  Looking at books and playing with one toy gets in the way of her meeting that goal, so her language stands to develop more slowly.

But I also think that Happy just doesn't have the speech motor skills to imitate speech.  She will imitate all sort of non-speech sounds and babble away with Charlotte.  She will point Nacho Average Cat and say two sentences of nonsense.  So she can connect sounds but if you ask her to imitate just one sound and she knows it is attached to a word, she can't do it.  I tried to get her to make the /m/ sound yesterday and she pursed her lips and blew air out her nose.

Like I said upfront, I do not want to be her Speech Language Pathologist.  But it is clear to me that she will get to talking when she is ready and to push her to talk now is unfair to her.  In the meantime, we'll use sign and gestures to help Happy find ways to communicate and not be frustrated.  A Speech Language Pathologist ethically really can't even work with a kid like Happy until she is two or three years old because chances are good she will get caught up on her own over the next eight months.  The youngest non-autistic kid I saw at my old job was 20 months and it didn't feel right to me to be servicing that kid but that wasn't my call.  In general we didn't start seeing kids until they were over 24 months, unless autism or a significant cognitive disorder was suspected.

At the end of the day, her disposition and social skills, and engagement with her parents and sister exceed any expectations I could have for her.  She is going to be fine and time is on her side.  I am not worried but recognize that she needs a little more help than her mom and dad can give her.

And there is the overriding rule of child development: kindergarten in the great equalizer.  Kids take their own path in which skills they develop and ignore and then they all meet at roughly the same spot by age six or seven.  Happy has five or six years to figure it all out, and there is one final truth about her, it is that she likes to carve out her own path.

Therapy Upates

1. Charlotte has graduated from Physical Therapy but will be reassessed in six months.  She still has exercises to do each night to help her along but the physical therapist was extremely pleased with how Charlotte has progressed.  She said Charlotte will always be a bit behind in her gross motor skills but that fact that Charlotte has progressed as far as she has is amazing.  Good job Charlotte .  She worked hard in therapy and did her nightly exercises with us with minimal complaint (usually she asked to do them).  So the credit truly does go to her.

2. Now Charlotte is beginning Occupational Therapy, beginning tomorrow.  I am anticipating a short course, but have been in the business of kids long enough to know that such predictions are often proven wrong.   We are going to get some help for some issues she has with sensory integration.  About four months ago I began thinking, "If Charlotte were a kid I was seeing at my old job, I wold have referred her parents to an Occupational Therapist for a sensory integration assessment."  At that exact same time, Charlotte's physical therapist told Emily we may want to have Charlotte assessed by an Occupational Therapist for sensory integration issues because Charlotte was freaking out about environmental sounds most kids her age no longer worry about.

Also, Charlotte is pretty intolerant of any moisture and dirt on her.  So she will do some activities in Occupational Therapy to desensitize her reactions to this.  And then I need help on how to help Charlotte cope with her disdain for environmental noises like thunder and trucks.  I think we hit rock bottom a few months ago, in terms of how much it was bothering her and she is starting to self-regulate a little better.  But it is still bugging her to the point that it is impacting her quality of life.

And I need to know when to intervene and when to let her sort it out on her own.  The Occupational Therapist will help give us effective, clinically-based strategies.  My instinct is to let Charlotte learn to figure it out on her own, but few weeks ago there I was, at dinner time, feeding Charlotte like a baby so she could cover her ears without interruption because she heard distant thunder once over a 30 minute period.  That is no way for her or I to live.  There are obviously better solutions out there and Charlotte, like most kids, will be more receptive to learning about and using these better solutions if they come from an adult teacher/helper, rather than from a parent.

 3. Happy will be assessed by the Minneapolis Birth to Three Team (special ed) for low muscle tone.  She is not yet standing alone and the pediatrician identified low muscle tone at Happy's 12 month wellness check.  So she has low muscle tone like her sister, just not as bad.  I know she won't qualify for services and we received excellent recommendations from Charlotte's physical therapist on things to do at home (hence the crawling around on the air mattress video) to help the motor development.  But I wouldn't mind the birth to three team taking a comprehensive look at Happy and giving us their feedback and recommendations.  She is behind in feeding, talking, and gross motor.  I'm not at all concerned at this point but I'd rather have her on the radar than not, and would like to hear what recommendations they have.  A team of experts looking at your kid's development never hurts.

My hunch is Happy is going to be standing on her own and walking in the next one to three months.  In terms of speech and language, her language seems okay because she is using sign and is good, not great, with receptive language.  I think her speech motor skills need a little more time to develop before she gets more words.  So far she says, "Hi" and "night night" and maybe "Mama" and "Dada."  About two weeks ago at lunch stared right at me, held up a banana and said, "Yu....      me" (yummy, which I often say to her).  It took so much effort that I can see why she is not talking more at this point.  Meanwhile, her disposition, self-regulation, patience, social skills, and play skills are pretty awesome.

Play Date

I'm not going to lie to you.  Summers off is a pretty sweet gig.  It makes the most frustrating and demoralizing parts of my job worthwhile.  I need to remember this post and this video when things start getting dark and deep in about five or six months.

A little context here.  At Happy's one year check-up the doctor identified low muscle tone in this Haps as well.  So I talked to Charlotte's physical therapist and she agreed that there is low muscle tone, just not as low as Charlotte's and she gave us some suggestions, including having Happy crawl on uneven surfaces.  This should explain the air mattress.  And now Haps will soon be evaluated by the school district special ed team, just like Charlotte was.

First Supper

Tonight Emily set the high chair up in recline and Happy joined us for the first time at the dinner table.  Upon seeing Happy was joining us for dinner, Charlotte insisted that she sit next to Happy.  A few months ago, Charlotte used to do this on a nightly basis, only it was pulling her chair next to mine so we could sit side-by-side.  Then the novelty of that wore off and she moved on to sitting next Emily.  And then she realized more personal space is better, and went back to having a side of the table to herself.

So in  few weeks the fun of sitting next to Happy will also pass.  And in a few months, when Happy is mobile and grabbing toys, Charlotte won't want to be next to her at all.  And in a few years they won't want to be in the same room at all.  But tonight it was very fun to see this.

The close observer will note the Rody (the green horse) is resting on top of the trampoline.  That's two toys bought solely for the purpose of physical therapy being used for very un-physical purposes... as per usual.  

Honors Graduate

She can run.  She can jump.  She can climb steps without pulling on a railing or hand.  She is a physical therapy graduate.  Friday was Charlotte's last session.  I was not sad to be done, and Charlotte certainly is just fine being done as well.  But I do appreciate all the work and patience our Physical Therapist brought to each session in working with Charlotte.  Knowledge and expertise is one thing, applying it to your work with a two year old is an entirely different animal all together.  Charlotte was very fortunate to have the physical therapist she had.  

So Charlotte is nowhere near at age level with all her skills, but her physical therapist felt she had enough core skills and strength in place that she will catch up on her own with a home program and some music therapy (hopefully we'll start that this month.  I am hammering out the schedule with the potential music therapist).  And then in six months we go back to the clinic for a physical therapy check-in/re-assessment to make sure Charlotte's gross motor skills are still on track.

Anyway, here is Charlotte a day after her graduation, squatting and getting up using only her legs, running, and climbing steps.  These are all things she could not do when she started physical therapy.

Behind the Scenes

Charlotte has made another small jump outwardly in showing her view of all things remote and abstract.  As Emily blogged yesterday her representational play is taking off, which is always nice for a parent to see because it rules out the last round of cognitive and learning delays or disorders someone like me has to worry about for awhile.  She is talking about things from the past all the time.  Suze still lives in Texas and tonight we were looking at a Richard Scarry book, as per usual, and she pointed to the fox or pig or dog or whoever was piloting a plane and said, "Suze!"  That's right, my mom is some perpetually smiling zoo or farm animal that flies airplanes.  I wanted to scold Charlotte so being so off-base but I decided to let it go.

So seeing what nuggets Charlotte pulls from the past continues to be fun but here are some bigger, although not all that huge, leaps she's made.

1. Out of nowhere on Friday she started talking about the zoo and then finally said, "Go zoo?  Daddy go zoo?  Charlotte go zoo?  Mommy go zoo?"  Maybe they talked about the zoo in her new school/daycare (Edgecumbe Montessori).  I asked her what she wanted to see at the zoo and she said, "otters."  Sure enough last month with Suze we went to the zoo and Charlotte saw the otters.  I asked what she remembered about the otters and she said, "Otters funny.  Otters swimming in a water."

Damnit, she nailed it.  I had not choice but to oblige and yesterday we were at the zoo.  We had just arrived, were one minute into thawing out near the indoor exhibits, when she insisted we go see the otters first.

A few of you reading this know that one of the many rants I have about Facebook right now is all the people bragging about how they went running in the cold.  There is nothing easier to do outside in the winter than run.  You have high tech gear on, you're doing this for leisure, and you are moving the entire time.  It really is no big deal.  And A LOT of people do it.

You know what is a big deal?  You know what A LOT of people don't do?  Stand out in the single digits, not moving at all for fifteen minutes, in what is essentially a wind tunnel, watching someone else  watch otters.  That activity is three times colder than going for a stupid run.  Fifteen minutes we stood there.  Love is funny that way.  No one else could have made me agree to those fifteen minutes besides Charlotte and every minute was awesome (and she was plenty warm by the way... she got sick of my checking in on her).

2. She has also been talking about the museum (she only know the Children's Museum).  After Physical Therapy on Friday we got into the car and she said, "Museum?"  I don't know if that was a specific request so much as a comment that she really didn't want to go to her new daycare, because it's new, and man wouldn't it be nice if the two of us chilled at the Children's Museum.  Anyway, per Emily. she spent a good chunk of the morning today lining her toy animals up to go the zoo (bus man's holiday) and then to the Children's Museum.  So clearly that stayed with her or was always with her.

3. Tonight she randomly did something kind of cool.  As we were going upstairs to bed, with no context whatsoever, she said, "Balloon, balloon!" and then acted like she was blowing up a balloon.  The two of proceeded to mime blowing up balloons for five minutes or so and she thought it was hilarious.  I have no idea where this came from.  I assume she is picking up a few things from Montessori.  Either way, it is fun to see the little brain of hers in action.

Other news:

1. She did indeed start a new daycare.  She is now in a Montessori with a nice range of kids from infants on up to pre-schoolers.  As expected, Emily had to deal with a lot of Charlotte's tears at drop-off time (well day one was more screaming per Emily and then when I picked her up the teacher said it took Charlotte half an hour to calm down after Emily left).  She'll be fine.  She is adjusting as quickly as we figured she would.  She still talks about Paula (her previous day care provider)  and the kids she played with there, so I think she misses that.  But I predict by the end of the week she'll be all in with her new place.  Like I told Emily, Charlotte is going to forget all of this in a year.  We are the ones who remember it all.  And once she is loving her new school we can always go back and see Paula and the kids Charlotte will remember from there.

2. Charlotte's Physical Therapist arranged for a therapy dog to come and help out with our sessions.  So now Charlotte has a dog doing PT with her.  I forgot it's name... Sandy?  I keep asking Charlotte but she says something that could be Sandy but it could be ten other names.  Regardless, that dog has really made a difference but not how you'd expect.  Charlotte likes the dog, but is really so hung up with working through all the demands we are asking of her.  So it is hard for her to let go and interact with the dog the same way she does our pets.  The intent was for the dog was to relax the dynamic of "do this hard activity" and "do that activity you're uncertain about doing." But that hasn't played out.  Instead what the PT and I have ended up doing is using the dog as a decoy to play off of Charlotte's work avoidance.  So if Charlotte bulks at doing something, we just ignore Charlotte and have the dog do the thing we want Charlotte to do, heap attention and praise on the dog and all of a sudden Charlotte is doing it too.  It's the oldest trick in the book, but I never would have thought of using the dog for such manipulation.  I guess it's better than using a sibling.  Speaking of which... Charlotte could use a sister, no?

Where Suze?

In a flash my mom's most recent visit to Charlotte has come and gone.  It was great to see Charlotte truly bond and connect with my mom and they fast became good friends.  I take Charlotte to physical therapy (PT) every Friday morning for a 7 a.m. appointment when it's still dark out (this detail will come into play soon).  My mom wanted to go along to see what PT is about.

So we went together the first week with mixed results.  It was the least compliant I had ever seen Charlotte.  It's important to remember that as fun as PT seems (climbing, running, crawling...) for Charlotte it can be stressful because she is being asked to do the exact thing that is extremely hard for her AND she knows it's hard for her AND we are pushing her to the breaking point.  It is no different than when I worked with kids her age for speech and language.  And a good clinician doesn't fear the breaking point, and knows when and how to push kids to the limit and when to pull back, give them a break, and decompress mid-session.  Our physical therapist is very good at this.  But since we are dancing to and from Charlotte's breaking point thoughout a session, it is very possible that simply having another person in the room can make the session rougher on Charlotte.  So although she showed no outward signs of it during the session, there was a chance having both my mom and me in the session with Charlotte's physical therapist was too much for Charlotte, hence more than typical resistance from her.

So the next week I decided I would drop my mom off with Charlotte for her PT appoitment and "go get coffee" (I just drove around the block and then sat in my car in the parking lot for 10 minutes).  Charlotte didn't fuss at all during the session and did a great job with my mom while I waitied first in my car and then the waiting room.

Anyway, when I parked my car in the parking lot just after 7 a.m. it was still dark outside, meaning I could see right into the PT clinic waiting room.  I could see Charlotte take her jacket off with my mom and wait for the physical therapist to greet them.  I saw them walk back to the PT room together.  And I don't know why, but it was super cool to see Charlotte go in with her grandma as if she were going back with me, as happy as can be.  I don't get mamy moments where I can see that Charlotte is a person whose life and relationships are bigger than me and Emily and it is special to see those moments even though in a blink of an eye this will be the rule, not the exception.  At least it better be.

So clearly Suze made an impact on Charlotte's life.  One morning Charlotte woke up and Emily brought her downstairs and my mom was in the shower and right away Charlotte asked, "Where Suze?"  And since my mom has gone Charlotte has on many occasions said, "Suze gone on airplane.  Texas."  I hope this memory sticks.  Two nights ago Charlotte started labling everything by who it belongs to.  "That a daddy's chair.  That a daddy's fork.  That a daddy's napkin.  That a mommy's chair.  That a mommy's fork.  That a mommy's napkin."  And then she pointed to where Suze usually sat and there with this long pregnant pause, and then she just said, "That a that a that a.... chair."  I don't know if she missed my mom at that moment but I sure did.

Get Your Motor Running

This morning Charlotte was assessed by Children's Clinic (physical therapy) in Roseville, MN for her gross motor delay.  Kind of weird being the consumer and not the provider in these assessments, and watch this parallel world where things play exactly like a language/speech/fluency evaluation, only for motor skills instead.

The physical therapist that assessed Charlotte was awesome and we are now on the waiting list for their services.  Back in my private practice days I referred kids to the Roseville clinic about five times a year so it was kind of a no-brainer in terms of where I wanted to go once Emily and I decided to pursue private physical therapy.

The assessment went really well and Charlotte did a great job in a new environment with a new person as the PT poked, prodded, and assessed.  The bottom line is Charlotte is kind of loosey goosey (hypotonia) with her muscles, including her ankles, legs, and trunk.  This gives her a lot of range of motion at all the joints as well as a lot of instability.  This why she uses her whole body to walk and has to sway and use her arms for balance the way a cat or monkey uses its tail.  She can't just stablelize herself at the calves and ankles like most of us do.

Also she pronates significantly.  So at the end of the assessment we came up with the plan to have orthotics made for Charlotte to help correct the pronation and we are on the waiting list at the Roseville Children's Clinic for physical therapy.  We could look elsewhere but I'd rather wait and go to the clinic I trust the most.

After all that I took Charlotte to the Children's Museum and for awhile we had Habitot to ourselves.  Then a few other kids her age came in and it is always kind of fun to watch them quasi-interact as they climb, slide, and explore.  But then the Waltons and the Von Traps all showed up at once and there was like 18392 siblings running aroud and Charlotte had enough and went to the "resource room" to chill out.

She is clearly her mother's daughter.