I have struggled for years combining my work as a developmental therapist in Early Intervention and my philosophy on child development and parenting. As a therapist, I've felt pressure to conform to the norms and widely-held beliefs about how therapy should "look." Though these norms always made me feel uncomfortable, I didn't know what else to do as a therapist until I learned about RIE and the idea of respectful parenting. With RIE I have found that less is often more. In the conversation below, the idea of "less is more" is explained in my response to the parent of an infant receiving physical therapy who shares her struggles with the approach to therapy and her philosophy on supporting a child's development. *Names have been changed for confidentiality. Hello Sandra and Janet,
I am writing in search of some advice and encouragement. My daughter, Jennifer, was born last year about 3 months early due to growth restriction and severe pre-eclampsia. She is doing well now and has overcome so many obstacles. However, she is still behind in her growth, which is contributing to some delayed milestones even for her adjusted age. Jennifer sees a physical therapist once a week and she will likely start occupational therapy very soon. The PT is especially working on her core strength, helping her to crawl on hands and knees (instead of army crawling) and getting her into a sitting position from the floor. She protests during these exercises and it is hard for me to stand by and watch. I really wanted to allow her the freedom to develop at her own pace, but since she is so far behind (13 months actual, 10 months adjusted) I understand the need to help her with these gross motor milestones. I am an aspiring Montessori educator. Independence and helping children help themselves is something I firmly believe in. I try to incorporate the RIE philosophy in our every day activities and interactions. Reading your posts about respectful parenting with special needs children and coping with a child's illness has been very helpful. What I am struggling with is whether or not it is okay to force Jennifer into positions in order to help her meet milestones? Her entire body stiffens or she screams in protest when we work on an exercise that she doesn't like (ie, hands and knees). She has shown us that she is doing things on her own timeline, and I wonder if these gross motor milestones will happen eventually when she is ready. Additionally, it has been challenging to find therapists and doctors who treat her with respect. We are about to move to a new city and I'm wondering if there are strategies that you might suggest for finding caregivers who will treat her with respect as a person, and not just a patient that they are pushing to reach specific goals? I know you both are very busy. Thank you so much for your time and consideration. Best, Carrie ```````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````` Hi Carrie! Thank you so much for reaching out. I'm so grateful that you're thinking about the things you've shared regarding your daughter and that you've reached out to us. And I so wish I had a simple answer for you. I have constantly struggled with the things you bring up in regard to how to balance my philosophy (what I've learned from RIE) on respect and trust and the more popular perspective in the physical therapy/Early Intervention world of "facilitating" gross motor development through handling/positioning. Just hearing those terms sounds disrespectful when I say them. I think I'm hearing in your email that you're wanting to do what's best for your daughter to help her achieve her developmental potential, as she's had many obstacles to overcome, but you want to support her in a way that aligns with your beliefs and doesn't compromise her sense of self or independence. The timing of your email is interesting, as I have been reading the RIE manual recently and realize how much I still have to learn and continue to change in my work to truly support long-term healthy full person development in the infants and toddlers I work with. I need to train myself to do less and trust more while supporting parents in the process. We as therapists and as adults have been programmed to DO, and if we as therapists aren't actively creating an "outcome" that we think is important because an assessment tool told us it is, we often feel like we aren't doing our job or are incompetent. You pointed out that Jennifer has made progress on her own timeline. I would venture to guess that she will likely continue to do so with or without PT or OT. It's so hard not to get caught up in the numbers (i.e. Developmental age vs. adjusted age vs. percent delay) that are often the most prominent part of evaluations. And based on numbers, recommendations are often made by therapists with very narrow lenses on development. Unless there are neurological or musculoskeletal abnormalities or there is a genetic disorder, typical development WILL unfold in due time and children will achieve the milestones their brains are wired for. Of course the environment and attachment relationship play a role in development as well. What I'm going to say next is a bold and somewhat scary thing for me to say, but I have often wondered if the well-intentioned therapy we provide infants and toddlers sometimes actually does more harm than good. When we focus so much on the tangible, concrete parts of development like gross motor and fine motor, it's easy to loose sight of the other areas that are less tangible and somewhat nebulous, like psycho-social and emotional development, regulation, and problem solving. I DO think we therapists impact those areas (not in a positive way) without realizing it. Will a child who learns to walk or use a crayon later than her peers, have long term consequences that will impact her the way a decreased healthy sense of self, ability to trust others, emotional regulation, persistence in challenges, and frustration tolerance (these are some of the common issues I see children struggling with) will? Probably not, yet unfortunately Early Interventionists' focus usually isn't on fostering those things. A family that I worked with in the hospital comes to mind, that always gives me encouragement and hope in the idea of nurturing relationships as the primary focus and allowing development to unfold within those supported relationships. This family had a little girl who was a micro-preemie and had oxygen requirements even after discharge, as well as feeding difficulties. She obviously had significant challenges at the most fundamental level-eating and breathing. She was neurologically intact. When she came to our hospital for supports prior to her discharge home, our rehab department had just implemented a new inpatient model of a primary therapist (infant development specialist) to work with and support the family around ALL the challenges and areas of development. Typically, the doctor would have ordered 4 different therapists to work with the child and family. With just one therapist, with the focus being on nurturing and supporting the family while providing coaching around basic caregiving routines, this little girl was discharged home (still on oxygen), with no delays in her motor skills, based on her adjusted age. I realize this is just one child and family and this outcome won't be the same for every child...BUT, my point is that even with all this little girl's challenges, development still happened for her without a bunch of therapy to make her "work" on skills that she wasn't ready for. I wonder if this might be the kind of intervention model that would fit best for Jennifer and your family, and where you will see the greatest outcomes-longterm. In your email, you asked for encouragement and advice...I'm hoping the story above gave you encouragement, while keeping in mind that every child is different. As far as advice, the best piece of advice I think I can give is to TRUST your instincts about what is best for Jennifer AND TRUST Jennifer and her developmental process. I do think it is wise to seek some supports from early interventionists, but what that looks like can be totally up to you. Perhaps a monthly consult with a motor therapist will be enough...or a developmental specialist who is trained in global development provides you with support, and that person consults with a motor therapist. Just some other ways to think about intervention. I know this email is really long, so I will end soon, but first I wanted to share just a few quotes from the RIE manual that stood out to me when thinking about your situation... "Selective intervention means knowing when to intervene, and this is more difficult than intervening indiscriminately." "Infants do naturally have access to their own resources, unless we superimpose tasks which are beyond their capabilities." "Although the...trainers make more noise, they will long be forgotten when the soft voice of reason will still be heard." Carrie, I trust that you will find what feels right for Jennifer and your family! (Janet, I would love to know any of your thoughts on this...I still really struggle with it all and find myself constantly questioning my way of providing intervention/therapy!) All my best, Sandra ```````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````` Sandra, Thank you so much for your thoughtful response! You have indeed provided advice and encouragement, and I feel certain that when I am doubting myself or doubting Jennifer's abilities, I will reread your message for some reassurance. I love the idea of a primary therapist and it helps to know that there are other potential options out there for our approach to early intervention. I think a lot of what I'm dealing with as Jeni works to meet her milestones is guilt that I am not "doing" enough. You mentioned dealing with parental trauma and PTSD in your post on Janet's blog and I am realizing that this would be incredibly helpful for me. It will help me to take a step back and let Jennifer just be, instead of worrying or feeling guilty for not constantly pushing her to do things that she may not be ready to do quite yet. This week I have been sitting back and observing as she plays and I am seeing a drastic difference in her enjoyment and in my stress levels. And I am noticing small progress towards milestones. She is so close to getting herself into that sitting position! Janet recently posted to Facebook an article about taking a mindful approach to early intervention. That combined with your suggestion of trusting myself and Jennifer have set me at ease with where we are. Thank you! Best, Carrie ```````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````` Wow, Carrie! You are incredibly insightful and your message was hugely encouraging to me! It's parents like you who keep me going in this work!! I'm so glad to hear that you've been able to take a breath, slow down, and de-stress a bit. AND see the positive impact that's having on you and Jennifer! You're not alone in the feelings of guilt and those contributing to your wanting to push her. I have never met a parent of a NICU-grad who doesn't share that struggle. During this process of re-thinking how early intervention will work for your family, please do consider pursuing some counseling/emotional supports to help you process the intense experience and feelings that you've had to cope with. I always share with parents the analogy of oxygen on an airplane. Maybe you've heard it before...They always say that the adults should put their oxygen mask on first and THEN help their child...I think it's a great reminder that when a parent is getting the supports they need, they will be better equipped to handle the challenges (especially those that trigger strong emotions) of parenting. I would love to continue to hear about your journey, Carrie! If you wish to share, please know that I'm always excited to hear from families about their process! I would love to read that article about mindfulness in EI that Janet shared. Would one of you let me know where I can find it, please? Thanks! ```````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````` Thank you, Sandra! I had not heard that analogy before, but it is so fitting. Here is the link to the mindfulness article Janet posted on her facebook page - http://www.thevisibleparent.com/taking-a-mindful-approach-to-early-intervention/ This morning Jennifer initiated the hands and knees position all on her own! We are over the moon! We haven't "practiced" this position in a while because she was so resistant to it. I think giving her the space and time to figure it out independently truly helped. Thanks again for listening and for your advice. Have a great weekend! Best, Carrie
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