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Regulatory Disorders

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									Regulatory Disorders
I                II                 III                   IV
Hypersensitive   Under-reactive     Motorically           Other
                                    Disorganized
                                    Impulsive

Fearful and      Withdrawn and       Behavioral pattern
cautious         difficult to engage

Negative and     Self-absorbed      motor and
defiant                             sensory patterns
Regulatory Disorders

   Noise                                         Oral motor difficulty
                             Gravitational
   Light visual images       insecurity          Poor muscle tone
   Odors                                         Muscle instability
   Tactile                   Sensory             Poor motor planning
    defensiveness             Sensorimotor        Not modulate motor
   Oral                      Processing           activity
    hypersensitivity          Difficulty
                                                  Def. fine motor skills
   Under-reactivity to
    touch or pain            Visual/spatial      Articulation problems
   Temperature               problems            Difficulties attention
Regulatory Disorders
Regulation of
                            Organizing a calm
 Behavior
                            state
 Physiological processes
                            or
 Sensory processes
                            Alert state
 Attentional processes
                            or
 Motor processes
 Affective processes       Affectively positive
                            state
Regulatory Disorders

Distinct Behavioral             Processing Difficulty
                       PLUS
Pattern                         Sensory
                                Sensorimotor
                                Organizational



Affects daily adaptation, interaction or relationships
Regulatory Disorders
                         Attentional           Affective
Physiology state
                         Organization          Organization
breathing, gag
                         driven, not settle,   predominant tone
hiccups, startle
                         or overfocused        range, modulation

Gross Motor              Behavioral            Language
Activity                 Organization
                         aggressive
Fine Motor Activity      impulsive behavior    Cognitive
                                               Difficulties
Elimination
Sleep         Patterns
Eating
     Regulatory Disorders

                      Underreactive Type

Withdrawn and
                                    Self-absorbed
difficult to engage
Disinterest in exploring            Tune into own sensations, thought
Appear withdrawn, apathetic         and emotions. Solitary exploration
easily exhausted. May appear        of objects. Appear inattentive,
delayed or depressed.               distracted. Escape into fantasy.
Repetitive sensory activity.        Imagination and creativity.
Underreactivity to sounds, mov.     Decreased audit. processing.
Auditory-verbal processing probl.   May or may not other irregularity.
                   Regulatory Disorders

Motorically disorganized
                                     Other
impulsive
Poor control of behavior, fearless   Motor or sensory
crave sensory input. May be          processing difficulty
aggressive. Impulsive and            Behavioral pattern not
disorganized. High motor             included in other descriptions
activity. Seek contact through
deep pressure, invades others’
space. Break things.
Poor motor planning.
Counterphobic behaviors.
Sensory underreactivity, crave
motor discharge.
      Regulatory Disorders

                      Hypersensitive Type

 Fearful and cautious              Negative and defiant
Excessive caution, inhibition     Negativistic, controlling, stubborn
fearfulness                       and defiant, prefers repetition
clinging in new situations        fussy, resist change.
frightened, inh. exploration      Self around negative patterns
easily upset, not soothe easily   Avoid change.
not recover quickly               Overreactive to touch and sound
overreactive to touch, light      avoid some textures, good visuo
and noises, poor visuo spatial    spatial. Poor audit. processing
Psychotherapeutic Approach
Floor time—Six steps
First  Foster engagement and a sense of connectedness
Second Encourage a problem solving orientation through action
       or thoughts, practice and discussion
Third Child experiences empathy toward him, and difficulties.
       Identify core assumptions
Fourth Through small steps, master new experiences
Fifth The adult establishes a structure, limits and incentives
Sixth If limits set, increase processing time, follow child’s lead
       in setting limits
 Infant Crying                                Dr. Maldonado

  If physically healthy        Conditions
Normal        Difficult
Crying        Temperam.                              Primary
Signal        More difficult      Colic              Excessive
              to soothe
Need of                                              Crying
attention
Wet           Less rhythmic            Regulatory Disorders
Hunger                              Hypersensitive   Motor Processing
              Cry at night
Bored                                                Impulsive
                                                     Motorically
Wish for      More                                     disorganized
interaction   frustrated
                                Transactional Model
Temperament                     Goodness of Fit
                                Biological Model
 Activity Level
 intensity of reaction
 adaptability                                 Difficult
 reaction to frustration                      10%
 Sociability                                              Easy
 approach/withdrawal            Indifferent               40%
 smiling, laughter              or average
 fear                                  35%
 soothability
 Attention Regulation
 persistence, distractibility
 attention span                                    Slow to
 Rhythmicity                                       warm up
 Quality of mood                                   15%
Excessive Crying
Definition and Relevance

   Wessel criteria—Duration over 3 hours in 24-hr. period,
    at least 3 days per week. (Cry Diary)
   Prevalence. Approx. 10% of infants in 1st year of life,
    open population
   Clinical concern. Consultation to manage intense or
    persistent, excessive crying
   Children at risk of maltreatment, physical abuse due to
    intractable crying
   Adds stressors, causes feelings of inadequacy and
    desperation in the parents
Differential Diagnosis of Excessive Crying

   Physical                                         No Clear
    Illness                                         Physical
                                                     Illness
 Cardiac    illness
 Hernias    (inguinal,        In               Withdrawal  from drugs
 others)                    Neonatal             exposed to in utero
                             Period             Cocaine, cannabis,
            condition.
 Neurological
                       Most common causes:       alcohol. Amphetamines
 Hydrocephalus
 Visceral   Hyperalgesia           Withdrawal from antidepressants
 Others                            Fluoxetine, tricyclics, chlorpamine
II. Differential Diagnosis of Excessive Crying

      Medical Illness                                        Colic
    As above                                        Onset at 6 weeks. Lasts
                                                     up to six months.
    Gastroesophageal                                 Starts in evening
         Reflux                                     Gas in abdomen. Arch legs
 Cry most if supine              Infant 6 weeks    Pain. Self limiting.
  Cry during feedings

  due to esophagitis             to 6 months old
 Frequent regurgitation of milk                   Regulatory disorders
 Dx: Ph probe, radiological study.
  Ecographic study.

      Allergy to milk                                  Long-term effects
                                Parenting
    Rarely is the cause                                 of street drugs
                                Problems
    Eosinophil count.
III. Differential Diagnosis of Excessive
Crying

    Regulatory                                              Relationship
    Disorders                                               Disturbances-Disorders
 Difficulty in maintaining                                 and Parenting Problem
  calm state
 Hypersensitive to stimuli:                                High parental stress
  Touch, sounds
 Visual stimuli
                                 Infant from                Insensitive parenting
                                                            Ignoring of cry
 Poor rhythmicity               6 months to                Failure to soothe
 Poor ability to habituate
                                3 years of age              Inadequate stimulation
 Other types
                                                            Poor fit between child’s
  Defiant and negative         Medical illness ruled out
  Hyposensitive                                              need and style of parents
                                                            ? Advice of family physician
 Multidisciplinary assessment
                                                             and pediatrician regarding
 Occupational therapy
  assessment                                                 management of cry
Management of Excessive-Persistent Crying

                 If Withdrawal            If Gastro-             If Colic
If Medical                                Esophageal
                 from Drugs or
Condition:       Antidepressants
                                          Reflux
                                                                 Reassurance   to
                                          Thickening   of
                 Adequate   diagnosis     infant formula         parents
                 Minimal handling or     Smaller and more      Increased carrying
Adequate                                   frequent feedings      of baby
                  stimulation of infant
diagnosis and    Soothing technique      Hold more in          Soothing
treatment,                                 upright posture        techniques may
                 Containment
                                          Increased carrying     be useful
e.g., surgery,    (swaddling?)             of infant             Car ride
                 Possibly
analgesics,                               Alkaline substances
                                                                 Rhythmic
                  Sedatives, if tremor     (Donnatal, etc.)
shunt, etc.       excessive startle       ? Propulsid,
                                                                  stimulation
                                           accelerate gastric    ?-Anticholinergic
                  convulsions
                                           emptying               medication
II. Management of Excessive-Persistent Crying

                                                  If Relationship Disorder
If Regulatory Disorder
                                                   or Parenting Problems
                                                   Alleviate stress if possible,
Become    acquainted with    “Floor Time”          increase support to parents
 infant’s sensitivities and
 aversion to stimuli,                              Concrete advice and help
 changes, etc.                                      to manage crying
                              Increase positive    Model empathic responses
Taylor stimuli to child
 according to these           pleasurable           and sensitivity vis a vis
                                                    infant
Sensory integration          interactions
                                                   Interactive guidance
 techniques
                                                   Explore fantasmatic
Empathic responsiveness                            interactions
                              Parent infant
 given uniqueness                                  Explore parents’ working
Reduce overstimulation
                              psychotherapy         model of child, and of
                                                    relationships in general
Classification of Relationship Disorders
Parent-Infant Relationship (or caregiver)
Disorder Specific to a Relationship
         Perceptions                        Perceptions
Parent   Attitudes                          Attitudes   Child
         Behaviors                          Behaviors

Observed behavior + Parent’s subjective experience of child.
  Perturbation Intensity of disturbance or distortion
  Disturbance    Frequency of disturbance
  Disorder       Duration of disturbance
Parent Infant Relationship Global Assessment Scale
(PIR-GAS)

(Rating below 40 is for disordered relationship, severely disordered or
grossly impaired relationship)
Behavior problems are intense, persistent and ongoing.

                           Behavioral qualities of interaction
                                                    (required for dx)
Qualities of
                           Affective tone
Relationship
                           Psychological involvement
Relationship Disorders
Parent                              Behavioral Quality                  Child
Sensitivity-insensitivity                                  Averting
Contingent-non contingent                                  Avoiding
genuineness                                                Arching
Regulation                                                 Lethargy
Predictability                                             Nonresponsiveness
Structuring and mediating                                  Defiance          Delays
Parent                              Affective Tone                      Child
Intense anxious                                            Intense, anxious
Tense                                                      tense
Negative affect                     dysregulating          Negative affect
(irritable, angry, hostile)         effect
Parent                         Psychological Involvement                Parent
Attitudes and perceptions of the child
(Meaning of child behavior to parents)
Parental image of a caregiving relationship
Past experiences in the parents
Relationship Disorders
Anxious and Tense Relationship Disorder

Interactions are tense, constricted, no sense of relaxed enjoyment or mutuality.
Clinician perceives anxiety, tension.
Quality of interaction                      Affective tone
   Sensitivity to cues by parent is extremely      Parent or infant shows anxious mood.
    heightened                                      Motr tension. Apprehension. Agitation
   Parent concerned freq. re:infant well           Facial expressions. Quality of speech and
    being, behavior, development may be              vocalizations
    overprotective                                  Parent and infant overreact. Escalation.
   Physical handling, tense, awkward
   May have negative interactions but not       Psychological involvement
    primary
                                                    Parent often misinterprets, responds
   Poor fit between infant’s temperament            inappropriately
    and activity level and that of parents           (e.g., feelings of failure or rejection in the
   Infant may be very compliant or anxious          parent when infant cries)
    around parents
Relationship Disorders
Angry and Hostile Relationship Disorder

Interactions are harsh and abrupt, lack emotional reciprocity.
Relationship conveys to clinician anger and hostility.
Behavioral quality                         Affective tone
   Parent insensitivity, mostly if infant is          Parent child interaction is hostile or
    demanding                                           angry
   Physical handling is abrupt                        Tension between parent and infant lack
                                                        of enjoyment or enthusiasm
   Parent may tease infant, taunt                     Child’s affect maybe constricted
   Infant may be frightened, anxious,
    inhibited, impulsive, or diffusely aggressive   Psychological involvement
   Child may be defiant or resistant toward           Parent may resent child’s needs (due to
    parent                                              stressors or own interpretations)
   Child may be fearful, avoidant and vigilant        Parent may see child as his dependent
   Child, tendency to concrete behavior                parents
    rather than fantasy or imagination                 Sees age appropriate independence as
                                                        defiance or attempt to control
                                                       Parent project neg. feelings to infant.
Relationship Disorders

 Overinvolved       Underinvolved
                                                Abusive
       1                    2               6
                Types                           A Verbally
           Relationship                           abusive
            Disorders               Mixed       B Physically
                                5
                                                  abusive
       3                4
                                                C Sexually
Anxious/Tense       Angry/Hostile                 abusive
Relationship Disorders
Overinvolved Relationship Disorder

Behavioral Quality          Affective Tone          Psychological Involv.
Parent often interferes    Parent  may have       Parent may perceive infant as
Parent dominates,
                             periods of anxiety,     partner or peer may
 overcontrols                depression or anger.    romanticize or erotize
                             Lack of consistency    Parent does not see infant as
Makes develop.              in interaction
 inappropriate demands                               separate
                            Infant  may react      Lack interest in infant’s
Infantmay be difuse,        passively or express    uniqueness
 unfocused, undifferent.     anger and obstinacy    Diffuse generational boundary
                             directly and whine     Confidante
Infant  submissive,                                Extreme physical closeness
 overcompliant or defiant
                                                    Meet parent’s own needs
May have lack of motor
 skills or language                                 No reciprocity
 expression
Relationship Disorders
Underinvolved Relationship Disorder
Behavioral Quality                              Affective tone
   Parent insensitive or unresponsive             In both parent and infant is constricted,
   Inconsistency between expressed attitude        withdrawn
    in parent and interaction                      Sad
   Parent ignores, rejects, fails to comfort      Flat
    the infant                                     Interaction of lifelessness
   Parent does not mirror infant’s behavior,      Absence of pleasure
    reflection of infant’s feeling states
   Not protect infant from harm by others      Psychological involvement
   Interactions underregulated, cues missed       Parent not aware of infant’s cues or
    or misinterpreted                               needs
   Dyad appears disengaged                        Parent may have history of deprivation,
   Infant may appear uncared for (often ill,       neglect
    no good med. care. infant dirty)
   NOFT. Delays in motor or language
    skills since no support.
  Sensorimotor Realm


                                             Reactive Behavior


                          Coping Abilities
                            of Infant


Self-initiated Behavior
Sensorimotor Organization

                     Reaction to                        Tolerates
Visual attention     touch                              variety of
                                                        positions
                              Pleasure in
                              self-initiated
                              movement

           Self-regulation                     Varies activity
           of basic body                       level according
           functions                           to situation
Reactive Behavior

Accepts emotional                   Adapts to daily routine
warmth and support
from people
                                    Bounces back after
                     Engages in     stressful situations
Reacts to feelings
and moods in other   reciprocal
people               social
                     interactions
                                    Adapts to some change
Some tolerance                      in the environment
of frustration
Self-initiated Behavior

              Tries new               Problem solving ability
Initiates
action        behaviors
to            by himself
communicate                           Demonstrates
need                                  persistence during
              Tries to achieve        activities
              a goal


              Balances independence
              with dependency
Interventions for Sensory
Processing Dysfunctions
Give feedback: Verbal and non-verbal
Avoid rushing the child. Pace interaction to allow time to respond
Emotional feedback is useful (smiling, hugs, looks of pleasure, etc.)
               Short sentences. Positive directions
               Short reasons for requests
Verbal
interaction    Praise
               Label of feelings
Building on previous achievement, rather than initiate new strategies,
i.e. scaffolding
Interactions: spontaneous. Playful, not ―teaching‖
Interventions Child Hypersensitive
   Look for early signs of distress. Stop. Time to recover. Slow pace
                 Firm pressure on skin
                 Massage–Induce relaxation
   Develop      Slow repetitive rocking. Child in vertical position or lap
    a calming    Rhythmic motion
    technique    Swaddling (young infant)
                 Soft melodies, lullabies or white sounds
                 Sucking. Pacifier
   Encourage development of self-comforting behaviors
    Mouthin. Cuddling a toy. Hug hands against chest. Quite place,
    snuggle. Favorite play activity
Interventions Child Hypersensitive (cont.)
   Assess complexity of input during interaction. (Several sensory
    modalities at one time or just one or two). Sensory diet.
   Examine if child irritability makes parent tense and amplify
    disorganization
   Grade environmental stimulation (not glaring light,
    overcrowding, noises)
   Increase sensory tolerance by pleasurable activities
   Provide reasonable routine. Rituals may help child organize.
    Forecast transitions and rituals.
   If possible provide choices for stimulation and build on self-
    initiated activity
   Sensory input may be cumulative. Schedule breaks of recovery
Interventions Child Hyposensitive
   Provide enough time to react. Slow response or additional
    input to elicit response
   Engage in child-directed play. Narrate child’s actions
   Model affective reactions during play. Exaggerate response
   Search for attempts at non-verbal communication
   Complete circles of interaction
   ―Jump start‖ the child’s reaction
   Avoid imposing input
   Free play with peers to model reactions
Interventions to Help child
Become Organized
   Child directed play without demands. Follow child’s lead
   In play, ask questions about next steps
   Work on child’s organization and not adult’s organization
   Allow repetition and practice
   Reinforce successive approximations
   Emphasize fantasy and emotional themes
   Forecast transitions
   Enhance body awareness and motor control.
    Somatosensory input
   Engage child in planning activities
Intervention.
Sensory Based Sleeping Problems
   Determine if day time is too stimulating, so child prefers night
   Calming input in evening: Slow linear movement in on axis
                                Touch pressure. Massage
                                Curl up in bean bag or chair
   Watch for sensory overload
   No arousing activities before sleep time
   Support self-comfort maneuvers before sleep onset
   Bed is compatible with sensitivities of child (scratchy fabric,
    lumpy surface) Sheets are not cold. Vestibular input?
   Background of white noise. Continuous sound
   Sleep clothing. Preference for textures
   Games of separation. Transitional objects
Intervention.
Sensory Based Feeding Problems
   Assess complexity of sensory input during feeding
   Feeding when child is relaxed and alert. Environment calm
   Routine associated with beginning and end of meal
   Calming techniques prior to feeding
   Avoid frequent wiping of mouth (face sensitive). Let child wipe
   No scraping of food off from lips
   Changes in food texture introduced slowly
   Use of tooth brushes
   Parents emotionally supportive and available. Social interaction
   Culturally based feeding practices

								
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