Watch, Wait and Wonder

One day, I watched a father hold the bus’ back door open for his, around, 3 year old son. He expected his son to get down from the bus to the sidewalk on his own. The boy hesitated. Rather than use words to urge the son past his hesitation, the father simply held the boy’s hand, perhaps, to help him down. The son suddenly jumped down to the street. Dad’s silent, connecting hand enabled an existing ability.

Delayed children also want their leap and use gestures, like pausing, to be understood. Kelly, for example, wanted and needed to eat more. Born at 23.5 weeks, at her 20th month the IFSP report stated she had been through seizures, bleeding in the brain, and pulmonary problems. She has hydrocephalus, vision problems, cannot sit on her own, move her left arm or hand much. Her right arm and hand could move some. When we met at her 24th month, she could intentionally move her head a bit to the right even though the IFSP stated that she had no control over her head. Her parents had trouble feeding her and were concerned with her weight. She ate barely enough of pureed food and had a feeding tube in her history. I wanted to keep tube feedings in the past. I wondered how I could help before I even met the family.

Wondering is part of a three step process for developmentally based therapy. Developmentally based therapy is about meeting the child’s needs from the child’s perspective. The other two steps are watching and waiting. Developmental therapists have to be patient and know that their particular disciplinary knowledge must fit in to the child’s desires expressed in gestures or words. Like the father on the bus, the therapist has to watch and learn about the child to help the child solve their own problem. Waiting, like quietly holding a hand, helps the child take the next step because we can see the child’s wishes.

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First, I watched the family. Mom and dad knew the basics of fattening up. Everyone except Kelly was plump or more. Mom and dad just needed to know how to apply their practical knowledge to Kelly. I watched dad, a professional cook, feed Kelly. She could move her head and hand sufficiently to signal hunger and satiety. She signaled satiety too soon. How could the family’s skill in fattening the whole family be applied to Kelly?

I wondered about two more things. First, would Kelly eat more if she was fed more responsively? Responsive feeding is associated with improved weight gain because it engages the child’s desire to act independently. Could Kelly signal hunger and begin to feed herself with her lack of speech and minimal gestural vocabulary? I wondered if Kelly needed some kind of cue, like a dinner bell, announcing the meal. The cue I wondered about held two parts. The first part was to let the spoon caress her cheek to see if activating the rooting reflex would help. Second, we tried placing her pureed food under her nose to activate her appetite via her sense of smell rather than her impaired vision. She responded to the cues by moving towards the spoon and by letting the feedings last longer. Her desire was also shown by her moving her right hand enough to help her parents move the spoon into her mouth. Kelly was now acting more independently and interacting more with her parents at mealtime. She was being fed in response to her developmental needs.

Second, I wondered what would happen if Kelly was offered pureed versions of the family’s high calorie foods during family meals. Kelly enjoyed the family foods. Here’s how we learned this fact. Her parents tried, a few times, to feed her food different from which the rest of the family was eating. She ate less at those times. After a month with cues and family foods, she gained two pounds. Mom, dad and Kelly were all satisfied with responsive feeding methods tailored to Kelly.